Cardiothoracic Surgery: Mediastinitis
Mediastinitis
Definition
- Definition: Inflammation of Infection of the Mediastinum
- High Mortality:
- Postoperative Mediastinitis: 1-14% (Improved from Past Reports of 12-50%)
- Descending Necrotizing Mediastinitis: 20-40%
Causes
- Postoperative Mediastinitis
- Sternotomy
- Thoracotomy
- Thoracoscopy
- Descending Necrotizing Mediastinitis
- Neck Abscess
- Ludwig Angina (Infection of the Sublingual/Submaxillary Spaces)
- Dental Infection
- Pharyngeal Abscess
- Fibrosing Mediastinitis
- Tracheal/Esophageal Perforation
- Boerhaave’s Syndrome
- Endoscopic Perforation
- Trauma
Pathophysiology
- Postoperative Mediastinitis
- Most Common Organisms:
- Staphylococcus aureus
- Coagulase-Negative Staphylococcus (Staphylococcus epidermidis)
- Risk Factors:
- Bilateral IMA Use (Skeletonized Decreases Risk vs Pedicled)
- Diabetes
- Obese
- Tobacco Use
- Renal Failure
- Most Common Organisms:
- Descending Necrotizing Mediastinitis
- Most Commonly Polymicrobial
- Can Spreads by Fascial Planes, Most Commonly into the Posterior Mediastinum
- Fibrosing Mediastinitis
- Exact Pathophysiology Uncertain
- Can Cause Compression of Major Vessels or Trachea/Bronchi
- Results in Recurrent Pulmonary Infections
- Closely Associated with Histoplasmosis & Tuberculosis
Presentation
- Dysphagia
- Chest Pain
- Fever
- Respiratory Distress
- Sternal Instability
- Wound Discharge
- Hamman’s Sign – Crunching by Auscultation
Diagnosis
- Diagnosis: CT or MRI
- Less Sensitive/Specific if < 14 Days Postoperative Due to Physiologic Postoperative Changes
- Imaging Not Necessary if Clinically Clear
Treatment
- Treatment: Antibiotics & Early Surgical Debridement
- Post-Sternotomy: Sternal Debridement & Pectoralis Flaps (May Use Omentum if Necessary)
- Descending Necrotizing Mediastinitis: Thoracotomy with/without Cervical Exploration