Laboratory Studies

The diagnosis of mediastinitis is often a clinical one. No single laboratory

investigation can confirm the diagnosis; however, studies that may help in
the diagnosis of mediastinitis include the following:

Inflammatory markers (white blood cells [WBC], C-reactive protein

[CRP], erythrocyte sedimentation rate [ESR], and procalcitonin) are
often elevated.

Metabolic measurements are often normal but may reveal anion gap,
hyponatremia, hypoglycemia or hyperglycemia, or hypoproteinemia

Blood cultures

Swab from any site of infection

It is important to notify the laboratory of the possible presence of anaerobic
organisms and the strong possibility of mixed growth, since many
laboratories routinely report only a single predominant organism. Close
coordination with the laboratory is vital to optimize the antibiotic regimen.

Imaging Studies
Plain-film radiography
Soft tissue radiography of the neck may show widening of the precervical
and retropharyngeal soft tissues.
Plain-film chest radiographs may show widening or haziness of the
mediastinum or mediastinal air.
The lateral chest radiograph may show an anterior bulge on the posterior
wall of the trachea.
Pleural effusions and lower lobe consolidation are not unusual findings.
It is important to note that plain films may appear normal and cannot by
themselves exclude the diagnosis.
Chest CT scanning
Chest CT scanning is the imaging modality of choice for the diagnosis of
mediastinitis.
If there is a concern for descending infection, it should be paired with a
neck CT scan.
Chest CT scanning can provide accurate information regarding both the
presence and extent of descending necrotizing mediastinitis (DNM),
helping guide the mode of surgical approach for drainage. Chest CT
scanning can also be used to monitor progress after treatment. [2]
Head and neck CT scanning
In the case of descending necrotizing mediastinitis, head and neck CT
scans may demonstrate abnormalities while the chest radiograph still
appears normal.
Abscess and soft tissue swelling are usually visible.

Neck CT scanning can help with planning the surgical approach.

MRI
Use of MRI to confirm the diagnosis of mediastinitis is becoming more
common but continues to be reserved more for children to limit radiation
and those with impaired kidney function. [1] It should be noted that
mediastinitis is a time-sensitive diagnosis - if MRI is utilized, it should not
be delayed.
Mediastinitis due to esophageal perforation is shown in the radiograph
below. CT of the same patient follows.

Chest radiograph of a
patient presenting with mediastinitis secondary to esophageal perforation
by a chicken bone. Image courtesy of Mark Silverberg, MD, FACEP, and
Rafi Israeli, MD.
View Media Gallery

Chest CT of same patient

showing gas-filled mediastinal abscess and widened esophagus. Image
courtesy of Mark Silverberg, MD, FACEP, and Rafi Israeli, MD.
Prehospital Care

Mediastinitis may result in airway compromise. Protection of the airway is

vital. Since patients may present in septic shock, adequate volume
resuscitation is essential.
Emergency Department Care

Ensure an adequate airway. Do not allow a patient who is potentially

unstable to be placed into the CT scanner without ensuring that the airway
is adequately protected. Intubation may be difficult because of soft tissue
swelling. Fiberoptic assistance may be required, and an emergent
cricothyrotomy or tracheostomy may become necessary. In addition to the
usual complications of intubation, it may be further complicated by trauma
to the retropharyngeal wall, laryngospasm, or aspiration of purulent
material.
Antibiotic therapy should be initiated without delay.
Fluid resuscitation and management of sepsis are essential.
The key component of ED management is expeditious diagnosis.
Mediastinitis may present a confusing clinical picture and may be mistaken
for entities such as pneumonia, acute coronary syndrome, pharyngitis, or
isolated pharyngeal abscess, among others. A high index of suspicion is
required, particularly in patients with findings of a concomitant
cervicopharyngeal infection or with a history of thoracic, esophageal, or
tracheal instrumentation or malignancy. Prompt diagnosis and surgical
treatment is associated with improved survival.
Consultations

Immediately make arrangements for surgical consultation. Extensive and

aggressive debridement of necrotic tissues with exploration of all
mediastinal fascial spaces may be required. Controversy exists about
whether the cervical approach or the transthoracic approach is best. Some
physicians support a combination of the two approaches. In some case
series, the combination approach has been associated with a lower
mortality rate. Depending on the resources available, consultations may
include otorhinolaryngology, cardiothoracic surgery, and general surgery.
The necessity for extensive drainage may mandate the transfer of some
patients to a tertiary referral center.

Medication Summary
Because mediastinitis is usually a mixed growth infection, wide
antimicrobial coverage is required. The cause of infection should be
determined. Extension of S aureus osteomyelitis should be managed
differently from an esophageal rupture; however, in the absence of a
source and definitive microbiological data, broad-spectrum therapy is
indicated. Antibiotic administration should not be delayed once the
diagnosis is suspected. Combinations such as piperacillin-tazobactam plus
vancomycin or vancomycin plus a fluoroquinolone and clindamycin should
be used. An aminoglycoside may be added to broaden gram-negative
coverage.

Antibiotics
Class Summary
Therapy must cover all likely pathogens in the context of the clinical setting.
Ceftriaxone (Rocephin)

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Third-generation cephalosporin that has broad-spectrum gram-negative
activity, lower efficacy against gram-positive organisms, and higher efficacy
against resistant organisms. By binding to one or more of the penicillinbinding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial
growth.
Clindamycin (Cleocin)

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Lincosamide that is useful treatment of serious skin and soft tissue
infections caused by most staphylococcal strains. Effective against aerobic
and anaerobic streptococci, except enterococci. Inhibits bacterial protein
synthesis by inhibiting peptide chain initiation at the bacterial ribosome
where it preferentially binds to the 50S ribosomal subunit, causing bacterial
growth inhibition.
Imipenem-cilastatin (Primaxin)

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Used for treatment of multiple organism infections in which other agents do
not have wide spectrum coverage or are contraindicated because of their
potential for toxicity.
Metronidazole (Flagyl)

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Active against various anaerobic bacteria and protozoa. Appears to be

absorbed into the cells and the intermediate metabolized compounds that
bind DNA are then formed and inhibit synthesis, causing cell death.
Gentamicin (Garamycin)

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An aminoglycoside antibiotic effective against Pseudomonas
aeruginosa,Escherichia
coli,Proteus,Klebsiella, and Staphylococcus species.
Numerous dosing regimens are available, and they are adjusted based on
creatinine clearance and changes in the volume of distribution. The dose of
gentamicin may be given IV or IM.
Piperacillin and tazobactam sodium (Zosyn)

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Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits the
biosynthesis of cell wall mucopeptide and is effective during the stage of
active multiplication. This medication has a broad antimicrobial spectrum
that is effective again most oral, respiratory, and GI bacterial pathogens.
Used in concert with gentamicin, strong anti-gram-negative activity occurs.
Ampicillin and sulbactam (Unasyn)

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Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with
bacterial cell wall synthesis during active replication, causing bactericidal
activity against susceptible organisms.
Vancomycin (Vancocin)

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Inhibits cell wall synthesis. Accomplished by binding to carboxyl units on
peptide subunits containing free D-alanyl-D-alanine.
Effective against methicillin-resistant S aureus.

Further Inpatient Care

As for any abscess, the essential management of this condition involves
prompt and extensive surgical debridement. [8]
The use of hyperbaric oxygen for this condition is controversial.
Recent studies have looked at the use of intravenous immunoglobulins for
mediastinitis, particularly when the condition arises as a complication of
cardiothoracic surgery.
Broad-spectrum antibiotics are necessary. Antibiotics should be capable of
treating aerobes, anaerobes, and gram-positive and gram-negative
infections.

Lengthy hospitalization (1 month) is common.

Transfer
Optimal treatment of this disease requires extensive surgical debridement.
This may require the services of cardiothoracic surgeons and
otorhinolaryngologists and may necessitate a transfer if these services are
not available.
Patients with mediastinitis often require highly skilled intensive care. Some
patients may require referral to a tertiary care center if these resources are
not available at the presenting hospital.

Complications
Complications of mediastinitis may include the following:

Death

Pericarditis

Sepsis

Multiorgan system failure

Adult respiratory distress syndrome

Cardiac tamponade

Empyema

Vascular thrombosis

Arterial hemorrhage via erosion of infection [3]

Prognosis
Early diagnosis and aggressive therapy seem to provide the best chance
for recovery.
Despite vast improvements in IV antibiotics, critical care medicine, and CT
imaging in the last 30 years, mediastinitis still carries a high mortality rate. [4]
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