Mediastinitis

Classification according to ICD-10
J98.5	Mediastinitis
ICD-10 online (WHO version 2019)

Under the mediastinitis is meant an inflammation of the middle coat ( mediastinum ). It is a serious illness with a high mortality rate. A distinction must be made between the acute and the chronic form.

Acute mediastinitis

etiology

Under an acute mediastinitis means a conditional usually bacterial, the structures of the mediastinum pus ( purulent ) einschmelzende inflammation. It can develop from lowering inflammatory processes in the head and neck area. The cause can be an inflamed tooth, sinus or retropharyngeal abscess , for example . The spread of an inflammatory process from the nasopharynx area into the mediastinum is facilitated by certain anatomical conditions. Bacterial diseases can spread along the fascia that descends vertically from the neck area into the mediastinum and cause severe inflammatory processes.

Mediastinitis can also be the result of an infection spreading directly to the chest ( intrathoracic space ). Lung pleura ( pleura ), lungs , pericardium , lymph nodes , abscesses adjacent to the spine and inflammation of the bones ( osteomyelitis ) of the breastbone ( sternum ) or of a vertebral body can serve as foci for middle inflammation .

Acute mediastinitis is much more common, however, as a result of a leak in the esophagus ( esophageal perforation ). The starting point of the inflammation is usually in the middle or lower third of the esophagus. Reasons for an esophageal perforation are ingestion ( ingestion ) of corrosive substances, iatrogenic (medically caused) damage to the esophagus ( gastroscopy , intubation ) or Boerhaave's syndrome . A disintegrating ulcer in the esophagus can also mediate the spread of germs into the mediastinum via a fistula .

Heart surgery is another cause of inflammation of the middle skin . Studies put the postoperative complication rate of acute mediastinitis following a median sternotomy (opening of the breastbone) at 0.15 to 8% of cases, with most studies seeing the rate between 1% and 2%.

Mediastinitis is rarely the result of a perforation of the windpipe ( trachea ) or the bronchi .

Pathogen spectrum

Causing germs of a mediastinis can be:

• For infections in the head and neck area as well as for severe esophageal injuries: streptococci , anaerobes, Corynebacterium species, Moraxella catarrhalis , Eikenella corrodens , Candida and rarely Pseudomonas aeruginosa
• For infections after thoracic surgery: staphylococci , enterococci , streptococci, Escherichia coli , enterobacteria , Pseudomonas aeruginosa , Candida species and rarely anaerobes.

Symptoms

Patients who suffer an esophageal perforation are usually acutely symptomatic. This manifests itself primarily through severe chest pain and shortness of breath ( dyspnoea ).

Damage to the airways , such as B. bronchoscopy , deceleration trauma (in the context of traffic accidents) or tumor eruptions can also occur, is also associated with acute symptoms. Acute respiratory impairment and mediastinal emphysema precede the inflammatory problem. Parallel pleural effusions indicate an additional injury to the mediastinal lung membrane.

The finding of a developing mediastinitis after a previous heart operation is more subtle. The examination findings are usually discreet initially. Central symptoms are retrosternal pain (behind the breastbone), local reddening of the surgical wound and general signs of infection (fever, tiredness, weakness).

Regardless of the cause, the disease can very quickly take a septic course and cause corresponding symptoms.

diagnosis

One means of diagnosis is the chest x-ray. You will find a widened middle layer and possibly signs of emphysema . A subcutaneous emphysema can sometimes above the jugular notch ( jugular be palpable). The safest and, in an emergency, probably the first detection method for mediastinitis is computed tomography . If an esophageal perforation is suspected, a gastrographin swallow (swallow of radiopaque contrast medium) can prove this on the one hand, and also reveal the exact point of the lesion on the other.

therapy

Regardless of the etiology (origin), any acute mediastinitis should be drained externally. A transjugular cross-section on the neck can be used to drain the inflammatory tissue in the anterior mediastinum (structures in front of the heart). Inflammatory processes in the posterior mediastinum (structures behind the heart) are addressed with a thoracotomy (opening of the chest). After opening the thoracic space, the posterior mediastinal space can also be opened and a drain can be placed outside.

The affected area is then rinsed for several days. It goes without saying that the cause of the inflammation must be eliminated immediately. An esophageal lesion requires suturing or plastic repair. Thereafter, treatment with antibiotics (staphylococcal antibiotics can be used) and long-term intensive medical care are required.

Before the result of a microbiological examination is available, a calculated antibiotic therapy can be started. Since there is often a mixture of germs, antibiotic combinations are recommended, e.g. B. a cephalosporin together with metronidazole or clindamycin. Other antibiotics can also be considered.

Careful necrosectomy (removal of dead tissue) is required in the case of necrotizing mediastinitis, such as occurs in descending (descending) infections ( Descending necrotising mediastinits ) . Furthermore, it is imperative to inspect all fascia boxes of the neck and a careful debridement . Fortunately, this particularly dangerous form of middle skin inflammation is very rare.

forecast

The central problem of all infectious mediastinitis is the great risk of developing life-threatening sepsis . The lethality of middle skin inflammation is high even with optimal medical care.

Chronic mediastinitis

etiology

Chronic mediastinitis must be clearly distinguished from the acute form. Both cause and symptoms, as well as therapy, are completely different. Often one finds fungi as the cause of chronic middle inflammation. A weakened immune system plays an important role in this. Well-known pathogens are Histoplasma capsulatum , Aspergillus flavus or Cryptococcus neoformans . The pathogens are usually transferred to the mediastinum via the bloodstream ( hematogenic dissemination ). Chronic mediastinitis is also found more often after radiation therapy or in the context of tuberculosis or sarcoid (Boeck's disease). Furthermore, lymphoproliferative ( lymphoma ) or immunological processes ( collagenosis ) can cause chronic mediastinitis. Chronic mediastinitis can be granulomatous (tuberculosis, sarcoid) or as a diffuse fibrosing form.

Symptoms

The chronic inflammatory process leads to a fibrosis of the mediastinum ( mediastinal fibrosis ). The resulting traction forces on the surrounding organs lead to the typical complaints. Compression of the windpipe leads to dyspnoea. Compression of the superior vena cava or pulmonary veins can cause congestion or pulmonary edema . Tensile forces on the nerves can lead to paresis of the phrenic nerve (phrenic nerve palsy) or the recurrent laryngeal nerve (recurrent palsy).

therapy

The mostly diffuse inflammatory penetration of the entire middle layer is problematic. Surgical access is therefore only possible to a very limited extent. Therapy consists of the administration of corticoids . The fibrosis process should be throttled through the catabolic effect of the corticoids. Any fungal infections are treated with antifungal drugs . Mediastinitis caused by tuberculosis can be treated with tuberculostatics . In general, however, the therapeutic options for chronic mediastinitis are unsatisfactory.

literature

• Harrison's Principles of Internal Medicine. Volume 2, 16th edition. McGraw-Hill, New York 2005, ISBN 0-07-139142-8 .
• Jörg Rüdiger Siewert: Surgery. 7th edition Springer, Berlin et al. 2001, ISBN 3-540-67409-8 .

Individual evidence

1. ^ Roger JF Baskett, Carolyn E. MacDougall, David B. Ross: Is mediastinitis a preventable complication? A 10-year review . In: The Annals of Thoracic Surgery . tape 67 , no. 2 , February 1999, ISSN  0003-4975 , p. 462-465 , doi : 10.1016 / S0003-4975 (98) 01195-3 .
2. ^ Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , p. 32 ( Mediastinis ).
3. ↑ Marianne Abele-Horn (2009), p. 32.

This article is about a health issue. It is not used for self-diagnosis and does not replace a diagnosis by a doctor. Please note the information on health issues !