History
Most patients with mediastinitis have experienced symptoms for a few days before presentation to the emergency department (ED). Occasionally, patients present with a fulminant course and symptoms that have lasted only a few hours.
Common symptoms in patients with mediastinitis include the following:
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History of an upper respiratory tract infection, recent dental infection (common), or thoracic surgery/instrumentation [8]
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Fever, chills
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Pleuritic, retrosternal chest pain radiating to the neck or interscapular pain
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Shortness of breath
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Cough
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Sore throat
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Swelling in the neck
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Odynophagia
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Confusion
History may be significant for recent endoscopy, bronchoscopy, intubation, surgery, thoracic malignancy, or consumption of fish or chicken bones.
Some patients are at an increased risk for mediastinitis. Obtaining the patient's medical history, which should include explicit questions about diabetes, possible immunocompromise (eg, malignancy/chemotherapy, HIV, autoimmune disease), and drug abuse, is very important.
Physical
A complete examination of the chest, head, and neck, including the oral cavity, is essential. Such an examination may yield the following findings:
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Ill appearance
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Fever
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Tachypnea
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Tachycardia
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Signs of sepsis disproportionate to the rest of the history and examination
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Edema of the neck and face
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Trismus
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Evidence of cervical or oropharyngeal abscess
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Crepitus of chest or neck
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Stridor
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Hamman sign (crunching sound upon auscultation of the heart)
Causes
Causes of mediastinitis may include the following:
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Iatrogenic mishap following esophageal instrumentation (eg, upper endoscopy, esophageal dilatation, transesophageal biopsy, esophageal surgery)
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Iatrogenic mishap following tracheal instrumentation (eg, bronchoscopy, tracheal dilatation, transbronchial biopsy)
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Esophageal foreign body (eg, fish bone)
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Mediastinitis may present as a delayed infection following thoracic surgery, such as coronary artery bypass
Primary cervicopharyngeal infections may include the following:
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Sialadenitis
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Suppurative thyroiditis
Endotracheal intubation
Perforation of the hypopharynx or esophagus during intubation may cause mediastinitis. This is particularly likely to occur if the intubation was difficult and required the use of a rigid stylet.
Patients usually develop symptoms and signs in the immediate postintubation period, although delayed presentations are reported. Consider this complication if a patient's condition deteriorates in the postintubation period and if signs of sepsis or cardiovascular compromise are observed.
Fibrosing mediastinitis
This very rare entity is an excessive fibrotic reaction in the mediastinum. It is usually observed as a result of histoplasmosis or other granulomatous disease.
Patients usually present with symptoms of compression or occlusion of mediastinal structures. Presenting symptoms include cough, superior vena caval obstruction, shortness of breath, chest pain, or hemoptysis.
Onset is usually insidious.
Other causes
Tuberculous mediastinitis may occur after the rupture of a tuberculous lymph node into the mediastinum. Diagnosis may be difficult because some patients initially have few symptoms or signs. Radiographic findings may indicate a mediastinal mass, and the diagnosis may not be made until further investigations, including an MRI, are completed.
Fungal infection, usually caused by Candida species, is observed after cardiothoracic surgery in 0.3% of cases.
Mediastinitis has been described as a complication of laparoscopic cholecystectomy.
Complications
Complications of mediastinitis may include the following:
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Death
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Pericarditis
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Sepsis
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Multiorgan system failure
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Adult respiratory distress syndrome
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Cardiac tamponade
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Empyema
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Vascular thrombosis
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Arterial hemorrhage via erosion of infection [2]
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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.
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Chest CT of same patient showing gas-filled mediastinal abscess and widened esophagus. Image courtesy of Mark Silverberg, MD, FACEP, and Rafi Israeli, MD.
