Thank you to Jimmy for presenting a truly fascinating case of a patient who presented with odynophagia and throat pain, who developed chest pain and was ultimately found to have mediastinitis, likely from an oral source. Ultimately, the patient underwent debridement and found to have necrotic strap muscles! One highlight about this case is that the medicine team had a great differential for the odynophagia, and as new symptoms emerged (i.e. chest pain), their differential expanded, necessitating a CT chest that ultimately clenched the diagnosis! Well done team!!
Deep Space Neck Infections and Mediastinitis:
- Post-operative mediastinitis is the most common cause of mediastinitis
- Incidence post-operatively ranges from 0.5-4% and depends on both patient factors (e.g. DM, obesity) and operative characteristics (e.g. how long the sterum is open)
- Other etiologies include esophageal perforation, contiguous spread of oropharyngeal infection, penetrating trauma or hematogenous spread
Mediastinitis From Oropharyngeal Infection:
- Mediastinitis is considered a complication of a retropharyngeal space infection
- Results from infection in the “danger” space between the alar and prevertebral fasciae may drain by gravity into the posterior mediastinum!
- Mortality is up to 25% in patients with acute necrotizing mediastinitis even when appropriatve antibiotics are administered
- Treatment necessitates source control with drainage if there is an abscess and washout along with antibiotics
- In retropharyngeal space infection complicated by acute necrotizing mediastinitis, surgical drainage of the mediastinum is required and may be performed by either the cervico-mediastinal or the transthoracic approach. Although the cervical approach may be effective in early mediastinitis, thoracotomy is generally indicated once the necrotizing process has entered the “danger” space.
- Chow, AW. (2017). Deep neck space infections. UpToDate. Accessed 12/20/2017. https://www.uptodate.com/contents/deep-neck-space-infections?search=mediastinitis&source=search_result&selectedTitle=3~97&usage_type=default&display_rank=3#H34