Clinical management and prognosis for descending necrotizing mediastinitis / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the clinical characteristics, treatment experiences and prognostic factors for descending necrotizing mediastinitis (DNM). Methods: A retrospective analysis was performed on the data of 22 patients with DNM diagnosed and treated in Henan Provincial People's Hospital from January 2016 to August 2022, including 16 males and 6 females, aged 29-79 years. After admission, all patients underwent CT scanning of the maxillofacial, cervical, and thoracic regions to confirm their diagnoses. Emergency incision and drainage were performed. The neck incision was treated with continuous vacuum sealing drainage. According to the prognoses, the patients were divided into cure group and death group, and the prognostic factors were analyzed. SPSS 25.0 software was used to analyze the clinical data. Rusults: The main complaints were dysphagia (45.5%, 10/22) and dyspnea (50.0%, 11/22). Odontogenic infection accounted for 45.5% (10/22) and oropharyngeal infection accounted for 54.5% (12/22). There were 16 cases in the cured group and 6 cases in the death group, with a total mortality rate of 27.3%. The mortality rates of DNM typeⅠand typeⅡwere respectively 16.7% and 40%. Compared with the cured group, the death group had higher incidences for diabetes, coronary heart disease and septic shock (all P<0.05). There were statistically significant differences between the cure group and the death group in procalcitonin level (50.43 (137.64) ng/ml vs 2.92 (6.33) ng/ml, M(IQR), Z=3.023, P<0.05) and acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score (16.10±2.40 vs 6.75±3.19, t=6.524, P<0.05). Conclution: DNM is rare, with high mortality, high incidence of septic shock, and the increased procalcitonin level and APACHE Ⅱ score combined diabetes and coronary heart disease are the poor prognostic factors for DNM. Early incision and drainage combined with continuous vacuum sealing drainage technique is a better way to treat DNM.

Mediastinitis por Aspergillus fumigatus en un paciente pediátrico inmunocompetente posterior a una cardiocirugía / Aspergillus fumigatus mediastinitis in an immunocompetent pediatric patient after heart surgery

Postsurgical aspergillosis occurs primarily in immunocompetent patients whose main predisposing factor is the loss of skin and mucosal integrity during surgery. Local infection tends to be destructive and refractory to treatment and relapses are common. It is important to consider aspergillosis in the differential diagnosis of slowly progressive and destructive surgical site infections with negative bacterial cultures. We present the case of a child who developed Aspergillus fumigatus mediastinitis months after heart surgery.

A Case of Pneumomediastinum and Parapneumonic Effusions Following Pharyngeal Perforation Caused by Shouting

Spontaneous pneumomediastinum is an uncommon disorder, and usually affects young men and has a benign course. Common triggers are asthma, the smoking of illicit drugs, the Valsalva maneuver, and respiratory infections. Most cases are usually due to alveolar rupture into the pulmonary interstitium caused by excess pressure. The air dissects to the hilum along the peribronchovascular sheaths and spreads into the mediastinum. However, pneumomediastinum following pharyngeal perforation is very rare, and has only been reported in relation to dental procedures, head and neck surgery, or trauma. We report a case of pneumomediastinum that developed in a 43-year-old patient with pharyngeal perforation after shouting. His course was complicated by mediastinitis and parapneumonic effusions.

Mediastinitis and pericardial effusion in a patient with AIDS and disseminated Mycobacterium avium infection: a case report / Mediastinite e derrame pericárdico em um paciente com AIDS e infecção disseminada por Mycobacterium avium: um relato de caso

We report the case of a 36-year-old man who had acquired immune deficiency syndrome and developed suppurative mediastinitis extending over the left lung and anterior thoracic wall around the sternum, pericardial effusions, splenomegaly, and mesenteric and periaortic lymphadenomegaly due to Mycobacterium avium (genotype I). The organism was isolated from an axillary lymph node and the bone marrow. Mediastinitis associated with disseminated M. avium complex infection is uncommon and, to the best of our knowledge, this manifestation has not reported before.

Relatamos o caso de um paciente de 36 anos vivendo com AIDS que desenvolveu mediastinite supurativa com extensão ao pulmão esquerdo e à parede anterior do tórax ao redor do esterno, derrame pericárdico, esplenomegalia e adenomegalia mesentérica e periaórtica, devido ao Mycobacterium avium genótipo I, isolado de linfonodo axilar e da medula óssea. A mediastinite associada à infecção pelo Mycobacterium avium é rara e, até onde conhecemos na literatura publicada, esta forma de apresentação ainda no foi relatada.

Validation of MagedanzSCORE as a predictor of mediastinitis after coronary artery bypass graft surgery / Validação do MagedanzSCORE como preditor de mediastinite após cirurgia de revascularização miocárdica

OBJECTIVE: The aim of this study is to evaluate the applicability of a new score for predicting mediastinitis - MagedanzSCORE - in patients undergoing coronary artery bypass graft (CABG) surgery in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE. METHODS: Retrospective study involving 500 patients operated between May/2007 and April/2010. The registers contained all the information used to calculate the MagedanzSCORE. The outcome of interest was mediastinitis. We calculated sensitivity, specificity, positive predictive value, negative predictive value, concordance and accuracy. The accuracy of the model was evaluated by ROC (receiver operating characteristic) curve. RESULTS: The incidence of mediastinitis was 5.6%, with a lethality rate of 32.1%. In univariate analysis, the five variables of the MagedanzSCORE were predictors of postoperative mediastinitis: chronic obstructive pulmonary disease (OR 6.42; 95.0% CI 2.76-14.96; P<0.001), obesity (OR 3.06; 95.0% CI 1.32-7.09; P=0.009), surgical reintervention (OR 82.40; 95.0% CI 30.40-223.30; P<0.001), multiple transfusion (OR 3.33; 95.0% CI 1.52-7.29; P=0.003) and stable angina class IV or unstable (OR 2.59; 95.0% CI 1.19-7.64; P=0.016) according to Canadian Cardiovascular Society. The score had a sensitivity of 96.4%, specificity of 90.0%, positive predictive value of 36.5%, negative predictive value of 99.8% and 90.4% concordance. The accuracy measured by the area under the ROC curve was 96.2% (95.0% CI 94.5%-97.9%). CONCLUSIONS: The MagedanzSCORE proved to be a simple and objective index, revealing a satisfactory predictor of development of postoperative mediastinitis in patients undergoing CABG surgery at our institution.

OBJETIVO: O objetivo deste estudo é avaliar a aplicabilidade de um novo escore de predição de mediastinite - MagedanzSCORE - em pacientes submetidos à cirurgia de revascularização miocárdica (CRM) na Divisão de Cirurgia Cardiovascular do Pronto Socorro Cardiológico de Pernambuco - PROCAPE. MÉTODOS: Estudo retrospectivo envolvendo 500 pacientes operados entre maio/2007 e abril/2010. Os registros continham todas as informações utilizadas para calcular o MagedanzSCORE. O desfecho de interesse foi mediastinite. Foram calculados sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo, concordância e acurácia. A acurácia do modelo foi avaliada pelo ROC (receiver operating characteristic curve). RESULTADOS: A incidência de mediastinite foi de 5,6%, com uma taxa de letalidade de 32,1%. Na análise univariada, as cinco variáveis do MagedanzSCORE foram preditoras de mediastinite no pós-operatório: doença pulmonar obstrutiva crônica (OR 6,42; IC 95,0% 2,76-14,96; P<0,001), obesidade (OR 3,06; IC 95,0% 1,32-7,09; P=0,009), reintervenção cirúrgica (OR 82,40; IC 95,0% 30,40-223,30; p<0,001), transfusões múltiplas (OR 3,33; IC 95,0% 1,52-7,29; P=0,003) e angina estável classe IV ou instável (OR 2,59; IC 95,0% 1,19-7,64; P=0,016) de acordo com a Sociedade Canadense de Cardiologia. O escore teve uma sensibilidade de 96,4%, especificidade de 90,0%, valor preditivo positivo de 36,5%, valor preditivo negativo de 99,8% e 90,4% de concordância. A acurácia medida pela área sob a curva ROC foi 96,2% (IC 95,0% 94,5%-97,9%). CONCLUSÕES: O MagedanzSCORE provou ser um índice simples e objetivo, revelando-se um preditor satisfatório de desenvolvimento de mediastinite no pós-operatório de pacientes submetidos à CRM em nossa instituição.

Mediastinite fibrosante: relato de caso / Fibrosing mediastinitis: a case report

Neste trabalho é relatado o caso de uma mulher de 51 anos de idade, com dor torácica, dispneia e engurgitamento de vasos do tórax superior, sem evidências clínicas de doença granulomatosa. O estudo por imagem do tórax revelou massa mediastinal com calcificações, abordada por mediastinoscopia com biópsia. A análise histopatológica mostrou padrão inflamatório crônico sem etiologia definida, compatível com mediastinite fibrosante.

The present study reports the case of a 51-year-old woman with chest pain, dyspnea and upper chest vessels engorgement, with no clinical evidence of granulomatous disease. Chest imaging study revealed a mediastinal mass with calcifications that was approached by mediastinoscopy with biopsy. Histopathological study demonstrated an etiologically undefined chronic inflammatory pattern compatible with fibrosing mediastinitis.

[Odontogenic descending necrotizing mediastinitis]

Descending necrotizing mediastinitis [DNM] following an oropharyngeal infection is a rare disease with a rapid course and a mortality rate of up to 40%. The aim of this study, is to outline the diagnosis and the appropriate treatment of DNM. A retrospective study [1986-2007] of patients with DNM was made. Only patients with cervical cellulitis associated with DNM were included. Eight men and two women with an average age of 43 years were treated. Five had diabets. The average for diagnosis and treatment was eight days. In eight cases, we found a dental origin and in two cases a pharyngeal origin. The diagnosis of DNM was made thanks to cervico thoracic CT scan in six cases. In the others patients. they had at presentation clinical and radiological evidence of mediastinal diffusion. All patients were treated by broad spectrum antibiotherapy. All had cervical drainage. Mediastinal drainage was made by cervical approach in 2 two cases and via a right thoracotomy in eight cases. Eight patients died. Odontogenic DNM is a rare disease with rapid course Clinical diagnosis is difficult and early recognition with a lowi thresold for CT scanning is essential. CT is also useful for the treatment and in the post operative assessment. All affected tissue plane must be debrided. Surgical management and mediastinal drainage remain controversial about the indication of thoracotomy

Mediastinite aguda: aspectos de imagem pós-cirurgias cardíacas na tomografia computadorizada de multidetectores / Acute mediastinitis: multidetector computed tomography findings following cardiac surgery

Mediastinite pós-cirurgias torácicas é definida como a infecção dos órgãos e tecidos do espaço mediastinal, ocorrendo em 0,4 por cento a 5 por cento dos casos. A gravidade da infecção pós-operatória varia desde infecção de tecidos superficiais da parede torácica até mediastinite fulminante com envolvimento esternal. O critério diagnóstico da tomografia computadorizada para mediastinite aguda pós-cirúrgica é a presença de coleção mediastinal, podendo estar associada ou não a anormalidades periesternais como edema/borramento de partes moles, separação dos segmentos esternais com reabsorção óssea marginal, esclerose e osteomielite. Achados associados incluem linfonodomegalias, consolidações pulmonares e derrame pleural e pericárdico. Pequenas coleções e gás mediastinais podem ser usualmente encontradas em pós-operatório recente de cirurgias torácicas sem a presença de infecções, limitando a eficácia da tomografia computadorizada nas duas primeiras semanas. Após esse período, a tomografia alcança quase 100 por cento de sensibilidade e especificidade. Pacientes com suspeita clínica de mediastinite devem ser submetidos a exame de tomografia para pesquisa de coleções, identificando a extensão da doença e sua natureza. A versão de multidetectores propicia recursos de reconstruções em diversos planos e janelas, contribuindo especialmente para o estudo do esterno.

Postoperative mediastinitis is defined as an infection of the organs and tissues in the mediastinal space, with an incidence ranging between 0.4 percent and 5 percent of cases. This disease severity varies from infection of superficial tissues in the chest wall to fulminant mediastinitis with sternal involvement. Diagnostic criterion for postoperative detection of acute mediastinitis at computed tomography is the presence of fluid collections and gas in the mediastinal space, which might or might not be associated with peristernal abnormalities such as edema of soft tissues, separation of sternal segments with marginal bone resorption, sclerosis and osteomyelitis. Other associated findings include lymphadenomegaly, pulmonary consolidation and pleural/pericardial effusion. Some of these findings, such as mediastinal gas and small fluid collections can be typically found in the absence of infection, early in the period following thoracic surgery where the effectiveness of computed tomography is limited. After approximately two weeks, computed tomography achieves almost 100 percent sensitivity and specificity. Patients with clinical suspicion of mediastinitis should be submitted to computed tomography for investigating the presence of fluid collections to identify the extent and nature of the disease. Multidetector computed tomography allows 3D images reconstruction, contributing particularly to the evaluation of the sternum.

Spondylodiscitis Complicated by the Ingestion of a Button Battery: a Case Report

A one-and-a-half year old boy who presented with a cough, irritability, and refusal of food was found to have an impacted foreign body in his upper esophagus. We present the radiologic findings of the foreign body (a button battery) impacted in the upper esophagus and its complications; namely, mediastinitis and spondylodiscitis after endoscopic removal. Further, plain radiograph and MR imaging findings are discussed along with literature review.

Descending necrotizing mediastinitis: a fatal complication of neglected esophageal foreign body.

Descending necrotising mediastinitis due to a neglected esophageal foreign body is uncommon. It is a lethal disease if it develops with full blown clinical picture. A case is reported of descending necrotising mediastinitis caused by a foreign body in oesophagus which is rarely reported in world literature. It is emphasized that prompt diagnosis and aggressive surgical mediastinal drainage is very important for the survival of these patients. Delayed diagnosis and treatment in our case may have been the cause of death of the patient. Delayed diagnosis in our case is due to the unavailability proper health facility in remote area in developing countries like Nepal.

Descending mediastinitis: a review

CONTEXT: Mediastinitis is an inflammation of connective tissue that involves mediastinal structures. When the condition has an infectious origin located in the cervical or oral region, it is termed "descending mediastinitis" (DM). DATA SOURCES: The subject was examined in the light of the authors' own experiences and by reviewing the literature available on the subject. The Medline, Lilacs and Cochrane databases were searched for articles, without time limits, screening for the term "descending mediastinitis". The languages used were English and Spanish. DATA SYNTHESIS: There are three main fascial pathways by which oral or cervical infections can reach the mediastinum: pretracheal, lateropharyngeal and retropharyngeal. About 70 percent of DM cases occur via the retropharyngeal pathway. The mortality rate is about 50 percent. According to infection extent, as seen using computed tomography, DM can be classified as focal (type I) or diffuse (type II). The clinical manifestations are nonspecific and resemble other systemic infections or septic conditions. The primary treatment for DM consists of antibiotics and surgical drainage. There are several approaches to treating DM; the choice of approach depends on the DM type and the surgeon's experience. In spite of all the improvements in knowledge of the microbiology and physiopathology of the disease, controversies still exist regarding the ideal duration of antibiotic therapy and whether tracheostomy is really a necessary procedure. CONCLUSION: Since DM is a lethal condition if not promptly treated, it must always be considered to represent an emergency situation.

CONTEXTO: Mediastinite é um processo inflamatório do tecido conectivo que envolve as estruturas mediastinais. Quando essa condição é causada por uma infecção em sítio cérvico-oral, a inflamação mediastinal é dita mediastinite descendente (MD). FONTE DE DADOS: O assunto foi examinado através de revisão da literatura disponível e à luz da experiência dos autores. Os bancos de dados Medline, Lilacs e Cochrane foram pesquisados, sem limite de tempo, através do termo "descending mediastinitis". As línguas utilizadas foram inglês e espanhol. SíNTESE DOS DADOS: Existem três vias fasciais principais pelas quais um foco infecioso em região cérvico-oral pode se espalhar para o mediastino: pré-traqueal, latero-faríngeo e retrofaríngeo. Cerca de 70 por cento dos casos de MD ocorrem através da via retrofaríngea. O índice de mortalidade situa-se ao redor de 50 por cento. De acordo com a extensão da infecção e baseado nos achados de tomografia computadorizada (TC), MD pode ser classificada como focal (tipo I) e difusa (tipo II). As manifestações clínicas são inespecíficas e semelhantes às de outras infecções sistêmicas. O tratamento primário da MD consiste em antibióticos e drenagem cirúrgica. Existem diversas formas de abordagem no tratamento cirúrgico da MD; a escolha de qual via será utilizada depende do tipo de MD e da experiência do cirurgião. Apesar de todo o avanço no conhecimento da microbiologia e fisiopatologia da doença, ainda há controvérsias quanto à duração ideal da antibioticoterapia e à necessidade de se realizar traqueostomia nos pacientes portadores de MD. CONCLUSÃO: Como a MD é uma condição rapidamente fatal se não diagnosticada e tratada a tempo, ela deve ser sempre considerada uma emergência médica.

Mediastinite esclerosante no diagnóstico diferencial de tumores mediastinais / Sclerosing mediastinitis in the differential diagnosis of mediastinal tumors

A mediastinite esclerosante é uma doença rara, caracterizada por tecido fibrótico mediastinal extenso, que mimetiza uma neoplasia devido à compressão ou invasão das estruturas mediastinais. Apresentamos três casos de síndrome de veia cava superior em que se comprovou a mediastinite esclerosante. A fisiopatologia relaciona-se a adenomegalias mediastinais, proliferação de fibroblastos e deposição de colágeno. As principais causas são histoplasmose e tuberculose, doenças prevalentes em nosso meio. O diagnóstico histopatológico geralmente é difícil por métodos pouco invasivos. Necessita-se de exploração cirúrgica para o diagnóstico definitivo e resolução da obstrução das vias aerodigestiva e vascular, uma vez que não há tratamento clínico efetivo para esta afecção.

Mediastinitis aguda / Acute mediastinitis

Antecedentes. La mediastinitis aguda es una de lasenfermedades torácicas más agresivas. La mortalidad publicada va del 14 al 42/100. Objetivo. Analizar una serie consecutiva de 52 pacientes. Diseño. Estudio descriptivo retrospectivo de una cohorte. Material y Métodos. Entre enero de 1984-agosto de 2005, se estudiaron 52 pacientes con mediastinitis agudas tratadosquirúrgicamente en el Servicio de Cirugía General número 1 Hospital Universitario Miguel Pérez Carreño en Caracas Venezuela, sin criterios de exclusión, 40 varones y 12 mujeres. Resultados. La mediastinitis aguda fue de origen esofágico en 34 pacientes (16 posquirúrgicas, 10 por ruptura iatrogénica, 6 por rotura no iatrogénica y dos por cuerpo extraño), de origen bucofaríngeo en 12 pacientes y secundarias a esternotomía media en 6. Se trataron quirúrgicamente 52 pacientes; además deldesbridamiento radical se colocaron drenajes, en 31 se practicó la esofaguectomía con plastia gástrica; en 16 suturas primarias de esófago; en tres plastias con el pectoral mayor, y en otro dos esternectomía más omentoplastia. Dos pacientes fallecieron en los 30 días después de la intervención. La mortalidad en nuestromedio resultó más baja que la descrita en la bibliografía.Conclusiones. Los resultados justifican el tratamientoagresivo y temprano en la mediastinitis aguda.

Mediastinitis necrotizante descendente: comunicación de dos casos y revisión de la literatura / Descending necrotizing mediastinitis: two case reports and a review of the literature

La mediastinitis necrotizante descendente es un cuadro grave, infrecuente y que tiene causas muy diversas. El pronóstico global de la enfermedad no ha mejorado, a pesar de los avances en cuanto a antibioterapia, tratamiento intensivo y técnicas diagnósticas. El tratamiento debe ser multidisciplinario con énfasis en el aspecto nutricional, manejo intensivo y tratamiento quirúrgico agresivo. Este último aspecto permanece hasta ahora controversial, aunque la mayoría de los autores prefiere el manejo agresivo con aseos quirúrgicos repetidos a través de cervicotomía y toracotomía.

Perfurações traumáticas do esôfago / Traumatic esophageal perforation

As perfurações esofágicas ainda representam um desafio quanto ao diagnóstico e tratamento. Objetivo - Descrever a experiência do serviço no tratamento das perfurações de esôfago...

Perforation of the esophagus remains a diagnostic and therapeutic challenger. Aim - To review our experience in the management of esophageal perforation...

Sclerosing mediastinitis: a case report.

A rare case of sclerosing mediastinitis in a 38 year old male is described. This interesting case illustrates how a seemingly benign fibrosing condition may lead to disastrous and fatal complications.