Acute mediastinitis: spectrum of computed tomography findings

[Lesions of the paravertebral mediastinum]

BACKGROUND

Lesions of the paravertebral mediastinum are rare, and knowledge of possible differential diagnoses is essential for clinical practice.

OBJECTIVE/METHODS

To review common lesions of the paravertebral mediastinum.

RESULTS

The paravertebral mediastinum mainly includes fatty tissue and neurogenic structures. Imaging is commonly performed using computed tomography (CT) and magnetic resonance imaging (MRI). Neurogenic tumors are the most common lesions of the paravertebral mediastinum. Other pathologies include extramedullary hematopoiesis, lipomatous, lymphogenic, inflammatory, and cystic lesions. Moreover, also diaphragmatic hernias, vascular and esophageal pathologies may be found in the paravertebral mediastinum.

Post-intubation iatrogenic tracheobronchial injuries: The state of art

Iatrogenic tracheobronchial injury (ITI) is an infrequent but potentially life-threatening disease, with significant morbidity and mortality rates. Its incidence is presumably underestimated since several cases are underrecognized and underreported. Causes of ITI include endotracheal intubation (EI) or percutaneous tracheostomy (PT). Most frequent clinical manifestations are subcutaneous emphysema, pneumomediastinum and unilateral or bilateral pneumothorax, even if occasionally ITI can occur without significant symptoms. Diagnosis mainly relies on clinical suspicion and CT scan, although flexible bronchoscopy remains the gold standard, allowing to identify location and size of the injury. EI and PT related ITIs more commonly consist of longitudinal tear involving the pars membranacea. Based on the depth of tracheal wall injury, Cardillo and colleagues proposed a morphologic classification of ITIs, attempting to standardize their management. Nevertheless, in literature there are no unambiguous guidelines on the best therapeutic modality: management and its timing remain controversial. Historically, surgical repair was considered the gold standard, mainly in high-grade lesions (IIIa-IIIb), carrying high morbi-mortality rates, but currently the development of promising endoscopic techniques through rigid bronchoscopy and stenting could allow for bridge treatment, delaying surgical approach after improving general conditions of the patient, or even for definitive repair, ensuring lower morbi-mortality rates especially in high-risk surgical candidates. Our perspective review will cover all the above issues, aiming at providing an updated and clear diagnostic-therapeutic pathway protocol, which could be applied in case of unexpected ITI.

Cervico-thoracic cellulitis at the Yalgado Ouedraogo University Hospital: About 50 cases

INTRODUCTION

Cervicofacial cellulitis is mainly due to neglected oral/pharyngeal diseases. Untreated or incorrectly treated, they can be complicated by thoraco-cervical necrosis, which has a gloomy prognosis and is difficult to manage, especially in an under-medicalized environment. The aim of this work was to report the difficulties of management in precarious context by underlining the interest of primary prevention.

PATIENTS AND METHOD

This was a descriptive cross-sectional retrospective study from January 2018 to March.

RESULTS

Fifty cases of thoracic-cervical necrosis were collected during this period. The man/woman sex ratio was 3.55. Dental etiology was found in 96% of cases. The main complications were: pneumopathy (n = 10), mediastinitis (n = 10), pleurisy (n = 3) and polyseritis (n = 2). The management combined medical and surgical treatment under local or general anesthesia. The mortality rate was 12.8%. The functional results were satisfactory in surviving cases.

CONCLUSION

The management of thoracic-cervical necrosis remains a challenge in precarious conditions. Primary must play a major role in these conditions.

Gram-negative bacteria as a cause of mediastinitis after cardiac surgery

PURPOSE OF REVIEW

Poststernotomy mediastinitis (PSM) remains a serious infection and is significantly associated with high morbidity, short-term and long-term mortality. Gram-negative bacteria (GNB) are an underestimated cause of PSM, and there is little information on the risk factors, prevention, diagnosis and management of GNB PSM.

RECENT FINDINGS

The pathogenesis of PSM is the result of a complex and multifactorial interplay between intraoperative wound contamination, host-related and surgical host factors but GNB are probably mostly translocated from other host site infections. GNB are frequent cause of PSM (18-38% of cases) and GNB PSM have shown to more frequently polymicrobial (20-44%). GNG PSM has shown to occur earlier than Gram-positive PSM. Early diagnosis is crucial to successful treatment. The management of PSM needs a combination of culture-directed antimicrobial therapy and an early extensive surgical debridement with either immediate or delayed closure of the sternal space. Antibiotic treatment choice and duration should be based on clinical evaluation, evolution of inflammatory markers, microbiological tests and imaging studies. Mortality has shown to be significantly higher with GNB PSM compared with other causes and the inappropriateness of initial antibiotic therapy may explain the worse outcome of GNB PSM.

SUMMARY

GNB PSM is usually undervalued in the setting of PSM and have shown to be a frequent cause of inappropriate treatment with adverse prognostic potential. There is a need for efforts to improve knowledge to prevent and adequately treat GNB PSM.

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES)

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain

Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings, and is often of musculoskeletal origin in the former. Chest wall syndrome collectively describes the various entities that can contribute to chest wall pain of musculoskeletal origin and may affect any chest wall structure. Various imaging modalities may be employed for the diagnosis of nontraumatic chest wall conditions, each with variable utility depending on the clinical scenario. We review the evidence for or against use of various imaging modalities for the diagnosis of nontraumatic chest wall pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Complications of Lung Transplantation: Update on Imaging Manifestations and Management

As lung transplantation has become the most effective definitive treatment option for end-stage chronic respiratory diseases, yearly rates of this surgery have been steadily increasing. Despite improvement in surgical techniques and medical management of transplant recipients, complications from lung transplantation are a major cause of morbidity and mortality. Some of these complications can be classified on the basis of the time they typically occur after lung transplantation, while others may occur at any time. Imaging studies, in conjunction with clinical and laboratory evaluation, are key components in diagnosing and monitoring these conditions. Therefore, radiologists play a critical role in recognizing and communicating findings suggestive of lung transplantation complications. A description of imaging features of the most common lung transplantation complications, including surgical, medical, immunologic, and infectious complications, as well as an update on their management, will be reviewed here. Keywords: Pulmonary, Thorax, Surgery, Transplantation Supplemental material is available for this article. © RSNA, 2021.

Imaging of Cardiac Infections: A Comprehensive Review and Investigation Flowchart for Diagnostic Workup

Infections of the cardiovascular system may present with nonspecific symptoms, and it is common for patients to undergo multiple investigations to arrive at the diagnosis. Echocardiography is central to the diagnosis of endocarditis and pericarditis. However, cardiac computed tomography (CT) and magnetic resonance imaging also play an additive role in these diagnoses; in fact, magnetic resonance imaging is central to the diagnosis of myocarditis. Functional imaging (fluorine-18 fluorodeoxyglucose-positron emission tomography/CT and radiolabeled white blood cell single-photon emission computed tomography/CT) is useful in the diagnosis in prosthesis-related and disseminated infection. This pictorial review will detail the most commonly encountered cardiovascular bacterial and viral infections, including coronavirus disease-2019, in clinical practice and provide an evidence basis for the selection of each imaging modality in the investigation of native tissues and common prostheses.

A rare cause of cervicomediastinal cellulitis: Oesophageal perforation case report

Esophageal perforation following an impacted foreign body (FB) is a rare and potentially life-threatening condition. Early clinical suspicion and imaging are important for a targeted management to achieve a good outcome. Endoscopic extraction of esophageal FB is a good and safe treatment alternative while the surgical procedure remains a necessary option for many patients. We present the case of a 50 years old woman, with no relevant medical history, who accidently ingested a chicken bone during a meal causing mild dysphagia. The patient consulted immediately but was reassured after normal clinical examination. We received the patient 9 days later with severe dysphagia and cervicomediastinal cellulitis. The cervical CT scan showed the significant collection and the FB impacted in the cervical esophagus wall. A first endoscopic exploration drained the pus and allowed the placement of a nasogastric tube. However, the removal of the FB required an open cervical surgery with the evacuation of the collection and the suture of the esophageal perforation followed by the placement of a drainage tube. The patient medical state improved rapidly and no further incidents were noted. The diagnosis of esophageal FB should be meticulous in order to avoid such life-threatening complications.

Imaging features and differential diagnoses of non-neoplastic diffuse mediastinal diseases

Acute or chronic non-neoplastic diffuse mediastinal diseases have multiple causes, degrees of severity, and a wide range of management. Some situations require emergency care while others do not need specific treatment. Although the diagnosis may be suspected on chest X-ray, it is mainly based on CT. A delayed recognition is not uncommonly observed. Some findings may prompt the radiologist to look for specific associated injuries or lesions.

This pictorial review will successively describe the various non-neoplastic causes of diffuse mediastinal diseases with their typical findings and major differentials.

First, pneumomediastinum that can be provoked by extra- or intra-thoracic triggers requires the knowledge of patient’s history or recent occurrences. Absence of any usual etiological factor should raise suspicion of cocaine inhalation in young individuals.

Next, acute mediastinitis may be related to post-operative complications, esophageal perforation, or contiguous spread of odontogenic or retropharyngeal infections. The former diagnosis is not an easy task in the early stage, owing to the similarities of imaging findings with those of normal post-operative appearance during the first 2–3 weeks.

Finally, fibrosing mediastinitis that is linked to an excessive fibrotic reaction in the mediastinum with variable compromise of mediastinal structures, in particular vascular and airway ones. Differential diagnosis includes tumoral and inflammatory infiltrations of the mediastinum.

Imaging evaluation using computed tomography after ascending aortic graft repair

Prosthetic aortic graft repair is employed in the management of various conditions such as annuloaortic ectasia, ascending aortic aneurysm, type A aortic dissection, and aortic root abscess. Correct interpretation of post-surgical prosthetic graft complications requires familiarity with the expected normal cross-sectional imaging appearance as well knowledge of additional surgical materials used in the repair, which could influence the imaging appearance. Multiple life-threatening complications of a prosthetic ascending aortic graft can be seen in the aorta and vicinity of the operative field. Complications can arise from involvement of the prosthetic aortic graft per se or secondary involvement of the coronary arteries, mediastinum, and sternotomy site. The optimal imaging protocol using multidetector computed tomography allows accurate interpretation of the expected benign postoperative changes as well as complications associated with the prosthetic graft, and differentiation of true complications from their mimickers. This review focuses on the normal imaging appearance of a prosthetic aortic graft on multidetector computed tomography, and imaging evaluation of multiple post-surgical complications that could arise after repair of the ascending aorta and the aortic valve.

Assessment of Prognosis in Odontogenic Descending Necrotizing Mediastinitis: A Longitudinal Retrospective Study

Background: Descending necrotizing mediastinitis [DNM] is a serious complication of odontogenic infections, being associated with a high mortality rate. The diagnosis, classification, and management depend on computed tomography [CT] findings. Incision, drainage, and debridement represent the principal management. This study aimed to assess the prognosis in odontogenic DNM. Methods: The DNM type I was managed by transcervical mediastinal drainage, while in DNM type II, a right or left posterolateral thoracotomy was used. Data were compared among survivors and deceased to detect the risk factors affecting the prognosis. Results: This study included 63 patients. Transcervical mediastinal drainage was performed in 57 patients with Endo Type I while drainage through a right posterolateral thoracotomy was performed in the other five patients with Endo Type I and one patient with Endo Type IIA. Of patients in the study, 82.5% survived while 17.5% died because of multiple organ failure. Multiple complications and severe sepsis or septic shock as risk factors were statistically significant. Conclusion: A CT scan is the modality of choice for diagnosis and classification of DNM. Incision and drainage of the maxillofacial infection with mediastinal drainage and debridement represent the main management. Multiple complications and severe sepsis or septic shock were associated with poor prognosis.

Pharyngeal Emergencies

Pharyngeal emergencies, which can be subdivided into traumatic versus nontraumatic, are a common cause of Emergency Department visits. Patients often present to Emergency Department with a wide variety of pharyngeal symptoms, for which computed tomography imaging has become the first line imaging modality. Familiarity with these conditions enables a radiologist to make a prompt diagnosis, assess the extent of disease, and evaluate for potential complications. In this chapter, we present a brief overview of nontraumatic pharyngeal emergencies based on anatomic subdivisions (nasopharynx, oropharynx, and hypopharynx), discuss their etiologies, clinical presentations, computed tomography imaging findings, and management options. We will also discuss differential diagnoses based on imaging findings.

Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review

BACKGROUND

Patients with esophageal foreign bodies or food bolus impaction may present to the emergency department with symptoms ranging from mild discomfort to severe distress. There is a dearth of emergency medicine-focused literature concerning these conditions.

OBJECTIVE OF THE REVIEW

This narrative review provides evidence-based recommendations for the assessment and management of patients with esophageal foreign bodies and food bolus impactions.

DISCUSSION

Esophageal foreign bodies and food bolus impaction are common but typically pass spontaneously; however, complete obstruction can lead to inability to tolerate secretions, airway compromise, and death. Pediatric patients are the most common population affected, while in adults, edentulous patients are at greatest risk. Foreign body obstruction and food bolus impaction typically occur at sites of narrowing due to underlying esophageal pathology. Diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia. The preferred test is a plain chest radiograph, although this is not required if the clinician suspects non-bony food bolus with no suspicion of perforation. Computed tomography is recommended if radiograph is limited or there are concerns for perforation. Management requires initial assessment of the patient's airway. Medications evaluated include effervescent agents, glucagon, calcium channel blockers, benzodiazepines, nitrates, and others, but their efficacy is poor. Before administration, shared decision making with the patient is recommended. Endoscopy is the intervention of choice, and medications should not delay endoscopy. Early endoscopy for complete obstruction is associated with improved outcomes.

CONCLUSIONS

This review provides evidence-based recommendations concerning these conditions, focusing on evaluation and management.

Treatment of Tracheobronchial Injuries: A Contemporary Review

Tracheobronchial injury is a rare but a potentially high-impact event with significant morbidity and mortality. Common etiologies include blunt or penetrating trauma and iatrogenic injury that might occur during surgery, endotracheal intubation, or bronchoscopy. Early recognition of clinical signs and symptoms can help risk-stratify patients and guide management. In recent years, there has been a paradigm shift in the management of tracheal injury towards minimally invasive modalities, such as endobronchial stent placement. Although there are still some definitive indications for surgery, selected patients who meet traditional surgical criteria as well as those patients who were deemed to be poor surgical candidates can now be managed successfully using minimally invasive techniques. This paradigm shift from surgical to nonsurgical management is promising and should be considered prior to making final management decisions.

18F-FDG-Labeled Autologous Leukocyte PET-CT in a Patient With Aortic Valve-Tube Graft Infection After Bentall Procedure

Infection of aortic valve-tube graft, although rare, is associated with high morbidity and mortality. Early identification of site and extent of infection is not only challenging but also crucial for adequate patient management and prognostication of disease. Combined clinical, laboratory investigation and imaging modalities assist in the identification of aortic valve graft infection. Molecular imaging techniques like PET/CT using F-FDG and F-FDG-labeled autologous leukocytes (LALs) have improved the sensitivity for detection of infection, resulting in better outcome for these patients. F-FDG-labeled autologous leukocyte PET/CT in our patient after Bentall procedure accurately localized the site and extent of infection.

Imaging findings of complications after thoracic surgery

Many surgical procedures are used for the treatment of lung, heart, and mediastinal diseases. The techniques can result in postoperative complications. The nature of these complications differs according to the duration of thoracic surgery and the onset of the complication. The complications occurring within 1 month and more than 1 month generally considered as early and late complications, respectively. Chest radiographs and CT scans obtained in patients who have undergone thoracic surgery show normal changes during the surgical procedure and diverse postsurgical complications. Familiarity with the clinical and radiologic findings of the normal alterations and possible complications after thoracic surgery is crucial in minimizing the increased morbidity and mortality.

Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery

OBJECTIVES

To identify CT parameters independently associated with infectious mediastinitis after cardiac surgery and to improve the discrimination of patients with acute infection from those with normal postoperative changes.

METHODS

In this single-center, retrospective, observational cohort study, we evaluated thoracic CT scans of poststernotomy cardiac surgery patients. Inclusion criteria were clinically suspected mediastinitis, unclear CT signs (e.g., retrosternal mass), and subsequent deep revision surgery. Revision surgery and microbiological samples determined the mediastinitis status. Overall, 22 qualitative and quantitative CT imaging parameters were assessed and associated with infectious mediastinitis in univariate and multivariate regression models. Discriminative capacity and incremental value of the CT features to available clinical parameters were determined by AUC and likelihood-ratio tests, respectively.

RESULTS

Overall 105 patients (82% men; 67.0 ± 10.3 years) underwent CT and deep revision surgery. Mediastinitis was confirmed in 83/105 (79%) patients. Among available clinical parameters, only C-reactive protein (CRP) was independently associated with infectious mediastinitis (multivariate odds ratio (OR) (per standard deviation) = 2.3; p < 0.001). In the CT, the presence of free gas, pleural effusions, and brachiocephalic lymph node size were independently associated with mediastinitis (multivariate ORs = 1.3-6.3; p < 0.001-0.039). Addition of these CT parameters to CRP increased the model fit significantly (X² = 17.9; p < 0.001; AUC, 0.83 vs. 0.73).

CONCLUSION

The presence of free gas, pleural effusions, and brachiocephalic lymph node size in CT is independently associated with infectious mediastinitis in poststernotomy patients with retrosternal mass. These imaging features may help to differentiate mediastinitis from normal postoperative changes beyond traditional clinical parameters such as CRP.

KEY POINTS

• Presence of free gas, pleural effusions, and brachiocephalic lymph node size on CT are associated independently with infectious mediastinitis. • Combination of these CT parameters increases the discriminatory capacity of clinical parameters such as CRP.

The "3M" Approach to Cardiovascular Infections: Multimodality, Multitracers, and Multidisciplinary

Cardiovascular infections are associated with high morbidity and mortality. Early diagnosis is crucial for adequate patient management, as early treatment improves the prognosis. The diagnosis cannot be made on the basis of a single symptom, sign, or diagnostic test. Rather, the diagnosis requires a multidisciplinary discussion in addition to the integration of clinical signs, microbiology data, and imaging data. The application of multimodality imaging, including molecular imaging techniques, has improved the sensitivity to detect infections involving heart valves and vessels and implanted cardiovascular devices while also allowing for early detection of septic emboli and metastatic infections before these become clinically apparent. In this review, we describe data supporting the use of a Multimodality, Multitracer, and Multidisciplinary approach (the 3M approach) to cardiovascular infections. In particular, the role of white blood cell SPECT/CT and [¹⁸F]FDG PET/CT in most prevalent and clinically relevant cardiovascular infections will be discussed. In addition, the needs of advanced hybrid equipment, dedicated imaging acquisition protocols, specific expertise for image reading, and interpretation in this field are discussed, emphasizing the need for a specific reference framework within a Cardiovascular Multidisciplinary Team Approach to select the best test or combination of tests for each specific clinical situation.

Endoscopic Management of Benign Esophageal Ruptures and Leaks

OPINION STATEMENT

Esophageal leaks (EL) and ruptures (ER) are rare conditions associated with a high risk of mortality and morbidity. Historically, EL and ER have been surgically treated, but current treatment options also include conservative management and endoscopy. Over the last decades, interventional endoscopy has evolved as an effective and less invasive alternative to primary surgery in these cases. A variety of techniques are currently available to re-establish the continuity of the digestive tract, prevent or treat infection related to the leak/rupture, prevent further contamination, drain potential collections, and provide nutritional support. Endoscopic options include clips, both through the scope (TTS) and over the scope (OTS), stent placement, vacuum therapy, tissue adhesive, and endoscopic suturing techniques. Theoretically, all of these can be used alone or with a multimodality approach. Endoscopic therapy should be combined with medical therapy but also with percutaneous drainage of collections, where present. There is robust evidence suggesting that this change of therapeutic paradigm in the form of endoscopic therapy is associated with improved outcome, better quality of life, and shortened length of hospital stay. Moreover, recent European guidelines on endoscopic management of iatrogenic perforation have strengthened and to some degree regulated and redefined the role of endoscopy in the management of conditions where there is a breach in the continuity of the GI wall. Certainly, due to the complexity of these conditions and the variety of available treatment options, a multidisciplinary approach is strongly recommended, with close clinical monitoring (by endoscopists, surgeons, and intensive care physicians) and special attention to signs of sepsis, which can lead to the need for urgent surgical management. This review article will critically discuss the literature regarding endoscopic modalities for esophageal leak and perforation management and attempt to place them in perspective for the physician.

Difficult Cases of Odontogenic Deep Neck Infections: A Report of Three Patients

BACKGROUND

Deep neck infections are important otolaryngologic emergencies due to serious complications and the risk of airway compromise, which can lead to mortality. Although the most common causes among pediatric patients are tonsillitis and pharyngeal infections, odontogenic infections are an important cause in adults.

CASE REPORT

We present three patients with multiple deep neck space abscess formation due to odontogenic infection. Two of them required tracheotomy due to airway compromise, and one had mediastinitis.

CONCLUSION

An underestimated tooth infection can cause hazardous complications such as mediastinitis and respiratory distress requiring tracheotomy.

Defining post-sternotomy mediastinitis for clinical evidence-based studies

Background

Considerable advances have already been made in the treatment of deep thoracic wound infections following a median sternotomy for cardiac surgery. Further improvement in diagnosis, treatment, and outcome will require a targeted approach by multidisciplinary teams. Clear communication and synergy between the various clinical and supportive disciplines would assist in removing the last barriers to standardized evidence-based studies and the development of improved evidence-based guidelines.

Methods

An extensive literature search without language restrictions was carried out on PubMed (Medline), EMBASE, and Web of Science, covering the period 1988 to week 16, 2014, and a manual search of the reference lists was performed regarding all possible definitions and classifications of post-sternotomy mediastinitis. Two hundred and eighteen papers describing post-sternotomy infections in a multitude of terms were identified, and the strengths and weaknesses of the most popular definitions and terms relating specifically to post-sternotomy infections were examined.

Results

This study revealed that clinicians use a multitude of terms to describe post-sternotomy infections without defining the condition under treatment. Occasionally, older epidemiological (surveillance) definitions were used. It also shows that supportive disciplines have their own definitions, or interpretations of existing definitions, to describe these infections.

Conclusion

The outcome of this study is that clinicians have adopted no single definition, which is essential for further improvement for evidence-based studies. We suggest that it is possible to adopt a single term for thoracic infection after a sternotomy (and only sternotomy), and propose a clinical definition for this purpose.

Esophageal Perforation and Acute Bacterial Mediastinitis: Other Causes of Chest Pain That Can Be Easily Missed

Esophageal perforation is a rare condition that is commonly missed. Male gender and alcohol use are predisposing risk factors. Most of the cases are iatrogenic or traumatic; nonetheless, spontaneous cases are not uncommon. It typically occurs after vomiting or straining as the increased intra-abdominal pressure transmits into the esophagus and results in the tear. One of the main complications is acute bacterial mediastinitis from contamination with esophageal flora. This condition can be life-threatening because it is very frequently misdiagnosed and appropriate management is often delayed.A 49-year-old man presented with worsening sudden-onset interscapular back pain that then changed to chest pain with odynophagia and was found to have fever and leukocytosis.Chest computed tomography revealed signs of mediastinitis with possible esophageal perforation. He reported symptoms started 2 days ago after lifting of heavy objects. Empiric antimicrobial was begun with conservative management and avoidance of oral intake. Barium esophagram and esophagogastroduodenoscopy revealed no signs of perforation or inflammation. His symptoms resolved and he gradually resumed oral intake. Blood cultures grew Methicillin-sensitive Staphylococcus aureus and he was discharged on appropriate antibiotics for 4 weeks. He did well on follow-up 3 months after hospitalization.The case highlights the importance of considering esophageal etiologies of chest pain.

Cervical Necrotizing Fasciitis--The Value of the Laboratory Risk Indicator for Necrotizing Fasciitis Score as an Indicative Parameter

PURPOSE

Cervical necrotizing fasciitis (CNF) is uncommon, difficult to diagnose, and rapidly progressive. The objective of the present study was to determine the predictive value of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for CNF.

MATERIALS AND METHODS

The LRINEC score for 16 consecutive cases of CNF and 595 cases of severe non-necrotizing neck infections was determined over a 6.5-year period in a single-center retrospective cohort study and case report. CNF was confirmed by histologic examination and operative report documentation.

RESULTS

Using a cutoff score of 6, the LRINEC score had a sensitivity of 0.94 (95% confidence interval [CI] 0.92 to 0.96) and specificity of 0.94 (95% CI 0.70 to 1.00). The positive predictive value was 0.29 (95% CI 0.17 to 0.44), and the negative predictive value was 0.99 (95% CI 0.99 to 1.00).

CONCLUSIONS

The LRINEC score can detect early cases of CNF. Patients with a LRINEC score of ≥6 must be carefully evaluated for the presence of CNF.

Pathogenesis and outcomes of traumatic injuries of the esophagus

Traumatic injury of the esophagus is extremely uncommon. The aims of this study were to use the Pennsylvania Trauma Outcome Study (PTOS) database to identify clinical factors predictive of esophageal trauma, and to report the morbidity and mortality of this injury. A cross-sectional review of patients presenting to 20 Level I trauma centers in Pennsylvania from 2004 to 2010 was performed. We compared clinical and demographic variables between patients with and without esophageal trauma both prior to and after arrival in the emergency room (ER). Primary mechanism of injury and clinical outcomes were analyzed. There were 231 694 patients and 327 (0.14%) had esophageal trauma. Patients with esophageal trauma were considerably younger than those without this injury. The risk of esophageal trauma was markedly increased in males (odds ratio [OR] = 2.62 [CI 1.98-3.47]). The risk was also increased in African Americans (OR = 4.61 [CI 3.65-5.82]). Most cases were from penetrating gunshot and stab wounds. Only 34 (10.4%) of esophageal trauma patients underwent an upper endoscopy; diagnosis was usually made by CT, surgery, or autopsy. Esophageal trauma patients were more likely to require surgery (35.8% vs. 12.5%; P < 0.001). Patients with esophageal trauma had a substantially higher mortality than those without the injury (20.5% vs. 1.4%; P < 0.005). In logistic regression modeling, traumatic injury of the esophagus (OR = 3.43 [2.50-4.71]) and male gender (OR = 1.52 [1.46-1.59]) were independently associated with mortality. For those patients with esophageal trauma, there was an association between trauma severity and mortality (OR = 1.10 [1.07-1.12]) but not for undergoing surgery within the first 24 hours of hospitalization (OR = 0.84; 0.39-1.83). Our study on traumatic injury of the esophagus is in concordance with previous studies demonstrating that this injury is rare but carries considerable morbidity (∼46%) and mortality (∼20%). The injury has a higher morbidity and mortality when the thoracic esophagus is involved compared to the cervical esophagus alone. The injury most commonly occurs in younger, Black males suffering gunshot wounds. Efforts to control gun violence in Pennsylvania are of paramount importance.

Volumetric Computed Tomography Angiography in the Evaluation of Mediastinal Fluid Collections following Congenital Cardiac Surgery

We present 3 patients with 4 causes of mediastinal fluid collection after congenital cardiac surgery in this extended case report. Volumetric computed tomography played an essential role in diagnosing causes and extent, relevant to subsequent management. Recent advances in volumetric computed tomography allow fast and accurate imaging of cardiovascular and extravascular structures in children with acceptable radiation dose, providing a powerful imaging tool for the evaluation of complications after congenital cardiac surgery.

Nonvascular, nontraumatic mediastinal emergencies in adults: a comprehensive review of imaging findings

Given their high frequency, mediastinal emergencies are often perceived as being a result of external trauma or vascular conditions. However, there is a group of nonvascular, nontraumatic mediastinal emergencies that are less common in clinical practice, are less recognized, and that represent an important source of morbidity and mortality in patients. Nonvascular, nontraumatic mediastinal emergencies have several causes and result from different pathophysiologic mechanisms including infection, internal trauma, malignancy, and postoperative complications, and some may be idiopathic. Some conditions that lead to nonvascular, nontraumatic mediastinal emergencies include acute mediastinitis; esophageal emergencies such as intramural hematoma of the esophagus, Boerhaave syndrome, and acquired esophagorespiratory fistulas; spontaneous mediastinal hematoma; tension pneumomediastinum; and tension pneumopericardium. Although clinical findings of nonvascular, nontraumatic mediastinal emergencies may be nonspecific, imaging findings are often definitive. Awareness of various nonvascular, nontraumatic mediastinal emergencies and their clinical manifestations and imaging findings is crucial for making an accurate and timely diagnosis to facilitate appropriate patient management.

Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours

Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity.

Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours

Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity.

Acute Mediastinitis Associated with Foreign Body Erosion from the Hypopharynx and Esophagus

Objective. Mediastinitis secondary to hypopharyngeal and esophageal foreign bodies is a rare but lethal complication. So far, no literature on a large scale has been reported. This investigation reviewed cases of mediastinitis associated with foreign body ingestion during the past 40 years.

Study Design. Case series with chart review.

Setting. Second Xiangya Hospital, Central South University.

Subjects and Methods. Of 2981 patients with hypopharyngeal and esophageal foreign body impaction included between 1969 and 2010, 93 had complications of acute mediastinitis. Four patients were dead within 4 hours after admission. The rest of the 89 patients underwent surgical drainage. Thirteen underwent primary repair (7 cases with suture, 6 cases with omentum onlay graft), and 9 patients underwent endoscopic stent placement at the same time.

Results. The mean (SD) time between ingestion and initial treatment of patients who developed mediastinitis was 7.72 (1.93) days, compared with 1.92 (1.41) days for those who did not ( P < .05). Morbidity was 3.1% and mortality was 30.1% (28/93), but the mortality of every decade has decreased from 38.7% in the 1970s to 8.3% today. Nine cases with local stent were all recovered.

Conclusions. Delay in initiating treatment and intrathoracic esophageal foreign bodies are the main risk factors of mediastinitis secondary to foreign body ingestion. Computed tomography plays an important role in diagnosis and guiding treatments. In conjunction with aggressive surgical debridement and drainage, endoscopic stent placement could be the optimal management for most patients.

Successful management of acute necrotizing mediastinitis with trans-cervical drainage

Acute necrotizing mediastinitis (ANM) is a lethal disease which without antibiotic therapy and surgical intervention can lead to about 40% mortality. With the development of imaging technology, spiral computed tomography (CT) scanning and shortening of the time of diagnosis and surgery, the prognosis of these patients is excellently improved. This study describes the clinical presentation, management and outcome of 4 patients (mean age: 35 years) with ANM. All patients were operated on by a trans-cervical approach, and only one patient was operated on by a trans-thoracic one. After surgery, patients were transferred to the intensive care unit and underwent daily washing and debridement with antibiotic treatments. Odontogenic infection (2 cases), pharyngeal perforation and cervical esophageal perforation were the causes of the ANM. Infection of cervical space (perivisceral spaces) and superior Mediastinum were found in all patients, and Infection below the carina was found in two. All patients were discharged with a good, general condition after an average of 24 days. Early diagnosis of ANM with clinical presentation and on-time CT scanning, early drainage and careful post operation care are very important in the management of patients with ANM and can improve the outcome of trans-cervical drainage to an acceptable technique.

Update on necrotizing mediastinitis: causes, approaches to management, and outcomes

Descending necrotizing mediastinitis (DNM) is one of the most feared and fatal forms of mediastinitis, occurring as a complication after odontogenic or cervicofascial infections or after cervical trauma. Delayed recognition, underestimation of the extent of disease, and insufficient therapy promote spread of infection. Primary treatment of DNM includes surgical eradication of the pharyngeal or odontogenic infection focus, and a concomitant major drainage applied to the neck and the mediastinum. However, the mortality rate of DNM remains high, even with the routine use of CT scanning, antibiotics, advancements in anesthesia and intensive care, and immediate surgical drainage. The present state of the optimal management of DNM is discussed controversially, in particular the question of whether thoracotomy should be performed routinely or if minimally invasive procedures (eg, video-assisted thoracoscopy) may be introduced. This review reports on the incidence and course of this disease and discusses management approaches to DNM.

[Mediastinitis]

Mediastinitis is defined as acute or chronic inflammation of the mediastinal structures and generally has a low incidence. The most frequent acute cause is sternotomy following cardiac revascularization surgery with both internal mammary arteries, with an incidence of 0.4% to 5% and a mortality of 16.5% to 47%. The most frequent vector is Staphylococcus aureus. Esophageal perforation, usually iatrogenic, is the second most frequent cause of acute mediastinitis, produced by common oropharyngeal flora, with a mortality rate of 20% to 60%, depending on the time of diagnosis. The third most frequent cause is descending necrotizing mediastinitis, the origin being an odontogenous focus in 60% and beta-hemolytic streptococcus the causative agent in 71.5% of cases. The most accurate diagnostic imaging technique is computed tomography. Treatment is almost always surgical and survival depends on its early performance. The worst postsurgical prognostic factor is septic shock.

[Mortality risk factors in descending necrotizing mediastinitis]

INTRODUCTION

The term descending necrotizing mediastinitis (MND) refers to an infection that begins in the oropharyngeal region and spreads through the fascial planes into the mediastinum. This study aims to estimate the incidence of MND in our centre, the epidemiology and clinical features of the disease and to evaluate prognostic factors influencing mortality.

PATIENTS AND METHODS

We performed a retrospective study on 43 consecutive patients diagnosed at the Hospital Universitari Vall d'Hebron in Barcelona from January 1996 to December 2006. We performed a descriptive study and a bivariate and a multivariate analysis of variables collected.

RESULTS

Overall mortality was 21%, but when we subdivided the study into two periods (1996-2000 and 2001-2006) it shows a significant decrease (40% versus 4.3%). Risk factors identified in the bivariate analysis were: diagnosis period 1996-2000, diabetes mellitus, comorbidity, number of surgeries, left lateral surgery, postoperative morbidity and septic shock. In multivariate analysis, only the presence of septic shock proved to be an independent predictor of mortality.

CONCLUSIONS

MND is a disease of low incidence and should be suspected clinically and confirmed immediately with a computed tomography (CT). Multidisciplinary and early treatment has allowed us to reduce mortality by 40% in the first initial period to 4.3% today.

Optimal treatment of cervical necrotizing fasciitis associated with descending necrotizing mediastinitis

Background

Cervical necrotizing fasciitis (CNF) associated with descending necrotizing mediastinitis (DNM) is a rapidly evolving and life-threatening condition. The aim of this retrospective study was to describe a treatment strategy for CNF with DNM and present a management algorithm for mediastinal extensions of CNF.

Methods

Patients diagnosed and treated for CNF with DNM over 14 years in a tertiary referral centre were included.

Results

Seventeen adult patients were included. The origin of infection was mainly oropharyngeal. The diagnosis of CNF/DNM was based on clinical and computed tomography findings. All patients underwent cervicotomy for CNF. In ten patients, DNM was located above the carina and could be accessed by a cervical approach. In seven patients, DNM was below the carina, and necessitated sternotomy for anteroinferior mediastinal involvement and posterolateral thoracotomy for posteroinferior mediastinal involvement. All patients received broad-spectrum antibiotics. One patient died 3 days after surgery. The median hospital stay was 30 days. There was no recurrence during long-term follow-up.

Conclusion

Prompt diagnosis and early surgical treatment are essential for reducing mortality in CNF/DNM. All patients should undergo extensive cervicotomy. The surgical approach to the mediastinum depends on the supracarinal or infracarinal location of the disease.

Mediastinal teratoma complicated with acute mediastinitis

We report a case of a mediastinal teratoma associated with acute mediastinitis that required an emergency operation. These tumors cause a variety of complications, but reports of acute mediastinitis are rare. A 24-year-old woman was admitted to our hospital for complaints of chest pain and fever and was subsequently diagnosed as having an anterior mediastinal tumor. Follow-up computed tomography showed rapidly progressing acute mediastinitis, which was diagnosed as a perforation of the teratoma. We performed emergency surgical extirpation of the tumor and mediastinal drainage. The histopathologic diagnosis was a mature teratoma that included pancreatic tissue. Although the apparent site of the rupture was not obvious, there was a wide area of acute inflammation in the mediastinal adipose tissue. The patient did well and was discharged from the hospital without major complications.