Mediastinitis in Emergency Medicine Clinical Presentation

  • Author: Ethan S Brandler, MD, MPH; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 14, 2010
 

History

Patients usually have experienced symptoms for a few days before presentation to the ED. Occasionally, patients present with a fulminant course and symptoms that have lasted only a few hours.

  • Common symptoms and signs of patients with mediastinitis include the following:
    • History of an upper respiratory tract infection or a recent dental infection (common), or thoracic surgery/instrumentation
    • Fever, chills
    • Pleuritic, retrosternal chest pain radiating to the neck or interscapular pain
    • Shortness of breath
    • Confusion
    • Sore throat
    • Swelling in the neck
    • Odynophagia
  • History may be significant for recent endoscopy, bronchoscopy, intubation, or surgery.
  • 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.
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Physical

A complete examination of the head and neck, including the oral cavity, is essential. Such an examination may yield findings such as the following:

  • Ill appearance
  • Fever
  • Edema of the neck and face
  • Crepitus of chest or neck
  • Hamman sign (crunching sound upon auscultation of the heart)
  • Stridor
  • Trismus
  • Cranial nerve deficits[3]
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Causes

Causes of mediastinitis may include the following:

  • Primary neck infection
  • Foreign body
  • Pharyngitis
  • Tonsillitis
  • Sinusitis
  • Otitis media
  • Dental infections
  • Sialadenitis
  • 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. The diagnosis may be difficult to make because some patients initially may 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.
    • Mediastinitis may present as a delayed nosocomial infection following coronary artery bypass surgery.
    • Fungal infection, usually caused by Candida species, is observed after cardiothoracic surgery in 0.3% of cases.
    • Iatrogenic mishap following endoscopy or endoscopic ultrasonographic-guided transesophageal biopsy may be a cause.
    • Ingestion of a sharp object and esophageal perforation may be a cause.
    • Mediastinitis has been described as a complication of laparoscopic cholecystectomy.
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Contributor Information and Disclosures
Author

Ethan S Brandler, MD, MPH  Clinical Assistant Professor, Attending Physician, Departments of Emergency Medicine and Internal Medicine, University Hospital of Brooklyn, Kings County Hospital

Ethan S Brandler, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Miller B Pearsall, MD  Resident Physician and Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate School of Medicine, Kings County Hospital Center, University Hospital of Brooklyn

Miller B Pearsall, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric M Kardon, MD, FACEP  Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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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.
Chest CT of same patient showing gas-filled mediastinal abscess and widened esophagus. Image courtesy of Mark Silverberg, MD, FACEP, and Rafi Israeli, MD.
 
 
 
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