eMedicine Specialties > Emergency Medicine > Infectious Diseases

Mediastinitis: Differential Diagnoses & Workup

Author: Ethan S Brandler, MD, MPH, Clinical Assistant Instructor, Staff Physician, Departments of Emergency Medicine and Internal Medicine, University Hospital of Brooklyn, Kings County Hospital
Coauthor(s): Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Apr 2, 2008

Differential Diagnoses

CBRNE - Anthrax Infection
Pharyngitis
Cellulitis
Pneumonia, Empyema and Abscess
Esophageal Perforation, Rupture and Tears
Shock, Septic
Necrotizing Fasciitis
Superior Vena Cava Syndrome

Other Problems to Be Considered

Ludwig angina

Workup

Laboratory Studies

  • The diagnosis of mediastinitis is often a clinical one. No single laboratory investigation can confirm the diagnosis; however, studies that may help in the diagnosis of mediastinitis include the following:
    • WBC count may be significantly elevated.
    • Electrolytes and glucose measurements may reveal anion gap or indication of underlying diabetes.
    • Blood cultures
    • Swab from any site of infection
  • It is important to notify the laboratory of the possible presence of anaerobic organisms and the strong possibility of mixed growth.
    • Many laboratories routinely report only a single predominant organism.
    • Close coordination with the laboratory is vital to optimize the antibiotic regimen.

Imaging Studies

  • Plain-film radiography  
    • Soft tissue radiography of the neck may show widening of the precervical and retropharyngeal soft tissues.
    • Any patient who presents with gas in the soft tissues of the neck and concern for possible mediastinitis probably should undergo further investigation (ie, CT, MRI) to determine if mediastinal spread of the infection has occurred.
    • Plain-film chest radiographs may show widening of the paratracheal soft tissues.
    • The lateral chest radiograph may show an anterior bulge on the posterior wall of the trachea.
    • Pleural effusions and lower lobe consolidation are not unusual findings.
  • Head CT  
    • The head CT scan may demonstrate abnormalities while the chest radiograph still appears normal.
    • Abscess and soft tissue swelling are usually visible.
    • Repeated head CTs are essential to follow the progress of therapy.
  • ChestCT: Chest CT should be rapidly performed in the ED and may help to determine the mode of surgical approach for drainage. ChestCT can also be used to follow the course of treatment in patients who are not surgically drained.
  • NeckCT  
    • NeckCT documents the path of descending infections.
    • It may be used to plan an operative approach for surgical drainage.
  • MRI: Use of MRI to confirm the diagnosis of mediastinitis is becoming more frequent.

More on Mediastinitis

Overview: Mediastinitis
Differential Diagnoses & Workup: Mediastinitis
Treatment & Medication: Mediastinitis
Follow-up: Mediastinitis
Multimedia: Mediastinitis
References
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References

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Further Reading

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Keywords

descending necrotizing mediastinitis, oropharynx, oropharyngeal infection, mediastinum, mediastinitis, infection of the mediastinum, head and neck infection, head infection, neck infection

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Contributor Information and Disclosures

Author

Ethan S Brandler, MD, MPH, Clinical Assistant Instructor, Staff Physician, Departments of Emergency Medicine and Internal Medicine, University Hospital of Brooklyn, Kings County Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Eric Kardon, MD, FACEP, Associate Staff, Division of Emergency Medicine, Athens Regional Medical Center
Eric Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jeter (Jay) Pritchard Taylor III, MD, Compliance Officer, Attending Physician Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, University of South Carolina
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.

CME Editor

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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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