Mediastinitis in Emergency Medicine Workup

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

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.
Next

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.
    • Mediastinitis due to esophageal perforation is shown in the radiograph below. CT of the same patient follows.Chest radiograph of a patient presenting with mediChest 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 mediasChest CT of same patient showing gas-filled mediastinal abscess and widened esophagus. Image courtesy of Mark Silverberg, MD, FACEP, and Rafi Israeli, MD.
  • 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.
  • Chest CT: Scaglione et al concluded that use of CT as a first imaging study can provide accurate information regarding both the presence and extent of descending necrotizing mediastinitis, thus helping guide the mode of surgical approach for drainage. Chest CT can also be used to follow progress after treatment.[2]
  • Neck CT
    • Neck CT 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, though continues to be reserved more for children to limit radiation and those with impaired kidney function.[1]
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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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