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The mediastinitis is swelling and irritation of the chest area between the lungs. This area contains the heart, large blood vessels, trachea, esophagus, thymus gland, lymph nodes, and connective tissues.
When a professional faces acute mediastinitis, all treatment efforts must be tailored to the primary pathology and associated clinical manifestations. Although surgery is often performed in acute cases of the disease, when it comes to chronic cases, the utility of surgical treatment is merely palliative.
In general, a specialized multidisciplinary approach is warranted, considering both the general condition of the patient and the dynamics and specific characteristics of the disease, which led to mediastinitis in the first place.
Therefore, early diagnosis, definitive initial therapy, and scheduled CT follow-up are needed, after initial treatment, to assess the need for reoperation.
General principles of mediastinitis treatment
Although the treatment of mediastinitis is guided by the etiology of the underlying disease, certain elements of care are common to all patients. As a fairly serious infection, mediastinitis often progresses to septic shock.
In patients with descending necrotizing mediastinitis, there is a strong correlation between time of admission to intensive care units and overall mortality. Therefore, a compromised airway should be expected early in the course of treatment, especially in cases known to affect the neck and upper mediastinum.
Because local inflammation and lockjaw, frontal airway access and laryngoscopic visualization may be compromised.
In this regard, expert guidelines stipulate that the anesthesiologist must manage the airways, with a well-delineated alternative plan.
However, the participation of both the maxillofacial surgeon and the otolaryngologist is supported during the intubation planning process, but also their presence at the time of intubation to mitigate potential difficulties.
Antimicrobial treatment
When considering antimicrobial treatment of mediastinis, one should be guided under the same principles similar to empirical antimicrobial therapy in patients admitted to the intensive care unit.
However, they must collect microbiological samples before starting antibiotics. Since specific data on the efficacy of antibiotics in mediastinitis are scarce, current recommendations are still largely based on expert opinion.
In mediastinitis caused by deep infection of the sternal wound, empirical antimicrobial therapy should cover methicillin-sensitive Staphylococcus aureus, Gram negative bacteria of gastrointestinal origin and commensal skin bacteria. Broad-spectrum beta-lactam penicillin is usually prescribed.
Patients with esophageal perforation mediastinitis usually receive intravenous broad spectrum antimicrobial agents covering both aerobic and anaerobic bacterial species that reside in the upper gastrointestinal tract. The drugs of choice include third-generation cephalosporins.
Finally, in mediastinitis arising from descending necrotizing mediastinitis, empirical treatment should cover aerobic and anaerobic bacteria associated with ear, nose, and throat infections. In addition, a similar scheme to the aforementioned approach to esophageal perforation is recommended, generally with the addition of clindamycin.
Surgical approaches
The control of the infectious source and tissue debridement are two fundamental steps in the surgical treatment of mediastinitis. The strategy is decided depending on the underlying cause and extent of the disease. This is generally established with the use of imaging techniques, more specifically cross-sectional imaging studies.
When mediastinitis is located in the upper part of the mediastinum, it is usually sufficient perform transcervical drainage. On the other hand, cases of disease that extend below the tracheal carina usually require cervical / transthoracic drainage.
It should be emphasized that a delay between diagnosis of the condition and surgery is associated with poorer outcomes and, therefore, that period should not exceed 24 hours.
