39 - Mediastinitis

Summary

The mediastinum is defined as the space in the thorax between the lungs; it houses the heart, great vessels, esophagus, trachea, thymus, and lymph nodes. The connective tissues of the mediastinum are continuous with the long fascial planes of the head and neck, one reason why until the advent of thoracic surgery, mediastinitis was primarily a complication of odontogenic infections. By virtue of its deep position within the thorax, the mediastinum is a relatively protected organ space. There are four major portals of entry into the mediastinum: (1) direct inoculation of the mediastinum following sternotomy (ie, postoperative mediastinitis (POM)); (2) spread along the long fascial planes of the neck (ie, descending mediastinitis); (3) rupture of mediastinal structures, such as the esophagus; and (4) contiguous spread of infection from adjacent thoracic structures.

POSTOPERATIVE MEDIASTINITIS

Postoperative mediastinitis (POM) is classified as an organ space infection by Centers for Disease Control and Prevention (CDC) criteria and is a dreaded complication of median sternotomy. POM classically presents as a febrile illness with sternal wound dehiscence and purulent drainage, usually 2 to 4 weeks after sternotomy. Occasionally POM presents as a more chronic, indolent infection months to years after sternotomy. Sometimes, only superficial signs of infection are present, making POM difficult to diagnose. Frequently, a high index of clinical suspicion is required to differentiate POM from a more superficial sternal wound infection.