Retropharyngeal Abscess Complicated by Mediastinitis in Infants.

INTRODUCTION: Most paediatric upper respiratory infections are virally mediated and result in self-limiting reactive lymphadenopathy. In children younger than 5 years, retropharyngeal lymph nodes may give rise to deep neck space infections in this potential space. Retropharyngeal infections are rare after 5 years because lymph nodes undergo atrophy. METHODS: We present a series of 6 cases of paediatric retropharyngeal abscesses (RPA) complicated by mediastinitis, managed at a tertiary hospital over a 4-year period. RESULTS: All our cases presented with fever, difficulty feeding, and neck swelling. The age range was 11 weeks-11 months, and all tested negative for human immunodeficiency virus. The diagnosis and complications were confirmed on computed tomography (CT) scan. The CT scans consistently revealed RPA with varying degrees of deep neck space and mediastinal extension. All children were promptly taken to theatre for source control. Two were extubated successfully immediately after surgery, and the other 4 were extubated in the paediatric intensive care unit, with the longest duration of intubation being 3 days. Methicillin-sensitive Staphylococcus aureus (MSSA) was cultured in all 6 cases. CONCLUSION: Management of these cases may be challenging, and young children with RPA require close care and airway monitoring. CT or magnetic resonance imaging is essential to delineate the extent of infection. Surgical drainage should be performed when there is a large abscess, a complication occurs, or an inadequate response in 24-48 h to medical management.

[Postoperative sternomediastinitis: morphology of lesion, treatment strategy]. / Posleoperatsionnyi sternomediastinit: morfologiya porazheniya, taktika lecheniya.

OBJECTIVE: To analyze bone tissue damage at different stages of disease (El Oakley classification), treatment options for each clinical situation and results after each approach. MATERIAL AND METHODS: There were 45 patients with wound complications after cardiac surgery between October 2022 and September 2023. Thirty-eight (84.4%) patients underwent CABG, 7 (15.6%) patients - heart valve or aortic surgery. Mean age of patients was 68.1±10.3 years. There were 35 men (77.8%) and 10 women (22.2%). The first type was found in 11 (24.5%) patients, type 2-3 - 19 (42.2%), type 4 - 4 (8.8%), type 5 - 11 (24.5%) patients. RESULTS: Systemic inflammatory response syndrome was observed in 7 (36.8%) persons of the 1st group, 14 (73.7%) ones of the 2nd group, 4 (100%) patients of the 3rd group and 2 (18.2%) patients of the 4th group. C-reactive protein and procalcitonin increased in all patients with the highest values in groups 2 and 3. Redo soft tissue inflammation occurred in all groups after treatment. Mean incidence was 25%. Two (10.5%) patients died in the 2nd group and 1 (25%) patient in the 3rd group. CONCLUSION: The modern classification of sternomediastinitis does not fully characterize severity of disease in a particular patient. Simultaneous debridement with wound closure demonstrates acceptable mortality (within 10%). The highest mortality rate was observed in patients with diffuse lesions of the sternum. Less aggressive treatment approaches are possible for stable anterior chest wall.

The utility of negative pressure wound therapy in the management of complex deep cardiothoracic surgical site infections.

BACKGROUND: Complex deep surgical site infection in the cardiothoracic surgery patient that reaches the sternum and even the mediastinum, causing osteomyelitis and mediastinitis, is associated with high rates of morbidity and mortality. Negative pressure wound therapy (NPWT) can aid in achieving favorable outcomes in patients with complex surgical site infections by promoting wound healing and shortening the hospital stay. NPWT is widely recognized for its advantages and has recently been used in both cardiothoracic and non-cardiothoracic settings. OBJECTIVE: To evaluate the efficacy of NPWT in the management of complex deep surgical site infection after cardiothoracic surgery. MATERIALS AND METHODS: A retrospective chart review of all complex cardiothoracic cases admitted to the cardiac and thoracic surgery divisions for surgical intervention to treat postoperative surgical wound infections. RESULTS: A total of 18 patients were included, with a male-to-female ratio of 5:4. The mean (SD) age was 48.7 (16.5) years. The cases reviewed were complex, and the duration of the NPWT application ranged from 4 days to 120 days, with an average hospital stay of 62.8 days. Seventy-eight percent of patients required antibiotics (or had positive wound cultures); in 55.6% of these patients, polymicrobial infection was detected. No major complications were related to NPWT. CONCLUSION: The study findings show that using NPWT in complex deep sternal and thoracic infections can enhance wound healing, shorten the hospital stay, and decrease morbidity and mortality secondary to wound infection in cardiothoracic patients.

Venous retrograde approach for endovascular angioplasty in chronic total pulmonary vein occlusion -a case report.

INTRODUCTION: Fibrosing mediastinitis (FM) is a rare disease characterized by excessive proliferation of fibrous tissue in the mediastinum and can cause bronchial stenosis, superior vena cava obstruction, pulmonary artery and vein stenosis, etc. CASE PRESENTATION: An aging patient with intermittent chest tightness and shortness of breath was diagnosed with FM associated pulmonary hypertension (FM-PH) by echocardiography and enhanced CT of the chest, and CT pulmonary artery (PA)/ pulmonary vein (PV) imaging revealed PA and PV stenosis. Selective angiography revealed complete occlusion of the right upper PV, and we performed endovascular intervention of the total occluded PV. After failure of the antegrade approach, the angiogram revealed well-developed collaterals of the occluded RSPV-V2b, so we chose to proceed via the retrograde approach. We successfully opened the occluded right upper PV and implanted a stent. CONCLUSIONS: This report may provide new management ideas for the interventional treatment of PV occlusion.

Descending necrotising mediastinitis: a rare entity in children.

We present a case of descending necrotising mediastinitis (DNM) originating from a retropharyngeal abscess in a healthy early childhood patient. The patient had a history of fever, odynophagia and refusal to eat, followed by rapid deterioration of the clinical state. Cervicothoracic CT was performed, which revealed a right parapharyngeal abscess, extending to the mediastinum and occupying the retropharyngeal/visceral space, with gaseous content throughout this collection, associated with bilateral pleural effusion, aspects compatible with DNM. She started broad-spectrum antibiotic therapy and transoral drainage of the parapharyngeal and retropharyngeal collections was performed under general anaesthesia. She was admitted to the intensive care unit. The patient showed clinical, analytical and imaging improvement, having been transferred to the ear, nose and throat department, with favourable evolution. Early diagnosis of DNM by cervicothoracic CT and multidisciplinary approaches, including intensive care, broad-spectrum antibiotics and surgical intervention, are crucial to minimise the morbidity and mortality.

The usefulness of chest drain and epicardial pacing wire culture for diagnosing mediastinitis after open-heart surgery.

PURPOSE: Culture of extracted drains or epicardial pacing wires is an easy and noninvasive method for detecting mediastinitis after open-heart surgery, although studies on its sensitivity and specificity are limited. We, therefore, investigated the usefulness of this approach for diagnosing mediastinitis. METHODS: We retrospectively studied the culture results of drains and epicardial pacing wires extracted from 3308 patients. Prediction models of mediastinitis with and without culture results added to clinical risk factors identified by a logistic regression analysis were compared. RESULTS: The incidence of mediastinitis requiring surgery was 1.89% (n = 64). Staphylococcus was the causative bacterium in 64.0% of cases. The sensitivity, specificity, and positive and negative predictive values of positive culture results were 50.8%, 91.8%, 10.7%, and 99.0%, respectively. Methicillin-resistant Staphylococcus aureus had the highest positive predictive value (61.5%). A multivariate analysis identified preoperative hemodialysis (OR 5.40 [2.54-11.5], p < 0.01), long operative duration (p < 0.01), postoperative hemodialysis (OR 2.25 [1.01-4.98], p < 0.05), and positive culture result (OR 10.2 [5.88-17.7], p < 0.01) as independent risk factors. The addition of culture results to pre- and postoperative hemodialysis and a lengthy operative time improved the prediction of mediastinitis. CONCLUSIONS: A culture survey using extracted drains and epicardial pacing wires may provide useful information for diagnosing mediastinitis.

Mimicking descending necrotizing mediastinitis as acute myocardial infarction in a patient with severe coronary artery disease: A case report.

RATIONALE: It is a crucial disease that descending necrotizing mediastinitis need to be treated promptly with proper antibiotics and drainage. The characteristics of its symptoms such as chest pain are difficult to distinguish from acute myocardial infarction. PATIENT CONCERNS: An 80-year-old female presented with severe squeezing chest pain. The cardiac marker was elevated. And coronary angiography showed the significant coronary stenosis. Although the revascularization through percutaneous coronary intervention was completed successfully, the patient still presented chest pain. Computed tomography of neck revealed that hypodense heterogeneous lesions with clear and distinguishable margin extended from the deep neck to mediastinum diffusely. DIAGNOSES: The patient was diagnosed with descending necrotizing mediastinitis. INTERVENTIONS: Percutaneous catheter insertion to patient's abscess lesion at was performed. OUTCOMES: Catheter drainage of descending necrotizing mediastinitis led to an improvement in the patient's condition. LESSON: Descending necrotizing mediastinitis made chest paint with elevated cardiac enzyme mimicked myocardial infarction.

Staphylococcus aureus bacteremia with a mediastinal abscess in a 9-month-old infant: a case report and literature review.

Non-traumatic mediastinal abscesses are very rare in children; we can classify them into 2 types: descending mediastinitis (or mediastinitis by extension or by contiguity) complicating an otorhinolaryngological or esophageal etiology and mediastinitis generated by direct blood inoculation in a context of a septicemia or primary mediastinitis which is exceptional. We describe a case of right pleuropulmonary staphylococcal disease with bilateral mediastinal localization in a previously healthy 9-month-old infant. It was revealed by sepsis with severe respiratory distress. The germ was isolated from the pleural puncture fluid. A thoracic computed tomography was indicated due to a widening mediastinum noted on chest X-ray in addition to pleuropulmonary involvement. Thoracic computed tomography revealed a huge bilateral mediastinal abscess which was curbed thanks to right pleural drainage with adapted antibiotic therapy. Other investigations did not show any immune abnormalities in this infant. Mediastinitis represents a diagnostic and therapeutic emergency; those that are secondary to direct blood or lymphatic dissemination even very rare; should be considered in any context of severe sepsis including staphylococcus or streptococcus pneumonia. Since 1985 only 11 cases of such mediastinal abscesses have been reported.

Descending necrotizing mediastinitis caused by Streptococcus constellatus: A case report and review of the literature.

RATIONALE: Descending necrotizing mediastinitis (DNM) is a rare but severe mediastinal infection. If not diagnosed and treated promptly, the consequences can be very serious. Here, we shared a successful diagnosis and treatment case of DNM that originates from oral to neck and mediastinum caused by Streptococcus constellatus (S constellatus). S constellatus is a clinically uncommon gram-positive coccus and is known for its ability to form abscesses. Timely surgical drainage and the correct use of antibiotics are key to successful treatment. PATIENT CONCERNS: A 53-year-old male admitted to hospital with painful swelling of the right cheek, persistent oral pus and moderate fever lasting 1 week, followed by rapid development of a mediastinal abscess. DIAGNOSES: He was diagnosed with DNM caused by S constellatus. INTERVENTIONS: On the evening of admission, an emergency tracheotomy and thoracoscopic exploration and drainage of the right mediastinum, floor of the mouth, parapharynx and neck abscess were performed. Antibiotics were administered immediately. OUTCOMES: At 28 days post-operatively, the abscess was absorbed, bilateral lung exudate decreased and the patient temperature, aspartate transaminase, alanine transaminase, bilirubin and platelets returned to normal. The patient was discharged after completing 4 weeks of antibiotic therapy. Follow-up at 3 months after discharge revealed no recurrence of the abscess. LESSONS: Early surgical drainage and antibiotics treatment are important in mediastinal abscesses and infectious shock due to Streptococcus asteroids.

Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences-a retrospective follow-up study.

PURPOSE: The primary aim of this retrospective study was to analyze the progression of descending necrotizing mediastinitis (DNM), evaluate the impact of comorbidities on complications and mortality and to observe long-term consequences of DNM on dysphagia and measurements quality of life. DNM is a serious infectious disease that requires multimodal treatment. Current literature varies in conclusions of risk factors, management and outcome of DNM. In addition, little is known about persisting effects on quality of life. METHODS: Retrospective data analysis of 88 patients with DNM representing the largest single-center study. Recording data of patients and diseases as well as clinical progression from 1997 to 2018. Two questionnaires were sent to the participants to measure quality of life and to detect dysphagia. RESULTS: 88 patients were included. The most frequently found pathogen were Streptococcus spp. (52%). 75% of the patients underwent multiple surgeries, mean count of surgical procedures was 4.3 times. 84% received intensive care treatment. Median length of stay on the intensive care unit was 7 days. 51% had pre-existing comorbidities associated with reduced tissue oxygenation (e.g., diabetes). The most common complication was pleural effusion (45%). During the observation period, the mortality rate was 9%. 12 questionnaires could be evaluated. 67% of the participants were affected by dysphagia at the time of the survey. CONCLUSIONS: Descending necrotizing mediastinitis (DNM) is a severe disease requiring an immediate initiation of multimodal treatment. Although quality of life usually isn´t impaired permanently, dysphagia may often persist in patients after DNM.

Extensive fibrotic wrapping of the heart: a rare echocardiographic diagnosis.

BACKGROUND: Fibrosing mediastinitis (FM) is considered a benign disease, but it can be fatal if progression leads to compression of the hilum of the lungs or invasion of the heart. Echocardiographic reports of this disease are very rare. CASE PRESENTATION: We present a 14-year-old male patient whose non-enhanced chest computed tomography showed unclear soft-tissue dense lesions in the anterior superior mediastinum. Echocardiography showed the heart was extensively wrapped by soft tissue lesions. The histology confirmed FM. CONCLUSIONS: When FM affects the heart, echocardiography can help to characterize the disease and aid in the diagnosis. Echocardiography should be considered an important tool to follow the progression of this disease and guide the therapeutic approach.

[Aspergillus mediastinitis following post-immunotherapy lobectomy for oligometastatic lung]. / Médiastinite à Aspergillus après lobectomie post immunothérapie pour un cancer du poumon oligométastatique.

The relationship between infectious disease and therapy with immune checkpoint inhibitors remains unknown. We report the case of a 50-year-old woman with metastatic lung adenocarcinoma who responded remarkably well to immunotherapy and underwent upper right lobectomy. Three weeks after hospital discharge, she was readmitted for severe dyspnea due to mainstem bronchus compression by mediastinal mass. Histological analysis of transbronchial needle aspiration revealed A. fumigatus. After six months of voriconazole regimen, her symptoms improved with the regression of bronchial compression. Postoperative progression of pseudo-tumoral mass in patients treated with long-term immunotherapy may be related to opportunistic infectious disease and requires investigation.

Comparison of fibrosing mediastinitis patients with vs. without markedly increased systolic pulmonary arterial pressure: a single-center retrospective study.

INTRODUCTION: Fibrosing mediastinitis (FM) complicated with pulmonary hypertension (PH) has been considered as an important cause of morbidity and mortality. This study was designed to observe the possible effects of abnormal hemodynamics on patients by conducting a between-group comparison according to the presence of markedly increased systolic pulmonary arterial pressure (SPAP), so as to provide more information for clinical management. MATERIALS AND METHODS: Fifty-one patients with clinically diagnosed FM were divided in two groups (SPAP < 50 mmHg group; SPAP ≥ 50 mmHg group) and retrospectively included in the study. Data mainly including demographic factors, echocardiographic data, results of right heart catheter and computed tomography (CT) examination were retrieved from the medical database. Echocardiographic parameters pre- and post- balloon pulmonary angioplasty (BPA) treatment were also collected in 8 patients. RESULTS: Significant changes in cardiac structure, hemodynamics and cardiac function were detected in patients complicated with markedly increased SPAP. Patients in the SPAP ≥ 50 mmHg group had increased right heart diameter, right heart ratio and velocity of tricuspid regurgitation (VTR) (p < 0.05). Deteriorated right heart function was also observed. There was no significant difference in CT findings between the two groups, except that more patients in the SPAP ≥ 50 mmHg group had pleural effusion (p < 0.05). After primary BPA in 8 patients, improvement in the right atrium proportion was observed. CONCLUSIONS: Changes due to significantly increased SPAP in patients with FM include adverse structure and function of the right heart, but differences in CT findings were not significant. Echocardiography has advantages as a noninvasive tool for the evaluation of cardiac structure, function and hemodynamics in patients with FM.

Comparison of death and survival cervical necrotizing fasciits cases.

BACKGROUND: Cervical Necrotizing Fasciitis (CNF) is associated with a high mortality rate. The occurrence of mediastinitis with CNF may increase mortality up to 70%. AIMS: We aimed to identify the differences between surviving and deceased cases. METHODS: The present study was conducted retrospectively by scanning the files of 16 patients between the ages of 19-71 who were diagnosed with CNF. Patients were divided into two groups as the surviving patient group (SPG) and the deceased patient group (DPG). Both groups were compared in terms of age, gender, Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, duration of symptom onset to hospital admission, use of antibiotherapy prior to admission, duration of hospitalization, presence of diabetes mellitus (DM), presence of dental etiology, mediastinitis, and respiratory distress at the time of admission. RESULTS: Diabetes mellitus was the most common comorbid disease. 5 out of 7 deceased patients had DM. Dental events were the most common etiology. Rapid surgical debridement and airway management was the first treatment method. The most frequently isolated species in the culture was Streptococcus. 6 of 11 patients who developed mediastinitis deceased at the end of the process. CONCLUSION: Dental pathologies mostly play a role in the etiology. It is obvious that dentists, another occupational group that frequently encounters this patient group, have a critical role in this process. Therefore, precise attention should be given to dental problems in patients with diabetes, and hospitalization and initiation of broad-spectrum antibiotherapy should be considered in case of suspicion of deep neck infection.

Optimal Airway Management in the Treatment of Descending Necrotizing Mediastinitis Secondary to Deep Neck Infection.

PURPOSE: To review our experiences of descending necrotizing mediastinitis (DNM) secondary to deep neck infection (DNI) and determine appropriate airway management for decreasing mortality and morbidity of patients with DNM. METHODS: Medical records of 20 patients (8 women and 12 men) who had been managed for DNM secondary to DNI between March 2006 and December 2019 were analyzed. Diagnosis and extent of infection were confirmed by computed tomography of the neck and chest. The upper airway was closely monitored with a fiberoptic laryngoscope. Complications were evaluated according to various types of airway management in our serial cases. RESULTS: Five (25%) out of 20 patients died as a result of septic shock and multiorgan failure. None of these patients died of accidental airway obstruction or airway management mishaps. Keeping short-term orotracheal intubation was safe and adequate after the initial surgery. Early tracheotomy was performed for 4 patients and it was significantly associated with mortality (P = .032). Three patients who underwent late tracheotomy had no mortality. Patients with tracheotomy had longer duration of overall hospital stay than those without tracheotomy. CONCLUSIONS: Well-controlled airway management might decrease mortality, hospitalization, and airway complications in patients with DNM secondary to DNI. Keeping orotracheal intubation rather than upfront tracheotomy should be first considered when managing airway along with examination of the upper airway with a fiberoptic laryngoscope.

Observation of Retropharyngeal Fluid Collection in 2 COVID-19 Positive Patients.

Our understanding of the novel coronavirus, COVID-19, is growing; yet, there remains much we do not understand, and unique presentations are abundant. One potential presentation is retropharyngeal edema, defined as fluid in the retropharyngeal space. Multiplanar imaging with computed tomography or magnetic resonance imaging is ideal for characterizing and diagnosing these fluid collections rapidly as possible life-threatening complications may develop (eg, airway obstruction and mediastinitis). Here, we discuss the presentation, imaging identification, treatment, and recovery of retropharyngeal fluid collection in 2 COVID-19 cases. The significance of this article is to suggest conservative management as a viable treatment option for retropharyngeal fluid collection, as opposed to incision and drainage, in the setting of COVID-19.