Search

Mediastinal tumors present a rather rare phenomenon with a variety of underlying causes. Important differential diagnoses include benign and malignant tumors as well as idiopathic sclerosing mediastinitis and parasitic infection.Here, we present the case of a mediastinal pseudotumor with compression of the superior vena cava in a young adult male who spent several years abroad in Brazil. Clinicians suspected either a mediastinal lymphoma, malignant mesenchymal tumor, teratoma, sarcoidosis, or tuberculosis. Biopsy tissue failed to provide a definite diagnosis. The subsequently resected mediastinal mass showed a necrotizing, granulomatous inflammation with prominent eosinophilia and sclerosis. Membranous structures were detected in the necrotic areas, which presented as collagen bundles ultrastructurally. Therefore, these membranes were proven to be constituents of lipid pseudomembranes. Consequently the lesion shows characteristics of sclerosing mediastinitis next to characteristics of adipose tissue necrosis with lipid pseudomembranes. Parasitic infection could not be proven.Mediastinale Tumoren sind relativ selten und ihre Ursachen vielfältig. Wichtige Differenzialdiagnosen sind benigne und maligne Tumoren sowie die sklerosierende Mediastinitis und eine parasitäre Genese.Im Folgenden schildern wir den Fall eines mediastinalen Pseudotumors bei einem jungen Mann mit oberer Einflussstauung der Vena cava superior nach mehrjährigem Auslandsaufenthalt in Brasilien. Klinisch standen der Verdacht auf ein mediastinales Lymphom, ein Sarkom, ein Teratom, eine Sarkoidose oder eine Tuberkulose im Vordergrund. Bioptisch gelang keine exakte diagnostische Einordnung, sodass eine Tumorresektion vorgenommen wurde. Histologisch fand sich eine fokal nekrotisierende, granulomatöse Entzündung mit starker Eosinophilie und Sklerose. In der Nekrose konnten membranöse Strukturen nachgewiesen werden, die ultrastrukturell als Kollagenfaserbündel im Sinne von Lipidpseudomembranen eingeordnet werden konnten. Somit liegt eine Läsion mit Zeichen einer sklerosierenden Mediastinitis und einer Fettgewebsnekrose mit Lipidpseudomembranen vor. Eine Parasitose konnte nicht nachgewiesen werden.

Descending necrotising mediastinitis (DNM) is a rare, but very severe, septic condition, caused by the spread of infection from the neck to the mediastinum. Delay in diagnosis and inadequate surgical procedures may lead to a life-threatening situation.We retrospectively evaluated a group of patients who suffered from DNM and were treated in our department by mediastinal drainage in the last 10 years (2010 - 2019). All patients required one of the following methods of drainage: cervicomediastinal, mediastinothoracic or cervicomediastinothoracic "Rendevouz" drainage (MTC-D). In the group, we evaluated the source of infection, microbiologic findings, method of mediastinal drainage, length of hospitalisation, ventilation duration and inflammatory laboratory parameters.In total, we treated 22 patients with DNM, including 14 men and 8 women, aged 23 - 85 years, with a mean age of 54.1 years. After the spread of infection, in 8 cases the initial cervicomediastinal type of drainage had to be followed by one of the types of thoracic drainage. As the final method, in 8 patients we chose irrigation drainage from the cervical approach, from thoracotomy in 6 cases and in 8 cases irrigation CMT-D. The method of mediastinal drainage was chosen according to the initial CT findings, and further intervention was chosen according to CT signs during the treatment. Four patients died of DNM (mortality 18.2%). Pharyngeal focus was responsible for 15 cases of DNM; odontogenic infection caused 6 DNM cases; in 1 case the origin was unclear. Although we always chose the method individually and CMT-D for the most difficult cases, there were no statistically significant (p 0.05) differences between the evaluated parameters. For CMT-D, there was even a shorter hospital stay (not significant) and ventilation duration.In cases of DNM with severe inflammation of caudal and distal compartments of the mediastinum we consider CMT-D as an ideal method of treatment. This appraoch is radical enough and in our group of patients, despite the severity of this illness, both the length of treatment and mortality were sufficient.Die deszendierende nekrotisierende Mediastinitis (DNM) ist ein seltener, aber sehr schwerwiegender septischer Zustand, der durch das Übertreten einer Infektion aus dem Hals ins Mediastinum hervorgerufen wird. Verzögerung in der Diagnostik und ein unzureichender chirurgischer Eingriff bedeuten für den Kranken einen lebensbedrohenden Zustand.Wir beurteilen retrospektiv eine Patientengruppe, bei der in unserer Abteilung die DNM durch eine Drainage in den letzten 10 Jahren (2010 – 2019) therapiert wurde. Bei allen Patienten war eine der folgenden Mediastinumdrainagen erforderlich: zervikomediastinale, mediastinothorakale oder zervikomediastinothorakale „Rendevouz“-Drainage (ZMT-D). Wir beurteilten in der Gruppe die Infektionsquelle, den mikrobiologischen Kultivierungsbefund, die Art der Mediastinumdrainage, den Krankenhausaufenthalt, die Beatmungsdauer und die Laborentzündungsparameter.Insgesamt wurden 22 Patienten mit DNM behandelt, 14 Männer und 8 Frauen im Alter von 23 bis 85 Jahren, Durchschnittsalter 54,1 Jahre. Durch weitere Ausbreitung der Entzündung musste in 8 Fällen der zervikomediastinalen Drainage eine der transthorakalen Drainagemethoden folgen. Letztendlich wurde in 8 Fällen von Mediastinitis eine Spüldrainage aus dem Halszugang, in 6 Fällen durch Thorakotomie und in 8 Fällen durch die Spül-ZMT-D durchgeführt. Die Art der Drainage wurde nach den ersten CT-Befunden ausgewählt, weitere Interventionen nach CT-Kontrollen während der Behandlung. Im Zusammenhang mit DNM starben 4 Patienten (Mortalität 18,2%). Bei 15 Patienten wurde eine Tonsillitis als Ursache einer DNM festgestellt, bei 6 Patienten eine odontogene Infektion und bei 1 Patient blieb die Ursache unklar. Obwohl wir die Methode immer individuell und die ZMT-D für die schwierigeren Fälle auswählten, gab es keine statistisch signifikanten (p 0,05) Unterschiede zwischen den bewerteten Parametern. Im Vergleich waren der Krankenhausaufenthalt und die Beatmungsdauer bei der ZMT-D kürzer als bei den anderen Drainagemethoden (nicht signifikant).Insbesondere bei einer Infektion der distalen Bereiche des Mediastinums halten wir ZMT-D für eine ideale Art der Drainage. Es handelt sich um einen genügend radikalen Behandlungsansatz. Sowohl die Behandlungszeit als auch die Mortalität sind nach Einschätzung in unserer Gruppe trotz des Schweregrads der Erkrankung positiv ausgefallen.

Mediastinitis occurs as a severe complication of thoracic and cardiac surgical interventions and is the result of traumatic esophageal perforation, conducted infections or as a result of lymphogenic and hematogenic spread of specific infective pathogens. Treatment must as a rule be accompanied by antibiotics, whereby knowledge of the spectrum of pathogens depending on the pathogenesis is indispensable for successful antibiotic therapy. Polymicrobial infections with a high proportion of anaerobes are found in conducted infections of the mediastinum and after esophageal perforation. After cardiac surgery Staphylococci are the dominant pathogens and a nasal colonization with Staphylococcus aureus seems to be a predisposing risk factor. Fungi are the predominant pathogens in immunocompromised patients with consumptive underlying illnesses and can cause acute or chronic forms with granulomatous inflammation. Resistant pathogens are increasingly being found in high-risk patient cohorts, which must be considered for a calculated therapy. For calculated antibiotic therapy the administration of broad spectrum antibiotics, mostly beta-lactams alone or combined with metronidazole is the therapy of choice for both Gram-positive and Gram-negative bacteria inclusive of anaerobes. For patients at risk, additional antibiotic classes with a spectrum against methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) can be administered. Increasing rates of multidrug-resistant Gram-negative bacteria (e.g. Enterobacteriaceae) and non-fermenting bacteria (e.g. Pseudomonas and Acinetobacter) in individual cases necessitates the use of polymyxins (e.g. colistin), new tetracyclines (e.g. glycylglycines) and newly developed combinations of beta-lactams and beta-lactam inhibitors. For treatment of fungal infections (e.g. Candida, Aspergillus and Histoplasma) established and novel azoles, amphotericin B and echinocandins seem to be successful; however, detection of Candida, particularly in mixed infections does not always necessitate treatment. Mediastinitis is still a severe infectious disease with a high mortality, which necessitates an early and broad spectrum antibiotic therapy; however, with respect to optimal duration of therapy and selection of antibiotics, data from good quality comparative studies are lacking.

Sternal osteomyelitis as a direct consequence of advanced mediastinitis or as in most cases after median sternotomy is still associated with a prolonged hospital stay, increased morbidity and postoperative mortality. Early diagnosis and an adequate surgical treatment are decisive for the prognosis. Prerequisites for a secondary stabilization of the chest wall using wires or plates are sterile wound conditions. Diverse reconstructive techniques are available for anterior chest wall reconstruction depending on the defect size and localization. The various reconstructive methods including local and free flap coverage are described in this review article.

A systematic approach to the etiology and possible course of acute mediastinitis is a prerequisite for adequate diagnostics and therapy. Chronic mediastinitis represents a rarity in the clinical practice.A selective literature search was carried out.An acute infection of the mediastinum occurs after perforation of mediastinal structures, such as the esophagus and trachea mostly of iatrogenic origin and as descending necrotizing mediastinitis (DNM) from oropharyngeal foci. The mortality rate of esophageal injuries, irrespective of the cause is currently given as 12 %. A DNM results from an unobstructed spread along the cervicothoracic spaces and is a severe infection which manifests as a clinical picture of sepsis. The mortality rate given in the currently available literature is 14 %. Chronic mediastinitis is a very rare condition which is characterized by the proliferation of fibrous and collagenous tissue in the mediastinum. Whereas the pathogenesis remains unclear, there are indications for a Histoplasma capsulatum infection as the causal link. The prognosis is good.After perforation of the esophagus or trachea there is always the risk of an infection of the mediastinum; therefore, the diagnosis is followed by further evaluation and early therapy. The DNM can cause unspecific symptoms of sepsis without an obvious focal point. It is important to be aware of a possible correlation between an oropharyngeal center of infection and mediastinitis in order to initiate appropriate diagnostic imaging in cases with the slightest suspicion. Chronic mediastinitis is a rare condition with varying courses and can be difficult to diagnose. An histological clarification for distinction from malignant diseases appears to be a sensible approach.

Despite modern intensive care management, acute mediastinitis is still associated with a high morbidity and mortality (up to approximately 40 %). Effective antibiotic therapy, intensive care management, elimination of the causative sources of infection and drainage of the affected mediastinal compartments are the cornerstones of therapy in a multidisciplinary treatment concept. Early diagnosis, prompt and uncompromising initial therapy and planned computed tomography (CT) control after the first stages of therapy in order to decide on the necessity for surgical re-interventions are essential for achieving optimal results. Knowledge of the specific anatomical characteristics is crucial for the understanding of this disease and its treatment; therefore, the current knowledge on fascial layers and interstitial spaces from the neck to the mediastinum is described and discussed. A possible foudroyant spread of the infection, especially within the posterior mediastinum, has to be anticipated. The approach to the mediastinum depends on the mediastinal compartments affected, on the causative disease and on the patient's clinical situation. The surgical approach should be adapted to the particular clinical situation of the individual patient and to the surgical experience of the surgeon. When in doubt, the more invasive approach to the mediastinum, such as bilateral thoracotomy, is recommended. An ascending mediastinitis due to pancreatitis is a very rare condition; however, as chest pains are often the main clinical sign surgeons should be aware of this differential diagnosis. An intraoperative brown-black serous fluid in the mediastinal tissue is virtually pathognomonic. The treatment results of esophageal perforation as the most frequent cause of mediastinitis have been improved by integration of various interventional procedures. Hyperbaric oxygen therapy or immunoglobulin treatment can play an auxiliary role in selected patients with acute mediastinitis.

Descending necrotizing mediastinitis (DNM) originates from odontogenic or oropharyngeal infections which spread along preformed cervicothoracic spaces into the mediastinum and requires emergency multidisciplinary treatment.A total of seven patients were diagnosed with DNM based on typical radiological features in a cervicothoracic computed tomography (CT) scan and subsequently underwent standardized transcervical and open transthoracic radical debridement.The initially detected polymicrobial spectrum of pathogens was dominated by streptococci followed by enterobacteriae. After calculated antibiotic treatment a shift in the spectrum of pathogens was noted and in particular a mycotic superinfection occurred in 43 % of the cases. Anterolateral thoracotomy was performed for radical removal of tissue necrosis and mediastinothoracic drainage extending to the posterior mediastinum was placed. In selected cases, cervico-mediastino-thoracic tubes were transmediastinally placed by the rendevouz technique either in the previsceral or retrovisceral mediastinal space. Despite predominantly advanced mediastinitis (Endo classification type II B) in this patient cohort, the mortality only reached 14 %.Rapid diagnosis, anatomical knowledge, understanding of the progression of infections as well as critical care, antimicrobial treatment and multidisciplinary radical surgical therapy are paramount for successful treatment of DNM. We favor anterolateral thoracotomy as the standard open transthoracic approach to the mediastinum. Placement of cervico-mediastino-thoracic irrigation drains can help to limit DNM.

Acute infection of the mediastinum remains a condition with high morbidity and lethality rates. The manifestation and course of the illness vary widely depending on the cause of infection. Lack of knowledge or awareness of the illness and mostly unspecific clinical symptoms often delay diagnosis and thereby the start of adequate therapy. Computed tomography (CT) of the neck and thorax is the method of choice for diagnostics and control of therapeutic success. An early diagnosis with immediate surgical debridement and drainage of all infected tissue compartments, as well as strict sepsis therapy, are decisive for the prognosis.

Surgical site infections after thyroid surgery are mostly superficial and can be well treated. Streptococcal mediastinitis in contrast is a rare but life-threatening complication.A 57-year-old female patient experienced septic fever, increase of inflammation parameters and erythema 2 days after thyroid surgery for Graves' disease. This process was triggered by a three-compartment infection by group A Streptococcus (GAS) with involvement of the mediastinum. Therapy over 6 weeks including seven wound revisions with the patient under general anesthesia, pathogen-adapted antibiotic treatment and cervical negative pressure treatment managed to control the infection. A total of 21 cases have been published on this phenomenon, 11 of which had a fatal outcome.High fever and surgical site erythema in the early postoperative period after thyroid surgery can be signs of a GAS infection, which might lead to necrotizing, descending, life-threatening mediastinitis. Early diagnosis with support of computed tomography (CT) scans, immediate therapy including wound opening, lavage, intravenous antibiotic treatment with penicillin and clindamycin are vital. If treatment resistance occurs, cervical negative pressure treatment should be considered.

Thoracic pain is a common symptom in the emergency medicine setting and represents a diagnostic and therapeutic challenge. A multitude of differential diagnoses must be considered many of which are associated with a high mortality. Management of this situation is complicated by the fact that rapid and unexpectedly occurring and rapidly progressing deterioration are not uncommon in patients who initially did not appear to be seriously ill. Also for some underlying pathologies the physical examination can have an inconspicuous or"false negative" result and atypical presentations can give rise to false interpretations. The clinical and technical diagnostic methods, the implementation and interpretation including possible sources of error and limitations will be described in detail.

Each and every hospital of any kind is forced, due to increased cost pressure, to work as economically and as efficiently as possible. This even applies when the operational orientations of the hospitals institutions are different. In the present article an analysis of the repercussions of the treatment of postoperative complications in terms of entrepreneurial practice is given. Our focus is on the opportunity cost.A theoretical calculation of opportunity costs is made based on the example of postoperative infections following cardiac surgery and the resulting treatment. The bases of the examinations are the results collected at the hospital Mediclin Herzentrum Lahr / Baden in 2008. The wound healing disorders were recorded from November 2004 until November 2007 and include 3675 patients who were operated on using a median sternotomy. Out of the 3675 patients 45 (1.2 %) were affected. Various treatment options are at hand. The used therapy algorithm in our practice is dependent on the stage and the development of the infection.If the high trim point, the medial trim point and the low trim point of the mediastinitis patients, as well as the average revenue and the surcharge omission on exceeding the high trim point (these data can be found in the annual accounts) and knowledge of the actual length of stay of the mediastinitis patient are known, the opportunity cost, respectively potential turnover increases, can be calculated. Reducing the medial trim point from 48.43 to, for example, 36.37 days could potentially produce a turnover increase of as much as 10 633.41 €.Keeping patient safety in mind, significant turnover increases can be achieved with adequate planning. The considered sales situation, however, can only be achieved under the same terms: these being free operating room and bed capacities, available personnel, equal cost of materials as well as enough patients. The consideration of opportunity costs could be important for entrepreneurs if staff shortage continues and, in economical terms, non-expendable capacities are created.

Foreign body ingestion is a common pediatric emergency and if the foreign body cannot be detected radiologically or endoscopically further investigations are required. In this article the case of a radiolucent, ingested foreign body (mini-candleholder of a birthday cake) is presented. The foreign body could not initially be identified via X-ray and endoscopy due to its parapharyngeal localization but was finally visualized by magnetic resonance imaging (MRI) which additionally uncovered the co-existence of acute mediastinal inflammation.

HISTORY AND CLINICAL SYMPTOMS: A 58-year-old man was admitted to our hospital with acute chest pain and subfebrile temperatures. Two years ago, endovascular aortic stent-graft placement had been performed for acute type B aortic dissection complicated by malperfusion syndrome.CT angiography showed a discrete soft-tissue attenuation mass between the aorta and esophagus. The patient developed progressive swallow disorder and esophago-gastro-duodenoscopy demonstrated deep esophageal ulcerations at the level of the implanted aortic stent-graft. Intravenous treatment with broad spectrum antibiotics was started. The FDG-PET/CT scan showed increased FDG uptake and air entrapment in the affected region establishing the diagnosis of aortoesophageal fistula formation.Given the generally poor condition of the patient and the high risk of any aggressive surgical intervention, a new limited surgical approach was chosen consisting of open transthoracic esophageal resection, blind closure of the stomach and cervical esophagostomy. A percutaneous endoscopic gastrostomy tube was placed. After three months, esophageal continuity was restored by retrosternal colon interposition. The presented therapeutic management resulted in a full recovery of the patient.Aortoesophageal fistula is a rare complication of thoracic aortic stent-graft placement. Patient may present with unspecific symptoms such as fever and rised inflammatory markers, but may also present with massive upper gastrointestinal bleeding. The herein presented limited therapy with esophageal resection represents a promising to the otherwise difficult therapy of aortoesophageal fistula.