Chapter 51
51 Acute Mediastinitis
K.P. Bhavan, D.K. Warren
51.1
Introduction
Mediastinitis is an infection of the structures in the
thorax excluding the lungs and pleural space. Most
cases of mediastinitis are secondary to spread of infec-
tion from a distant site or direct inoculation of organ-
isms secondary to trauma or esophageal perforation
due to malignancy. The last 30 years have seen a dra-
matic increase in the annual number of cardiac surgical
procedures performed. Consequently, post-sternotomy
surgical site infections have accounted for an increas-
ing number of cases of mediastinitis. Despite signifi-
cant advances in antibiotic therapy, surgical technique,
and intensive care management, mediastinitis contin-
ues to have a high morbidity and mortality. This chap-
ter will focus on three major categories of mediastini-
tis, including descending necrotizing infections, medi-
astinitis secondary to esophageal perforations, and
post-sternotomy surgical site infections, and will dis-
cuss the pathogenesis, presentation, diagnosis, and
management associated with each. The anatomy of the
neck and mediastinum, which is crucial to understand-
ing the pathogenesis and complications of mediastini-
tis, as well as unusual causes of mediastinitis will also
be reviewed.
51.1.1
Historical Overview
The first major review of suppurative mediastinitis was
by Pearse [1] in 1938 involving 110 cases. In this series,
58 % of cases were due to esophageal perforation and
the remainder were secondary to descending infections
of the head and neck, along with post-surgical compli-
cations. Mortality in the pre-antibiotic era without sur-
gical drainage was 85 %; with surgery mortality de-
creased to 35 %.
With the increasing use of the median sternotomy
incision, a new cause of mediastinitis rapidly became
apparent. Overall, the infection rate for median sterno-
tomy is low, but given the volume of patients who un-
dergo this procedure for cardiac surgery each year,
even a low rate translates into a potentially large num-
ber of patients with post-operative mediastinal infec-
tions. In a 1976 review by Culliford [2], mortality
ranged from 7 % in the group that was recognized early
to 20 % among patients diagnosed late post-operative-
ly. The surgical management of these infections has
evolved from initial debridement with closure by sec-
ondary intention, to primary closure with closed irri-
gation, to the use of omental and muscle flaps.
The advent of antibiotics did little alone to change
the outcome of mediastinitis. In 1983, Estera et al. [3]
reviewed 21 cases of descending necrotizing mediasti-
nitis from 1960 to 1980 and reported a mortality of
42.8 %, with the majority of these cases being diag-
nosed at autopsy. This high mortality rate was attribut-
ed to the frequent lack of physical and radiographic
findings early in the course of the disease. The develop-
ment of computerized tomography (CT) has increased
the capacity for earlier diagnosis and improved pre-op-
erative planning of surgical management. An analysis
of 48 cases of mediastinitis from 1990 to 1998 revealed
that the mortality for descending infections had im-
proved to 23 % [4], which the authors attributed to the
availability of CT.
51.1.2
Anatomy of the Neck and Mediastinum
Understanding the pathogenesis, complications, and
successful management of mediastinal infections re-
quires knowledge of the anatomical relationships be-
tween the organs and vascular structures of the neck
and mediastinum. The mediastinum contains the
heart, great vessels, trachea, esophagus, paratracheal
lymph nodes, and the thymus. This is bordered ana-
tomically by the thoracic inlet superiorly, the dia-
phragm inferiorly, the sternum anteriorly, the vertebral
bodies posteriorly, and the pleural cavities laterally.
The fascial planes of the head and neck are of great im-
portance in understanding the spread of infection in
the chest. The most important of these fascial planes
are the retropharyngeal, visceral, prevertebral, lateral
pharyngeal, and previsceral spaces which communi-
cate directly with the mediastinum, and determine the
mechanism by which perforations in the cervical
esophagus and infections of the oropharynx can spread
to the thorax.
The clinically important areas in the neck are divid-
ed into three sections determined by their relationship
to the hyoid bone (Fig. 51.1). The retropharyngeal and
the visceral spaces extend both above and below the hy-
oid bone. The retropharyngeal space, or retrovisceral
space, is limited anteriorly by the middle layer of the

Fig. 51.1. The deep fascial layers of the neck and their relation-
ship to the mediastinum
deep cervical fascia and the deepest layer of the deep
cervical fascia, or the alar fascia posteriorly. This space
exists behind the hypopharynx and esophagus from
the base of the skull to the superior mediastinum. Ret-
ropharyngeal infections in this space can descend easi-
ly into the superior mediastinum. This was recognized
early to be the space most likely involved in cervical
esophageal perforations [1, 5]. This space is often in-
volved in extension of infections of the cervical verte-
bra. Just posterior to the retropharyngeal space, be-
tween the alar fascia and the prevertebral fascia, is an
area called by some authors the “danger space” [5],
which extends from the base of the skull to the crus of
the diaphragm and is a source of potential dissemina-
tion of retropharyngeal or lateropharyngeal infection
to the base of the posterior mediastinum and the retro-
peritoneal space [3, 5].
The visceral space is located within the carotid
sheath and includes all three layers of the deep cervical
fascia. Infections in this space less commonly extend
down to the mediastinum, but given their location in
relationship to the great vessels, can cause internal jug-
ular vein septic thrombophlebitis and carotid artery
rupture. Classically, suppurative lymphadenitis, peri-
tonsillar abscess, and Ludwig’s angina were causes of
infections in this space; however, any of the structures
of the pharynx and neck can serve as a source.
Above the hyoid bone are the submandibular space,
the lateral pharyngeal space, the masticator space, and
the parotid space. The submandibular and masticator
spaces are most involved with dental infections, with
Ludwig’s angina being a result of submandibular space
51.2 Descending Necrotizing Mediastinitis 543
infection. The lateral pharyngeal space communicates
with many of the spaces in the neck and is associated
with infections of the pharynx, teeth, tonsils, or paro-
tids. The parotid space communicates directly with the
“danger space” and the lateral pharyngeal space.
Therefore, infections in the parotids can rapidly extend
throughout the mediastinum.
Below the hyoid bone is the anterior visceral or pre-
visceral space. This extends from the hyoid bone supe-
riorly to the anterior mediastinum inferiorly. It is bor-
dered by the strap muscles anteriorly, and surrounds
the trachea, with the esophagus forming its posterior
border. The pretracheal investing fascia is attached to
the pericardium and the parietal pleura, which can re-
sult in pericarditis and empyema from infection in this
space. The most common causes of infection in this
space include tracheal or esophageal disruption. Final-
ly, the course of the esophagus is important to review,
as esophageal perforation is a significant cause of me-
diastinitis and the complications of this can be predict-
ed partially from the site of the perforation. The upper
two-thirds of the thoracic esophagus lies in close prox-
imity to the right pleural space, while the distal third
deviates to the left to enter the diaphragmatic hiatus.
Perforations of the lower thoracic esophagus are more
likely to cause left-sided empyemas and possible retro-
peritoneal extension.
51.1.3
Pathogenesis
The causes of mediastinitis are multiple (Table 51.1).
However, cases can be divided by source, which ex-
plains the microbiology of the infection and also in part
determines treatment strategies. Head and neck infec-
tions, esophageal perforations, and post-sternotomy
infections are the primary causes of mediastinitis. Oth-
er more unusual causes of mediastinal infection will al-
so be addressed.
51.2
Descending Necrotizing Mediastinitis
Descending necrotizing mediastinitis is an unusual in-
fection arising from the structures of the mouth, neck,
and pharynx. This begins as a localized infection,
which then descends inferiorly via the fascial planes of
the neck into the thorax. Several factors facilitate the
spread of these infections to the mediastinal structures,
including gravitational drainage, negative intrathorac-
ic pressure with inspiration, and the lack of significant
barriers in the retropharyngeal space. The fascial
planes of the neck can be penetrated by these infec-
tions, and subsequently involve all compartments of
the neck and mediastinum. Often, patients can rapidly