UMEM Educational Pearls

Mediastinitis is an infection of the mediastinum; a rapidly fatal surgical emergency if not recognized and treated early.

Causes include esophageal perforation, oropharyngeal infections (e.g., Ludwig’s angina), prevertebral or carotid space infections, and iatrogenically (endoscopy, hypopharyngeal perforations during intubation, etc.).

Plain films (neck / chest) may serve as a screening tool, but CT best defines the source and extent of disease; the CT below demonstrates gas within the soft-tissues and the mediastinum (red arrrows).

Infections may be polymicrobial and broad-spectrum antibiotics with anaerobic coverage (e.g., pipercillin-tazobacam) should be started initially.

Immediate treatment should also include:

  • Intubation (with co-existing soft tissue swelling)
  • Fluid resuscitation and hemodynamic support
  • Surgical consult for necrotic tissue debridement


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Ridder G, et al. Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome. Ann Surg. Mar 2010;251(3):528-34.

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