Recognition and management of mediastinitis

RECOGNITION

AND MANAGEMENT W.

EMORY BURNETT,

PHILADELPHIA,

M.D.

PENNSYLVANIA

A

LTHOUGH chronic mediastinitis is a rare disease, acute mediastinitis is not nearly so infrequent as the profession once beIieved. Numerous reports in the past few years indicate the fairly common occurrence of acute infections of the cervica1 and thoracic mediastinum. When one considers the ease of access to the fascial pIane& for spontaneous infections of the mouth, nose and throat, cervicaI Iymph-nodes, neopIasms of the pharynx and esophagus, and foreign bodies, it is fortunate that nature is so kind in building inff ammatory barriers to prevent the downward extension of many of these infections. An accurate concept of the practica1 anatomy of these fascial pIanes of the neck and thorax, as so vividIy described by Furstenberg and YgIesias, demonstrates the continuity of the retroviscera1 space as a compartment (Figs. I and 2) bounded behind by the prevertebra1 Iayer of cervica1 fascia, in front by the pharynx and esophagus and the IateraI extension of the retroesophageal fascia, which is a derivative of the pretrachea1 Iayer, and IateraIIy by the carotid sheaths. It extends from the base of the skuII to the diaphragm. This makes easy migration of infection from the retropharyngea1 or retroesophagea1 Iocations into the posterior thoracic mediastinum, and it is remarkabIe that inffammatory barriers so frequentIy IocaIize the infection to the cervica1 portion. Surrounding the viscera of the neck consisting of the pharynx and esophagus behind and trachea and thyroid in front, is a cyIindrica1 sheath. This consists of the pretrachea1 Iayer which extends IateraIIy to join the prevertebra1 Iayer at the carotid sheath and is continued posteriorIy as the retropharyngea1 or buccopharyngea1 fascia above and the retroesophagea1 fascia beIow, constituting the vascuIoviscera1 fascia. This bIends with * From the Department

OF MEDIASTINITIS*

the aorta as the arch crosses the trachea and encIoses the descending Iimb. It continues downward to fuse with the pericardium at about the IeveI of the bifurcation of the trachea at the sixth thoracic vertebra. Thus the other practica1 mediastina1 the anterior or viscera1 space, space, extends from pharynx and Iarynx above to the bifurcation of the trachea beIow. The potentia1 space immediateIy behind the sternum, incIuded in anatomy textbooks as a part of the anterior mediastinum, is protected from the spread of cervica1 infections by the junction of the superficial Iayer of cervica1 fascia and its muscuIar investments, with the posterior surface of the manubrium sterni so that infections reach this space onIy when they originate from injury or infection of the anterior chest waI1 at the IeveI of the first and second Costa1 cartiIages. In the vascuIoviscera1 fascia1 compartment Iie many Iymph-nodes and vesseIs, and it is into this space that nose, throat and ear infections frequentIy trave1. On the other hand, perforations of the posterior pharyngea1 or esophagea1 waIIs by foreign bodies usuaIIy invoIve the retroviscera1 space and are more prone to extend deep into the thorax. One or both of these spaces may be impIicated and the intimate reIationship to the pIeurae and pericardium Ieads to infection of these at times. PracticaIIy, then, there are two main spaces, the retroviscera1 and the vascuIoviscera1, which may be infected and are continuous from neck to thorax with onIy theoretica1, but no actua1 division between the cervica1 and thoracic portions. The concept that the mediastinum extends from the base of the skuI1 to the diaphragm is a good one for practica1 purposes. The extent to which infection of these spaces may spread is influenced by the

of Surgery, TempIe University

99

School of Medicine.

100

American

Journal

of Surgery

Burnett-Mediastinitis

amount of contamination, the virulence and the frequent muItipIicity of organisms on the one hand, and the patient’s resist-

OCTOBER, 1941

mitted to a11 services of TempIe University HospitaI over a period of the past five years, the source of infection is indicated in

Ant visceral space

FIG. I. Diagram of coronal section at the Ieve the sixth cervical vertebra.

of

ante on the other. Thus a bad combination of perforation by foreign body through a smaI1 opening which does not aIIow spontaneous drainage, in a patient who has streptococci and spirochetes from ora sepsis and is suffering from more or Iess nutritiona deficiency, may frequentIy Iead to a rapidIy spreading, diffuse, and necrotizing pIegmon with such extreme absorption and toxemia as to resuIt in death in one or two days. For such a patient, the prospects are poor, even with early drainin patients with good age. Conversely, resistance who have sustained perforations of the pharynx or esophagus with the demonstration of gas in the tissues, but in whom virulent bacteria were not present in Iarge numbers, spontaneous and fairIy rapid recovery has occurred on a few occasions. Between these two Iie the great majority of cases resuIting from either infections about the mouth, ears, or throat, or trauma to the pharynx and esophagus in which a11 combinations of the above two extremes occur. In many of these the infection is Iocalized by inflammatory barriers and retained in the cervica1 region as a retropharyngea1 abscess for a Ionger or shorter time. Even these, if negIected, tend to spread downward in many instances. In a review of twenty-eight cases of cervica1 and thoracic infection of the mediastinum and ten cases cIassed as retropharyngea1 abscess who were ad-

FIG.

2. Diagram

of midsagitta1

section.

TabIe I. The most common causes were perforation by foreign body and neopIasm and infections of the mouth and throat. Three of these Iatter foIIowed extraction of teeth. One case occurred after otitismedia and six cases after diagnostic instrumentation in the presence of uIcerative lesions, some of whom had symptoms suggestive of infection before examination. Two cases folIowed Iaryngectomy, and one thyroidectomy for extensive maIignant disease. One patient sustained spontaneous perforation of the esophagus. Of the abscesses cIassed as retropharyngea1, eight foIIowed upper respiratory infection, in most of which sore throat was stated, and two were secondary to otitis media. TABLE I ORIGIN OF MEDIASTINITIS Foreign body.. Carcinoma esophagus.. Perforation esophagus. Infections..................................... Otitis media.. Upper respiratory. Ludwig’s angina after tooth extraction. FoIlowing endoscopy. FoIIowing operation. Laryngectomy............................. Thyroidectomy., FolIowing passage of feeding tube.

No. 9 4

I 6

I 2 3 4 3 2

I .

of the twenty-eight The symptoms cases (excIuding retropharyngeal abscess) EIeven showed dysphagia, eight dyspnea-

I 28

:

New SERIES VOL. LIV. No. I

Burnett-Mediastinitis

two of whom required tracheotomy-six had pain in the throat and seven pain in the chest, neck or back. In four there was vomiting, in three hemoptysis, and in two there was hoarseness. AI1 but two had fever and in twenty it was moderate to high and frequently septic in character. ChiIIs occurred in onIy three cases. Cyanosis was present in seven, sweIIing of the neck in thirteen and cervical tenderness in tweIve. Abnormal chest signs were present in four cases. The most constant evidence was demonstrated by x-ray. Due to obvious diagnosis or failure to consider the possibility, no x-ray was taken in four cases, but in the remainder a11 showed widening of the mediastinum or of the retrotrachea1 soft tissues depending upon Iocation, and in fourteen there was gas present in the tissues. Of the so-caIIed “retropharyngea1 ” group, the symptoms consisted rather constantly of sore throat and diff%uIty in swaIIowing. A few references were made to Iabored or noisy breathing and to sweIIing of the neck. In the occasiona case in which roentgen examination was done, thickening of the space between the vertebra and pharynx was reveaIed. A review of the muItipIe cases in the Iiterature shows that the etioIogy, symptoms and signs ascribed to the patients reported correspond to these we have outIined as to frequency of occurrence. The rare circumstance of mediastinitis secondary to osteomyelitis of the thoracic vertebra, suppurative Iymphadenitis of peribronchia1 or peitrachea1 Iymph-nodes from perforation or operation of neoplasms of the thoracic esophagus, and foIIowing puImonary suppuration, empyema, or thoracic operations, is reported. Such origins usuaIIy resuIt in abscesses IocaIized to the thoracic portion of the mediastinum and may not be accessibIe from the cervica1 approach but require posterior mediastinotomy. Acute mediastinitis is susceptibIe to accurate diagnosis if one wiI1 onIy consider

American Journal of Surgery

IO1

the possibiIity of its occurrence with infection or trauma of the mouth, nose, throat, ears or esophagus. Any patient may be considered a candidate for such diagnosis if any one or combination of the folIowing is present: difEcuIty in breathing or swaIIowing, pain in the throat, tenderness or sweIIing in the neck. The only acuteconditions which are IikeIy to confuse one cIinicaIIy are acute Iymphadenitis, possibIy tuberculous adenitis and the rare conditions causing increased superior vena cava1 pressure. The finding of emphysema in the cervical or thoracic mediastinum by cIinica1 or x-ray means and the thickening of the viscera1 and retroviscera1 spaces or widening of the mediastinum by x-ray associated with fever and Ieukocytosis, cIinch the diagnosis. The main factors are the consideration of the condition in potentiaJ cases and the examination by x-ray of these soft tissues. Results. In our group of ten cases in which drainage was not estabIished surgicaIIy, four recovered and six died. Of the eighteen cases in which drainage was estabrished surgicaIIy, tweIve recovered and six died. These Iast six deaths were in patients with thoracic mediastina1 invoIvement. The causes of death ascribed are tabuIated. (TabIe II.) Thus the mortality was 3345 per cent of patients in whom surgica1 drainage was estabIished and 60 per cent for those in whom it was not. (Table III.) DeIay before admission, before recognition, and before surgery contributed significantIy to the mortaIity of both groups since there was no intention to deny surgery to those patients. In only three of the tweIve fata cases did it appear that the viruJence and extent were too great for surgica1 saIvage, aIthough it is questionabIe in two others even if earIy recognition and drainage had been accompIished. AIthough a few cases recover without operation, it is diffIcuIt if not impossibIe to seIect these in the earIy stages and it seems extremeIy dangerous to deIay surgica1 drainage because of the occasional nonsurgica1 reDeIay not onIy increases the covery.

American

102

parenchymatous damage from proIonged toxemia, but frequentIy Ieads to spread of an otherwise circumscribed infection. ParticuIarIy with the perforations of the pharynx and esophagus, constant recontamination occurs unIess an adequate externa1 vent is produced. The ten cases cIassed as retropharyngea1 abscess were drained earIy through the posterior pharyngea1 waI1 with rapid recovery. TABLE

-

-

CAUSES

Days from Onset to Drain-

Case

OF

II DEATH

With SurgicaI

Drainage

an emergency procedure in every case with the exception of those rare infections which begin and remain beIow the fourth rib posteriorIy. With such rare exceptions, posterior mediastinotomy shouId be done by resecting portions of two or three ribs and transverse processes at the appropriate IeveI and retracting the pIeura IateraIIy and anteriorIy unti1 the mediastina1 coIIection is entered. Soft rubber tubes, rubber dam or gauze are inserted to maintain the opening, and irrigations with oxidizing soIutions are utiIized unti1 the drains can be graduaIIy shortened and withdrawn. No posterior mediastinotomies were empIoyed in this group, aIthough indicated in Case XXIII. TABLE III

age

197

Carotid hemorrhage twelve days postoperative-Iigation of carotid-hemipIegia-died in twenty-four hours Delay-moribund at operationedema-thin ctoudy Auid Died suddenIy two days postoperatively-vascular accident Inadequate drainage-temporary improvement-readmitted and died seven weeks later with heaIed wound and continued mediastinitis FoIIowed Iaryngectomy-extensive sIoughing of wound FoIIowed thyroidectomy for advanced malignancy-extensive sloughing of wound and metastases

9 I2 43 8

8 7

Without

2

4

3

IO

4 6

I

SurgicaI

Drainage

Too iII for muItipIe surgery-pericardia1 and biIateraI pleura1 infection Error in diagnosis-empyema onIy was drained Moribund--error in diagnosis-onIy superficial extensions to neck and shoulder were drained Unrecognized unti1 postmortem examination; pericardia1 and biIatera1 pIeura1 infection DeIay-moribund on admission-died during diagnosis in eighteen hours Error in diagnosis

17 hrs.

I

OCTOBER, ,941

Burnett-Mediastinitis

Journal of Surgery

4 3o

MANAGEMENT

When the diagnosis is estabIished, cervica1 mediastinotomy shouId be instituted as

CASES

FROM

THE

LITERATURE

Operated RWOV. ered

Pearse. 99 collected.. personal. Phillips. Neuhof..

44

Died

-

!

Nonoperative

-

RCXWered

Died

24

6

36

3 7

9

25 ____

II

86

34 (39.5 Per cent)

-I

61

15

(80

per Cellt)

L

CervicaI mediastinotomy shouId be instituted on the side of the neck which is indicated by cIinica1 or radioIogica1 IocaIization, or upon the right side if the infection is biIatera1 or onIy posterior. There is Iess Iikelihood of entering the pIeura on this side than on the Ieft. An obIique or transverse incision is made aIong the anterior border of the sternomastoid muscIe through the superficia1 Iayer of the deep cervica1 fascia. The sternomastoid and carotid sheath are retracted IateraIIy and the thyroid retracted mediahy which usuaIIy entaiIs division between ligatures of the IateraI vein and at times the inferior thyroid artery. If the abscess is anterior, it wiI1 be found more media1 under the pretrachea1 fascia and if posterior, directIy backward through the dense union of the pretrachea1 and retroesophagea1 fascia1

NEW SERIESVOL. LIV. No. I

Burnett-Mediastinitis

pIanes with the carotid sheath. If paIpation reveaIs a Iarge space extending to the opposite side, some surgeons advocate repeating this procedure on the opposite side, aIthough usuaIIy a uniIatera1 approach aIIows adequate drainage. If foreign body or instrumenta Iaceration is suspected, search shouId be made for it. Foreign bodies can frequentIy be removed by esophagotomy aIone or combined with esophagoscopy. Lacerations or surgica1 wounds have a marked tendency to reopen after suture unIess fine stee1 wire is used. If adequate drainage is estabIished, such openings hea spontaneousIy. With the finger, one must expIore cephaIicaIIy and caudaIIy to determine the extent of the abscess and pIace two smaI1 rubber tubes at the extremities in each direction. Two tubes give better drainage than one, both through the Iumens and between the pair, and aIIow for irrigation of deep spaces without production of dangerous positive pressure. Constant irrigation by drip with oxidizing soIution such as Dakin’s or azochIoramid, offer the best chance for rapid diIution and mechanica remova of infectious products. One shouId avoid too great or too proIonged pressure on the carotid or juguIar vein because of the danger of serious hemorrhage. When the abscess invoIves the thoracic portion of mediastinum, postura1 drainage by modified TrendeIenburg position is important to assist drainage by gravity. To overcome dysphagia and promote rest of this area, and particuIarly if the esophagus is the source of contamination, a feeding tube shouId be inserted into the stomach at the time of operation so that it can be guided beyond the Iaceration by the operator. Of particuIar vaIue here is the doubIe barre1 tube such as the AbbottRawson through one channe1 of which feeding can be carried on whiIe the esophagea1 secretions are constantIy aspirated through the other to Iessen recontamination by the swaIIowed saIiva. Of course, nothing is given by mouth for the same reason. Nutrition, fluid and chemica1 baIance must be

American

Journal

of Surgery

to3

maintained by feeding tube or intravenous administration. Additiona therapy such as the suIfonamide drugs in adequate dosage, neoarsphenamine if mouth organisms enter the picture, and frequent smaI1 bIood or pIasma transfusions to activate compIement and combat anemia and nutritiona disturbances heIp to Iimit further spread and to hasten cure. Progress is gauged by cIinica1 means, but must incIude check-up bIood count and x-ray examinations to avoid too earIy remova of drainage with the possibiIity of resuItant reaccumuIation. UnfortunateIy, one of our patients died from faiIure to foIIow this scheduIe and to determine the extension of the abscess into the thoracic mediastinum. With adequate drainage and supportive measures, patients shouId recover in from two to four weeks. The pain, dyspnea and dysphagia disappear in a few days, and the temperature usuaIIy faIIs to norma in from five to ten days. Profuse drainage after two weeks or proIongation of more than four weeks usuaIIy means stenosis of the drainage tract with inadequate vent. CASE

REPORTS

CASE I. H. C., aged fifty-nine, was admitted January 31, 1940. He compIained of pain in the renaI area radiating to pubes and hematemesis five days before. He felt better on an uIcer diet until the evening of the next day when bloody vomitus recurred with hoarseness and anterior swelIing of the neck. On physica examination there was cyanosis, stridor, uIceration of right pyriform sinus and swelhng of the neck and supraclavicuIar regions. Breathing was diffIcuIt but there was no increased mediatinal duIIness. The day after admission a tracheotomy was performed and adequate drainage obtained by cervica1 mediastinotomy. X-ray examinations postoperativeIy showed esophagea1 perforation and retropharyngeal abscess with extension to the mediastinum. Temperature receded from 102.2OF.immediateIy postoperative to 98’F. in eleven days, and he was discharged on March 2 without symptoms. (Fig. 3A and B.) CASE II. G. M., aged nineteen, was admitted May 20, 1936, with the history that

104

Amencan

Journd of Surgery

Burnett-Mediastinitis

eight days before he had swaIIowed a denture containing two teeth whiIe eating cream pie. He did not miss the denture unti1 he tried to say

Octmm, rgj1

98.3%. and .x-ray reveaIed gas in the mediastinum, both cervica1 and thoracic. There was no definite thickening of the retrotrachea1

a

FIG. 3. a, Case I. H. C., x-ray fiIms of February I, 1940, showing widening of the retroviscera1 space with gas extending to the IeveI of the fifth rib posteriorly. b, x-ray films of February 7, depth, and barium extending into 1940, showing trachea1 tube, decreased retroviscera1 perforation.

or “v.” After x-ray, attempt at remova was done in his home town foIIowed by two further unsuccessfu1 attempts, the Iast under cycIopropane. A few hours Iater there was hemoptysis and emphysema of the neck with temperature of I o I .J%. Two attacks of cyanosis with irreguIar heart action occurred in the next two days. On admission temperature was “

f

9,

tissues, but there was a small amount of gas in both pIeura1 spaces. The foreign body was visuaIized in the neck. There had beenmarked regression of gas since examinations before admission. Under observation the gas entireIy disappeared so that by June I none could be demonstrated radioIogicaIIy. The temperature meanwhile ranged between 98 and 9g’F. The

NEW SERIES

VOL.LIV.

No.

I

Burnett-Mediastinitis

esophagus was observed on severa occasions and when suffxcient recession of inflammation had occurred an attempt was made to remove the foreign body, but it was found too badIy imbedded for safe endoscopic inspection. After another such attempt, external remova by cervical mediastinotomy was done on June29, six weeks after admission. Operation revealed no pus but there was gray puruIent drainage for ten days and the temperature reachednorma in tweIve days. He was discharged Jury 15, cured. CASE III. M. K., aged sixty-nine, was admitted June 2 I, 1936, for dysphagia of nine weeks’ duration due to carcinoma of the esophagus. Physical examination was entireIy negative except for a suggestion of mass in the epigastrium. On this day he had a chiI1 which was ascribed to intravenous gIucose and the foIIowing day biopsy was obtained through the esophagoscope. On JuIy 24, he suffered another chiI1 and fever to 104”~. which subsided for a few days to beIow IOO’F. There was duIIness posteriorIy in the intrascapuIar region. Four days Iater the temperature had continued with additiona chiI1 and a tender sweIIing occurred at the base of the neck with increased width of mediastina1 duIIness. This increased and on August 3, superficial drainage of a necrotizing infection of the sternomastoid, scaIenus, and trapezius muscIes was instituted, but the mediastinum was not entered. He died the foIIowing day, August 4, and postmortem examination revealed a spontaneous perforation through the esophagea1 carcinoma with pus in the viscera1 and retroviscera1 spaces. CASE IV. J. C., aged sixty-four, was admitted January 17, 1938, with hoarseness of two months’ duration due to carcinoma of the larynx. On January 20, Iaryngectomy was done and by January 31, the wound had broken down with considerabIe sIoughing and exposure of infection in the pretrachea1 tissues. MuItipIe debridement and attempts at cIosure of the esophagea1 fistma were done unti1 ApriI 14, when a portion of necrotic sternum was excised and better drainage of the mediastinum was established. X-ray examination on March 8 reveaIed widening of the superior mediastinum, a horizonta1 streak of density above the Ieft diaphragm, and eIevation of both Ieaves of the diaphragm. He was discharged on June 9, with continued drainage, most of which was due to esophagea1 fistuIa.

American

Journal of Surgery

103

CASE v. F. W., aged fifty-nine, was admitted August 17, 1939, for hoarseness of two and one-half years due to carcinoma of the larynx. On August 24, Iaryngectomy was done and three days Iater the temperature rose to 104’~. and remained eIevated. Drainage was instituted and on September I the wound was opened wideIy for adequate drainage reveaIing invoIvement of the peritrachear tissues in the mediastinum. His temperature continued to rise and he died on September 4. No postmortem examination was obtained. CASE VI. L. B., aged seventy-two, was admitted January 17, 1937, with fairly extensive carcinoma of the thyroid (microscopicaIIy giant ceI1). On January 19, tracheotomy and thyroidectomy were done. His temperature graduaIIy rose until January 26 when he was dyspneic, had auricuIar fibriIIation, and a four sloughing wound communicating with the anterior mediastinum. On January 28, x-ray reveaIed muItipIe puImonary metastases. He became progressiveIy worse and died on February 9. Postmortem examination reveaIed residual carcinoma in the neck, muItipIe pulmonary metastases, mediastinitis, right empyema and a termina1 bronchopneumonia. CASE VII. G. McD., aged six, was admitted January 14, 1939, with a history of sore throat and stiffness in the neck beginning five days before, and foIIowed on the next day by sweIIing of the right side of the neck. Two days before her temperature had gone to IO~‘F., there was vomiting, and the folIowing day dyspnea, cough and pain in the left lower chest. On examination she was cyanotic, dyspneic and there was a tender fuIIness in the neck anteriorIy. The Ieft chest reveaIed restricted movement, duIIness and diminished breath sounds. Her temperature was 102’~. and respiration 44. X-ray revealed mediastinal widening and fluid in the Ieft pIeura. She was given prontolin intravenously and suIfapyridine by mouth and her brood concentration varied between 2 and 13 mg. per cent. FIuid was aspirated from the pIeura on January 16, I 7, and 21, and she was given five transfusions. CuItures of pIeura1 fluid showed Streptococcus hemolyticus. Medication was discontinued on February 12, four weeks after admission because the patient had apparentIy been cured. She was discharged as cured on February 16 with negative physica examination and x-ray evidence of sIight limitation

106

American

Journal

of Surgery

Burnett-Mediastinitis

ol’ diaphragmatic movement but otherwise negative. CASE VIII. M. C., aged five, was admitted August 17, 1938, for biIatera1 otitis media and right mastoiditis of three weeks’ duration. On August 29, there was considerabIe nasaI discharge, ahhough the ears and mastoid had improved markedly. She deveIoped cough, grunting respiration, and cyanosis and there were abnorma1 physical signs in the Ieft upper Iobe area. X-ray reveaIed tracheobronchia1 Iymph-node enlargement with obstructive emphysema. This Iater progressed to ateIectasis and by September 6, the Ieft Iower Iobe was aIso airIess. SeveraI aspirations were unsuccessfu1 in producing fluid, and bronchoscopy reveaIed huge quantities of pus from the Ieft bronchus containing hemoIytic streptococci and fusiform baciIIi. The patient was treated by bIood transfusion, suIfonamide drugs and neo-arsphenamine, but progressed to death on September 29. X-ray had reveaIed diminution in the mediastinal width as the suppurative pneumonitis progressed, which was interpreted in retrospect as being due to drainage of the mediastinitis spontaneousIy into the Ieft upper Iobe. The x-ray diagnosis of mediastina1 Iymph adenopathy and a positive Mantoux test had Ied to the erroneous diagnosis stated above. No postmortem examination was obtained. CASE IX. A. B., aged twenty, was admitted May 6, 1938, with a toxic psychosis for which tube feedings were begun. The patient withdrew the tube on two occasions and on May 8, there was considerabIe diffrcuIty and struggIe in reinserting it. The foIIowing day, May 9, there was emphysema of the face, neck, thorax and arms. Temperature was 104’F., puIse 160, respiration 20, white bIood ceIIs 17,750 with 88 per cent poIymorphonucIear neutrophils and of these 38 were nonfiIament forms. He was placed on nothing by mouth, SuIfaniIamide, IOO gr. daiIy, and daiIy smaI1 bIood transfusions. X-ray reveaIed emphysema but no thickening of the cervica1 and thoracic mediastina1 tissues. There was rapid improvement, the temperature reaching norma in six days, aIthough there were two subsequent rises from May 17 to 21 and from May 23 to June 3, as high as 104’F. on one day, but x-ray reveaIed no thickening and decreased gas in the mediastinum. Observation over the next three months during which the psychosis improved, showed no further evidence of mediastinal infection.

OcTonrn. ,041

T. C., aged fifty-six, was admitted CASE x. December I I, 1937, with a three-month history of dysphagia due to carcinoma of the esophagus. Endoscopic examinations were made on December 13 and 16 without diffIcuIty and the constriction visuaIized. On December 17, temperature rose to IOO’F. and there was sweIIing and tenderness on the Ieft side of the neck aIong the anterior border of the sternomastoid. This was drained and 5 to IO cc. of thin odorIess pus evacuated, which upon cuIture was steriIe. Seven days Iater a gastrostomy was done and the patient was discharged on January 15, I 938, with no further evidence of mediastina1 infection. CASE XI. S. W., aged seventy, was admitted February 15, 1938, with a history that she had suffered dysphagia progressiveIy for six weeks and substerna pain for the past two or three weeks. She had Iost twenty pounds in weight. Examination reveaIed temperature of I 0 I OF. with sweIIing and tenderness of the Ieft side of the neck. White blood ceIIs, 25,000 with 90 per cent poIymorphonucIear neutrophiIs of which 50 were nonfdament. Two days Iater a gastrostomy for feeding and cervica1 mediastinotomy were done. On February 19, two days postopertiveIy, she died suddenIy, apparentIy of a vascuIar accident. CASE XII. G. E., aged eight, was admitted November 14, 1935, for IaryngeaI stenosis of severa months’ duration. On October 12, 1936, foIIowing Iaryngeal diIatation temperature rose to 102’F. In the next three days it rose in septic fashion to 104OF., and on October 16, 1936, x-ray reveaIed widening of the retrotrachea1 space with presence of gas. CervicaI mediastinotomy was attempted but no pus couId be found and the wound was packed with vaseIine gauze. A second attempt on October 23 drained about 60 cc. of thick gray fetid pus and gas. Temperature returned to 99’F. in five days and to norma in eIeven days and she continued to compIete convalescence. CASE XIII. A. S., aged forty-four, was admitted May 12, 1939, with a history that a11her teeth had been extracted four days before. The foIIowing day she awakened with marked sweIIing of the jaw, fever and genera1 aching. The next day there was sweIIing of the floor of the mouth and neck with dysphagia and the third day this was increased and she noted pain in the chest substernaIIy and under the Ieft scapula. Examination reveaIed temperature

New SERIES VOL.LIV, No. I

Burnett-Mediastinitis

IO~‘F., herpes Iabialis, toxic appearance with fouI drainage from tooth sockets and marked sweIIing of the ffoor of the mouth preventing observation of the pharynx. There was marked sweIIing of the Ieft neck and the white bIood ceIIs numbered 13,900 with 80 per cent poIymorphonucIear neutrophils of which 34 were nonfiIament. Smears and cuItures showed no spirochetes ar,d many viridans streptococci. Two blood cuItures were negative. In the foIIowing three days dyspnea appeared and became pronounced, there was one chiI1, and the patient became diririous and cyanotic and suffered severe abdomina1 pain and distention. This picture progressed till her death on May 17. Postmortem examination revealed pus in the retrovisceral space from neck to diaphragm, pericarditis, and bilateral empyema, each space containing more than IOO cc. of gray green pus, cultures of which showed Streptococcus hemoIyticus and Streptococcus viridans in aerobic and anerobic cuIture. CASE XIV. E. G., aged forty-nine, was admitted March 20, 1938. Nine days before whiIe eating fish, she choked on a bone, since which time there has been sticking pain in the throat. In the past three days pain was severe and there was aImost complete dysphagia. Examination showed temperature 99.8”F. with sweIIing of the mucous membrane of the posterior pharyngeal waI1; Wassermann 3, white brood ceIIs 7,700 with 70 per cent poIymorphonucIear neutrophiIs of which 34 were nonfilament. An x-ray reveaIed retropharyngea1 thickening of soft tissues and gas. On March 22, cervica1 mediastinotomy produced 60 cc. of thick fou1 pus from about the esophagus. CuItures showed viridans streptococcus and bacteroids. Her temperature reached norma in eight days and she was discharged heaIed on ApriI 16, four weeks after admission. CASExv. R. T., aged seven, was admitted ApriI 5, 1940, with a history of sharp pain in the throat since he had swaIIowed a sharp object whiIe eating jam two days before. At that time his physician induced vomiting without improvement, and the mother discovered a section of gIass missing from the jam jar. Examination reveaIed temperature 102’F., the patient was unabIe to move his head or swaIIow without pain, and there was tenderness over the neck. X-ray reveaIed a triangurar piece of glass and emphysema of the retroviscera1 space, both cervica1 and thoracic. The foIIowing day cervi-

American Journal of Surgery

107

ca1 mediastinotomy was done reIeasing gas and fou1 pus, and aIthough the gIass fragment was paIpated, it was disIodged and moved down the esophagus preventing removal. His temperature feI1 to normal in five days, ApriI I I, and he passed the gIass by rectum. Sulfapyridine was administered for one day but was discontinued because of hematuria. He was discharged ApriI 26 with a healed wound as cured. CASE XVI. J. S., aged forty-six, was admitted September 2, 1937, with a history that ten days before, while eating crab meat, he had swallowed a piece of shell. This caused coughing and a cutting pain in the throat with pain in the chest which persisted to admission. On examination, temperature was IOI’F., puIse 100, respiration 30, but no physica signs could be found in the neck or the thorax. Esophagoscopy revealed esophagitis with urceration. The foIIowing day there was more pain and emphysema with tenderness in the left neck anteriorIy. The next day white bIood ceIIs 19,300, with 75 per cent polymorphonuclear neutrophiIs of which I 5 were nonfilament forms, and x-ray revealed retroviscerar thickening and gas. In the next seven days there was steady improvement and he was discharged for observation as an outpatient. On September 15, the throat became very sore and in a few hours he coughed up a large quantity of pus. He was readmitted the following day, September 16, with marked dysphagia and induration aIong the anterior border of the Ieft sternomastoid. The foIlowing day cervica1 mediastinotomy was done reIeasing gas and fou1 pus under tension. The temperature dropped from IOI to 98°F. in two days and he was discharged on September 24 improved. CASE XVII. A. W., aged forty-two, was admitted May 13, 1937, for esophageal stenosis of unknown etioIogy. She was examined endoscopicaIIy and the next day her temperature rose to 102’F. The foIlowing day x-ray revealed retrotrachea1 thickening and gas, and barium penetrating the esophagea1 waI1. However, temperature sIowIy subsided and there was genera1 improvement except for x-ray evidence on May 19 of increased gas and sweIIing in the retroviscerar space with narrowing of the trachea from outside pressure on the right. On May 21, eight days after the onset a cervica1 mediastinotomy releasing fetid was done yeIIowish gray pus from the retrovisceral space. Her convalescence was good unti1 June 2, her

108

Anlerrcan Journalof Surgery

tweI ve postoperative haul ‘s she had three requ .iring secondary

Burnett---Mediastinitis

day. In the next twenty rather severe hemorrhages operation on June 3. This

OcroeER, 1941

CASE XIX. G. B., aged fifty-four, was admitted October 9, I 939, for dilatation of car .diospasm associated with hiata1 hernia. On

FIG. 4. Case XIX. G. B., left, x-ray fiIm of October 14, 1939, showing extensive retrovisceral thickening and gas. Right, x-ray film of February

showed a sIough of the carotid artery which required Iigation of same for contro1. She developed a hemipIegia from Ioss of crania1 bIood suppIy and died the folIowing day. Postmortem examination reveaIed continued posterior mediastinitis, fibrinous pIeurisy but no ff uid on the Ieft and softening of the right cerebral hemisphere. CASE XVIII. K. C., aged seventy-five, was admitted January 27, 1939, with a history of swaIIowing a fish bone five days before. For two days there had been severe pain on swaIIowing which then decreased. For the past three days she had fever and pain in the right upper chest anteriorly. Examination showed temperature of 100.4’~. and tenderness in the neck anteriorIy. There were 14,800 white bIood ceIIs of which 77 per cent were poIymorphonucIear neutrophiIs and 30 of these nonfiIament forms, and bIood sugar of 270. On January 28, cervical mediastinotomy was done reIeasing about 60 cc. of odorous pus and gas from the retroviscera1 space. Temperature receded to norma in ten days and she was discharged February 12, 1939, as cured.

2, 1940, showing decreased depth and gas.

dilatation was done October I 2, esophagoscopic and two days Iater there was pain, tenderness, sweIIing and emphysema in the Ieft neck anteriorIy. White bIood ceIIs, 5,800 of which 88 per cent were poIymorphonucIear neutrophiIs and 28 of these nonfiIament forms. The x-ray reveaIed peritrachea1 gas and phIegmon. The foIIowing morning, October 14, the patient was deIirious and cervical mediastinotomy was done reIeasing IO to 15 cc. of foul brownish pus from the retroviscera1 space. Temperature dropped to norma in eIeven days but drainage persisted due to esophagea1 fistuIa. The puruIent character disappeared within two weeks and heaIing was compIete in 2 months. (Fig. 4.) CASE xx. D. S., aged seventeen, was admitted May 14, 1937, with a history of swalIow-ing a chicken bone a few hours before. Sticking pain had been present since. Temperature was IOO’F. and there was slight tenderness in the neck. During esophagoscopy the bone passed on down the esophagus. Temperature increased to 102~~. and there was evidence by x-ray of gas in the mediastinum and Ieft pIeura and a white bIood count of 17,000 with 83 per cent poIy-

NEWSHHIES VOL.LIV. No. 1

Burnett-Mediastinitis

morphonucIear neutrophils of which 50 were nontiIament forms on May I 5. On May I 7, fluid was found in the Ieft pIeura and this was drained on May 18 by intercosta1 drainage revealing four gray pus and gas. No mediastinotomy was done. The patient made sIight temporary improvement folIowed by steady regression and finaIIy hemorrhagic drainage through the thoracostomy ended in death on May 25. K. M., aged thirty-eight, was CASE XXI. admitted January I, 1937, with a history that eIeven days before whiIe eating a veaI cutIet a sharp object stuck in his throat. A physician and x-ray examination couId find nothing abnormal. Six days Iater a Iump appeared on the neck aIong the anterior border of the sternomastoid and two days Iater he began to expectorate fou1 pus. Additiona x-ray revealed a piece of wire in the esophagea1 waI1, and he was sent to the hospita1. Examination revealed temperature IOI’F., sweIIing on both sides of the neck more marked on the right which was tender and caused pain radiating to the right arm. SwaIIowing caused simiIar pain. The following day, tweIve days after onset, cervical mediastinotomy reveaIed 13 cc. of fetid gray pus and a piece of wire. On January 13, temperature was normal, there was very IittIe drainage, and the patient was symptom free. He was discharged to the care of his family physician. (Fig. 5 .) CASE XXII. S. D., aged four was admitted ApriI I, 1938, with history of swaIIowing catsup bottle top seven days before. There was choking and cyanosis for a short time foIIowed by vomiting and anorexia. RemovaI was attempted before admission foIIowing which there was cough and cyanosis. Examination reveaIed temperature of IoI’F. with some reddening in the pharynx but no sweIIing or emphysema of the neck. There were a few raIes over the right Iower Iobe area. White bIood cells 18,400 with 42 per cent poIymorphonucIear neutrophiIs of which 21 were nonfiIament Four days Iater x-ray showed foreign body had moved into the stomach. There was a marked increase in temperature to 104OF. and in the white bIood ceIIs to 90,000 with 56 per cent poIymorphonucIear neutrophiIs of which 45 were nonfiIament. Two days Iater she was extremely toxic. There was no emphysema of the neck and x-ray showed widening of the mediastinum and the presence of gas. In this critica condition cervi-

American Journal of Surgery

109

ca1 mediastinotomy was done and thick cIoudy fluid with considerabIe ceIIuIitis and edema was reveaIed which showed a cuIture of hemoIytic streptococcus. She died the same day, ApriI 6, 1938. CASE XXIII. J. T., aged fifty-seven, was admitted JuIy 12, 1937, for a carcinoma of the esophagus producing symptoms over the past six months. FoIIowing biopsy on JuIy 12, the patient sIowIy deveIoped temperature to I o I OF. over the next three days with subcutaneous emphysema of the neck and x-ray evidence of retrotrachea1 widening and gas. There was aIso an increase of the Iung marking on the Ieft as compared to previous fiIms. Two days later, JuIy 17, there was increase in symptoms and IocaI evidence and a cervica1 mediastinotomy was productive of fou1 pus and gas. FoIIowing this the patient improved rapidIy over a period of two weeks and was discharged with continued drainage and without x-ray check-up. He was readmitted on September IO, 1937, seven weeks after mediastinotomy with a heaIed mediastinotomy and increasing dysphagia which was ascribed to his carcinoma. On September I I, a gastrostomy was done. On September 15, the patient had circuIatory coIIapse with pain in the chest and Ieft Iower abdomina1 quadrant and physica signs suggesting ateIectasis at the left base. X-ray revealed evidence of aterectasis or pneumonitis left base. The patient became progressiveIy worse and died on September 25, having been moribund for five days. Postmortem examination reveaIed 400 cc. of thick fou1 pus in the posterior mediastina space, puruIent pericarditis and hemorrhagic effusion in both pIeura, 800 cc. on one side and 1,800 on the other. CASE XXIV. H. B., aged eighteen months, was admitted December 28, 1938, two months after she had swaIIowed Iye, with increasing difficuIty in swaIIowing since. Her temperature was IOI’F., physica examination negative and white bIood cells, 16,500 with 40 per cent polymorphonuclear neutrophiIs of which I 4 were nonfiIament. On December 30, esophagoscopy showed ulceration and swehing of the mucosa. ImmediateIy after the patient began vomiting and within four hours there was fever of 103”~., cyanosis, and Iabored breathing. This progressed rapidIy, there was emphysema of neck and x-ray evidence of gas in the mediastinum, pericardium, and Ieft pIeura. Aspiration removed 40 cc. of miIky ffuid and gas from the

I IO

American

Journal

of Surgery

Burnett-Mediastinitis

Ieft pIema and similar material from the pericardium. CuItures of these showed hemoIytic staphyIococcus aureus and non-hemolytic

OCTOBER. 19.41

pain in the Ieft ear which had been host to otitis media at the age of three and again at the age of eight. His temperature was gg to IOOOF., pulse

a

b

FIG. g. a, Case XXI. K. M., x-ray fiIms of January 2, 1937, showing thickening of the retroviscera1 space extending to the fifth rib posteriorly with gas and wire. b, x-ray fiIms of January 12, 1937, showing decreased depth and gas and three wire sutures.

streptococcus on both aerobic and anaerobic cuIture. The chiId was too III to consider the muItipIe surgica1 procedures necessary for drainage and died in the next seven hours, December 31, 1938. (Fig. 6.) CASE XXV. C. VanF., aged twenty-five, was admitted November 3, 1939, with a history of sore throat and swelling anterior to the Ieft mastoid beginning eight days before. He had

74 and respiration 20. The pharyngea1 wall, uvuIa, and Ieft tonsiIIar fossa were red and swoIIen. There was poor denta hygiene and neck was hot, tender and indurated in the Ieft anterior portion from the mandibIe to the base of the neck. The foIIowing day, November 4, a quantity of fou1 smeIIing pus was evacuated by superficia1 incision and apparentIy the character of the abscess was not recognized. CuIture

NEUr SERIES VOL. LIV, No. I

Burnett-Mediastinitis

viridans on aerobic and sho wed Streptococcus hen IoIytic streptococcus and bacteroids on ana erobic cuIture. Profuse drainage continued

Americnn Journal of Surgery

III

hemoIytic staphyIococcus aureus. His temp Ierature returned to normaI in five days and his progress was good. On December 13, opa lque

FIG.6. Case XXIV. H. B., x-ray films of December 30. 1938, showing extensive mediastina1 emphysema extending from skull to diaphragm,

Ieft hydropneumothorax

for three days then decreased, and he was discharged six days later as improved. He was readmitted December I, three weeks Iater, stating that for one week after discharge he improved but was constantIy hoarse. One week ago the sIight pain on swaIIowing which he had suffered increased as did the hoarseness. One haIf hour before admission severe cough, dyspnea and some hemoptysis had occurred, and he was rushed to the hospita1 by his physician. Examination showed marked dyspnea and cyanosis anc1 continued drainage from the cervica1 wound. Mirror Iaryngoscopy reveaIed fixation in adduction of both voca1 cords with dispIacement of the Iarynx to the right. Emergency tracheotomy was done with marked reIief. On December 2, x-ray reveaIed gas and phIegmon of the retroviscera1 and viscera1 spaces-not communicating with tracheotomy wound. DispIacement of the trachea to the right was aIso demonstrated. There were 10,800 white bIood ceIIs with 65 per cent poIymorphonucIear neutrophiIs, 13 of which were no&ament. CuIture from the drainage reveaIed

and hydropneumopericardium.

materia1 was introduced through the cervica1 wound and x-ray taken outIining the retroviscera1 space from the cIavicIe to the base of the skuI1. He was again discharged on December 22, with continued cervica1 drainage so that he might spend the Christmas hoIidays at home. He was readmitted on January 4 in the same condition. Because of persisting drainage the cervica1 wound was enIarged on January I 7, I 940, and he was discharged on February 5 with Iessened drainage continued paraIysis of the cords and sweIIing of the epigIottic and subgIottic regions. Treatment was continued over the next year for IaryngeaI stenosis requiring wearing of the tracheotomy tube. X-ray of showed persistence of soft August 30, 1940 tissue sweIIing about the Iarynx, chiefly to the right. CASE XXVI. H. S., aged twenty-three, was admitted June 5, 1937, with a history of extraction of the first Ieft Iower moIar four days ago. Two days Iater there was sweIIing and pain in the Ieft submaxiIIary area which has progressed to trismus and sweIIing under the tongue.

I I2

American Journal of Surgery

Burnett-Mediastinitis

Examination reveaIed pus exuding from the swoIIen socket, trismus and tenderness with induration in the Ieft submaxillary region extending in lessened degree to the left cIavicIe. There was aIso marked Iymphadenopathy on this side, temperature IOI’F., puIse I IO, respiration 22. CuIture showed Streptococcus viridans. He was given suIfaniIamide go gr. daiIy, bIood transfusions, and ice bag to the affected area, foIIowing which there was rapid and marked improvement so that the surgica1 drainage pIanned for the foIIowing day was postponed. Temperature reached norma in three days and he was discharged June I I as cured. CASE. XXVII. R. DiG., aged forty-six, was admitted ApriI 17, 1940, seven days after toothache began in the right Iower third moIar. The foIIowing day there was sweIIing about the mandibIe which increased, and two days Iater chiIIs and fever occurred. The next day the tooth was extracted and much pus evacuated. However, the sweIIing increased, fever persisted and respiratory difflcuIty occurred just before admission. Examination showed sweIIing of the IateraI and posterior pharyngea1 waI1, the ffoor of the mouth, and the entire neck anteriorIy. The appearance of the gums suggested Vincent’s angina and there was very poor denta hygiene. The patient was cyanotic and in a state of vascuIar coIIapse. The temperature was IOIOF., puIse 140, respiration 50, white bIood ceIIs 13,450 with 89 per cent poIymorphonucIear neutrophiIs of which 61 were nonfiIament forms. X-ray reveaIed retropharyngea1 and posterior mediastina1 induration, and possibIe bronchopneumonia of the Ieft Iower Iobe. He died within a few hours before anything couId be done except the administration of SuIfaniIamide for two or three doses. Postmortem examination reveaIed Ludwig’s angina, IateraI pharyngea1 space and retropharyngea1 abscess extending into the posterior mediastinum, pericarditis and biIatera1 empyema. BIood cuhures were overgrown with contaminants. CASE XXVIII. L. S., aged forty-seven, was admitted January 13, 1937, with a history that four days before a chicken bone had stuck in his throat causing temporary choking. He made an effort to remove it with his finger but the symptoms persisted. That night there was dyspnea on Iying down and at 4 A.M. his doctor tried to force the bone down the esophagus. Two days

before admission x-ray reveaIed the bone and an attempt at esophagoscopical removal was unsuccessfu1. Since that time the patient was unabIe to swaIIow and there was pain in the throat and chest for which he was referred to the hospital. Examination reveaIed temperature g8.4%., puIse 84, and respiration 22 with no sweIIing or tenderness of the neck but a swoIIen posterior pharyngea1 waI1. X-ray reveaIed retroviscera1 phlegmon and gas and an opaque area suggestive of bone. Barium penetrated the posterior pharyngea1 waI1. He improved and was discharged on January 16 to his famiIy physician. One month Iater he coughed up a portion of tooth-pick measuring two and one-haIf inches with compIete reIief except for occasiona choking sensation over the past five months. CONCLUSIONS Acute mediastinitis is a fairIy common disease as indicated by pubhshed reports and thirty-eight cases at TempIe University HospitaI in five years. KnowIedge of the practica1 anatomy of the fascia1 pIanes of the neck and thorax as reviewed is of vita1 importance. AnaIysis of the etiology, symptoms, and resuIts of our cases compared with rg7 cases coIIected from the Iiterature indicates that the mortaIity of undrained cases ranges between 60 and 80 per cent and that for the group in which adequate drainage was estabIished varies between 3344 and 40 per cent. Accurate diagnosis is possibIe if the Iesion is considered in potentia1 cases. X-ray study has been the most dependabIe method of investigation. Immediate drainage by cervica1 mediastinotomy with the additiona supportive measures outIined offers the best prospect for cure. The author is very gratefu1 to the foIIowing for their permission to anaIyze some of their cases: Doctors G. Mason AstIey, W. Wayne Babcock, J. Norman Coombs, Matthew S. Ersner, TempIe Fay, ChevaIier L. Jackson, Savere F. Madonna, Robert F. Ridpath and WilIiam A. SteeI.

NEW SERIESVOL.LIV. No.

I

Burnett-Mediastinitis

REFERENCES BRILL, N. Q. and SILBERMAN, D. E. Pyogenic osteomyelitis of the spine, mediastinat abscess and compression of the spinat cord. J. A. M. A., I IO: ZOOI, 1938. CHURCHILL, E. D. Esophageal surgery. Surg., Gyner. @ Obst., 60: 417, 1935. EQUEN, M. and NEUFFER, F. Carcinoma of upper esophagus, Iaryngectomy and resection; postoperative mediastinitis and drainage: 3 year cure. South. Surg., 7: 71 I, 1938. FURSTENBERG,A. C. and YGI.ESIAS, L. Mediastinitis, a chnical study with practica1 anatomic considerations of the neck and mediastinum. Arch. Otol., 23: 539. 1937. JEMERIN, E. E. and NEUHOF, H. A demonstration of cervicomediastina1 continuity with comments on extrapleura extension of mediastinat abscess. .I. Tboracic. Surg., g: I, rg3g.

American

Journal

of Surgery

“3

JONES, C. C., BROWN, S. and FINE, A. MediastinaI abscess complicating retropharyngea1 abscess; case. Radiology, 28: 747, 1937. KAMPMEIER, R. H. TubercuIous mediastinitis; case with focal reaction to tubercubn. Am. Rev. Tuberc., 37: 71, 1938. KEEFER, C. S. Acute and chronic mediastinitis; 60 cases. Arch. Inc. Med., 62: Iog, 1938. NEUHOF, H. Acute infections of the mediastinum with specia1 reference to mediastinal suppuration. J. Tboracic. Surg., 6: 184, 1936. PEARSE, H. E., JR. Mediastinitis foIlowing cervica1 suppuration. Ann. Surg., 108: 588, 1938. The operation for perforations of the cervicat esophagus. Szlrg., Gynec. @ Obst., 61: 192, 1933. PHILLIPS, C. E. Mediastinal infection from esophageal perforation. J. A. M. A., I I I : 998, 1938. TREMBLE, G. E. and HEWITT, P. MediastinaI abscess foIlowing tonsillectomy. Arch. Otol., 28: 768, 1938.

A GOITER fixed by capsuIar infiItration which makes the technic diffIcuIt is more IiabIe to Iead to disaster than those in which the gIand is freeIy movabIe. Therefore if the gIand is fixed, one had better wait unti1 it Ioosens.