Fatal Mediastinal Abscess from Upper Respiratory Infection

Abstract

Suppurative mediastinitis following neck infection is an uncommon entity that carries a 40% mortality. It is most commonly associated with esophageal perforation or odontogenic abscess. The rapidity of spread has been attributed to dependent drainage from the neck into the mediastinum, negative intrathoracic pressure, and synergistic necrotizing bacterial growth. Cultures obtained usually grow streptococci and/or Bacteroides. We report the case of a 34-year-old woman with an upper respiratory infection who subsequently was found to have a para-/retropharyngeal and mediastinal abscess. Septic shock, respiratory failure, and death ensued, despite aggressive treatment with broad-spectrum antibiotics (for both aerobes and anaerobes), surgical drainage of the neck and mediastinum, and cardiorespiratory support. The danger of a rapid downhill clinical course with mortality due to suppurative mediastinitis makes early diagnosis of critical importance. All clinicians evaluating a “sore throat” should consider neck edema or gas on neck radiograms as evidence of cervical abscess, and subsequent widening of the mediastinum on chest x-ray as an ominous sign suggesting mediastinal abscess.

Placement of transnasal drainage catheter and covered esophageal stent for the treatment of perforated esophageal carcinoma with mediastinal abscess

“…The incidence of mediastinal abscess is low, and it commonly occurs secondary to the following factors: downward spread of neck infections, operation, tracheal endoscopy-guided mediastinal biopsy, presence of a foreign body in the esophagus, and presence of an esophagomediastinal fistula. The associated mortality rate is high at 40%, because of delayed diagnosis and treatment [1][2][3]. Esophageal carcinoma can infiltrate the esophageal tissue, and an esophagomediastinal fistula is formed when cancerous tissue undergoes necrosis and ulceration.…”

Spontaneous descending retropharyngeal abscess

“…Given the inferior extent of the retropharyngeal space, it is not surprising that mediastinitis and abscess formation can also occur. Therefore, early recognition and aggressive management of a retropharyngeal abscess are essential due to the significant morbidity and associated mortality 6. Mortality rates as high as 30%, even now, are still reported 7.…”

Chest Drainage

“…Mortality rates can be as high as 40% in cases when the diagnosis is not readily suspected and treatment is delayed. 37,38 Common etiologies of mediastinal abscess include head and neck infections that descend into the mediastinum, trauma, and postsurgical. Mediastinal abscesses following esophagogastric surgery have a reported frequency of 8 to 21% and are the leading cause of postoperative morbidity, stricture, and repeated operation.…”