Mediastinitis: Symptoms, Types, Causes and Treatment

Mediastinitis is a rare but potentially life-threatening condition involving inflammation and infection of the mediastinum—the central compartment in the chest that houses the heart, great vessels, trachea, and esophagus. Despite advances in medical care, mediastinitis remains a serious disease due to its proximity to vital structures, challenging diagnosis, and complex treatment. In this article, we explore the core aspects of mediastinitis: its symptoms, types, causes, and modern management strategies.

Symptoms of Mediastinitis

Recognizing mediastinitis early is crucial for improving patient outcomes. The symptoms can vary depending on the underlying cause and type but generally signal severe infection and inflammation within the chest cavity. Both acute and chronic forms can present differently, and some symptoms may mimic other serious conditions.

Symptom	Description	Severity/Presentation	Source(s)
Pain	Chest, neck, or upper back discomfort	Often severe and constant	1 3 5
Edema	Swelling in neck/chest	Noticeable, may be brawny	1 7
Dysphagia	Difficulty swallowing	Common, often pronounced	1 3
Dyspnea	Shortness of breath	May progress to airway obstruction	1 2 11
Sepsis	Systemic infection signs	Fever, tachycardia, shock	1 5 12
Cough	Productive or dry	Sometimes with expectoration	2
Dysphonia	Hoarse voice	More significant in severe cases	1
Other	Restriction of neck movement, vascular/nerve compression symptoms, pneumonia	Variable	1 3 5 12

Table 1: Key Symptoms

Common Symptoms of Acute Mediastinitis

Acute mediastinitis usually presents suddenly, with severe chest pain, fever, and rapid deterioration. The pain may radiate to the neck, back, or shoulders. Swelling or brawny edema of the neck and upper chest, difficulty swallowing (dysphagia), and shortness of breath (dyspnea) are frequent complaints. The infection can quickly lead to sepsis, a life-threatening systemic response with high fever, rapid heart rate, and low blood pressure 1 3 5 7 12.

Chronic and Fibrosing Mediastinitis

Chronic forms, such as fibrosing mediastinitis, tend to develop slowly. Symptoms result mainly from compression of mediastinal structures rather than acute infection. Patients may present with persistent cough, progressive shortness of breath, and signs of obstruction (e.g., swelling of the arms, face, or neck due to superior vena cava syndrome). Some experience recurrent pneumonia or hemoptysis (coughing up blood) 2 8.

Symptoms Related to Origin and Spread

The initial source of infection can influence symptoms:

• Odontogenic or tonsillar sources: More likely to present with neck pain, restricted neck movement, and rapid progression to respiratory symptoms 1 3 5.
• Postoperative or traumatic mediastinitis: Often presents with wound dehiscence, fever, and chest pain following surgery 9 10.
• Compression symptoms: Chronic fibrosis may cause symptoms mimicking other diseases (e.g., myocardial infarction, gastric ulcer), complicating diagnosis 3 8.

Complications

Complications such as airway obstruction, pneumonia, and multi-organ failure are common, particularly in severe or untreated cases 1 5 12. Early recognition of key symptoms—especially in at-risk populations—is essential for prompt intervention.

Types of Mediastinitis

Mediastinitis is not a single disease but encompasses several distinct clinical entities, each with its own triggers, progression, and management requirements.

Type	Characteristics	Common Etiology/Features	Source(s)
Acute (Necrotizing)	Rapid onset, tissue necrosis	Esophageal perforation, deep neck infection	5 6 12
Postoperative	After thoracic surgery, especially sternotomy	Wound infection, dehiscence	4 9 10 14
Descending Necrotizing	Infection spreads from head/neck downward	Odontogenic, pharyngeal sources	1 5 6 7
Chronic (Fibrosing)	Slow progression, dense fibrosis	Histoplasmosis, TB, idiopathic	2 8 12
Granulomatous	Granuloma formation in mediastinum	Tuberculosis, fungal infection	2 8 12

Table 2: Types of Mediastinitis

Acute Mediastinitis

Acute mediastinitis is most often due to perforation of the esophagus or direct contamination during thoracic surgery. It is characterized by rapid onset, severe symptoms, and tissue destruction within the mediastinum 5 12.

Postoperative Mediastinitis

A significant subset arises after cardiac or thoracic surgery, particularly median sternotomy for open-heart operations. Postoperative mediastinitis (also known as deep sternal wound infection) may occur due to infection of the surgical site, sternal instability, or foreign body reaction. It is associated with high morbidity and mortality 4 9 10 14.

Descending Necrotizing Mediastinitis (DNM)

This aggressive variant results from the downward spread of infection from the head and neck, often due to odontogenic or pharyngeal sources. DNM is notorious for its rapid progression and high mortality if not recognized and treated aggressively 1 5 6 7.

Chronic Mediastinitis

Chronic mediastinitis includes fibrosing (sclerosing) and granulomatous types. Fibrosing mediastinitis is characterized by proliferation of fibrous tissue, often leading to compression of vital mediastinal structures. It most commonly results from granulomatous infections (e.g., Histoplasma capsulatum in the US, tuberculosis in some regions), but may be idiopathic 2 8 12.

Granulomatous Mediastinitis

This less common form is marked by granuloma (organized clusters of immune cells) formation, typically due to tuberculosis or fungal infections 2 8 12. It often overlaps with fibrosing mediastinitis.

Causes of Mediastinitis

Understanding the root causes of mediastinitis aids in both prevention and targeted therapy. Etiologies range from infectious sources to surgical complications.

Cause	Description	Risk Factors/Contexts	Source(s)
Postoperative Infection	After cardiac/thoracic surgery	Obesity, COPD, long surgery	9 10 14
Esophageal Perforation	Rupture or injury to esophagus	Trauma, surgery, caustics	11 12
Descending Infection	Spread from head/neck infections	Dental, tonsillar, pharyngeal	1 5 6 7
Chronic Infection	Granulomatous/fibrosing processes	TB, histoplasmosis	2 8 12
Trauma	Penetrating injuries to chest/neck	Accidents, violence	12

Table 3: Causes of Mediastinitis

Postoperative and Iatrogenic Causes

The most frequent modern cause is infection following median sternotomy or thoracic surgery. Risk factors include:

• Obesity
• Chronic obstructive pulmonary disease (COPD)
• Sternal dehiscence (instability or separation of the breastbone)
• Long operative times
• Reoperation
• Use of foreign materials (e.g., wires, grafts) 9 10 14

Microbiologically, these infections are commonly due to coagulase-negative staphylococci, Staphylococcus aureus, and occasionally gram-negative organisms 9.

Esophageal Perforation

Esophageal injury—whether from trauma, surgery, or caustic ingestion—can rapidly introduce infection into the mediastinum, leading to acute necrotizing mediastinitis. This is a medical emergency due to the proximity to the heart and great vessels 11 12.

Descending Infections

Odontogenic, tonsillar, and pharyngeal infections can spread downward along fascial planes into the mediastinum, causing descending necrotizing mediastinitis. Individuals with cardiovascular or pulmonary comorbidities are at higher risk for this extension 1 5 6 7.

Chronic and Granulomatous Infections

Chronic mediastinitis often develops due to a prolonged immunologic response to certain infections. In the United States, Histoplasma capsulatum is the most common cause; in other regions (e.g., China), tuberculosis is more prevalent 2 8. Some cases remain idiopathic (cause unknown).

Trauma

Direct penetrating trauma to the neck or chest can introduce pathogens into the mediastinum, although this is now a less common cause 12.

Treatment of Mediastinitis

Managing mediastinitis requires a multifaceted approach tailored to the type, severity, and underlying cause. Early intervention is crucial for survival.

Treatment	Application/Indication	Effectiveness/Notes	Source(s)
Surgical Debridement	Removal of infected/necrotic tissue	Essential for most cases	4 5 6 13 14 16
Drainage	Mediastinal and wound drainage	Transcervical or thoracic approaches	6 7 16
Antibiotics	Broad-spectrum, culture-guided	Always used in combination	11 12 14
Wound Management	Irrigation, negative pressure, sugar packing	VAC, sugar packing, flaps	13 14 15
Reconstructive Surgery	Sternal closure, tissue flaps	Improves stability/outcomes	4 13 14
Supportive Care	ICU monitoring, sepsis management	Critical for severe cases	11

Table 4: Treatment Modalities

Surgical Management

Debridement and Drainage
The cornerstone of treatment is aggressive surgical removal of infected and dead tissue, combined with drainage of the mediastinum. The surgical approach depends on disease extent:

• Transcervical drainage is suitable for limited, upper mediastinal disease.
• Thoracic approaches (thoracotomy or subxiphoid incision) are necessary for extensive or lower mediastinal involvement 5 6 7 16.
• Early and repeated interventions may be required for ongoing sepsis 16.

Reconstructive Techniques
Once infection is controlled, closure of the sternum and coverage with vascularized tissue flaps (e.g., pectoralis major advancement) improve healing and reduce mortality 4 13 14. Modern techniques such as the modified Robicsek closure and muscle flaps have proven effective 13.

Wound Care Innovations

• Negative Pressure (VAC) Therapy: Applying local negative pressure (vacuum-assisted closure) promotes wound healing and reduces infection rates, especially in poststernotomy mediastinitis 14.
• Sugar Packing: Application of granulated sugar to open mediastinal wounds has demonstrated effective debridement and rapid granulation, with relatively painless dressing changes 15.

Medical Therapy

Broad-spectrum intravenous antibiotics are started empirically, then tailored to culture results. Therapy must cover likely pathogens based on the cause (e.g., staphylococci for postoperative cases; mixed aerobic/anaerobic flora for descending infections) 11 12 14.

Supportive and Adjunctive Measures

ICU-level supportive care is often required, with attention to:

• Sepsis management (fluids, vasopressors)
• Airway protection and respiratory support
• Management of comorbidities
• Nutritional support 11

Chronic and Fibrosing Mediastinitis

In chronic cases, surgery is generally palliative, aimed at relieving obstruction. Immunosuppressive therapy, antifungals, or anti-tuberculous therapy may be considered, but responses are often inconsistent 2 8 12.

Conclusion

Mediastinitis is a complex and dangerous disease requiring rapid diagnosis and multidisciplinary management. Key takeaways include:

• Symptoms are often severe and include chest pain, neck swelling, dysphagia, dyspnea, and signs of systemic infection.
• Types range from acute and postoperative forms to chronic fibrosing and granulomatous mediastinitis.
• Causes include postoperative infection, descending neck infections, esophageal perforation, chronic granulomatous processes, and rarely trauma.
• Treatment is centered on prompt surgical intervention, effective wound care, appropriate antibiotics, and supportive ICU care, with innovative wound management strategies improving outcomes.

In summary:

• Early recognition and intervention are vital.
• Treatment is surgical and multidisciplinary.
• Chronic forms remain challenging and often require palliative measures.
• Advances in wound management are improving survival and recovery.

Staying vigilant for this rare but deadly disease—especially in at-risk patients—remains a cornerstone of modern thoracic and critical care medicine.