Mediastinit - aseptic or microbic inflammatory process in sredoyosteniye cellulose with a sharp or chronic current. Development of a sharp mediastinit is characterized by pain behind a breast, fever, oznoba, tachycardia, heavy endogenous intoxication. At a chronic mediastinit to the forefront there are symptoms of a compression of bodies of a sredosteniye (cough, short wind, a dysphagy). Diagnostics of a mediastinit is carried out taking into account the given x-ray inspection, KT, ultrasonography, an ezofagoskopiya, a bronkhoskopiya, a mediastinoskopiya. Medical tactics at a mediastinita – active, demands elimination of the reason of an inflammation and carrying out a mediastinotomiya with adequate drainage of the purulent center.
Mediastinit is a life-endangering state and in case of overdue diagnostics or inadequate treatment is followed by high rates of a lethality. Practice shows that only 15-20% of cases of a mediastinit come to light prizhiznenno that is connected with quickly progressing course of a disease and insufficiently patognomonichny manifestations against the background of the general heavy infection.
Mediastinitom can become complicated considerable number of pathological conditions of lungs, pleurae, tracheas, necks, oral cavities, throats, drinks, a gullet, heart etc. Taking into account versatility of the causes, mediastinit is of clinical interest not only to pulmonology and thoracic surgery, but also to otolaryngology, gastroenterology, cardiology, stomatology.
Sredosteniye – the space in a chest cavity, is central located in relation to lungs. In front the sredosteniye is limited to a breast, behind - a spine column, on each side – a mediastinalny pleura, from below – a diaphragm; above without clear boundary the sredosteniye passes into the area of a neck. In a sredosteniye allocate the top and lower floors with conditional border in the area IV of a chest vertebra. In the top sredosteniye allocate forward and back departments; in lower – forward, average and back departments.
In forward department of the top sredosteniye the thymus, an aorta arch, the top hollow vein, a pulmonary artery are located. A forward part of a back sredosteniye is occupied by heart and a pericardium; average - bifurcation of a trachea, lymph nodes, a trunk and branches of a pulmonary artery, the ascending part of an aorta. In a back sredosteniye of forward and lower floors there pass the gullet, a chest lymphatic channel, a boundary sympathetic trunk, the descending part of an aorta, the lower hollow vein, unpaired and pair veins.
All floors and departments of a sredosteniye represent uniform, topografo-anatomic the connected space without clear boundary therefore the purulent inflammation at a mediastinita can extend from one part of a sredosteniye to another. To some extent it is promoted by the constant movement of bodies of a sredosteniye: warm pushes, a pulsation of vessels, trachea shift at a conversation and cough, a gullet vermicular movement, etc.
Classification of a mediastinit
According to etiopatogenetichesky mechanisms allocate primary (traumatic) mediastinita at wounds of bodies of a sredosteniye and the secondary mediastinita caused by contact and metastatic penetration of an infection from other areas. On a clinical current of a mediastinita can be lightning, sharp and chronic; on character of an inflammation – serous, purulent, anaerobic, putrefactive, gangrenous, tubercular.
Chronic mediastinita happen aseptic and microbic. Distinguish from aseptic mediastinit idiopathic, rheumatic, post-hemorrhagic adipozosklerotichesky, etc.; among microbic – specific (tubercular, syphilitic, mikotichesky) and nonspecific. Sharp mediastinita, as a rule, have infectious character.
Taking into account a tendency to distribution distinguish lymphadenites with sredosteniye cellulose involvement, abscesses and phlegmons of a sredosteniye which can be inclined to restriction or progressing.
On topography and anatomic interest of structures of a sredosteniye of a mediastinita are subdivided on:
- peredneverkhny (it is higher than the level III of a mezhreberye)
- perednenizhny (it is lower than the level III of a mezhreberye)
- the poured lobbies (with involvement of the top and lower departments)
- zadneverkhny (it is higher than the level V of a chest vertebra)
- zadnenizhny (it is lower than the level V of a chest vertebra)
- poured back (with involvement of the top, average and lower departments)
- total (with distribution on a forward and back sredosteniye).
Reasons of a mediastinit
Primary traumatic mediastinita arise owing to exogenous infection. Most often it occurs at opened, including fire, injuries of bodies of a sredosteniye. As the reason of primary mediastinit, the second for frequency, gullet injuries at tool manipulations act (buzhirovaniya of a gullet, cardiodilatation, an ezofagoskopiya, an intubation of a trachea, a trakheostomiya, gastric sounding). Quite often injuries of a gullet are caused by foreign matters, a spontaneous rupture of a gullet, burns, perforation of a diyovertikul, an ulceration of tumors, etc.
Also carry the postoperative inflammations of cellulose of a sredosteniye caused by violation of tightness of esophageal and gastric anastomoz to number of primary mediastinit (after performance of a resection and plasticity of a gullet, a stomach resection), complications of cardiac interventions (mammarokoronarny shunting, aortocoronary shunting, prosthetics of the mitralny valve and the aortal valve).
Secondary mediastinita are a complication of any purulent or destructive process and develop upon direct transition of an inflammation to cellulose of a sredosteniye or metastasis of activators from the established or unspecified infectious centers. Contact mediastinit the perikardita, osteomyelitis of edges, a breast and chest department of a backbone can develop against the background of wounds and phlegmons of a neck, a purulent tireoidit, pneumonia, wounds of a lung and pleura, abscess and gangrene of lungs, tuberculosis, an empiyema of a pleura, a bronkhoektatichesky disease, esophageal and pleural fistulas.
At metastatic mediastinita phlegmons of the top and lower extremities, freezing injuries can be primary source of an infection, periostit, osteomyelitis of the lower jaw, zaglotochny abscess at tonsillitis, flegmonozny parotitis, quinsy, ulcer colitis, dysentery, an ugly face, lymphadenitis, sepsis and . other.
The microbiological basis of a mediastinit is presented, the flora generally mixed. As urgent pathogens at a mediastinita anaerobe bacterias (bakteroida, peptostreptokokk, prevotella, porfiromonada, fuzobakteriya) and aerobes (staphylococcus, streptococci, a klebsiyell), fungi act. Feature of the mixed microflora consists in synergysm of anaerobe bacterias and aerobes in associations that predetermines a zlokachestvennost of a current of a mediastinit and a high lethality.
Symptoms of a mediastinit
Sharp mediastinit usually develops suddenly, demonstrating from zagrudinny pains, tremendous oznob, high fever (to 39-40 C °), profuzny sweating, short wind. In the presence in an organism of purulent process of other localization, with accession of a mediastinit the general state sharply worsens, the phenomena of purulent intoxication accrue. The concern and motive excitement characteristic of an initial stage of a mediastinit, soon are replaced by an adinamiya, sometimes - confusion of consciousness.
As the leading local symptom of a mediastinit serves intensive thorax pain which amplifies during swallowing and a zaprokidyvaniye of the head back. At a forward mediastinit pain is localized behind a breast, at back – in nadchrevny area or interscapular space. Patients, seek to adopt the compelled provision - semi-sitting with the head inclined to a breast, facilitating, thus, breath and reducing pain. There is a face edema, necks and the top half of a trunk, hypodermic emphysema, expansion of superficial veins, skin cyanosis.
Heavy intoxication at a mediastinita causes disorders of warm activity: the expressed tachycardia (do110-120 . in min.), arrhythmia, decrease HELL and increase of TsVD. Sdavleniye edematous cellulose of a sredosteniye of nerves, vessels, a trachea and gullet is followed by development of suffocation, persistent cough, dysphonia, a dysphagy.
The lightning form of a sharp mediastinit leads to death of patients within the first 2 days. It is characterized by poor mestyony manifestations and heavy general intoxication. At chronic aseptic mediastinita the symptomatology is connected with development of a sclerosis and scarring of mediastinalny cellulose, a compression of bodies of a sredosteniye. Clinically it can be expressed in emergence of astmoidny attacks and an osiplost of a voice, development of a syndrome of the top hollow vein or Horner's syndrome.
Chronic microbic mediastinit arises in the presence in a sredosteniye of the encapsulated abscess around which jet cicatricial process develops subsequently. At the same time it is noted long subfebrilitt with the periods of increase and decrease in temperature, perspiration, weakness, moderate thorax pains. At development of a compression syndrome cough, short wind, violations of a voice, a dysphagy join.
Diagnostics of a mediastinit
Early recognition of a mediastinit presents great difficulties. Detailed studying of the anamnesis and carrying out the careful analysis of a clinical picture is necessary. At survey of the patient on mediastinit can specify existence of objective symptoms: strengthening of pains at a pokolachivaniye on a breast, pressing on awned shoots of vertebras, a ducking; pastosity in a breast and chest vertebras; a swelling and a krepitation in a jugular hollow and over a clavicle; VPV sdavleniye syndrome, etc.
Careful radiological examination (thorax X-ray analysis, tomography, gullet X-ray analysis, pnevmomediastinografiya) is conducted. Radiological at a mediastinita expansion of a shadow of a neck and a sredosteniye, sredosteniye emphysema, pheumothorax, , liquid level in sredosteniya, esophageal fistulas can come to light.
At suspicion on perforation of a gullet carrying out an ezofagoskopiya (EGDS) is shown; at probability of an injury of trachea and bronchial tubes - bronyokhoskopiya. Existence of a pleural and pericardiac exudate allows to find ultrasonography of a pleural cavity and a pericardium. In recent years for diagnostics of a mediastinit use transezofagealny ultrasonography.
From invasive methods of inspection resort to a diagnostic tonkoigolny puncture of a sredosteniye with the subsequent microbiological research of a punktat, mediastinoskopiya, diagnostic torakoskopiya. In the first days from the moment of development mediastinit it is necessary to differentiate from pneumonia, a perikardit, pleurisy, a sharp stomach.
Treatment of a mediastinit
The basic principles of treatment of a mediastinit is purpose of early massive antibiotic treatment, implementation of adequate drainage of the purulent centers, radical surgical elimination of the reason of a mediastinit. For fight against intoxication active infusional therapy, correction of water and electrolytic and proteinaceous balance, symptomatic therapy, an extracorporal detoxication, hyperbaric oxygenation, intravenous, intra arterial, endolymphatic administration of antibiotics is carried out.
In situations of a sharp purulent and traumatic mediastinit the mediastinotomiya and sanitation of a sredosteniye is shown. At the top forward mediastinit the cervical mediastinotomiya is carried out; the lower forward - a vnebryushinny forward mediastinotomiya; at forward poured the combination over - and podgrudinny approaches is used.
Drainage of the top back mediastinit is carried out by cervical access; the lower back - chrezdiafragmalny (extra pleural) access; diffusion back – chrezplevralny access (a side torakotomiya). At perforation of a gullet in one stage with a mediastinotomiya the gastrostomiya or an ezofagostomiya is carried out. For sanitation of a sredosteniye carry out active aspiration, washing of a sredosteniye antiseptics, introduction of antibiotics and proteolytic enzymes.
In early terms (from 12 to 24 h from the moment of development of a mediastinit) the ushivaniye of defects in a wall of bronchial tubes or a gullet, drainage of a pleural cavity and a sredosteniye is made. In more pozdyony period perforative openings are not taken in. At the postoperative mediastinita which are found in a heart surgery the breast resection, removal of necrotic fabrics, a mediastinoplastika by rags from big pectoral muscles, an epiploon or a direct muscle of a stomach is made.
At osumkovanny abscesses of a sredosteniye resort to a transthoracic puncture and washing of a cavity of abscess or opening of abscess and its maintaining in the open way. Elimination of the reasons causing a compression of a sredosteniye and supporting inflammatory process is necessary. At chronic mediastinita of a specific etiology active treatment of syphilis, tuberculosis, mycoses is shown.
Forecast and prevention of a mediastinit
The forecast of a mediastinit is always very serious. The outcome of a disease is influenced by the nature of the main disease or trauma, timeliness of recognition of a mediastinit, adequacy of surgical intervention and correctness of maintaining the postoperative period. At a sharp purulent mediayostinit the lethality reaches 70%.
Ways of prevention of a mediastinit consist, mainly, in the prevention of yatrogenny damages and intraoperative wounds of bodies of a sredosteniye, timely diagnosis and rational treatment of the diseases leading to a mediastinit.