Merck Manual

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Najib M Rahman

, BMBCh MA (oxon) DPhil, University of Oxford

Reviewed/Revised Aug 2023

Mediastinitis is inflammation of the mediastinum. Acute mediastinitis usually results from esophageal perforation or occurs after median sternotomy. Symptoms include severe chest pain, dyspnea, and fever. The diagnosis is suggested by chest x-ray and usually confirmed by CT. Treatment is with antibiotics (eg, clindamycin plus ceftriaxone) and sometimes surgery.

The 2 most common causes of acute mediastinitis are

  • Esophageal perforation

  • Median sternotomy

Esophageal perforation

Esophageal perforation Esophageal Rupture Esophageal rupture may be iatrogenic during endoscopic procedures or other instrumentation or may be spontaneous (Boerhaave syndrome). Patients are seriously ill, with symptoms of mediastinitis... read more Esophageal Rupture may complicate esophagoscopy or insertion of a Sengstaken-Blakemore or Minnesota tube (for esophageal variceal bleeding). Rarely, it results from forceful vomiting (Boerhaave syndrome). Another possible cause is swallowing caustic substances (eg, lye, certain button batteries). Certain pills or esophageal ulcers (eg, in patients with AIDS and esophagitis) can contribute.

Patients with esophageal perforation become acutely ill within hours, with severe chest pain and dyspnea due to mediastinal inflammation.

Diagnosis is usually obvious from clinical presentation and a history of instrumentation or of another risk factor. The diagnosis should also be considered in patients who are very ill, have chest pain, and may have a risk factor that they cannot describe (eg, in patients who are intoxicated and may have vomited forcefully but do not remember and in preverbal children who may have ingested a button battery). The diagnosis is suggested by chest x-ray showing air in the mediastinum and confirmed by CT, although other disorders (eg, spontaneous pneumomediastinum Pneumomediastinum Pneumomediastinum is air in mediastinal interstices. The main causes of pneumomediastinum are Alveolar rupture with dissection of air into the interstitium of the lung with translocation to... read more Pneumomediastinum ) can also cause air in the mediastinum.

Treatment is with parenteral antibiotics selected to be effective against oral and gastrointestinal flora (eg, clindamycin 450 mg IV every 6 hours plus ceftriaxone 2 g IV once a day, for at least 2 weeks). Patients who have severe mediastinitis with pleural effusion Pleural Effusion Pleural effusions are accumulations of fluid within the pleural space. They have multiple causes and are usually classified as transudates or exudates. Detection is by physical examination,... read more Pleural Effusion or pneumothorax Pneumothorax Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures. Diagnosis is based on clinical... read more Pneumothorax require emergency surgical exploration of the mediastinum with primary repair of the esophageal tear and drainage of the pleural space and mediastinum.

Median sternotomy

This procedure is complicated by mediastinitis in about 1% of cases (1 Reference Mediastinitis is inflammation of the mediastinum. Acute mediastinitis usually results from esophageal perforation or occurs after median sternotomy. Symptoms include severe chest pain, dyspnea... read more ). Patients most commonly present with wound drainage or sepsis. Diagnosis is based on finding infected fluid obtained by a needle aspiration through the sternum. Treatment consists of immediate surgical drainage, debridement, and parenteral broad-spectrum antibiotics. Mediastinitis after median sternotomy has a high mortality rate.

Chronic fibrosing mediastinitis


  • 1. De Feo M, Renzulli A, Ismeno G, et al. Variables predicting adverse outcome in patients with deep sternal wound infection. Ann Thorac Surg 2001;71(1):324-331. doi:10.1016/s0003-4975(00)02137-8

Drugs Mentioned In This Article

Drug Name Select Trade
Cleocin, Cleocin Ovules, Cleocin Pediatric, Cleocin T, CLIN, Clindacin ETZ, Clindacin-P, Clinda-Derm , Clindagel, ClindaMax, ClindaReach, Clindesse, Clindets, Evoclin, PledgaClin, XACIATO
Ceftrisol Plus, Rocephin
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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