S Tercier, R Meier, S Vasseur-Maurer, V Matoso, J Joseph
child, mediastinal abscess
S Tercier, R Meier, S Vasseur-Maurer, V Matoso, J Joseph. Huge Mediastinal Abscess In A 12-Month-Old Child: Case Report And Review Of The Literature. The Internet Journal of Thoracic and Cardiovascular Surgery. 2004 Volume 7 Number 2.
A 12-month-old highly feverish boy showed progressive dyspnea with a necrotic adenopathy in the axillla upon an extensive anterior mediastinal abscess. The abscess was drained with a suprasternal incision and Staphylococcus aureus was identified. A subsequent antibiotic therapy with tazobactam and clindamycin was performed. In the following recovery was uneventful. In paediatric population aggressive treatment of mediastinal abscesses is needed to obtain full recovery. However, thoracotomy should be avoided in contrast to adults. We present a rare case of a huge non-traumatic mediastinal abscess in a 12-month-old boy. Literature of the last 15 years was reviewed and principals of paediatric surgical approach discussed.
Mediastinal abscesses in children are relatively rare. They usually occur following esophogeal perforation and thoracic surgery, respectively (1). However, paediatric non-traumatic mediastinal abscesses are extremely rare. Only eight cases were reported in the literature in the past 15 years. Haematogenous spread from a distant infected site or direct infection of the mediastinum are possible causes of non-traumatic mediastinal infection. We report the successful case management of a huge non-traumatic mediastinal abscess in a 12-month-old boy. The abscess was surgically drained by a suprasternal cervicotomy and subsequently treated with antibiotics to avoid extensive thoracotomy. In the following recovery was uneventful. In this report we discuss the therapeutic strategies and the literature of the last 15 years.
A 12-month-old previously healthy boy was referred to our tertiary care university hospital where an empiric antibiotic treatment with amoxicillin/clavulanic acid for suspected pneumonia was already started. The boy was transferred due to deterioration of his general condition. Upon admission he was highly feverish (axillary temperature 40°C) and suffered from progressive dyspnoea. On physical examination a pericardial rub and left pulmonary hypoventilation was noticed. Cellulitis of the left hemithorax was noted and rapidly evolved to multiple abscesses in the left axilla. The abscesses and pleural effusion were drained and
Figure 1A: Initial thoracic CT Scan at the aortic arch level.
Further investigations such as radionuclide scan and echocardiography revealed no other underlying pathologies. The mediastinal abscess was surgically drained via a suprasternal, horizontal cervicotomy (Fig. 1B) associated to pleural drainage.
Figure 1B: Thoracic CT-Scan after drainage of mediastinal abscess via cervicotomy and left necrotic axillary abscess.
During the same procedure the abscess of the thoracic wall was also drained. Microbiological studies of the drained pus revealed again
Figure 2: Thoracic CT-Scan at the aortic arch level at the 8-months follow-up. Total resolution
Mediastinal abscess formation is a rare entity, especially since the advent of widespread antibiotic treatment. Whereas non-traumatic mediastinal abscesses in children are extremely rare. In general they consequently occur due to an infection in a different organ. They may be a direct extension of bucco-pharyngeal or pulmonary infection by anatomic pathways (2, 3). However, some cases of haematogenous spread from a distant infection site (4,5,6) are also reported. Most likely the mediastinal abscess reported here occurred by haematogenous or lymphatic spread of the axillary abscess. Here lymphatic spread seems to be a reasonable consideration since the anatomic drainage route of the internal mammary lymphatics closely communicate in the upper mediastinum. (7).
So far only 8 cases of children with a non-traumatic mediastinal abscess were published in the last 15 years (Table 1).
Age of presentation is very variable, from 15 days to 11 years There are two patients reported with primary intrathoracic disease where
Indeed early diagnosis and aggressive treatment of mediastinal infections is of utmost importance to reduce mortality and morbidity (12). In addition to the antibiotic therapy, a minimal invasive percutaneous drainage is a very good option to achieve sustained healing (10). CT-guided drainage is a good alternative as well (11). All but one patients from table 1 were successfully treated with antibiotic therapy and mediastinal abscess drainage. Surgical treatment consisted always of extrathoracic approach. Extensive thoracotomy has not been reported in the published cases. One patient was successfully treated with conservative medical therapy following local retropharyngeal drainage (9). In our case, the presented surgical approach was chosen because of pertinent life threatening situation, considering the size of the mass and the urgent need of a sufficient drainage. In most adults nontraumatic mediastinal abscesses are secondary to a descending necrotizing mediastinitis. Their common treatment consists in general of extensive thoracotomy or median sternotomy (13,14,15,16). By opposition to adults in children extensive thoracotomy usually was avoided in the published articles to prevent thoracic wall and hemithoracic spread (3, 9, 11).
Paediatric surgeons should keep in mind that in non-traumatic mediastinal abscesses extensive thoracotomy is not necessary and may be avoided. Suprasternal cervicotomy to drain the abscess and subsequent appropriate antibiotic treatment for several weeks is, at least in the presented case above, sufficient to provide sustained recovery.
Stephane Tercier, MD, Service de Chirurgie Pédiatrique, DMCP, Centre Hospitalier Universitaire Vaudois, 1011- Lausanne, Switzerland Tel : +41 21 314 34 86 ; Fax : +41 21 314 30 76 ; E-mail : Stephane.Tercier@chuv.ch