Poststernotomy Infections Presenting as Deep Neck Abscess

Abstract

\s=b\A review of the world literature has failed to reveal any published reports of poststernotomy mediastinitis presenting as a deep neck infection. This article presents two such cases. Since the fascial layers of the mediastinum are a direct continuation of the cervical fascia, a number of potential pathways between the neck and mediastinum exist. Descending infection from the neck into the mediastinum is well documented. The reverse situation, an ascending infection from the mediastinum into the neck, is not described despite the potential natural pathways available for spread of infection. Our proposed mechanism for these two cases is that a surgically created pathway from the mediastinum to the lower neck allows for mediastinitis to point in the intercommunicating fascial spaces of the neck. Recognition of this clinical presentation will allow the surgeon to use prompt intervention for such a serious complication.(Arch Otolaryngol Head Neck Surg 1988;114:909-912) Otol aryngol ogi sts and thoracic sur¬ geons are aware of the potential for the development of mediastinitis secondary to deep neck abscess. The cervical fascia and the spaces between its layers communicate directly or indirectly with the fascia of the medi¬ astinum, providing natural pathways for the spread of infection from the neck to the chest. We should, there¬ fore, theoretically see some cases of neck infection resulting from medias-tinitis. However, there are no pub¬ lished reports of this clinical picture.This article presents two cases of poststernotomy mediastinitis that resulted in deep neck infection. More¬ over, the neck abscess was the initial sign, and the only clue that a more life-threatening infectious process was ongoing.Although infections can spread along natural pathways, we propose that a pathway from the mediastinum to the neck was created surgically, allowing for the sternotomy infection to point in the lower neck in the fasciai spaces that had been entered.Though obviousy rare, knowing this scenario of silent mediastinitis will allow the surgeon to take early and aggressive surgical measures that could significantly decrease the mor¬ bidity and mortality associated with such a serious complication. REPORT OF CASESCase 1.-A 66-year-old man with a fiveyear history of syncopal episodes was eval¬ uated at the University of Alabama at Birmingham. Cardiac catheterization showed calcific aortic stenosis. On July 16, 1985, a median sternotomy incision for aortic valve replacement was performed. Cephapirin sodium therapy was used for four days postoperatively. On the fifth postoperative day, the patient had lowgrade fever, along with an enlarging tender left-sided neck mass. Physical examination revealed induration, warmth, and exquisite tenderness of the entire left sternocleidomastoid muscle. Also noted were erosions in the subglottic area bilat¬ erally. A chest roentgenogram was normal. Computed tomographic scan of the neck revealed an abscess within the belly of the sternocleidomastoid muscle as demon¬ strated in Fig 1. Th...

Penetrating injuries to the oropharynx

“…But if the fascia is penetrated in a surgical operation or trauma, inflammation or abscess can spread through the fascia and involve other intrafascial spaces. (Hollinshed, 1982;Simpson and Peters, 1988;Thompson et al, 1988). For this reason, penetrating injuries must be treated carefully.…”