Pulmonary Medicine Department Ain Shams University http://telemed.shams.edu.eg/moodle5

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MEDIASTINAL DISEASES
By Pulmonary Medicine DepartmentAin Shams
Universityhttp//telemed.shams.edu.eg/moodle5
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At the end of this lecture the student should be
able to

1. Describe the anatomy of the mediastinum.
2. Distinguish the mediastinal space occupying
   lesions and site of appearance.
3. Discuss the clinical picture including
   mediastinal syndrome .
4. Interpret the investigations including computed
   tomograpghy.
5. Predict the diagnosis and discuss the diagnostic
   interventions including imaging-guided biopsy.
6. Describe the different treatment modalities.

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Anatomical Consideration

• The mediastinum is the region between the 2
  pleural sacs.
• It extends from the thoracic inlet to the
  diaphragm, and
• from the sternum to the spine.
• It is maintained in the central position by a
  balance
• between the pleural pressures on both side.
• In infants and children the mediastinum is
  highly mobile.
• Later in life, it becomes more rigid, so that
  unilateral changes
• in pleural pressure have less effect on its
  mobility.

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Cont.
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Cont.
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Cont.
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Divisions of the mediastinum

• Superior mediastinum it contains
• Aortic arch its 3 branches
• S.V.C. its 2 innominate veins
• Trachea, esophagus, thoracic duct
• Vagus, phrenic n., left recurrent laryngeal n.
• and sympathetic n.
• L.N. thymus.

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Cont.

• (2) Anterior mediastinum
• Boundary Anterior Sternum
• 
  Posterior Pericardium
• Contents Thymus
• L.N.
• Fatty
  tissue

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Cont.

• (3) Middle mediastinum
• Boundary By the 3 divisions.
• Contents Heart pericardium
• 
  Ascending aorta, S.V.C I.V.C.
• 
  Pulmonary arteries veins
• 
  Tracheal bifurcation
• 
  Phrenic nerves

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Cont.

• (4) Posterior mediastinum
• Boundary Anterior pericardium
  diaphragm
• Posterior
  lower 8 thoracic vertebrae
• Contents Descending aorta
• Esophagus
• Sympathetic vagus nerves
• Thoracic
  duct
• L.N.

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Types and sites of mediastinal lesions

• Superior mediastinum
• Thymic tumors
• Intrathoracic thyroid
• Teratoma
• Esophageal lesions
• Cystic hygroma
• Lymphomata
• Mediastinal abscess

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Thymic tumor
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Cont.
X-ray showing enlarged mediastinal Lymph nodes
in Hodgkins disease .
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Cont.
Intrathoracic thyroid displacing the esophagus to
the left ( barium swallow )).
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Cont.
Cystic hygroma
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Cont.

• (B) Anterior mediastinum
• Thymic tumors cysts
• Teratoma
• Intrathoracic thyroid
• Cystic hygroma
• Pleuro-pericardial cyst
• Lymphomata

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Cont.
X-ray of a large anterior mediastinal mass
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Cont.

• (C) Middle mediastinum
• Aortic aneurysm
• Anomalies of great vessels
• Bronchogenic cyst
• Lipoma

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Cont.

• (d) Posterior mediastinum
• Neurogenic tumors
• Gastroenteric bronchogenic cysts
• Esophageal lesions
• Meningocele
• Aortic aneurysm
• Cold abscess
• Hernia through foramina of Bochdalek

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Mediastinal Syndrome

• This is usually results from compression of the
  mediastinal
• structures by a mediastinal lesion.
• Causes
• Mediastinal tumors
• Chronic mediastinitis
• Mediastinal emphysema

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Cont.
Primary location of specific neoplasma cysts
within the subdivisions of the mediastinum
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Cont.
Manifestations
1) Pressure symptoms 2) Hormonal
effects These depend on Site of lesion
Structure
involved
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Cont.

• Pressure symptoms
• Esophagus dysphagia.
• Trachea bronchi brassy cough, stridor,
  obstructive
• emphysema or
  atelectasis
• Arteries unequal pulse, ischaemic
  manifestations
• ( pallor, pain and
  syncope ).

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Cont.

• Veins usually S.V.C distension of neck
  veins, collaterals.
• Nerves Sympathetic Horners
  syndrome .
• Vagus dysphagia
  arrhythmia .
• Recurrent laryngeal
  hoarseness of voice .
• Phrenic
  diaphragmatic paralysis.

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Cont.

• Hormonal
• Retrosternal goiter Toxic changes
• Thymic tumor Myasthenia gravis
• Parathyroid adenoma Hyperparathyroidism

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Cont.
S.V.C.obstruction , note the swollen arms and
the tortuous collaterals over the anterior chest
wall
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Cont.
S.V.C. obstruction
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Cont.
Horners syndrome. Note ptosis constricted
pupil .
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Cont.
Brachial plexus affection.
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Cont.
Myasthenia gravis. This is common with Thymic
tumors.
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Acute Mediastinitis

• Causes
• Esophageal perforation
• Traumatic endoscopies, dilatation,
  intubations
• Spontaneous
• Operation in the larynx, trachea, esophagus
• Suppurative L.N. secondary to infection of the
  lung,
• esophagus larynx.

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Cont.

1. T.B, osteomyelitis of cervical or thoracic spine.

• Direct extension of infection from the
• neck, retropharyneal space, pleura, pericardium.

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Cont.

• Clinical features
• Substernal pain
• Rigors
• Fever
• Neck pain
• Torticollis
• Brassy cough ( if trachea is involved )

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Cont.

• O / E
• Toxic
• Cyanosis
• Restless
• Anxious
• Tenderness over the sternum
• WBCs leucocytosis
• Pleural effusion or pyopenumothorax
• Mediastinal emphysema

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Cont.

• X Ray
• May be normal or, if fluid or pus is collecting
• in the mediastinum, a smooth walled
  convex
• opacity may be seen bulging laterally
  beyond
• the mediastinal boundaries.
• Pleural effusion, mediastinal emphysema,
• pyopneumothorax.

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Cont.
A mediastinal abscess following a
perforation of the esophagus
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Cont.

• Treatment
• Broad spectrum antibiotics.
• Abscess surgical drainage.

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Cryptogenic Mediastinal Fibrosis

• Other names include
• Chronic fibrous or fibrosing mediastinitis,
• Idiopathic mediastinal fibrosis, and
• Chronic mediastinal fibrosis.

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Cont.

• Etiology
• Unknown, theories
• T.B Syphilis
• Keloid
• Autoimmune
• Histoplasmosis
• Methysergide
• Due to stimuli infective, traumatic, toxic,
  immunologic
• Idiopathic.

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Cont.

• Pathology
• Masses of ill-defined tissue encase and may
  compress the
• mediastinal structures.
• Histology shows that the predominant feature is
  the
• presence of bundles of hypocellular
  collagenous tissue
• containing an infiltrate of plasma cells
  with some
• lymphocytes, polymorphs and fibroblasts.

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Cont.

• Clinical picture
• Age any age, but common in 4th decade.
• Sex males females are equally affected.
• Onset insidious.
• Site
• S.V.Cava obstruction is mainly
  present , but
• also the innominate azygos veins
  can be affected.
• Veins of upper limb may be affected
  to a lesser extent.

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Cont.
S.V.C.obstruction, note the swollen arms and
tortuous collaterals
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Cont.
S.V.C obstruction, dilated veins on front of chest
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Cont.

• Appearance
• The face neck begin to swell especially when
  the
• patient stoop or lies down.
• Later swelling of eye lids subconjunctival
  edema
• Headache, breathlessness epistaxis which
• become worse on coughing ,straining or
  exercise.

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Cont.

• As time passes collateral venous channels
  appear,

• which allows features to undergo slow
  improvement.
• Stricture of pulmonary veins, trachea, main
  bronchi.

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Cont.

• X - Ray
• Nothing characteristic
• Widening of upper mediastinum
• Tomography tracheobroncheal stricture
• Barium swallow esophageal stricture
• Angiography.

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Cont.
Mediastinal widening in idiopathic mediastinal
fibrosis
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Cont.

• Treatment
• Stop drugs Methysergide
• Surgical removal
• S.V.Cava bypass
• Stricture of esophagus dilatation
• Corticosteroid ??????

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Mediastinal Emphysema

• Def. Air in the mediastinal tissues.
• Etiology Pathogenesis
• The air enter the mediastinum from
• Ruptured bronchus
• Ruptured esophagus
• Indirectly along the perivascular sheath of
  pulmonary
• vessels, following rupture of alveoli
• Through the retro peritoneal tissue, in rare
  cases following
• rupture of some part of GIT, or
  perianal insufflations

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Cont.

• Precipitating factor
• Rupture of alveoli is usually ppt. By straining
  with
• the breath held in inspiration labour
  or any lung disease
• in which airway obstruction is
  combined with cough.
• In newborn, rupture of alveoli or congenital
  cyst.
• This may occur in resuscitation of
  apneic infant .

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Cont.

• Endoscopy
• Spontaneous rupture of esophagus
• The air may escape-
• a) Upwards into s.c tissue of neck
• b) Downwards into retroperitoneal
  tissue

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Cont.

• Clinical picture
• Ruptured bronchus 2/3 accompanied with
  pneumothorax.
• Ruptured esophagus pleural effusion.
• However most of cases is symptomless, sometimes
  the
• patient feels crepitus.
• When air accumulate in the mediastinal tissue
  ?
• compression effect ? pain like myocardial
  infarction
• dyspnea, cyanosis, hypotension .

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Cont.
Surgical emphysema of the face.
Same patient after 2 weeks
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Cont.

• O / E
• Absence of cardiac dullness.
• Hammans sign a crepitus, crackling or
  crunching
• sound heard with the stethoscope ,
  synchronous with systole.
• On rare occasions sufficient air surround the
  heart
• and caused cardiac tamponade with
  breathlessness,
• cyanosis and hypotension.
• Fever may indicate the onset of mediastinitis

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Cont.

• X- Ray
• Arc shaped translucency scalloping the outline
• of upper mediastinum, and air may outline the
• heart border especially the left border
• Air in the soft tissue surgical
  emphysema
• Lateral view neck ? air
• Pneumothorax or pleural effusion

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Cont.
Air appears as a narrow translucent halo
outlining the heart and aortic arch
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Cont.

• Treatment
• Treatment of the cause
• Assurance resuscitation
• O2 therapy
• Skin incision above suprasternal notch

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End
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