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Mediastinum

HFD
2016
Spudich

Learning Objectives

Describe the mediastinum, its divisions, contents and relational elements.


Describe the clinical relevance regarding various anatomical relationships of
the mediastinum and its contents.
Describe the plane and anatomical relationships which divides the superior
from the inferior mediastinum.
Describe the axial anatomy as seen on CT/MRI/VHD of the mediastinal
contents.

Mediastinum
Space between the
pulmonary cavities
Extends from the
superior thoracic
aperture to diaphragm
Covered with
mediastinal pleura

Highly Mobile
Loose C.T.
Hollow viscera
Accommodates
movement and pressure
changes

Superior Mediastinum
Inferior border is a line
through the sternal angle

Superior Vena cava


Brachiocephalic vessels
Aortic arch
Thoracic and r. lymphatic
ducts
Trachea
Esophagus
Thymus
Vagus, phrenic and recurrent
laryngeal nerves
Lodes of nodes
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Anterior Mediastinum
Deep to sternum
From sternal angle to
diaphragm
Fat
Nodes
Pericardial ligaments
Inferior lobe of thymus
Internal thoracic vessels

Middle Mediastinum
Deep to anterior
mediastinum
From angle to diaphragm
Pericardium,
Heart
Ascending aorta,
Pulmonary trunk, and veins
SVC
Arch of azygos v.,
Main bronchi
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Posterior Mediastinum
Just ventral to Thoracic
vertebrae 5-12
Extends posterior to
diaphragm
Thoracic aorta
Thoracic duct
Azygos system vessels
Esophagus
Thoracic Sympathetic
trunk
Thoracic Splanchnic
nerves

Superior Mediastinum

Superior Mediastinum
Thymus
Deep to the manubrium
Superficial to the pericardium

Lower lobe in anterior


mediastinum
Involutes in adulthood
Calcifies or fatty deposits

Blood supply from the


internal thoracic and
anterior intercostal arteries

Great Vessels
Brachiocephalic Veins
Form deep to Sternoclavicular
joints

Subclavian and the internal


jugular vein merge
Venous angles
Lymphatic drainage

Left is much longer than the


right vein
Courses ventral to the main
arterial branches
Receives the thoracic duct for
lymph drainage

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Great Vessels
Right Brachiocephalic
Vein
Receives Right
Lymphatic duct

Brachiocephalic Veins
join to form the SVC
Dorsal and to ascending
aorta

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Great Vessels/SVC
SVC
Receives blood from all
structures superior to the
diaphragm EXCEPT heart
and lung parenchyma
Right side of mediastinum
Right Phrenic nerve lateral
and between SVC and
Mediastinal pleura

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Great Vessels/Aortic Arch


Arch of aorta
Continuation of the ascending
Aorta
Begins at sternal angle
Ends at T4 body as the thoracic
aorta

Arches posteriorly and to the left


Passes over root of the left lung

Superficial to the SVC and the


Tracheal bifurcation
Left Recurrent Laryngeal Nerve
Branch of vagus nerve
Loops under arch

Ligamentum arteriosum
Medial to Recurrent Laryngeal n
Fetal remnant
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Great Vessels/Arch Branches


Aortic Arch Branches
Brachiocephalic Trunk
Medial to SVC
Deep to the Left BCV

Divides at sternoclavicular
joint level
Right subclavian
Deep to the anterior scalene
muscles

Common carotid

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Great Vessels/Arch Branches


Aortic Branches
Left common carotid is
2nd branch off arch
Ascends deep to Left
BCV; lateral to Trachea;
medial to scalene muscle

Left Subclavian is 3rd


branch
Posterior to the LCC
No branches in the
mediastinum
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Nerves in Superior Mediastinum


Vagus Nerves (CNX)
Arises from the Medulla
Oblongata
Descends posterior to the
common carotids
w/in Neurovascular bundles

Several plexuses served by


vagus
Cardiac, pulmonary
esophageal

Recurrent Laryngeal nerve


Right loops under r.
subclavian
Left loops under aortic arch
Diagnostically important
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Nerves in Superior Mediastinum


Phrenic Nerve
C3-5
Innervates the
diaphragm
Anterior to Sub clavian
arteries, deep to veins
Lateral to the great
vessels
Anterior to the lung
roots
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Posterior Mediastinum

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Thoracic Aorta
Begins at the T4 body/
iv disc
Posterior to the root of
left lung, esophagus and
pericardium
Continues to the
abdomen through the
aortic Hiatus in the
diaphragm
T12
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Branches off Thoracic Aorta


Ventral Branches
Bronchial
Pericardial
Mediastinal
Esophageal
Superior phrenic**
Mostly considered
visceral
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Thoracic Aorta
Posteriorly and laterally
the branches are paired
Posterior Intercostals
and subcostals
Considered mostly
parietal

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Esophagus
Long hollow fibro-muscular
tube
Superior and posterior
mediastinum

Lies between the trachea


and the vertebral column
Enters the abdominal cavity
by the esophageal hiatus
T10

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Esophagus
Points of constriction
Junction with Pharynx
Aortic arch
Left main bronchus
Diaphragm
physiological

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Esophagus
Blood supply from the
bronchial and
esophageal arteries off
the thoracic aorta
Autonomic innervation
is from Esophageal
plexus
Derived from CNX and
Sympathetic trunk

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Veins and Lymph Vessels

Azygos vein

Collateral pathway between


the Vena Cavas
Arises from the abdominal
IVC
Right side of vertebral bodies
Drains back,
thoracoabdominal walls and
mediastinum

Hemiazygos vein does the


left caudal side and drains to
azygos
Accessory hemi does cranial
portions

Pass behind the diaphragm

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Veins and Lymph Vessels


Thoracic Duct ascends
anterior to body of vertebrae
Drains lymph from all but the
right upper body quadrant
Begins as chyle cisterna in
abdomen
Empties to left venous angle

Right lymphatic duct on


right side

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Thoracic Sympathetic Trunk


Chain of Sympathetic
ganglion along posterior
wall
PARAvertebral

Lateral to the Vertebral


Bodies
Superficial to the
Intercostal vessels

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Thoracic Sympathetic Trunk


Give off the
Cardiopulmonary
splanchnic nerves
Post-ganglionic
sympathetic

Destined for thoracic


visceral plexuses
Cardiac
Pulmonary
Esophageal
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Thoracic Sympathetic Trunk


Give off the Thoracic
Splanchnic nerves
PREganglionic
Will synapse in Abdomen on
PREvertebral ganglia

Greater
T5-T9/10
Celiac ganglia

Lesser
T10-11
Aorticorenal

Least
T12
SM and IM ganglia and
plexuses

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Red Side of the Mediastinum


(Left side)

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Blue Side of the Mediastinum


(Right side)

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Diaphragm
Domed partition of
variable position
Muscle fibers
Central tendon

Right dome a little


higher
Three regions
Sternal
Costal
Lumbar

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Blood Supply
to Diaphragm
Thoracic origin
Pericardiocophrenics (w/
vv)
Musculophrenics ( w/ vv)
Superior phrenics

Abdominal origin
Inferior Phrenics (w/vv)

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Nerves of the Diaphragm


Motor Innervation
Phrenic nerve (C3-5) ONLY
Somatic and Autonomic (sympathetic vascular
control)

Sensory Innervation
Phrenic (referred pain to shoulder/neck) serves
central regions
Intercostal and Subcostal nerves (local pain along
region of trunk )
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Diaphragmatic Referred Pain

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Paralysis of the Hemidiaphragm

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Congenital Diaphragmatic Hernia


Only relatively common
congenital anomaly of the
diaphragm
Once in every 2,200 newborns
Herniation of abdominal
contents into thoracic region
Primary cause of lung
hypoplasia (??)
Retinoic acid signaling perturbed
A-P embryonic axis defect

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