Mediastinal Disorders

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1 بسم الله الرحمن الرحيم

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2 By : Chest Department Ainshams University MEDIASTINAL DISEASES

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3 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. Anatomical Consideration

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4 Cont ….

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5 Cont ….

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6 Cont ….

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7 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. Divisions of the mediastinum :

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8 (2) Anterior mediastinum : Boundary: Anterior Sternum Posterior Pericardium Contents: Thymus L.N. Fatty tissue Cont ….

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9 (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 Cont ….

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

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11 Superior mediastinum : Thymic tumors Intrathoracic thyroid Teratoma Esophageal lesions Cystic hygroma Lymphomata Mediastinal abscess Types and sites of mediastinal lesions

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12 Thymic tumor

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13

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14

Anterior mediastinal cyst:

15 Anterior mediastinal cyst

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16 X-ray showing enlarged mediastinal Lymph nodes in Hodgkin’s disease . Cont ….

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17 Intrathoracic thyroid displacing the esophagus to the left ( barium swallow ) ). Cont ….

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18 Cont …. Cystic hygroma

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19 (B) Anterior mediastinum : Thymic tumors & cysts Teratoma Intrathoracic thyroid Cystic hygroma Pleuro-pericardial cyst Lymphomata Cont ….

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

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21 (C) Middle mediastinum : Aortic aneurysm Anomalies of great vessels Bronchogenic cyst Lipoma Cont ….

Bronchogenic Cyst:

22 Bronchogenic Cyst

Bronchogenic Cyst:

23 Bronchogenic Cyst Bronchogenic cyst arises from an abnormality in the development of the primitive foregut. It is lined with respiratory epithelium and contains mucoid material. They may be located anywhere in the mediastinum but the middle mediastinum is the most common site especially in the subcarinal and right paratracheal areas. Less than 15% of cysts are located within the lung parenchyma. Most brochogenic cysts are asymptomatic and discovered incidentally. They may become symptomatic if infection or haemorrhage or compression of adjacent structures occurs. On CXR, a bronchogenic cyst appears as a smooth lobulated mediastinal mass. On CT scan, the cyst is usually round with low attenuation contents. Some of the cysts may appear to have soft tissue attenuation due to proteinacious material or haemorrhage in the cyst. The cyst wall does not enhance with contrast.

Bronchogenic Ca:

24 Bronchogenic Ca

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25 (d) Posterior mediastinum : Neurogenic tumors Gastroenteric & bronchogenic cysts Esophageal lesions Meningocele Aortic aneurysm Cold abscess Hernia through foramina of Bochdalek Cont ….

Ganglioneuroma in a teenage boy. Contiguous 3-mm contrast-enhanced computed tomography scan sections reveal a low-attenuation mass in the posterior mediastinum. :

26 Ganglioneuroma in a teenage boy. Contiguous 3-mm contrast-enhanced computed tomography scan sections reveal a low-attenuation mass in the posterior mediastinum .

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27 Esophageal Diverticulosis

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28 Esophageal Ca displacing left atrium

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

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30 Primary location of specific neoplasma & cysts within the subdivisions of the mediastinum Cont ….

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31 1) Pressure symptoms 2) Hormonal effects These depend on : * Site of lesion * Structure involved Cont …. Manifestations :

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

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33 Veins : usually S.V.C distension of neck veins, collaterals. Nerves : * Sympathetic Horner’s syndrome . * Vagus dysphagia & arrhythmia . * Recurrent laryngeal hoarseness of voice . * Phrenic diaphragmatic paralysis. Cont ….

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34 Hormonal : Retrosternal goiter Toxic changes Thymic tumor Myasthenia gravis Parathyroid adenoma Hyperparathyroidism Cont ….

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35 S.V.C.obstruction , note the swollen arms and the tortuous collaterals over the anterior chest wall Cont ….

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36 S.V.C. obstruction Cont ….

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37 Horner’s syndrome. Note ptosis & constricted pupil . Cont ….

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38 Brachial plexus affection. Cont ….

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39 Myasthenia gravis. This is common with Thymic tumors. Cont ….

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40 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. Acute Mediastinitis

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41 Direct extension of infection from the neck, retropharyneal space, pleura, pericardium. T.B, osteomyelitis of cervical or thoracic spine. Cont ….

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42 Clinical features : Substernal pain Rigors Fever Neck pain Torticollis Brassy cough ( if trachea is involved ) Cont ….

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43 O / E : Toxic Cyanosis Restless Anxious Tenderness over the sternum WBCs : leucocytosis Pleural effusion or pyopenumothorax Mediastinal emphysema Cont ….

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44 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. Cont ….

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

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46 Treatment : Broad spectrum antibiotics. Abscess: surgical drainage . Cont ….

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47 Other names include: Chronic fibrous or fibrosing mediastinitis, Idiopathic mediastinal fibrosis, and Chronic mediastinal fibrosis. Cryptogenic Mediastinal Fibrosis

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48 Cont …. Etiology : Unknown, theories T.B & Syphilis Keloid Autoimmune Histoplasmosis Methysergide Due to stimuli: infective, traumatic, toxic, immunologic Idiopathic.

Focal fibrosing mediastinitis due to histoplasmosis in a 37-year-old woman. Axial reformation demonstrates that the right mediastinal mass obstructs the superior vena cava (SVC) and narrows the bronchus intermedius. :

49 Focal fibrosing mediastinitis due to histoplasmosis in a 37-year-old woman . Axial reformation demonstrates that the right mediastinal mass obstructs the superior vena cava (SVC) and narrows the bronchus intermedius.

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50 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. Cont ….

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51 Clinical picture : Age : any age, but common in 4 th 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 . Cont ….

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52 S.V.C.obstruction, note the swollen arms and tortuous collaterals Cont ….

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53 S.V.C obstruction, dilated veins on front of chest Cont ….

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54 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. Cont ….

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55 As time passes collateral venous channels appear, which allows features to undergo slow improvement. Stricture of pulmonary veins, trachea, main bronchi. Cont ….

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56 X - Ray : Nothing characteristic Widening of upper mediastinum Tomography: tracheobroncheal stricture Barium swallow: esophageal stricture Angiography. Cont ….

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57 Mediastinal widening in idiopathic mediastinal fibrosis Cont ….

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58 Treatment : Stop drugs: Methysergide Surgical removal S.V.Cava bypass Stricture of esophagus: dilatation Corticosteroid ?????? Cont ….

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59 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 Mediastinal Emphysema

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60 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 . Cont ….

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

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62 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 . Cont ….

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

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64 O / E : Absence of cardiac dullness. Hamman’s 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 Cont ….

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65 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 Cont ….

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

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67 Pneumomediastinum in acute respiratory distress syndrome (ARDS) . High-resolution CT shows diffuse bilateral areas of ground-glass opacity with a superimposed linear pattern (“crazy-paving”) consistent with ARDS. Irregular hyperlucent areas, representing focal areas of pulmonary laceration, are seen in the right upper lobe. Extensive pneumomediastinum and small bilateral pleural effusions are also seen.

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68 Treatment : Treatment of the cause Assurance & resuscitation O2 therapy Skin incision above suprasternal notch Cont ….

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69

Contrast-enhanced CT scan of the chest shows bilateral hilar lymphadenopathy, and calcified mediastinal lymph nodes can be seen. High-resolution, axial CT scan of the chest shows nodules involving the lung parenchyma bilaterally :

70 Contrast-enhanced CT scan of the chest shows bilateral hilar lymphadenopathy, and calcified mediastinal lymph nodes can be seen. High-resolution, axial CT scan of the chest shows nodules involving the lung parenchyma bilaterally

The patient was a 71-year-old man with SVC syndrome due to small cell pulmonary carcinoma :

71 The patient was a 71-year-old man with SVC syndrome due to small cell pulmonary carcinoma Contrast-enhanced CT at the level of the aortopulmonary window shows extensive soft tissue infiltration throughout the middle and posterior mediastinum, with almost complete obstruction of the SVC.. at the level of the right, upper lobe bronchus shows extensive soft tissue infiltration throughout the middle and posterior mediastinum, with almost complete obstruction of the SVC the level of the bronchus intermedius shows encasement of the SVC, subcarinal lymphadenopathy. Notice the extensive collateral venous circulation in the right chest wall and a right pleural effusion

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72 Areas of decreased attenuation and vascularity on inspiratory high-resolution CT may be present mainly in lower lobes; areas of air trapping commonly seen on expiratory

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73 Thanks End

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