Mediastinum

Area between two pleural cavities

Boundary
Anteriorly
Sternum

Posteriorly

Vertebral column

Superiorly
Thoracic inlet

Inferiorly
Diaphragm

On each side
Mediastinal pleura
2

 Superior

and
inferior
mediastinum by the plane
passing through the sternal
angle (transverse thoracic
plane) and IV disc between
T4-T5 vertebrae

Inferior mediastinum
Anterior
Middle
Posterior
3

Contents of
superior mediastinum
Thymus
SVC, brachiocephalic veins
Arch of aorta and its branches
Trachea
Esophagus
Vagus nerves, left recurrent

laryngeal nerve, phrenic nerves

Thoracic duct, lymph nodes

4

 Narrow space in front of the

pericardium
Contents
Sternopericardial ligament
Lymph nodes
Mediastinal branches of

the internal thoracic artery

Lowest part of thymus
and areolar tissue

 Pericardium and its contents

Heart, ascending aorta (AA),

pulmonary
trunk
pulmonary arteries

(PT),

Superior vena cava (SVC), arch

of azygos vein, pulmonary veins

Bifurcation of trachea with main

bronchi (primary bronchi)

Phrenic nerve
6

Posterior
mediastinum

Space behind pericardium

Contents
Descending thoracic aorta

Esophagus and esophageal

plexus

Left brachiocephalic vein

Thoracic duct

Azygos, hemiazygos, accessory

hemiazygos veins

SVC
Esophagus
Azygos
vein

Thoracic duct
Posterior mediastinal lymph

Aorta

nodes

Thoracic sympathetic trunks

Diaphragm

and splanchnic nerves

Cisterna chyli

Clinical correlation

Infection of the neck can spread to the superior and inferior mediastinum

In Hodgkin's disease mediastinal lymph nodes are enlarged

Compression of medistinal structures by tumors can give rise to specific symptoms known as
"Mediastinal syndrome".

Symptoms of the mediastinal syndrome:

Dilatation of the veins of upper half of the body because of the compression of superior vena
cava
Dyspnoea (difficulty in breathing) caused by the compression of trachea
Dysphagia (difficulty in swallowing) caused by the pressure over esophagus
Hoarseness of voice because of involvement of left recurrent laryngeal nerve
Paralysis of the corresponding half of the diaphragm because of involvement of phrenic nerve
Pain over the thoracic dermatomes because of involvement of intercostal nerves

Thymus
Brachiocephalic veins
Superior vena cava
Aorta
Phrenic nerve,
Vagus nerve
Pericardium and contents
Trachea
Esophagus
Thoracic duct
Azygos, hemiazygos, accessory hemiazygos veins
Thoracic sympathetic trunks
Splanchnic nerves

CONTENTS OF THE MEDIASTINUM

9

Thymus
Lymphoid organ
Located in inferior part of the

neck and anterior part of the

superior and anterior
mediastinum
After puberty, it goes gradual

involution and is largely replaced

by fat
Arterial supply - internal thoracic

artery
Veins
Left brachiocephalic, internal

thoracic, inferior thyroid

Lymphatics
Parasternal, tracheobronchial

10

Brachiocephalic vein
2 - Right and left
Formed posterior to the

sternoclavicular joint
Internal jugular + subclavian

v.
Left is longer than the right
Passes anterior to the

roots of the three major

branches of the aorta

11

 Formed at the level of 1st costal

cartilage by union of right and

left brachiocephalic vein

Azygos vein joins it at the level

of 2nd costal cartilage

Pierces the pericardium to end

into the RA at level of 3rd cc

Great vein
Collects blood from upper half of

body and drains it into RA

12

 Receives oxygenated blood

from LV and distributes to

all parts of body
Divided in 3 parts

Ascending aorta
Arch of aorta
Descending aorta

13

5 cm long and enclosed in

pericardium
Content of middle mediastinum

Begins behind left half of sternum

at level of lower border of 3rd CC

Continues as arch of aorta at sternal

end of upper border of 2nd right CC

At its commencement there are 3

dilations called aortic sinuses
corresponding to the cusp of aortic
valve

Branches:
Right and left coronary arteries

14

Arch of aorta

Continuation of ascending aorta

Lies in superior mediastinum behind

lower half of manubrium

Begins behind rt. 2nd CC, runs upwards,

backwards and to left, across left side
of bifurcation of trachea

Ends at lower border of T4

continuing as descending aorta

by

Brachiocephalic trunk
(artery)
Left common carotid artery
Left subclavian artery
15

Relation of arch of aorta

Anterior and to left

Left vagus
Cervical cardiac branches of left
sympathetic chain and left vagus
Left superior intercostal vein
Left phrenic

Posterior and to right

Trachea
Esophagus
Rt. recurrent laryngeal nerve

Superiorly
Left brachiocephalic vein (in upper part)

Inferiorly
Bifurcation of pulmonary trunk and left
pulmonary artery
Left bronchus
Ligamentum arteriosum with superficial
cardiac plexus
Left recurrent laryngeal nerve

16

 Dilatation of aorta
Symptoms are due to compression of

neighboring structure like dysphagia due to

compression of esophagus, dyspnea due to
compression of trachea

17

Descending
thoracic aorta

Continuation of arch beyond

lower border of T4
Lies in posterior mediastinum
Enters abdomen in front of body

of T12 vertebra

18

Branches

9 posterior intercostal arteries 311 spaces (both side)

Subcostal artery on both side

2 left bronchial arteries

Mediastinal branches

Esophageal branches

Pericardial branches

Superior phrenic arteries

19

Clinical correlation

Coarctation of aorta
Localized narrowing of aorta opposite to or just beyond ductus

arteriosus
Hypertension in UL and hypotension in LL
Tortuous arteries, notching of ribs due to pulsation of enlarged
posterior intercostal arteries in radiography is important
diagnostic signs
20

Ductus arteriosus and ligamentum

arteriosum

Wide channel connecting left pulmonary

artery to the aorta

Conducts most of the blood from rt. ventricle

to aorta thus short circuiting the lung in the
fetus

Closes functionally within a week and

anatomically within about 8 weeks and form
forms ligamentum arteriosum

Left recurrent laryngeal nerve hooks around it

PDA-patent ductus arteriosus

Ductus arteriosus fail to close

Conducts blood from aorta to the pulmonary

arteries

Pulmonary hypertension
Increased vascularity of the lung

21

Trachea

Tubular structure

Begins
Lower border of larynx

Ends
Sternal angle by bifurcating into
2 primary bronchus

About 16cm in length and is

surrounded by about 16-20 C
shaped hyaline cartilaginous ring
Replaced posteriorly by trachialis
muscle

Carina
A ridge separating the openings
of right and left main bronchus

Projection
cartilage

of

last

tracheal
22

Esophagus

Narrow muscular tube about 10

inches in length (25 cm)

Begins at lower border of cricoid

cartilage as a continuation with
lower end of pharynx

Runs in front of vertebral column

through superior and posterior
mediastinum

Pierces diaphragm at T10 vertebra

Ends by opening into the cardiac

end of stomach at T11 level
23

Constrictions of esophagus
4 constrictions
From upper central incisor

teeth

6 inches
At its beginning

9 inches
Where it is crossed by aortic arch

11inches
Where it is crossed by left
bronchus

16 inches
Where it pierces diaphragm
24

Blood supply/lymphatics

Artery

Upper (Cervical) part

Inferior thyroid artery

Middle (Thoracic) part

Esophageal branches of aorta

Lower (Abdominal) part

Esophageal branches of left gastric

Vein

Upper part
Brachiocephalic

Middle part
Azygos vein

Lower part
Left gastric vein

Lymphatic

Upper part
Deep cervical nodes

Middle part
Posterior mediastinal nodes

Abdominal part
Left gastric nodes
25

Nerve supply
Esophageal plexus
From sympathetic (T2-T4
segments)
Parasympathetic
from
vagus
or
recurrent
laryngeal nerves

26

Applied
Portal hypertension leads to esophageal varices
Left atrial enlargement presses esophagus (dysphagia)
Tracheoesophageal fistula
Achalasia cardia
GERD (gastro esophageal reflux disease)
Barrett's esophagus
Malignancy (Adeno Ca, Squamous cell Ca)
27

Endoscopic appearance of
esophagus
Normal

28

Barium swallow radiograph of

esophagus
Normal Barium swallow

Achalasia cardia
Rat tail appearance (birds
beak)

29

Barrett's esophagus

30

Thoracic duct
Largest lymphatic channel

Left brachiocephalic vein

Drains most of the body

Thoracic duct

lymph to venous system

SVC

Length -18 inches

Esophagus
Azygos
vein

Extend from upper part of

abdomen to lower part of

neck

Aorta

Diaphragm

Beaded in appearance due to

numerous valves in its lumen

Cisterna chyli

31

Course
Continuation of cisterna chyli

present in abdomen

Left brachiocephalic vein

Thoracic duct

Enters thorax at the level of

T12 through aortic opening

Comes to left side at the level

SVC
Esophagus
Azygos
vein

of T5 vertebra

Runs along the left edge of

esophagus and reaches the

neck

Aorta

Diaphragm

Arches at the level of C7 and

ends at angle between left

subclavian and left internal
jugular vein

Cisterna chyli

32

Tributaries
Receives lymph from both halves of

body below diaphragm and left half

above diaphragm
Left

internal
subclavian vein

jugular

and

left

Left mediastinal trunk

33

Azygos vein
Formed

by right ascending
lumbar and subcostal vein at T12
vertebra

Enters the thorax through aortic

opening of diaphragm or by
piercing the rt. crus

Ascends up to the T4, arches

over right lung root and ends

into the posterior aspect of SVC

Drains thoracic wall and upper

lumbar region

Right ascending
lumbar vein

Important channel connecting

the two venae cava

34

Tributaries of azygos vein

Rt. post. intercostal veins except

1,2,3,4 intercostal vein

Rt. superior intercostal vein

(formed by 2,3,4 intercostal vein)

Hemiazygos vein at T9

Accessory hemiazygos at T8

Right bronchial veins

Esophageal,
mediastinal
pericardial veins

and

35

Hemiazygos veins
Formed

by union of left
ascending lumbar and left
subcostal vein

Pierces left crus of diaphragm

Turns to the rt. at T9 to end in

azygos vein

Tributaries

Left ascending lumbar

Left subcostal
9th to 11th left post. intercostal
veins
36

Accessory hemiazygos vein

Begins at 4th ICS
At T8 turns to the rt. behind the

aorta, esophagus and thoracic

duct and joins azygos vein
Tributaries
5th to 8th left intercostal veins
Left bronchial veins

37

Clinical correlation
Azygos system of veins

form alternate
pathway for venous
drainage in case of
superior and inferior
vena cava obstruction

38

Thoracic sympathetic trunk

Ganglionated chain located on

each side of thoracic vertebral

column

There are 10 or 11 ganglia as

upper one(1st thoracic)

commonly fuses with the
inferior cervical gang. to form
stellate ganglion

Chain crosses neck of first rib

and heads of 2nd to 10th rib and

bodies of 11th and 12th thoracic
vertebra

Chain is anterior to intercostal

nerves and vessels

Passes beneath the medial

arcuate ligament to be
continuous with lumbar chain

39

Branches
Lateral branches-for the limb

and body wall

Medial branches
Upper 5 ganglia supply to

heart, lung, esophagus

through
Pulmonary branches
Cardiac branches
Aortic branches
Esophageal branches

Lower 7 ganglia form

splanchnic nerves that are

preganglionic
40

Splanchnic nerves
Greater
5-9

Lesser
10 and 11

Least

T10

12

41

Greater splanchnic (T5-9)

Pierce the crus of diaphragm and
ends into the upper part of
celiac ganglion

Lesser splanchnic (T10-11)

Ends into lower part of celiac
ganglion (aorticorenal ganglion),
superior mesenteric ganglion

Least splanchnic
Ends in the aorticorenal ganglion
/ inferior mesenteric ganglion

42

Clinical correlate
Stellate block
Is

an injection of local
anesthetics near the stellate
ganglion by placing the tip of
needle near neck of 1st rib

Produces a temporary

interruption of sympathetic
function such as a patient
with excessive
vasoconstriction in the upper
limb

43

Phrenic nerve

Arises in neck from C3,4,5 nerves of

cervical plexus

Runs on the scalenus anterior muscle

Enters thorax by passing in front of

the subclavian artery and runs in
superior and middle mediastinum

Only motor nerve supply to the

diaphragm

Also sends sensory branches to

Fibrous and parietal pericardium

Parietal pleura (mediastinal and central
part of diaphragmatic)
Parietal peritoneum near diaphragm
44

Applied anatomy of phrenic nerve

Each phrenic nerve supplies

corresponding
diaphragm

half

of

the

Phrenic nerve can be injured by

penetrating wounds in neck

Paralyzed half of the diaphragm

relaxes and is pushed up into the

thorax by the positive abdominal
pressure
PA chest radiograph shows marked elevation of the left
hemidiaphragm (left phrenic nerve palsy)

Consequently lower lobe of lung

on that side may collapse

45