Posterior Mediastinum

Define the boundaries of posterior mediastinum

10/15/2013 5:13:00 AM

Posterior Mediastinum
Structures in PM

1. Esophagus 2. Thoracic aorta/ Descending aorta 3. Azygos venous system i. Azygos ii. Hemiazygos iii. Accessory hemiazygos 4. Thoracic duct 5. Sympathetic nerve i. Sympathetic trunk ii. Splanchnic nerve 6. Vagus nerve

The major boundaries of the posterior mediastinum are: Angle of Louis for superior portion T5-T12 for the posterior portion The posterior diaphragm for the inferior portion And the Mediastinal cavity as the anterior portion

Describe and relate structures found in the posterior mediastinum (i.e., descending aorta, esophagus, major veins, thoracic duct, splanchnic, sympathetic nerve and vagus nerves)

Posterior Mediastinal Structures

Sagittal Views of PM Structures

Right

Left View:

Left

Right View:

Vagus n.

Sympathetic trunk

Thoracic duct Esophagus Azygos v. Great splanchnic n.

Hemiazygos Thoracic aorta/Descending aorta Great splanchnic n.

Thoracic

Aortic Arch Begins at left of T4 Descends from T5-T12 Posterior to root of LeftLung, Esophagus, Pericardium Most inferior portion Midline displacing esophagus

Rel

Beg des

Loc lung

Branches o Anterior Unpaired (A) Branches of thoracic aorta Branch to Gut A Anterior Unpaired Branches to the gut Pericardial Branch Pericardial branches Mediastinal arteries Mediastinal Arteries B Lateral Paired o Lateral Paired (B) Branches to visceral other than the gut e.g. Bronchial arteries Bronchial arteries and other visceral organs C Posterolateral Paired 3-11 posterior intercostal arteries Not gut 1 subcostal a. supply the diaphragm o Posterior Unpaired (C)
Posterior intercostal arteries

Mos line
Thoracic duct Azygos vein

3-11 posterior intercostal Rt. Posterior Intercostal is longer b/c they pass over vertebral bodies 1 subcostal art -> diaphragm

c aorta

3rd -11th Posterior intercostal arteries

other than the es

Relationship:

ostal arteries

pply the

runs along the Located posterior to the left side of vertebral bodies pericardium and left atrium. Constitutes theAnastomosis main posterior part of the heart base.

Rt. posterior intercostal arteries are longer than the left ones: because they pass over the vertebral bodies.

Thoracic aorta

Close to the diaphragm, it deviates Posterior intercostal to the left. arteries Esophagus: Exit through the esophageal hiatus Posterior and left of atrium Main posterior part of heart in the diaphragm at T10 vert. level Once cut into diaphragm, deviates to the left Esophagus togetherRelationship: with anterior and posterior Exits Esophagus Hiatus at T10 w/ anterior and posterior Vagal trunks Located posterior to the vagal trunks pericardium and left atrium.
Constitutes the main posterior part of the heart base. Close to the diaphragm, it deviates to the left. Exit through the esophageal hiatus in the diaphragm at T10 vert. level pericardium together with anterior and posterior vagal trunks

pericardium

Ascends to the right side of vertebral bodies T5-L2 (left of azygos v., posterior to esophagus & right of thoracic aorta). Crosses to the left at the sternal angle e level and runs posterior to the esophagus.

Thoracic Duct:
Empties at the left venous angle (union Largest Lymph Channel of left internal jugular and subclavian vein). Empty at Left Venous Angle (union of left Jugular and Subclavian Vein) Origin: Chyle Cistern @ L2 As viewed from Ascends on right side of T5-T12 the feet Left of Azygus The duck w b tween t o gooses (duck = Right of Thoracic Aorta thoracic duct) 2 gooses = azyGOUS and esophaGOUS Posterior to Esophagus Crosses to the left of sternal angle Lt. venous Thoracic Duct

Largest lymphatic channel in the body. Originates from the chyle cistern in the abdomen at L2 vertebral body level.

angle

Ascends to the right side of vertebral bodies T5-L2 (left of azygos v., posterior of thoracic aorta). to esophagus & right

Crosses to the left at the sternal angle e level and runs posterior to the esophagus. Empties at the left venous angle (union Right lymphatic ductand subclavian vein). of left internal jugular

Azygos v. Thoracic aorta Thoracic duct

Right lymphatic duct

As viewed from the feet The duck w b tween t o gooses (duck = = azyGOUS and thoracic duct) 2 gooses esophaGOUS Right Lymphatic Duct: Enters at right Venous Angle Rt. lymphatic duct drains Drains upper right quadrant of body the rt. Upper Quadrant Right lymphatic duct
Right lymphatic duct

Chyle cistern

Azygos Vein
Azygos Vein: Rt. lymphatic duct drains
the rt. Upper Quadrant

Drain the back, thoracoabdominal wall and mediastinal viscera. Forms collateral circulation between SVC and IVC.

SVC

Azygos vein

Accessory hemiazygos

Drains: o Back o Thoracoabdominal Wall o Mediastinal Viscera Collateral Circulation with IVC and SVC Arch over root of right lung -> join with SVC

Left Azygus Equivalents 1st Posterior Intercostal veins o Drains into Brachiocephalic veins Left superior intercostal vein (A) o Drain 2nd-4th intercostal space o Drains into left Brachiocephalic vein Accessory Hemiazygos (B) o Drains left 5th-8th intercostal Veins o May drain into left bronchial vein o Crosses to right side at T7/T8 to drain into Azygos Hemiazygos (C) o Drains 9th-12th intercostal space o Crosses to right side at T9 to drain into Azygos

Left-side equiva

1st bra

A- L
Azygos

D D

B- A

D Som

Cr bod
Lt. & rt. Renal v.

C- H

Ascending lumbar v.

D Cr into

Nerves in Posterior Mediastinum: Sympathetic Trunk Splanchnic Nerves Vagus (Esophageal plexus) Sympathetic Trunk:

Note th

Options followed by sympathetic nerves:

1- enter chain, synapse and exit at same level 2- enter chain, ascend or descend to synapse 3- enter chain and pass through to prevertebral Ganglia splanchnic nerve

Splanchnic nerve

Sympathetic trunk

Splanchnic = Visceral = Internal organs

Splanchnic Nerves:

Thoracic sympathetic trunks & splanchnic nerves:

a) Greater splanchnic T5 - T9 b) Lesser splanchnic T10 - T11 c) Least splanchnic T12
Sympathetic trunk Intercostal n. Greater splanchnic n. Lesser splanchnic n.

Splanchnic nerves:

-Contains pre-synaptic sympathetic fibers to abdominal Contains presympathetic fibers tothe abdominal organsorgans. Sympathetic trunk

Least splanchnic n.

Vagus n. Phrenic n.

Paravertebral ganglia

Greater splanchnic n. T5-T9 Fibers to Lesser splanchnic n. T10-11 -Least splanchnic n. T12 (inferior to diaphragm)
At T10 is the Diaphragmatic Hiatus. T12 is under the Diaphragm Esophageal Vagal Plexus:

Collection of: o POSTsynaptic sympathetic fibers Esophageal vagal plexus o PREsynaptic parasympathetic fibers o Visceral Afferent Collection of: Due to embryological development, there is a twisting in the Gut tube. Causing the Left a) Postsynaptic sympathetic fibers Vagus Nerve to be turned Anteriorly and the Right Vagus Nerve to be turned b) Parasympathetic presynaptic fibers Posteriorly. o Mnemonic: LARP Leftc) becomes Anterior, Right become Posterior Visceral afferent fibers
90 embryologic rotation Left vagus nerve Esophageal plexus Anterior vagal trunk (Vagus nerve) Exit Thoracic cavity via Esophageal hiatus at T10

'LARP (Left becomes Anterior, Right becomes Posterior) Diaphragm:

Diaphragm
Left phrenic n.

Right phrenic n. Pericardial sac Esophageal opening

Central tendon

Inferior caval opening Azygos vein

Aortic opening

Splanchnic nerves

Symphathetic trunk

view:

Phrenic nerve

Diaphragmatic openings

I Ate 10 Eggs AAT 12

Opening
Vena caval hiatus Esophageal hiatus Aortic hiatus

Vert. level
T8 T10

Location
Central tendon of diaphragm Muscular part at the right crus of the diaphragm Between the diaphragm and vertebral column

Structures passing through

Inferior Vena Cava Rt. phrenic n. Esophagus Vagus nerve, Left inferior phrenic vessels, Aorta Azygos v. Thoracic duct

T12

Mnemonic: I Ate 10 Eggs AAT 12 o I Ate Inferior Vena Cava, T8 o 10 Eggs T10, Esophagus, Vagus, Left inferior Phrenic Vessels o AAT 12 Aorta, Azygos v, Thoracic duct

Explain the manifestations and clinical significance of the following: esophageal constrictions, esophageal (Thoracic diverticula, laceration ofClinical thoracic relevance: duct and Troisiers sign, aortic thoracicaneurysm) aortic aneurysm, SVC obstruction, Risk Factors paradoxical motion of diaphragm, swollen rt. superior tracheobronchial nodes I. Ascending aortic aneurysm
II. Aortic arch aneurysm III. Descending aorta aneurysm (CR) Thoracic Aortic Aneurysm Atherosclerosis Connective tissue disorder Inflammation of aorta Tunica Trauma Media (e.g. car accidents)

Abdominal aortic aneurysm Aneurysm thatIV. causes separation of the Tunica Intimia And Risk Factors

o o o o

Atherosclerosis Connective tissue disorder Inflammation of Aorta Trauma

Internal Bleeding

(CR) Esophageal Constrictions: Three main sites: Left main bronchi Aortic Arch Diaphragmatic Esophageal Hiatus

Clinical Relevance: (Esophageal Diver

I. Parabro True

(CR) Esophageal Diverticula Parabrochial Diverticulum (outside) True traction diverticula Protrusion of all layers (not a weak spot) Pulling force from outside Cause: Tumor Epipherenic Diverticulum False Pulsion Diverticula Herniation Histology of the mucosa and submucosa through weak spots of Esophagus Pushing force from inside Causes: Neuromuscular Dysfunction (affect Vagus Nerve)

Protrus typica Cause pulling

II. Epiphre False

Hernia submu in the Caus dysfun pushi

Muscular layer

(CR) Virchows Node and Troisiers Sign Virchows Node

Clinical relevance: (Virchow's node and Troisier s sign)

Troisiers Sign Lymph Nodes in Left Supraclavicular Fossa Virchow s nodes: lymph nodes in the left supraclavicular fossa.

Enlarged Virchow s nodes diagnosed as a Troisier s sign: indicative of Enlargment of Virchows Node GI (gastric) that has metastasized through the Thoracic Duct. GI Cancercancer metastasized through Thoracic Duct

Troisier s sign

(CR) Laceration of Thoracic Duct Injured during surgery. Hard to spot Lymph escapes and produces chylothorax o Causes: Trauma Lymphoma Family History Premature babies o Test Pleura for triglyceride level to eliminate pleural effusion (CR) Azygos Vein Collateral Circulation Supra-Azygos SVC obstruction Distended arm and neck veins Dilated and tortuous veins on ubber chest and back Superior Vena Cava Syndrome

Clinical relevance: Azygos vein collateral circulation

Supra-Azygos SVC obstruction Infra-Azygos SVC obstruction

Infra-Azygos SVC obstruction s vein collateral circulation Distended arm and neck veins.

on

Dilation of collateral vessels on the anterior and posterior abdominal walls Dilated and tortuous veins on the on the anterior and Back flow upper chest and back. abdominal walls. Rerouted to IVC

Dilation of collateral vessels posterior

Infra-Azygos SVC obstruction

(Superior vena cava syndrome SVCS)

he

Dilation of collateral vessels on the anterior and posterior abdominal walls.

VCS)

Clinical relevance (Paradoxical Motion of the Diaphragm)

(CR) Paradoxical Motion of the Diaphragm Each hemidiaphragm is supplied by a separate phrenic n. Hemidiaphragm supplied with separate phrenic n. Damage to a phrenic nerve results in paradoxical movement of the diaphragm. Damage to phrenic n. -> paradoxical Motion Inspiration: During inspiration: the paralyzed dome ascends instead of descending, since it o The paralyzed dome ascends instead of descending, pushed down by abdominal is pushed by abdominal viscera. vicera Expiration: During expiration: the u paralyzed dome descends in response to l ngs positive pressure. o Paralyzed dome descends because of lungs positive pressure.

10/15/2013 5:13:00 AM