MISTLEY JANE 1

SUPERIOR MEDIASTINUM AND GREAT VESSELS ORDER OF THE MAJOR STRUCTURES IN THE SUPERIOR
MEDIASTINUM, FROM ANTERIOR TO POSTERIOR, IS:
SUPERIOR MEDIASTINUM: Thymus
i SUPERIOR TO: the transverse thoracic plane Veins
s PASSING THROUGH: the sternal angle and the junction Arteries
a (IV disc) of vertebrae T4 and T5. Airway
h Alimentary tract
i Lymphatic trunks
g
THYMUS
h i a primary lymphoid organ
l s located in the:
y a inferior part of the neck
m h anterior part of the superior mediastinum
o i (Figs. 1.65 and 1.66A)
It is a flat gland with flask-shaped lobes that lies:
b g
POSTERIOR: to the manubrium
i h
extends into the anterior mediastinum
l l ANTERIOR: to the fibrous pericardium
e FROM ANTERIOR TO POSTERIOR, THE CONTENTS y After puberty, the thymus undergoes gradual involution
r OF THE SUPERIOR MEDIASTINUM ARE THE: m and is largely replaced by fat.
e Thymus o ARTERIAL SUPPLY OF THE THYMUS IS DERIVED
Great vessels MAINLY FROM:
g b
with the veins: the anterior intercostal
i i
brachiocephalic veins anterior mediastinal branches of the internal
o SVC l thoracic arteries
n anterior to the arteries: e VEINS OF THE THYMUS END IN THE:
arch of aorta r left brachiocephalic
roots of its major branches: e internal thoracic
- the brachiocephalic trunk inferior thyroid veins.
g
- left common carotid artery LYMPHATIC VESSELS OF THE THYMUS END IN THE:
- left subclavian artery
i
Parasternal
related nerves: o
Brachiocephalic
vagus nerve n Tracheobronchial lymph nodes
phrenic nerves
the cardiac plexus of nerves GREAT VESSELS
Inferior continuation of the cervical viscera: i
BRACHIOCEPHALIC VEINS:
ANTERIORLY: trachea s THE RIGHT AND LEFT BRACHIOCEPHALIC VEINS
POSTERIORLY: esophagus a ARE FORMED:
related nerves: h POSTERIOR: to the sternoclavicular (SC) joints
left recurrent laryngeal nerve i BY THE UNION OF: the internal jugular and
Thoracic duct and lymphatic trunks. subclavian veins
g
AT THE LEVEL OF THE INFERIOR BORDER OF
h
THE 1ST RIGHT COSTAL CARTILAGE:
l the brachiocephalic veins unite to form the SVC
y (Figs. 1.65B and 1.66B)
m The left brachiocephalic vein is more than twice as
o long as the right brachiocephalic vein because:
b IT PASSES: from the left to the right side
ANTERIOR: to the roots of the three major
i
branches of the arch of the aorta. (Fig. 1.66B)
l The brachiocephalic veins shunt blood from the
e head, neck, and upper limbs to the right atrium.
r
e SUPERIOR VENA CAVA (SVC):
g Returns blood from all structures superior to the
i diaphragm, except the lungs and heart.
It passes inferiorly and ends at the level of the 3rd
o
costal cartilage, where it enters the right atrium of
n the heart.

CLINICAL ANATOMY | SUPERIOR MEDIASTINUM AND GREAT VESSELS

 MISTLEY JANE 2
THE SVC LIES IN THE:
RIGHT SIDE: of the superior mediastinum
ANTEROLATERAL: to the trachea
POSTEROLATERAL: to the ascending aorta
THE RIGHT PHRENIC NERVE:
lies between the SVC and the mediastinal pleura
THE TERMINAL HALF OF THE SVC IS IN:
the middle mediastinum, where it lies beside the
ascending aorta and forms the posterior boundary of
the transverse pericardial sinus

ARCH OF THE AZYGOS VEIN

Occupies a position corresponding to the aorta on
the right side of the trachea over the root of the
ASCENDING AORTA
right lung, although the blood is flowing in the
approximately 2.5 cm in diameter
opposite direction (Fig. 1.63).
begins at the aortic orifice
LIGAMENTUM ARTERIOSUM:
ITS ONLY BRANCHES ARE THE:
the remnant of the fetal ductus arteriosus,
coronary arteries, arising from the aortic
passes from the root of the left pulmonary
sinuses
artery to the inferior surface of the arch of the
The ascending aorta is:
aorta.
Intrapericardial (Figs. 1.66A & B)
USUAL BRANCHES OF THE ARCH ARE:
lies inferior to the transverse thoracic plane
brachiocephalic trunk
thats why it is considered a content of the
left common carotid artery
middle mediastinum (part of inferior
left subclavian artery
mediastinum).

BRACHIOCEPHALIC TRUNK:
ARCH OF THE AORTA (AORTIC ARCH):
the first and largest branch of the arch of the aorta,
the curved continuation of the ascending aorta
ARISES POSTERIOR: to the manubrium
(Figs. 1.65A and 1.67)
WHERE IT IS:
BEGINS: posterior to the 2nd right sternocostal
ANTERIOR: to the trachea
(SC) joint at the level of the sternal angle.
POSTERIOR: to the left brachiocephalic vein
IT ARCHES:
THE TRUNK ASCENDS:
Superiorly, posteriorly and to the left, and then
superolaterally to reach the right side of the
inferiorly.
trachea and the right SC joint
THE ARCH ASCENDS ANTERIOR TO:
where it divides into:
The right pulmonary artery and the bifurcation
the right common carotid and
of the trachea, reaching its apex at the left side
right subclavian arteries.
of the trachea and esophagus as it passes over
the root of the left lung.
LEFT COMMON CAROTID ARTERY
THE ARCH DESCENDS POSTERIOR TO:
the second branch of the arch of the aorta
the left root of the lung beside the T4 vertebra
ARISES:
THE ARCH ENDS:
POSTERIOR: to the manubrium
By becoming the thoracic (descending) aorta
SLIGHTLY POSTERIOR AND TO THE LEFT:
posterior to the 2nd left sternocostal joint.
brachiocephalic trunk

CLINICAL ANATOMY | SUPERIOR MEDIASTINUM AND GREAT VESSELS

 MISTLEY JANE 3
IT ASCENDS: LEFT VAGUS NERVE (LVN)
anterior to the left subclavian artery and is at DESCENDS: in the neck posterior to the left
first anterior to the trachea and then to its left common carotid artery (Fig. 1.68A).
IT ENTERS THE NECK BY: ENTERS THE MEDIASTINUM:
passing posterior to the left SC joint Between the left common carotid artery and left
subclavian artery.
LEFT SUBCLAVIAN ARTERY When the LVN reaches the left side of the arch of
the third branch of the arch of the aorta the aorta:
ARISES: It diverges posteriorly from the left phrenic
From the posterior part of the arch, just nerve.
posterior to the left common carotid artery. The LVN is separated laterally from the phrenic
IT ASCENDS: nerve by the:
Lateral to the trachea and left common carotid Left superior intercostal vein.
artery through the superior mediastinum As the LVN curves medially at the inferior border of
it has no branches in the mediastinum the arch of the aorta:
As it leaves the thorax and enters the root of the It gives off the left recurrent laryngeal nerve.
neck, it passes posterior to the left SC joint. LEFT RECURRENT LARYNGEAL NERVE PASSES:
INFERIOR: to the arch of the aorta,
immediately
LATERAL: to the ligamentum arteriosum
ASCENDS: to the larynx in the groove between
the trachea and the esophagus (Figs. 1.63, 1.66B,
1.68AC, and 1.69).
The LVN passes:
POSTERIOR: to the root of the left lung, where
it breaks up into many branches that contribute
to the left pulmonary plexus.
The LVN leaves this plexus as a single trunk and
passes to the esophagus, where it joins fibers from
the right vagus in the esophageal (nerve) plexus (Fig.
1.68B & C).
NERVES IN THE SUPERIOR MEDIASTINUM
i
VAGUS NERVES:
s Exit the cranium and descend through the neck
a posterolateral to the common carotid arteries (Fig.
h 1.68A).
i Each vagus nerve enters the superior mediastinum
g posterior to the respective SC joint and
brachiocephalic vein.
h
RIGHT VAGUS NERVE (RVN)
l ENTERS THE THORAX:
y ANTERIOR: to the right subclavian artery
m IT GIVES RISE: to the right recurrent
o laryngeal nerve (Fig. 1.68AC).
b RUNS:
Posteroinferiorly through the superior
i
mediastinum on the right side of the trachea
l THEN PASSES:
e posterior to the right brachiocephalic vein, SVC,
r and root of the right lung.
e Here it divides into many branches, which contribute
g to the right pulmonary plexus (Fig. 1.68C).
i Usually, the RVN leaves this plexus as a single nerve
and passes to the esophagus, where it again breaks
o
up and contributes fibers to the esophageal (nerve)
n plexus.
The RVN also gives rise to nerves that contribute to
the cardiac plexus.
RIGHT RECURRENT LARYNGEAL NERVE
hooks around the right subclavian artery and
ASCENDS: between the trachea and esophagus
to supply the larynx.

CLINICAL ANATOMY | SUPERIOR MEDIASTINUM AND GREAT VESSELS

 MISTLEY JANE 4

TRACHEA
i DESCENDS: anterior to the esophagus and
s ENTERS: the superior mediastinum, inclining a little to
a the right of the median plane.
h POSTERIOR SURFACE OF THE TRACHEA:
PHRENIC NERVES: i is flat where it is applied to the esophagus
Supply the diaphragm with motor and sensory fibers,
g TRACHEA ENDS: at the level of the sternal angle by
the latter accounting for approximately one third of dividing into the right and left main bronchi
the nerves fibers.
h
TRACHEA TERMINATES: superior to the level of the
Also supply sensory fibers to the pericardium and l heart and is not a component of the posterior
mediastinal pleura. y mediastinum.
Each phrenic nerve enters the superior mediastinum m
between: oESOPHAGUS
the subclavian artery and the origin of the i
b is a fibromuscular tube that extends from the pharynx
brachiocephalic vein. s to the stomach.
The fact that the phrenic nerves pass anterior to
i
a ENTERS THE SUPERIOR MEDIASTINUM:
the roots of the lungs provides an important means l
h between the trachea and vertebral column, where it
of distinguishing them from the vagus nerves, which e lies
i
pass posterior to the roots. r ANTERIOR: to the bodies of the T1T4 vertebrae.
g
RIGHT PHRENIC NERVE: e The esophagus is usually flattened anteroposteriorly.
Passes along the right side of:
h
g Initially, it inclines to the left but is pushed back to the
the right brachiocephalic vein, SVC, and the l median plane by the arch of the aorta.
i
pericardium over the right atrium. y It is then compressed anteriorly by the root of the left
It also passes anterior to: o
m lung.
the root of the right lung and n IN THE SUPERIOR MEDIASTINUM:
o
DESCENDS: on the right side of the IVC to the
b the thoracic duct usually lies on the left side of the
diaphragm, which it pierces near the caval esophagus, deep (medial) to the arch of the aorta.
opening.
i
Inferior to the arch, the esophagus again inclines to the
LEFT PHRENIC NERVE: l left as it approaches and passes through the esophageal
DESCENDS: e hiatus in the diaphragm.
Between the left subclavian and left common r
carotid arteries. e
It crosses the left surface of the arch of the aorta g
anterior to the left vagus nerve and passes over the
i
left superior intercostal vein.
The left phrenic nerve then descends: o
anterior to the root of the left lung and n
runs along the fibrous pericardium,
superficial to the left atrium and ventricle of
the heart,
where it pierces the diaphragm to the left of
the pericardium (Fig. 1.70B)
Most branching of the phrenic nerves for
distribution to the diaphragm occurs on:
the diaphragms inferior (abdominal) surface.

CLINICAL ANATOMY | SUPERIOR MEDIASTINUM AND GREAT VESSELS