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The Big Picture: Gross Anatomy, 2e

CHAPTER 5: Superior and Posterior Mediastinum

DIVISIONS OF THE MEDIASTINUM

BIG PICTURE

The mediastinum is the anatomic region medial to the pleural sacs, between the sternum, vertebral column, rib 1, and the diaphragm. The
mediastinum is further divided into inferior and superior regions by the transverse thoracic plane, which is a horizontal plane passing from the sternal
angle to the T4–T5 intervertebral disc (Figure 5-1A). The inferior mediastinum is classically subdivided into anterior, middle, and posterior parts.
Therefore, the four subregions of the mediastinum are the anterior mediastinum, middle mediastinum, posterior mediastinum, and superior
mediastinum.

Anterior mediastinum. The anterior mediastinum is deep to the sternum and bounded by the sternal angle, pericardial sac, and diaphragm;
contains the following:

Adipose tissue.

Thymus. The thymus in adults is involuted and is primarily a connective tissue remnant.

Middle mediastinum. The middle mediastinum contains the pericardial sac and heart (see Chapter 4 for further details).

Posterior mediastinum. The posterior mediastinum contains the following anatomic structures, which are posterior to the pericardial sac
(Figure 5-1B):

Descending aorta. The thoracic portion of the aorta that gives rise to posterior intercostal arteries.

Azygos system of veins. Receives venous blood from the thoracic wall.

Thoracic duct. The primary lymphatic duct that receives lymph from all tissues below the diaphragm and from the left side of the head,
neck, upper limb, and thorax.

Esophagus. The esophagus courses vertically directly posterior to the left atrium.

Sympathetic nerves.

Figure 5-1:

A. The lateral view of the thorax illustrating the mediastinal subdivisions. B. The posterior mediastinum in axial section (superior view).

image
This chapter focuses on the structures located in the posterior mediastinum and their projection into the superior mediastinum.

Superior mediastinum. The superior mediastinum is the region above the sternal angle and contains the following structures:

Aortic arch. The aortic arch arises at the level of the transverse thoracic plane, ascends up into the superior mediastinum, and descends in
the posterior mediastinum. The aortic arch gives rise to the following three primary branches:

Brachiocephalic trunk. Supplies the right side of the head and neck and right upper limb.

Left common carotid artery. Supplies the left side of the head and neck.
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Left subclavian artery. Supplies the left upper limb.
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Superior vena cava (SVC). The SVC collects all venous blood from tissues above the diaphragm. The primary tributaries of the SVC are the
azygos vein and the left and right brachiocephalic veins.
 Aortic arch. The aortic arch arises at the level of the transverse thoracic plane, ascends up into the superior mediastinum, and descends in
the posterior mediastinum. The aortic arch gives rise to the following three primary branches:
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Brachiocephalic trunk. Supplies the right side of the head and neck and right upper limb.

Left common carotid artery. Supplies the left side of the head and neck.

Left subclavian artery. Supplies the left upper limb.

Superior vena cava (SVC). The SVC collects all venous blood from tissues above the diaphragm. The primary tributaries of the SVC are the
azygos vein and the left and right brachiocephalic veins.

Trachea. The trachea bifurcates at the level of the transverse thoracic plane into the left and right primary bronchi.

Esophagus. The esophagus is a vertical, muscular tube that is located posterior to the trachea and transports food from the pharynx to the
stomach.

Nerves. The phrenic nerves (en route to the diaphragm) and vagus nerves (en route to thoracic and abdominal organs) course through the
superior mediastinum.

Thymus. In an adult, the thymus is usually atrophied and presents as a fatty mass.

SYMPATHETIC TRUNK AND ASSOCIATED BRANCHES

BIG PICTURE

A nerve ganglion is a collection of neuronal cell bodies in the peripheral nervous system. The ganglia that comprise the sympathetic chain are neuronal
cell bodies from postganglionic sympathetic neurons. The ganglia associated with the sympathetic chain are organized in a vertical fashion and are
segmentally linked with each of the thoracic spinal nerves via white and gray communicantes. The sympathetic chain is associated with the preaortic
ganglia by way of greater, lesser, and least splanchnic nerves.

SYMPATHETIC NERVES OF THE THORAX

The thoracic sympathetic chain or trunk courses vertically across the heads of the ribs along the posterior thoracic wall, deep to the parietal
pleura. The chain continues superiorly into the neck and inferiorly into the abdominal cavity (Figure 5-2A). The sympathetic chain parallels the
vertebral column and is therefore also referred to as the paravertebral ganglia.

Figure 5-2:

A. Sympathetic trunk and splanchnic nerves. B. Sympathetic pathways: (1) synapse in a paravertebral ganglion at the same level; (2) synapse in a
paravertebral ganglion at a different level; (3) synapse in a prevertebral ganglion (i.e., celiac ganglion) via a splanchnic nerve.

image
The thoracic portion of the sympathetic trunk typically has 12 bilateral ganglia connected to adjacent thoracic spinal nerves by white and gray rami
communicantes.

White rami communicantes have myelinated nerve fibers and thus appear white.

Gray rami communicantes have unmyelinated nerve fibers and, therefore, appear gray.

The thoracic sympathetic ganglia are:

Numbered according to the thoracic spinal nerve with which they are associated.

Collections of nerve cell bodies for postganglionic sympathetic neurons.

Connected together by internodal fibers, which are composed of ascending and descending processes of preganglionic sympathetic neurons.

Recall that cell bodies for preganglionic sympathetic neurons originate in the lateral horn of the spinal cord gray matter. The axons exit the ventral
root into the ventral ramus where white rami convey the preganglionic sympathetic neurons from the ventral ramus to a sympathetic chain
ganglion. Once the preganglionic sympathetic neurons enter the sympathetic chain, the following possible pathways may occur (Figure 5-2B):
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Preganglionic sympathetic neurons synapse with postganglionic sympathetic neurons within the ganglion, and the segmental gray rami
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communicantes carry the postganglionic sympathetic neurons back to the ventral ramus at the same segmental level. The postganglionic
sympathetic neurons innervate blood vessels, sweat glands, and arrector pili muscles of hair follicles within the associated dermatome.
 Collections of nerve cell bodies for postganglionic sympathetic neurons.

Connected together by internodal fibers, which are composed of ascending and descending processes of preganglionic sympathetic neurons.

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Recall that cell bodies for preganglionic sympathetic neurons originate in the lateral horn of the spinal cord gray matter. The axons exit the ventral
root into the ventral ramus where white rami convey the preganglionic sympathetic neurons from the ventral ramus to a sympathetic chain
ganglion. Once the preganglionic sympathetic neurons enter the sympathetic chain, the following possible pathways may occur (Figure 5-2B):

Preganglionic sympathetic neurons synapse with postganglionic sympathetic neurons within the ganglion, and the segmental gray rami
communicantes carry the postganglionic sympathetic neurons back to the ventral ramus at the same segmental level. The postganglionic
sympathetic neurons innervate blood vessels, sweat glands, and arrector pili muscles of hair follicles within the associated dermatome.

Preganglionic sympathetic neurons enter the sympathetic chain and ascend or descend to a different segmental ganglion (e.g., the superior
cervical ganglion). At this location, a synapse between pre- and postganglionic sympathetic neurons occurs. Postganglionic sympathetic neurons
exit the ganglion and course to the cardiac plexus (see the section Innervation of the Heart in Chapter 4).

Preganglionic sympathetic neurons en route to abdominal organs course through the sympathetic ganglion without synapsing and become
thoracic splanchnic nerves. Thoracic splanchnic nerves are as follows (Figure 5-2A):

Greater splanchnic nerve. Union of the T5–T9 splanchnic nerves; synapses are in the celiac or superior mesenteric ganglia.

Lesser splanchnic nerve. Union of the T10–T11 splanchnic nerves; synapses are in the superior mesenteric or aorticorenal ganglia.

Least splanchnic nerve. The T12 splanchnic nerve; synapses are in the aorticorenal ganglion.

AZYGOS VEINS, THORACIC DUCT, AND THORACIC AORTA

BIG PICTURE

The structures superficial to the sympathetic chain are the azygos system of veins (which drain blood from the posterior thoracic wall), the thoracic
lymphatic duct (which courses between the thoracic aorta and esophagus), and the thoracic aorta (located left of the midline, along the anterior
surface of the thoracic vertebrae).

AZYGOS SYSTEM OF VEINS

The azygos system of veins is considered to be the azygos vein on the right side of the thorax and the hemiazygos and accessory hemiazygos veins on
the left side (Figure 5-3):

Azygos vein. Formed by the union of the right ascending lumbar and right subcostal veins.

Receives blood directly from the right posterior intercostal veins and indirectly via the left-sided connections from the hemiazygos and
accessory hemiazygos veins.

Terminates by arching over the right primary bronchus and converging with the SVC at the level of the sternal angle.

Hemiazygos vein. Formed by the union of the left ascending lumbar and left subcostal veins.

Receives blood from the lower four left posterior intercostal veins.

Joins the azygos vein via tributaries that cross the vertebral column from left to right.

Accessory hemiazygos vein. Usually begins at the fourth intercostal space.

Receives blood from the fourth to eighth left posterior intercostal veins.

Joins the azygos vein via tributaries that cross the vertebral column or that join with the hemiazygos vein.

Figure 5-3:

Azygos system of veins, thoracic duct, and thoracic aorta.

image
The first posterior intercostal vein on each side drains into the corresponding brachiocephalic vein. Posterior intercostal veins two through four join to
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CHAPTER 5: Superior and Posterior Mediastinum,
form the superior intercostal vein, which drains into the azygos vein on the right side and the brachiocephalic vein on the left side. Page 3 / 6
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LYMPHATIC DRAINAGE
 Joins the azygos vein via tributaries that cross the vertebral column or that join with the hemiazygos vein.

Figure 5-3:

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Azygos system of veins, thoracic duct, and thoracic aorta.

image
The first posterior intercostal vein on each side drains into the corresponding brachiocephalic vein. Posterior intercostal veins two through four join to
form the superior intercostal vein, which drains into the azygos vein on the right side and the brachiocephalic vein on the left side.

LYMPHATIC DRAINAGE

Lymph in the thoracic region drains via two lymphatic vessels, the thoracic duct and the right lymphatic duct.

1. The thoracic (lymphatic) duct:

Is the main lymphatic vessel that receives lymph from the entire body, with the exception of the right upper limb, the right side of the head and
neck, and the right upper thorax.

May have a beaded appearance because of its numerous valves.

Begins in the abdomen just inferior to the diaphragm at a dilated sac created by convergence of the intestinal and lumbar lymphatic trunks,
called the cisternal chili.

Ascends deep to the diaphragm by coursing through the aortic hiatus.

Continues superiorly between the esophagus and thoracic aorta.

Shifts to the left of the esophagus at the level of the sternal angle.

Curves laterally at the root of the neck and empties into the junction of the left internal jugular and subclavian veins.

2. The right lymphatic duct:

Drains the right side of the thorax, the right upper limb, and the right head and neck and empties into the junction of the right internal jugular
and subclavian veins.

THORACIC AORTA

The thoracic (descending) aorta begins at the T4 vertebral level and courses anterior to the vertebral column, just left of the midline. The thoracic aorta
enters the abdominal cavity through the aortic hiatus at vertebral level T12. The following thoracic branches arise from the thoracic aorta:

Posterior intercostal arteries (3–11). Segmental arteries that arise bilaterally and supply the intercostal spaces and overlying skin. The first
two intercostal arteries arise from the costocervical trunk.

Bronchial arteries. Branches that supply the non-respiratory tissues in the lungs (usually one to the right bronchus and two to the left
bronchus).

Esophageal arteries. Supply the middle third of the esophagus.

Subcostal arteries. Segmental arteries that arise bilaterally and supply the T12 segment.

Superior phrenic arteries. Bilateral branches that supply the posterior regions of the diaphragm.

POSTERIOR AND SUPERIOR MEDIASTINUM

BIG PICTURE

The esophagus is a muscular tube that is continuous with the pharynx in the neck and enters the thorax posterior to the trachea. The superior
mediastinum is located between the transverse thoracic plane at the T4 vertebral level and the T2 vertebral level. The posterior and superior
mediastinum serve as a thoroughfare for vessels, nerves, and lymphatics that pass between the neck, upper limbs and thorax.

ESOPHAGUS AND VAGUS NERVE

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Topography. The esophagus descends against the thoracic vertebrae, deep to the pericardium, and has its anterior surface pressed by the left
atrium (Figure 5-4). At the T10 vertebral level, the esophagus exits the thorax through the esophageal hiatus of the diaphragm. Note that the
esophageal hiatus is formed by the right crus of the diaphragm, splitting to wrap around the esophagus to become the so-called esophageal
BIG PICTURE

The esophagus is a muscular tube that is continuous with the pharynx in the neck and enters the thorax posterior to the trachea. The superior
mediastinum is located between the transverse thoracic plane at the T4 vertebral level and the T2 vertebral level. The posterior and Access Provided by:
superior
mediastinum serve as a thoroughfare for vessels, nerves, and lymphatics that pass between the neck, upper limbs and thorax.

ESOPHAGUS AND VAGUS NERVE

Topography. The esophagus descends against the thoracic vertebrae, deep to the pericardium, and has its anterior surface pressed by the left
atrium (Figure 5-4). At the T10 vertebral level, the esophagus exits the thorax through the esophageal hiatus of the diaphragm. Note that the
esophageal hiatus is formed by the right crus of the diaphragm, splitting to wrap around the esophagus to become the so-called esophageal
sphincter.

Vascular supply. The esophagus receives its arterial supply via esophageal, left gastric, and inferior phrenic arteries. Blood drains from the
distal end of the esophagus (near the diaphragm) through the (1) azygos system of veins and (2) left gastric vein, which ultimately drains into the
hepatic portal vein (this knowledge will assist in understanding the complications of portal hypertension; see Chapter 10).

Innervation. The vagus nerves supply parasympathetic innervation to the esophagus.

Right vagus nerve. Descends into the thoracic cavity anterior to the right subclavian artery and gives rise to the following:

Right recurrent laryngeal nerve. Hooks around the right subclavian artery and ascends back into the neck en route to intrinsic
laryngeal muscles.

Esophageal branches. The right vagus nerve continues to the deep surface of the esophagus, becoming the posterior vagal trunk.

Cardiac and pulmonary plexuses. The right vagus nerve contributes to the cardiac plexus, which slows heart rate, and pulmonary
plexus, which causes bronchoconstriction.

Left vagus nerve. Enters the thorax between the left common carotid and subclavian arteries and gives rise to the following:

Left recurrent laryngeal nerve. Hooks around the aortic arch by the ligamentum arteriosum and ascends back into the neck en route
to the intrinsic laryngeal muscles.

Esophageal branches. The left vagus nerve continues to the anterior surface of the esophagus, becoming the anterior vagal trunk.

Cardiac and pulmonary plexuses. The left vagus nerve contributes to the cardiac plexus, which slows heart rate, and pulmonary
plexus, which causes bronchoconstriction.

Figure 5-4:

Structures of the superior and posterior mediastinum.

image
The anterior and posterior vagal trunks exchange fibers, creating an esophageal plexus of nerves. The vagus nerve carries visceral sensory
neurons whose sensory cell bodies are located in the inferior vagal ganglion. The visceral afferents from the vagus nerves transmit information to the
brain about normal physiologic processes and visceral reflexes. They do not relay pain information.

TRACHEA AND BRONCHIAL TREE

The trachea begins at the cricoid cartilage, at the C6 vertebral level, and has 18 to 20 incomplete hyaline cartilaginous rings, which are open posteriorly.
The cartilaginous rings prevent the trachea from collapsing during exhaling. The trachea is anterior to the esophagus and bifurcates into the right and
left primary (principal or main-stem) bronchi at the level of the sternal angle. The point of bifurcation, called the carina, is marked in the inside of the
airway by a cartilaginous wedge that projects upward into the airway lumen.

Right primary bronchus. Courses more vertically and is shorter and wider than the left primary bronchus; gives rise to the superior, middle,
and inferior secondary (lobar) bronchi.

Left primary bronchus. Courses more obliquely and is longer and thinner than the right primary bronchus; gives rise to the superior and
inferior secondary (lobar) bronchi.

Secondary (lobar) bronchi. Each secondary bronchus further divides into tertiary (segmental) bronchi and then continue to branch. The
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Because of its wider, more vertical orientation, the right bronchus usually has inhaled foreign objects fall into it from the trachea (e.g.,
 Right primary bronchus. Courses more vertically and is shorter and wider than the left primary bronchus; gives rise to the superior, middle,
and inferior secondary (lobar) bronchi.

Left primary bronchus. Courses more obliquely and is longer and thinner than the right primary bronchus; gives rise to the superior and
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inferior secondary (lobar) bronchi.

Secondary (lobar) bronchi. Each secondary bronchus further divides into tertiary (segmental) bronchi and then continue to branch. The
smallest bronchi give rise to bronchioles, which terminate in alveolar sacs, where the exchange of gases takes place.

Because of its wider, more vertical orientation, the right bronchus usually has inhaled foreign objects fall into it from the trachea (e.g.,
peanut).▼

PULMONARY ARTERIES

The pulmonary arteries:

Arise from the pulmonary trunk at the level of the sternal angle.

Course inferior to the aortic arch and azygos vein.

Parallel the bronchial tree throughout the lungs.

The relationship of the pulmonary arteries to the bronchi at the root of the lungs can be remembered by the mnemonic R A L S: The Right pulmonary
artery is Anterior to the right primary bronchus, and the Left pulmonary artery is Superior to the left primary bronchus.

AORTIC ARCH AND ASSOCIATED BRANCHES

The aortic arch arises at the T4 vertebral level, ascends into the superior mediastinum over the pulmonary vessels and left primary bronchus, and
descends to the T4 vertebral level where it continues as the thoracic aorta (Figure 5-4).

Ligamentum/ductus arteriosus. A fibrous connective tissue cord, called the ligamentum arteriosus, connects the deep surface of the aortic
arch to bifurcation of the pulmonary trunk in the adult. The ligamentum arteriosus is the remnant of the ductus arteriosus, which, during fetal
development, shunted blood from the pulmonary trunk to the aorta to bypass the lungs.

The aortic arch has the following three branches, from right to left:

Brachiocephalic trunk/artery. Courses to the right where it bifurcates into the right common carotid and right subclavian arteries,
supplying the right side of the head and neck and upper limb, respectively.

Left common carotid. Supplies the left side of the head and neck.

Left subclavian arteries. Supplies the left upper limb.

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