AIRWAYS AND ESOPHAGUS S231

The Retrotracheal
RadioGraphics

Space: Normal Ana-

tomic and Pathologic
Appearances1
Tomás Franquet, MD ● Jeremy J. Erasmus, MD ● Ana Giménez, MD
Santiago Rossi, MD ● Rosa Prats, MD

A variety of diseases can arise from the normal contents of the retrotra-
cheal space or from adjacent structures. Mediastinal diseases in the
retrotracheal space typically manifest radiographically as a contour ab-
normality or an area of increased opacity, although computed tomog-
raphy (CT) or magnetic resonance (MR) imaging is usually required
for diagnosis. The most common aortic arch anomaly, a right subcla-
vian artery that originates from an otherwise normal left-sided aortic
arch, appears at posteroanterior chest radiography as an obliquely ori-
ented soft-tissue area of increased opacity that extends superiorly to the
right from the superior margin of the aortic arch. CT and MR imaging
can reveal associated vascular or mediastinal abnormalities. Aortic an-
eurysms and pseudoaneurysms can manifest radiographically as fusi-
form or saccular masslike lesions that protrude into the retrotracheal
space. Thoracic MR imaging and spiral CT angiography are the diag-
nostic procedures of choice for evaluating diverse pathologic condi-
tions of the thoracic aorta. Esophageal diseases can manifest as an ab-
normality in the retrotracheal space, which may be the initial clue to
the diagnosis. At CT, lymphatic malformations in the mediastinum
manifest as lobular, multicystic tumors that surround and infiltrate ad-
jacent mediastinal structures. Familiarity with the normal radiologic
appearance of the retrotracheal space and with the clinical manifesta-
tions of diseases that affect the retrotracheal space and adjacent struc-
tures can facilitate detection, diagnosis, and management.
©
RSNA, 2002

Index terms: Aneurysm, aortic, 56.73 ● Aorta, abnormalities, 562.1521, 562.1532 ● Esophagus, abnormalities, 71.141, 71.142 ● Esophagus, neo-
plasms, 71.3131, 71.321 ● Mediastinitis, 67.272 ● Mediastinum, abscess, 67.272 ● Mediastinum, hemorrhage, 67.4128 ● Mediastinum, neoplasms,
67.31, 67.3151, 67.319

RadioGraphics 2002; 22:S231–S246

1From the Department of Radiology, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Avda Sant Antoni M. Claret 167,
08025 Barcelona, Spain (T.F., A.G., R.P.); the Department of Radiology, M. D. Anderson Cancer Center, Houston, Tex (J.J.E.); and the Depart-
ment of Radiology, Fundación Dr Enrique Rossi, Buenos Aires, Argentina (S.R.). Presented as an education exhibit at the 2001 RSNA scientific as-
sembly. Received February 22, 2002; revision requested April 2 and received May 29; accepted June 12. Address correspondence to T.F. (e-mail:
19429tfc@comb.es).
©
RSNA, 2002
 S232 October 2002 RG f Volume 22 ● Special Issue

RadioGraphics

Figure 1. Normal radiologic anatomy of the retrotracheal space. (a) Lateral chest radiograph shows
the lung tissue posterior to the trachea as a radiolucent triangular space (*). This space extends from the
thoracic inlet superiorly to the aortic arch inferiorly and is bounded posteriorly by the spine. The anterior
edge of the scapula (arrow) projects over the space and may sometimes be misidentified as the posterior
border of the retrotracheal space (arrowheads). (b) Computed tomographic (CT) scan shows the normal
retrotracheal space occupied by a dilated esophagus.

Introduction facilitate the detection and diagnosis of intratho-

The retrotracheal space (also known as the Raider
triangle or retrotracheal triangle) is a radiolucent
area that extends from the thoracic inlet to the
aortic arch and is visible on lateral chest radio-
graphs (1). A wide spectrum of diseases can occur
in this region; they may arise either from the nor-
mal contents of the retrotracheal space (esopha-
gus, left recurrent laryngeal nerve, thoracic duct,
lymph nodes, lung) or from adjacent structures.
Mediastinal disease in the retrotracheal space
typically manifests radiographically as a contour
abnormality or an area of increased opacity (1,2).
Although lung diseases may project over the ret-
rotracheal space, they have been excluded from
this discussion because they do not occur within
the retrotracheal space. A comprehensive under-
standing of the normal radiologic appearance of
the retrotracheal space and of the manifestations
of diseases that affect the retrotracheal space can
racic disease. In this article, we review the anat-
omy and normal radiologic appearance of the ret-
rotracheal space and discuss and illustrate dis-
eases that affect the retrotracheal space. These
disease entities include congenital vascular mal-
formations, acquired vascular lesions, esophageal
abnormalities, tumors, and infections.
Normal Anatomy
The retrotracheal space is best visualized on lat-
eral chest images as a radiolucent triangular area
bounded anteriorly by the trachea, posteriorly by
the spine, inferiorly by the aortic arch, and superi-
orly by the thoracic inlet. Both lungs contribute to
the radiolucency of the space: The right lung ex-
tends posterior to the trachea and outlines the
tracheal wall, whereas the left lung extends above
the transverse aorta and outlines the aortic arch
(1,2). The retrotracheal space is triangular and
varies in size depending on the patient’s age and
habitus (Fig 1). The size of the space is also af-
fected by the degree of lung inflation. In patients
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RadioGraphics the air-filled esophagus or, in some instances, the

Lesions of the Retrotracheal Space
collapsed esophagus outlined by retroesophageal
Congenital vascular lesions lung tissue (3,4).
Left aortic arch with aberrant right subclavian
artery Pathologic Conditions
Right aortic arch with aberrant left subclavian A wide spectrum of abnormalities can occur in
artery
the retrotracheal space (Table). The most com-
Double aortic arch
mon lesions are vascular in origin and are due to
Acquired vascular lesions
Aneurysm of an aberrant subclavian artery developmental anomalies of the aortic arch (5).
Aortic aneurysm
Esophageal abnormalities Congenital Vascular Lesions
Zenker diverticulum Anomalous development of the aortic arch can
Achalasia result in a variety of anatomic variants that en-
Esophageal atresia circle the trachea or esophagus (2,5,6). The most
Duplication cyst frequently encountered vascular rings in the ret-
Esophageal carcinoma rotracheal space are (a) a left-sided aortic arch
Esophageal leiomyoma
with an aberrant right subclavian artery, (b) a
Mediastinal masses
right-sided aortic arch with an aberrant left sub-
Intrathoracic goiter
Schwannoma and neurofibroma clavian artery, and (c) a complete double aortic
Hemangioma arch (6 –10). Vascular rings are often asymptom-
Lymphatic malformation atic but can produce symptoms in infants (stri-
Posttraumatic and iatrogenic hematoma dor, wheezing, dysphagia) that are due to com-
Infections pression of the trachea or esophagus (7). Aneu-
Tuberculous and pyogenic mediastinitis rysmal dilatation of the vascular rings may also
Abscess occur in adults (8,9).

Left-sided Aortic Arch with an Aberrant

with emphysema, the space is typically larger and
its upper margin is extended and may appear
trapezoidal. A vertically oriented line behind the
tracheal air column, the posterior tracheal line,
usually forms the anterior margin of the retrotra-
cheal space (3,4). This line is produced by lung
tissue in contact with the posterior wall of the tra-
chea and is up to 2.5 mm in thickness. On occa-
sion, a stripe up to 5.5 mm in thickness, the tra-
cheoesophageal stripe, will form the anterior mar-
gin of the normal retrotracheal space (3,4). The
tracheoesophageal stripe is composed of the pos-
terior wall of the trachea and the anterior wall of
Right Subclavian Artery.—The most common
aortic arch anomaly is an aberrant right subcla-
vian artery that originates from an otherwise nor-
mal left-sided aortic arch. This anomaly occurs in
approximately 1% of the population and is fre-
quently encountered incidentally at upper gas-
trointestinal or chest radiographic examination
(5,9). The aberrant right subclavian artery arises
from the posterior portion of the aortic arch and
crosses the mediastinum obliquely from left to
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Figure 2. Left-sided aortic arch with an aberrant right subclavian artery in an asymptomatic 53-
year-old man. (a) Close-up view of a lateral chest radiograph shows an area of increased opacity in
the retrotracheal space and displacement of the trachea anteriorly (arrows). (b) Contrast material–
enhanced CT scan shows an aberrant right subclavian artery that arises as the last branch of a left-
sided aortic arch posterior to the esophagus.

Figure 3. Aberrant right subclavian artery in a 64-year-old man with esophageal carcinoma and
dysphagia. (a) Close-up view of a lateral chest radiograph shows an area of increased opacity in the
retrotracheal region (arrows). (b) Contrast-enhanced CT scan shows the retrotracheal space occu-
pied by an aberrant right subclavian artery that courses posterior to an esophageal carcinoma.

right, posterior to the esophagus and trachea (Fig
2). Dilatation of the origin of the right subclavian
artery (Kommerell diverticulum) is common in
the elderly, occurring in up to 60% of all elderly
patients, and can manifest as dysphagia (2,9).
Findings at lateral chest radiography can be nor-
mal, but the anomalous artery often manifests as
an area of increased opacity in the retrotracheal
space associated with a focal indentation on the
posterior wall of the trachea (2,6,9). Posteroante-
rior chest radiography reveals an obliquely ori-
ented soft-tissue area of increased opacity that
extends superiorly to the right from the superior
margin of the aortic arch. CT and magnetic reso-
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Figure 4. Right-sided aortic arch with an aberrant left

subclavian artery in a 58-year-old man. (a) Posteroante-
rior chest radiograph shows a right-sided thoracic aorta.
(b) Lateral esophagogram shows an aberrant left subcla-
vian artery as a masslike area of increased opacity in the
retrotracheal space. The artery displaces the trachea ante-
riorly and leaves its classic posterior impression on the
esophagus. (c) Contrast-enhanced CT scan reveals the
origin of the anomalous left subclavian artery.

aberration may be associated with dysphagia and

nance (MR) imaging can be helpful by revealing
associated vascular or mediastinal abnormalities
(Fig 3) (7–10).
Right-sided Aortic Arch with an Aberrant
Left Subclavian Artery.—The most common
right-sided aortic arch anomaly is an aberrant left
subclavian artery. This anomaly has a prevalence
of approximately 0.05%, is usually diagnosed in-
cidentally, and is usually not associated with con-
genital heart disease (11). Like a left-sided aortic
arch with an aberrant right subclavian artery, this
may be exacerbated if the origin of the aberrant
subclavian artery from the aorta is dilated. Recog-
nition at radiography of the absence of a left-sided
aortic arch associated with a well-defined soft-
tissue area of increased opacity in the right para-
tracheal region is useful in suggesting the diagno-
sis. Lateral radiography typically reveals a mass-
like area of increased opacity in the retrotracheal
space that silhouettes the upper aspect of the aor-
tic arch (Fig 4) (2,5,8). CT and MR imaging are
useful in confirming the diagnosis and differenti-
ating this abnormality from a right-sided aortic
arch with mirror image branching (an anomaly
associated with a high prevalence of congenital
heart disease) and a double aortic arch (7). In
addition, CT and MR imaging can demonstrate
associated abnormalities or complications (Fig 5)
(8,9,12).
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Figure 5. Right-sided aortic arch with an aneurysmal left subclavian artery in an asymptomatic 74-year-old man.
(a) CT scan shows a partially calcified, aneurysmal retrotracheal left subclavian artery. An azygous lobe (arrowheads)
is seen adjacent to a right-sided aortic arch. (b) Contrast-enhanced CT scan shows the aneurysm without associated
mural thrombus.

Figure 6. Double aortic arch that was incidentally discovered in an

asymptomatic 58-year-old man. (a) Frontal chest radiograph reveals
bilateral paratracheal masses that represent double aortic knobs. Fo-
cal wall calcification is present in the right aortic arch (arrowheads).
(b) Coronal T1-weighted MR image shows right and left aortic arches.
(c) On a sagittal T1-weighted MR image, the retrotracheal space is
obscured by both aortic arches.
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Figure 7. Progressive enlargement of an aneurysm of the transverse aortic arch in an 82-year-old man. (a) Unen-
hanced CT scan shows a mass that was caused by a large aortic aneurysm and fills the retrotracheal space. The
esophagus (arrowhead) is displaced to the right and posterior to the mass. (b) Contrast-enhanced CT scan shows a
penetrating atherosclerotic ulcer and a contained rupture or mediastinal hematoma (arrow).

Double Aortic Arch.—The double aortic arch
is one of the most common symptomatic arch
anomalies (10). Because of esophageal and tra-
cheal compression, it usually manifests in infancy
as respiratory distress or difficulty in feeding. The
anomaly is rarely associated with congenital heart
disease and can, in rare cases, remain undiag-
nosed into adulthood (13). The right arch is usu-
ally larger, higher, and more posterior than the
left arch. The arches join posteriorly to form a
single descending aorta that is typically left-sided.
Chest radiography shows a right paratracheal
masslike area of increased opacity with a focal
tracheal impression that can simulate mediastinal
adenopathy (5,13). Lateral chest radiography
typically shows a large area of increased opacity in
the retrotracheal space. Diagnostic imaging mo-
dalities include surface echocardiography in in-
fants and children and MR imaging and CT in
adults (Fig 6) (13).
Acquired Vascular Diseases
Aneurysmal dilatation of the thoracic aorta, de-
fined as enlargement of the aorta to more than
twice its normal caliber, is common, occurring in
up to 10% of elderly adults (14). Dilatation usu-
ally occurs as a result of degenerative changes in
the aorta associated with aging or as a result of
congenital abnormalities, connective tissue disor-
ders, infections, prior surgery, trauma, or valvular
disease (15,16). Aneurysmal dilatation can also
be due to pseudoaneurysms of the aorta (false
aneurysms that do not contain all components of
the aortic wall), which are usually the result of
chest trauma, infection, or surgery (14,17). A
penetrating atherosclerotic ulcer of the aorta (ul-
ceration of an atheromatous plaque that disrupts
the internal elastic lamina and results in an intra-
mural hematoma) is another cause of aortic pseu-
doaneurysm (18,19). A potential complication of
thoracic aneurysms is rupture, the prevalence of
which is as high as 70% (Fig 7). Because the risk
of rupture increases fivefold if the aneurysm is
over 6 cm in diameter, most aneurysms with di-
ameters over 5–5.5 cm are surgically repaired
(14,15). Aortic aneurysms and pseudoaneurysms
can manifest radiographically as fusiform or sac-
cular masslike lesions that protrude into the retro-
tracheal space. Thoracic MR imaging and spiral
CT angiography are the diagnostic procedures of
choice to evaluate diverse pathologic conditions
of the thoracic aorta (14,16,20 –22).
Esophageal Abnormalities
Diseases of the esophagus can manifest as an ab-
normality in the retrotracheal space, which may
be the initial clue to the diagnosis.
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Figure 8. Esophageal atresia in a newborn. Frontal (a) and lateral (b) radiographs show an air-dis-
tended pouch in the retrotracheal space (arrows in a) that deforms the adjacent portion of the trachea. A
radiopaque tube has been placed on the blind pouch of the proximal portion of the esophagus (arrow in
b). (Case courtesy of Elida Vázquez, MD, Hospital Vall D’Hebrón, Barcelona, Spain.)

Figure 9. Esophageal duplication cyst in a 23-year-old woman in whom a mass was incidentally found at chest ra-
diography. (a) Lateral chest radiograph reveals an area of increased opacity in the retrotracheal region and anterior
displacement of the trachea. (b) CT scan shows a well-circumscribed mass with water attenuation adjacent to the
esophagus. The appearance and location of the mass are typical for an esophageal duplication cyst.

Esophageal Atresia and Tracheoesophageal esophagus with or without abnormal communica-

Fistula.—Esophageal atresia and tracheoesoph-
ageal fistula are congenital anomalies charac-
terized by incomplete formation of the tubular
tion with the trachea (23). Esophageal atresia can
manifest as an air-distended pouch or, owing to
mucosal secretion, as a masslike lesion in the ret-
rotracheal space that deforms the adjacent part of
the trachea (Fig 8) (23).
 RG f Volume 22 ● Special Issue
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Figure 10. Zenker diverticulum in a 54-year-old man with dysphagia and cough. (a) Posteroanterior
chest radiograph shows abnormal widening of the superior portion of the mediastinum. An air-fluid level
is also seen (arrows). (b) CT scan shows a large retrotracheal diverticulum with an air-fluid level due to
retained alimentary content.
Duplication Cyst.—Esophageal duplication
cysts are congenital abnormalities that account
for 0.5%–2.5% of all tumors and tumorlike le-
sions of the esophagus (24,25). Approximately
60% of duplication cysts are in the lower part of
the esophagus (24). Many patients are asymp-
tomatic, the abnormality sometimes being discov-
ered incidentally at an advanced age. Bleeding or
infection may cause mediastinal cyst enlargement
and associated symptoms. Cysts may also be
complicated if ectopic gastric mucosa is present
in the lining of the cyst. Esophageal duplication
cysts, either symptomatic or asymptomatic, are
treated with complete surgical excision to prevent
complications (26). Duplication cysts that arise in
the upper portion of the esophagus can manifest
as masses in the retrotracheal space (2). At CT,
they typically manifest as spheric or tubular
masses in proximity to the esophageal wall (Fig 9)
(24). They are usually homogeneous and have
water attenuation. However, they may have soft-
tissue attenuation owing to intracystic hemor-
rhage or proteinaceous debris. At MR imaging,
duplication cysts have variable signal intensity on
T1-weighted images, depending on cyst contents,
and markedly increased signal intensity on T2-
weighted images (26).
Franquet et al S239
Esophageal Dilatation and Diverticula.
—Esophageal dilatation and diverticula may in-
clude focal dilatation in the Zenker (pharyngo-
esophageal) diverticulum (upper part of the
esophagus), traction diverticula due to granulo-
matous disease (middle part of the esophagus),
and epiphrenic diverticula (lower right part of the
esophagus). The Zenker diverticulum usually ex-
tends dorsally into the postcricoid area and, if
large, can be detected in the retrotracheal space
as a large air-filled or fluid-filled masslike lesion
(Fig 10) (27). Diffuse dilatation of the esophagus
can occur as a result of motility disorders (achala-
sia, postvagotomy syndrome, Chagas disease,
scleroderma, systemic lupus erythematosus, pres-
byesophagus, diabetic neuropathy, esophagitis) or
distal obstruction (carcinoma, stricture, extrinsic
compression) (28). Achalasia, a motor disorder
that results in dilatation of the esophagus because
of aperistalsis of the lower part of the esophagus
and inadequate relaxation of the lower esophageal
sphincter, frequently manifests as an abnormality
in the retrotracheal space (29). Retained fluid,
food debris, and an air-fluid level are common, as
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Figure 11. Achalasia in a 47-year-old woman with chest pain. (a) Close-up
view of a posteroanterior chest radiograph shows abnormal widening of the
superior part of the mediastinum. An air-fluid level is seen (arrowheads). A
calcified paratracheal lymph node is also visible. (b) Lateral radiograph
shows anterior displacement and bowing of the trachea caused by the fluid-
filled esophagus. An air-fluid level within the retrotracheal space is also ap-
parent (arrowheads), a finding that suggests the diagnosis of achalasia.

Figure 12. Esophageal carcinoma in a 68-year-old man with dysphagia and stridor. (a) Lateral chest
radiograph shows marked widening of the retrotracheal stripe. Posterior indentation and irregularity of
the tracheal air column, produced by neoplastic infiltration of the tracheal wall, are also apparent (arrow-
heads). (b) CT scan shows marked inhomogeneous thickening of the esophageal wall. Infiltration of the
posterior tracheal wall is also seen (arrowhead).

are anterior displacement and bowing of the tra-
chea by the fluid- or food-filled esophagus. Aspi-
ration pneumonia is an associated complication
(Fig 11) (30).
Esophageal Tumors.—Esophageal tumors that
affect the retrotracheal space include esophageal
carcinoma and leiomyoma (25,31). On lateral
chest radiographs, widening of the posterior tra-
cheal-tracheoesophageal stripe and the presence
of an esophageal air-fluid level are the two most
common manifestations of esophageal carcinoma
 RG f Volume 22 ● Special Issue
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in the retrotracheal space (Fig 12) (3,4). Widen-
ing of the posterior tracheal-tracheoesophageal
stripe may be secondary to (a) paratracheal and
paraesophageal lymphatic engorgement due to
obstruction or direct invasion by a tumor, or (b)
retained secretions due to a tumor that occludes
the esophagus at a lower level (3,4).
Leiomyomas, the most frequently occurring
benign tumors of the esophagus, nevertheless rep-
resent less than 1% of all esophageal neoplasms
(32). They are usually slow-growing tumors that
range from 2 to 8 cm in size (31). Although
leiomyomas typically occur in the lower part of
the esophagus, those that arise in the upper por-
tion can manifest as masses in the retrotracheal
space.
Miscellaneous Mediastinal Masses
Mediastinal Lymphatic Malformations.
—Lymphatic malformations (previously de-
scribed as lymphangiomas) are rare benign lesions
Franquet et al S241
Figure 13. Lymphatic malformation of the superior
mediastinum in an asymptomatic 46-year-old woman.
(a) Axial T1-weighted MR image shows a large, lobu-
lated lymphatic malformation with intermediate signal
intensity. (b) T2-weighted MR image shows a charac-
teristic hyperintense lesion that surrounds but does
not displace the trachea and great vessels. The tumor
extends toward the anterior soft tissues of the chest
wall. (c) Photomicrograph (original magnification,
⫻40; hematoxylin-eosin stain) of a biopsy specimen
shows large, dilated lymphatic channels (*) with walls
that contain connective tissue and lymphocytes
(arrowheads).
(32). Approximately 75% occur in the neck and
5% in the mediastinum (33). Most mediastinal
lesions are due to tumor extension from the neck
into the superior and anterior mediastinum, al-
though such tumors can extend into the retrotra-
cheal space. They usually occur in patients less
than 2 years old, and they have a male predilec-
tion. In adults, lymphatic malformations in the
mediastinum are usually due to recurrence of an
incompletely resected childhood tumor. At CT,
these lesions manifest as lobular, multicystic tu-
mors that surround and infiltrate adjacent medi-
astinal structures. They can appear solid at CT
because of intracystic protein or hemorrhage
(34). MR imaging can be useful in confirming the
cystic nature of these lesions; lymphatic malfor-
mations usually have markedly increased signal
intensity on T2-weighted images (Fig 13) (34).
Their appearance on T1-weighted images is more
variable: Although most have low to intermediate
signal intensity, they can occasionally have high
signal intensity similar to that of fat (34).
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Figure 14. Mediastinal hemangioma in a 67-year-old

man. (a) CT scan shows a well-defined heterogeneous
mass that lies behind the trachea and displaces the
esophagus laterally. A small, rounded calcification
(phlebolith) appears within the mass (arrow). (b) Con-
trast-enhanced CT scan demonstrates the mass with
intense central and rimlike peripheral enhancement.
(c) Photomicrograph (original magnification, ⫻40;
hematoxylin-eosin stain) of a surgical specimen shows
multiple vascular spaces lined by a thin endothelial
layer (arrow).

Hemangiomas.—Hemangiomas are rare medi-

astinal tumors that usually occur in the anterior or
posterior mediastinum (68% and 22% of cases,
respectively) (35,36). Most are cavernous heman-
giomas composed of large interconnecting vascu-
lar spaces with varying amounts of interposed
stromal elements such as fat and fibrous tissue.
Focal areas of organized thrombus can calcify as
phleboliths. At radiography, hemangiomas mani-
fest as smooth, well-marginated mediastinal
masses. Phleboliths are present in less than 10%
of cases (36). CT typically reveals a heteroge-
neous mass with intense central and rimlike
peripheral enhancement after intravenous admin-
istration of contrast material. Hemangiomas typi-
cally have heterogeneous signal intensity on T1-
weighted MR images. In lesions with significant
stromal fat, linear areas of increased signal inten-
sity on T1-weighted images can occasionally be
identified. The central vascular lakes typically
become markedly hyperintense on T2-weighted
images, a potentially diagnostic feature (Fig 14)
(35,36).
Thyroid Goiter.—Most thyroid masses in the
mediastinum are caused by intrathoracic exten-
sion of thyroid goiters, a condition that occurs
most often in women in their 60s and 70s and
accounts for up to 10% of mediastinal masses
resected at thoracotomy (36). True ectopic thy-
roid masses in the mediastinum are rare. A thy-
roid goiter typically extends into the thyropericar-
diac space anterior to the recurrent laryngeal
nerve and brachiocephalic vessels, although pos-
terior extension behind the esophagus and adja-
cent to the trachea in the retrotracheal space oc-
curs in 20% of cases (36). Many patients with
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Figure 15. Intrathoracic goiter in a 62-year-old woman. (a) Lateral chest radiograph shows a large thy-
roid mass that fills the retrotracheal space and displaces the trachea anteriorly. (b) CT scan shows a well-
defined, homogeneous soft-tissue mass that fills the retrotracheal space and displaces the trachea, esoph-
agus, and supraaortic vessels anteriorly.

an intrathoracic goiter are asymptomatic, the
anomaly being incidentally discovered at screen-
ing chest radiography. On radiographs, posterior
intrathoracic thyroid goiters can manifest as
sharp, smoothly marginated mediastinal masses
that displace the trachea anteriorly and occupy
the retrotracheal space (Fig 15). CT scans typi-
cally reveal a heterogeneous mass continuous
with the cervical thyroid gland. Areas of hemor-
rhage, necrosis, and calcification are common
(36).
Mediastinal Hemorrhage.—Mediastinal hem-
orrhage can result from iatrogenic procedures
such as central venous catheter placement or
from vascular injuries secondary to chest trauma
(37,38). Traumatic aortic injury typically occurs
in patients who sustain rapid deceleration injury
or blunt injury to the chest. Traumatic transec-
tion of the aorta is usually immediately fatal, al-
though 10%–25% of patients survive the initial
injury (39,40). Transection typically occurs be-
tween the origin of the left subclavian artery and
the attachment of the ligamentum arteriosum
(ligament of Botallo), although the ascending and
descending portions of the aorta at the level of the
diaphragmatic hiatus are other sites of injury. Ra-
diographic manifestations of traumatic aortic in-
jury are nonspecific and include widening of the
mediastinum, tracheal displacement, inferior dis-
placement of the left primary bronchus, displace-
ment of a nasogastric tube to the right of the T4
spinous process, and extrapleural blood tracking
along the subclavian vasculature (apical pleural
cap) (41). Mediastinal hemorrhage, an indirect
sign of aortic injury, can extend posteriorly and
manifest as a masslike area of increased opacity in
the retrotracheal space. Spiral CT is the initial
procedure of choice for evaluating a mediastinal
abnormality after traumatic injury to the chest
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Figure 16. Aortic transection in a 36-year-old man who had sustained a rapid deceleration injury. (a) CT scan
shows a mediastinal hematoma that obscures the mediastinal vessels, occupies the retrotracheal space, and displaces
the trachea to the right. (b) Contrast-enhanced CT scan shows a pseudoaneurysm (*) medial to the proximal de-
scending thoracic aorta. Bilateral pleural effusions are also seen.

(40 – 42). Aortic transection can manifest as ex-

travasation of contrast material, a pseudoaneu-
rysm (Fig 16), abrupt change in aortic caliber, or
an intimal flap with diffuse mediastinal hemor-
rhage (38).

Infectious Lesions
Infection can spread to the retrotracheal space
from contiguous structures such as the thoracic
spine and paravertebral spaces or from retropha-
ryngeal and prevertebral spaces.

Cervical Abscess with Mediastinal Exten-

sion.—Infections in the retropharyngeal and pre-
vertebral spaces can spread caudad to the retro-
tracheal space. In children, cervical abscesses
usually result from tonsillar infection or traumatic
perforation of the pharynx (Fig 17) (42– 44),
whereas in adults, they are often associated with
mediastinal tuberculosis and pyogenic spondylitis
(45,46).
Acute Mediastinitis.—Rupture of the esopha-
gus may be due to diagnostic and therapeutic en-
doscopic procedures as well as to blunt thoracic
trauma and foreign body impaction (41,44). The
cervical and upper thoracic portions of the esoph-
agus are the most common sites of rupture. The
majority of pharyngeal or esophageal foreign body
Figure 17. Retropharyngeal infection with mediasti-
nal abscess formation in an 18-year-old man with iatro-
genic pharyngeal perforation. CT scan shows widening
of the middle mediastinum with a large retrotracheal
abscess that fills the retrotracheal space and displaces
the trachea and esophagus anteriorly. An air-fluid level
within the abscess cavity is also seen.
impactions occur in children who accidentally or
intentionally ingest coins, toys, or other foreign
objects (43). In adults, the most common foreign
bodies within the esophagus are animal or fish
bones. Esophageal foreign bodies can manifest
radiographically in the retrotracheal space as a
focal area of increased opacity or as a retrotra-
cheal abscess or mediastinitis due to esophageal
perforation. Esophageal fistulization secondary to
esophageal carcinoma may also be a cause of me-
diastinal abscess (Fig 18) (47,48).
 RG f Volume 22 ● Special Issue
RadioGraphics
Figure 18. Retrotracheal abscess due to fistulized
esophageal carcinoma in a 56-year-old man. CT scan
shows marked esophageal wall thickening. Air bubbles
and a small amount of contrast material within the ret-
rotracheal space due to formation of a fistula (arrow)
are also seen.
Fulminant mediastinitis with abscess forma-
tion occurs in 1% of patients with esophageal
perforation (44,49). The combination of high
mortality and difficulty in establishing the clini-
cal diagnosis increases the importance of the radi-
ologist in detection of this complication. Radio-
logic features include mediastinal widening,
pneumomediastinum, obliteration of fat planes,
loculate fluid collections, and abscess formation.
Loculate fluid collections and abscesses can
manifest radiographically as large masslike lesions
in the retrotracheal space. CT is optimal for es-
tablishing the diagnosis and is useful for assisting
in percutaneous drainage of loculate fluid collec-
tions (44).
Conclusions
A wide spectrum of diseases can manifest as ra-
diographic abnormalities in the retrotracheal
space. Knowledge of the normal radiologic ap-
pearance of the retrotracheal space is required to
appropriately interpret lateral radiographs. This
knowledge, together with an understanding of the
clinical manifestations of diseases in this region
and of the diseases that commonly occur in the
retrotracheal space, can facilitate detection,
diagnosis, and management. However, the
radiographic manifestations of diseases in the
retrotracheal space are often nonspecific, and
CT and MR imaging may be required for
diagnosis.
Franquet et al S245
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