Mediastinum atf

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TABLE OF CONTENTS
Mediastinum 1.
2.
Organization of the Mediastinum
Arteries and Blood Supply
3. Veins and Venous Drainage
4. Lymphatics
5. Nerves and Innervations
6. Practice Questions
REVIEW OUTLINE
1. Arteries 3. Nerves
Mediastinum ● Aortic arch

○ Brachiocephalic trunk
●
●
Left recurrent laryngeal
Esophageal plexus
■ Right common carotid ● Vagus
■ Right subclavian ● Sympathetic trunk
○ Left common carotid ● Sympathetic chain (paravertebral)
○ Left subclavian ganglia
● Descending aorta ● White and gray rami
○ Posterior intercostal communicantes
● Greater splanchnic
2. Veins ● Intercostal
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● Brachiocephalic
● Azygos 4. Miscellaneous
● Posterior intercostal ● Esophagus
● Hemiazygos ● Ligamentum arteriosum
● Accessory hemiazygos ● Trachea
● Cartilaginous tracheal rings
● Bronchi
● Thoracic duct
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WHAT IS THE MEDIASTINUM
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CARTILAGINOUS
TRACHEALRINGS
TRACHEA
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I
no
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THORACIC DUCT
LYMPHATIC VESSEL CONTAINING LYMPH
DRAINS RETURNS LYMPH TOTHESYSTEMIC VENOUS SYSTEM

LOWERLIMBS
ABDOMEN
LEFTUPPERLIMB
ORIGINATES BEGINS AROUND 112LEVEL
DRAINSINTO LEFTSUBCLAVIAN V INTERNALJUGULARV
https://upload.wikimedia.org/wikipedia/commons/7/75/Gray599.png
LIGAMENTUM ARTERIOSUM FETAL DUCTUS ARTERIOSUS

FOUNDBETWEENTHEAORTIC ARCHAND PULMONARY TRUNK
ADULTFUNCTION NOFUNCTION VESTIGIALSTRUCTURE
FETALFUNCTION SHUNTS BLOODFROM PULMONARYTRUNK TOAORTA
BYPASSES LUNGS IN THEFETUS WHY
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https://upload.wikimedia.org/wikipedia/commons/3/3c/Gray505.png
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AORTIC ABC's
A AORTIC ARCH
B BRACHIOCEPHALICTRUNK
C COMMON CAROTID A LEFT
S SUBCLAVIAN A LEFT
RCCA ICCA
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TRACHEA
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BLOOD SUPPLY CANYOUIDENTIFYTHEABC'S
Rsubclaviann
AORTIC ARCH i SUBCLAVIANA BRACH ceramic
trunk
HEADNECK UPPERLIMB E HEART AORTICARC
BRACHIOCEPHALIC TRUNK BRONCHIAL

RIGHTSIDEOFHEAD ENECK
RIGHTUPPERLIMB BRONCHI
COMMONCAROTID A
HEAD NECK
SUBCLAVIAN A
PosteriorIntercostalAa
RIGHT RIGHTUPPERLIMBANDSUPERFICIALTHORAX E
LEFT LEFTUPPERLIMB ANDSUPERFICIALTHORAX
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POSTERIORINTERCOSTAL AA E
INTERCOSTALSPACES MUSCLES a
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AREAS DRAINED BY VEINS supreme

supreme
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BRACHIOCEPHALIC V s
r s
HEADNECKE UPPERLIMB 4 4
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AZYGOS V 6 a
RIGHTSUPERFICIAL THORAX 7 7
RIGHTLUMBAR REGION 8 s
a 1 a
HEMIAZYGOSU to to
LEFTLOWERSUPERFICIALTHORAX 11 a
LEFTLUMBARREGION subcostal subcostal
ACCESSORY HEMIAZYGOSU
LEFTUPPERSUPERFICIALTHORAX
REVIEW OUTLINE
1. Lymph Nodes of the Mediastinum

Lymphatics of ● Superior phrenic
● Posterior intercostal
the ● Posterior mediastinal
● Parasternal
Mediastinum ●
●
Brachiocephalic
Paratracheal
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2. Thoracic Duct
● Location and path of the thoracic duct
3. Case Study
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Mediastinal Lymph Nodes

1. Superior phrenic
2. Posterior intercostal
3. Posterior mediastinal
4. Parasternal
5. Brachiocephalic
Mediastinal Lymph Nodes

1. Inferior tracheobronchial Right lymphatic duct
Internal jugular
2. Superior tracheobronchial vein
Thoracic duct
3. Brachiocephalic
4. Paratracheal
AfraTafreeh.com Subclavian vein Left

bronchomediastinal
trunk
Right
bronchomediastinal
trunk
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Thoracic Duct
Clinical Application
● A patient presents to your clinic with the following
symptoms:
○ Dyspnea
○ Orthopnea
○ Non-productive cough
● A CXR is ordered
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○ What is abnormal about this image?
○ What is on your differential diagnosis?
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● What is abnormal about this image?
● What is on your differential diagnosis?
Normal Abnormal
● The patient had esophageal surgery two weeks ago
● You perform a thoracentesis and the fluid appears
milky
1. What is this fluid?

2. What was damaged to cause this to happen?
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3. What is the treatment for this condition?
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● The patient had esophageal surgery two weeks ago
● You perform a thoracentesis and the fluid appears
milky
1. What is this fluid?

2. What was damaged to cause this to happen?
3. What is the treatment for this condition?
References
1. Slide 2&3: Created with BioRender.com
2. Slide 5&6: Matani S, Pierce JR, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>,
via Wikimedia Commons
3. Slide 6: Stillwaterising, CC0, via Wikimedia Commons
4. Slide 7: James Heilman, MD, CC BY-SA 4.0
<https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
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POSTERIOR INTERCOSTAL V
POSTERIOR INTERCOSTAL A
INTERCOSTAL N
VAN
INTERCOSTAL NERVES
ORIGIN
ANTERIORRAMIOFTI TH
DIVISIONS BRANCHES
ANTERIOR E LATERAL CUTANEOUSNN
SENSORY FUNCTION
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TI TH SENSORY DERMATOMES
MOTOR FUNCTION
EXTERNAL INTERCOSTAL
INTERNAL INTERCOSTAL
INNERMOST INTERCOSTAL
TRANS
VERSUSTHORACIS
LESION
https://upload.wikimedia.org/wikipedia/commons/b/b1/Gray819.png
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SYMPATHETIC NERVOUS SYSTEM PARASYMPATHETIC NERVOUS SYSTEM

FIGHTORFLIGHT RESTANDDIGEST
INCREASE HEART RATE DECREASE
VASOCONSTRICTION VEINS VASODILATION
DILATION BRONCHIALSMOOTH MUSCLE CONTRACTION

DECREASE GI MOTILITY INCREASE
GLYCOGENOLYSIS GLYCOGEN OR GLUCOSE GLYCOGEN SYNTHESIS
DECREASE URINARY OUTPUT INCREASE
CONTRACTS SPHINCTER OFBLADDER RELAXATION
INCREASE SWEATGLANDSECRETIONS DECREASE
SYMPATHETIC TRUNK
NERVEROOTS
TI L2113
BRANCHES
CARDIOPULMONARY SPLANCHNIC
GREATER LESSERLEAST ELUMBAR SPLANCHNIC

NN
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SYMPATHETIC CHAIN GANGLIA

NERVEROOTS
TI L2113
BRANCHES
WHITE GREYRAMI COMMUNICANTES

SPLANCHNIC NN
PREGANGLIONIC POST
GANGLIONIC
PREGANGLIONIC SYMPATHETICNEURONSSYNAPSE
WITHPOSTGANGLIONIC SYMPATHETIC NEURONS
WHITE GRAY RAMI SPINALN LEVELSTI 1213

COMMUNICANTES
WHITERAMICOMMUNICANS i
SYMPATHETIC PRE
GANGLIONIC
a
GRAYRAMICOMMUNICANS
SYMPATHETICPOST
GANGLIONIC
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SYMPATHETICCHAINGANGLIA
WHATDOTHEYDO
WHITE CONNECTALLSPINALNERVESTO THE SYMPATHETIC TRUNK
GRAY CONNECT THESYMPATHETICTRUNK TOTHE
SPINALNERVES
WHITE MYELINATEDPRE
GANGLIONICNEURONS
GRAY UNMYELINATEDPOSTGANGLIONIC NEURONS
https://upload.wikimedia.org/wikipedia/commons/thumb/e/ee/Gray799.svg/1920px-Gray799.svg.png
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SYMPATHETIC TRUNK
AND
SYMPATHETIC CHAIN GANGLIA
SENSORYFUNCTION
VISCERASENSORY
SYMPATHETIC FUNCTION
INCREASESHEARTRATE
INCREASESVASOCONSTRICTION
RELAXATIONOFBRONCHI 0L SMOOTHMUSCLE
BRONCHIA DILATION
DECREASE GI MOTILITY
CONVERTS GLYCOGENTOGLUCOSE IN LIVER
DECREASESURINARYOUTPUT
CONTRACTS SPHINCTER OFBLADDER

INCREASES SWEATGLANDSECRETIONS
LESION
GREATER SPLANCHNIC NERVE

ORIGIN
THORACIC NN TS T9
DIVISIONS
CONTRIBUTESTO THECELIACPLEXUS
is
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to
17
Ts
Toi
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PATHWAY
THEGREATERSPLANCHNIC N PIERCESTHE
DIAPHRAGM ATTHE AORTICHIATUS AND
SYNAPSES ONTHE CELIACPLEXUS TO GIVE
RISE TO POSTGANGLIONIC SYMPATHETIC
NEURONS
THE SPLANCHNIC NN CARRY SYMPATHETIC

PREGANGLIONIC FIBERS

SENSORYFUNCTION
VISCERASENSORY
SYMPATHETIC FUNCTION CELIACPLEXUS

INCREASES VASOCONSTRICTION
DECREASES GI MOTILITY
INCREASES CONVERSION
AfraTafreeh.com OFGLYCOGENTOGLUCOSE IN LIVER
DECREASES URINARY OUTPUT
LESION
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VAGUS NERVE
ORIGIN
BRAINSTEM MEDULLA
DIVISIONS BRANCHES
RIGHTELEFT RECURRENT LARYNGEALNN
ANTERIOR 4POSTERIOR VAGALTRUNKS LARP
PATHWAY
TRAVELSPOSTERIORTOROOT OF LUNG
LEFT RECURRENTWRAPS AROUND LIGAMENTUM ARTERIOSUM
LEFTSIDE FORMS ANTERIORVAGALTRUNK
RIGHTSIDE FORMS POSTERIOR VAGALTRUNK
https://upload.wikimedia.org/wikipedia/commons/thumb/6/64/Recurrent_laryngeal_nerve.svg/926px-Recurrent_laryngeal_nerve.svg.png
VAGUS NERVE
SENSORY FUNCTION
VISCERAL SENSORY INFORMATION FOR MOST
OFTHEDIGESTIVE TRACT UPTOSPLENIC FLEXURE
PARASYMPATHETIC FUNCTION
DECREASESHEARTRATE
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INCREASES VASODILATION
INCREASES CONSTRICTION OF BRONCHI0L
SMOOTH MUSCLE
INCREASES GI MOTILITY PERISTALSIS
INCREASES GLYCOGEN SYNTHESIS IN LIVER
INCREASES URINARYOUTPUT
RELAXES SPHINCTER OF BLADDER
WHATWOULD HAPPEN IF THIS

NERVEWAS LESIONED
https://en.wikipedia.org/wiki/Phrenic_nerve#/media/File:Gray806.png
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LEFT RECURRENT LARYNGEAL NERVE

ORIGIN
BRANCHOFTHEVAGUSN
PATHWAY
WRAPS UNDERTHESUBCLAVIAN A
FOUNDBETWEEN POSTERIORTRACHEA ANTERIOR ESOPHAGUS
E
SENSORYFUNCTION
SENSORYINNERVATION TOINFERIOR LARYNX
BELOWVOCALCORDS
MOTORFUNCTION
INTRINSICLARYNGEALMUSCLES
THYROARYTENOID
POSTERIORCRICO
ARYTENOID
LATERALCRICOARYTENOID
TRANSVERSE OBLIQUE ARYTENOIDS
LESION
https://upload.wikimedia.org/wikipedia/commons/thumb/6/64/Recurrent_laryngeal_nerve.svg/926px-Recurrent_laryngeal_nerve.svg.png
ESOPHAGEAL PLEXUS
ORIGIN
VAGUS N SYMPATHETICTRUNK
DIVISIONS
ANTERIOR ESOPHAGEAL PLEXUS LEFTVAGUS
POSTERIORESOPHAGEAL PLEXUS RIGHTVAGUS
SENSORYFUNCTION
VISCERA SENSORY
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SYMPATHETIC FUNCTION
DECREASES GI MOTILITY
POSTVAGAL PARASYMPATHETIC FUNCTION
TRUNK INCREASES GI MOTILITY
ANTVAGAL
LARP PREGANGLIONIC 1POST
GANGLIONICFIBERS
TRUNK PRE PARASYMPATHETIC
POST SYMPATHETIC
LESION
INABILITYTOCARRYOUTDIGESTIVE FUNCTIONS
ESOPHAGEAL DYSMOTILITY
https://upload.wikimedia.org/wikipedia/commons/4/4b/Gray793.png
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WHERE DOES THE THORACIC DUCT ORIGINATE

AND WHERE DOES IT DRAIN INTO
WHERE DOES THE THORACIC DUCT ORIGINATE

AND WHERE DOES IT DRAIN INTO
ORIGINATES BEGINS AROUND 112 LEVEL
DRAINSINTO LEFT SUBCLAVIAN V INTERNALJUGULAR V
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REVIEW OUTLINE
1. Arteries 3. Nerves
Mediastinum ● ARE
Aortic arch THE PREGANGLIONIC
○ Brachiocephalic trunk
● Left
● Esophageal
WHITE COMMUNICANS ●SYMPATHETIC
laryngeal IN
recurrentFIBERS
NERVE
plexus
OR
■ Right common carotid Vagus
■ PARASYMPATHETIC
Right subclavian ● Sympathetic trunk
○ Left common carotid ● Sympathetic chain (paravertebral)
SPINALN LEVELSTI 1213
○ LeftPOST
Review Questions GANGLIONIC
subclavian
● Descending aorta
IN
GRAY
ganglia
COMMUNICANS
● White and gray rami
• Can you draw the branches ○ Posterior intercostal communicantes
WHITERAMICOMMUNICANSe ● Greater splanchnic
coming off of the aortic arch? 2. Veins ● Intercostal
• Can you identify the n ● Brachiocephalic
differences between the ● Azygos 4. Miscellaneous
GRAYRAMICOMMUNICANS
● Posterior intercostal ● Esophagus
azygos, hemiazygos, and ● Hemiazygos ● Ligamentum arteriosum
accessory hemiazygos
SYMPATHETIC veins?
CHAINGANGLIA ● Accessory hemiazygos ● Trachea
● Cartilaginous tracheal rings
● Bronchi
● Thoracic duct
ARE THE PREGANGLIONICNERVE FIBERS IN

WHITE COMMUNICANS SYMPATHETIC OR
PARASYMPATHETIC
SPINALN LEVELSTI 1213 POSTGANGLIONIC IN GRAY COMMUNICANS

WHITE PRE SYMPATHETIC
WHITERAMICOMMUNICANSe
SYMPATHETIC PRE
GANGLIONIC GRAYPOST SYMPATHETIC
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a
GRAYRAMICOMMUNICANS
SYMPATHETICPOST
GANGLIONIC
SYMPATHETICCHAINGANGLIA

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Mediastinum ● Aortic arch

WHAT IS THE MEDIASTINUM

DRAINS RETURNS LYMPH TOTHESYSTEMIC VENOUS SYSTEM

LIGAMENTUM ARTERIOSUM FETAL DUCTUS ARTERIOSUS

BYPASSES LUNGS IN THEFETUS WHY

BRACHIOCEPHALIC TRUNK BRONCHIAL

AREAS DRAINED BY VEINS supreme

1. Lymph Nodes of the Mediastinum

Mediastinal Lymph Nodes

Mediastinal Lymph Nodes

AfraTafreeh.com Subclavian vein Left

1. What is this fluid?

1. What is this fluid?

SYMPATHETIC NERVOUS SYSTEM PARASYMPATHETIC NERVOUS SYSTEM

INCREASE HEART RATE DECREASE

VASOCONSTRICTION VEINS VASODILATION

DILATION BRONCHIALSMOOTH MUSCLE CONTRACTION

GREATER LESSERLEAST ELUMBAR SPLANCHNIC

SYMPATHETIC CHAIN GANGLIA

WHITE GREYRAMI COMMUNICANTES

WHITE GRAY RAMI SPINALN LEVELSTI 1213

CONTRACTS SPHINCTER OFBLADDER

GREATER SPLANCHNIC NERVE

GREATER SPLANCHNIC NERVE

THE SPLANCHNIC NN CARRY SYMPATHETIC

GREATER SPLANCHNIC NERVE

SYMPATHETIC FUNCTION CELIACPLEXUS

WHATWOULD HAPPEN IF THIS

LEFT RECURRENT LARYNGEAL NERVE

WHERE DOES THE THORACIC DUCT ORIGINATE

WHERE DOES THE THORACIC DUCT ORIGINATE

ARE THE PREGANGLIONICNERVE FIBERS IN

SPINALN LEVELSTI 1213 POSTGANGLIONIC IN GRAY COMMUNICANS

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