MEDIASTINUM

• ~50% of the mediastinal tumors discovered incidentally on chest

x-rays (limited information regarding the morphology and extent
of the lesion)
• X-ray:
• Normal (CT/MRI)
• mediastinal soft tissue mass
• widening of the mediastinum
• Pneumomediastinum
• The commonest abnormalities:
– Adults:
• Lymph node enlargement
• Vascular abnormalities
• Hiatus hernia
– Children:
• Thymus gland pathology
• CT -Excellent contrast discrimination between fat, air
calcification and soft tissue structures, vascularity
Mediastinum -9 compartments:
• The anterior mediastinum - between the back of the
sternum and the anterior face of the tracheo-
bronchial spindle/axis and the pericardium
• Middle mediastinum - between the anterior and
posterior of the tracheo-bronchial axis
• Posterior mediastinum - between the posterior of
the tracheo-bronchial axis and the spine
• Upper floor - between the chest aperture and a
horizontal plane that passes through the aortic cross
• The middle floor - from the aortic cross to the
bifurcation of the trachea
• Lower floor - from bifurcation of the trahea to
diaphragm
• Location (mediastinal compartments)
• Invasive / noninvasive
• Content: fat, cystic, solid

• Normal variants causing a wide mediastinum:

– Anteroposterior projection
– Mediastinal fat – obesity, steroid therapy
– Vascular tortuosity – elderly patients
– Low inspiration, supine position
 SUPERIOR
Anterior posterior
Thyroid masses
Intrathoracic multinodular
goiter/ carcinoma Neurogenic tumors
Lymphadenopathies
Lesions of the thymus Foregut cyst
Lymphadenopathies

Aortic
arch
Germ cell tumors
(seminoma)
Mesenchymal tumors Lymphadenopathies Neurogenic tumors
Lymphadenopathies Bronchogenic cyst Foregut cyst

Tracheal
bifurcation
Pericardic cysts Lymphadenopathies
Neurogenic tumors
Lymphadenopathies Pericardic cyst
Foregut cyst

Anterior Posterior
tracheal tracheal
wall INFERIOR wall
 Semiology
• Opacities (well defined/ diffuse)
• Hyperluncencies/ air-fluid image
• Calcifications
• Mediastinal deviations
 Mediastinal Lession
• There are 3 radiological signs confirming the
mediastinal membership of a formation:
• 1. a mediastinal mass has clear, well-defined
contour/border
• 2. it forms an obtuse angle with pulmonary
parenchyma
• 3. a mass that is in contact with or is moving the
mediastinal structures is most likely to have
mediastinal origin
 Anterior Mediastinum
• Contains the: thymus, lymph nodes, adipose tissue and
internal mammary vessels
• Timus: <15 mm; involutes between 20-60 years;
• ----- thymic hyperplasia; timom (benign, invasive); thymic
carcinoma; cyst; timolipom
• Germinal cell tumors: located in the thymic space or inside
the thymus; Malignant forms - in young men
• ----- Types: teratom (origin of all 3 germ layers); dermoid cyst
(origin of ectoderm); choriocarcinoma; embryonic carcinoma;
seminoma.
• Thyroid: Volume increase with intrathoracic extension
following: hyperplasia (hyperparathyroidism, iodine
deficiency) or inflammatory processes -Hashimoto, Riedel)
• Parathyroid adenoma: ectopic, rarely in the
tracheoesophageal space
• Hodgkin's lymphoma: 30 and 70 years; cervical,
supraclavicular, paratracheal and pre-vascular
limphnodes.
• Non-Hodgkin's lymphoma: child (> 5 years) or
60-70 years old, immunodominant, after organ
transplant, with collagen diseases;
• Limfangioma: rare congenital malformation of
the lymphatic system with the formation of
lymphatic channels or cysts
Anterior mediastinum
• prevascular
– - Thymic masses
– - Retrosternal thyroid
– - Teratoma
– - Lymph nodal mass (policiclic conture!!!)
• precardiac (cardio-phrenic opac sinus!!!)
– - Epicardial fat pad
– - Morgagni ‘ s hernia
– - pleuropericardial cyst
Posteroanterior
chest radiograph
clearly depicts
the
hila (white
arrow), which
indicates that
the
mass is either
anterior or
posterior
to the hila. In
addition, the
descending aorta
is
clearly seen
(black
arrow), indicating
that the mass is
not
within the
thyroid goiter (arrow) extending into the
middle
mediastinum and causing deviation of
the
trachea to the left.
Middle mediastinum
Contains
- heart and pericardium;
- the ascending and transverse aorta;
- SVC and IVC;
- The brachiocephalic vessels;
- the pulmonary vessels;
- the trachea and main bronchi;
- lymph nodes;
- the phrenic, vagus, and left recurrent laryngeal nerves
Right-sided aortic arch
Posterior Mediastinum
Contents
-Esophagus,
- Descending aorta,
- azygos and hemiazygos veins,
- Thoracic duct,
- vagus and splanchnic nerves,
- lymph nodes
- fat
 Posterior Mediastinal Masses

• • Esophageal lesions,
• hiatal hernia
• • Foregut duplication cyst
• • Descending aorta aneuyrsm
• • Neurogenic tumour
• • Paraspinal abscess