MEDIASTINUM Dr.
Elif
Keskinöz
INTRODUCTION
◼ The mediastinum is
the region in the
chest between the
right & left pleural
cavities that contain
the heart and other
thoracic viscera
except the lungs
BOUNDARIES
◼ Lateral
▪ Parietal pleura
◼ Anterior
▪ Sternum
◼ Posterior
▪ Vertebral column and
paravertebral
gutters
◼ Superior
▪ Thoracic inlet
◼ Inferior
▪ Diaphragm
◼
DIVISIONS OF MEDIASTINUM
◼ Sternal angle
◼ Lower border of 4th
thoracic vertebra
1. Superior mediastinum:
above the plane
2. Inferior mediastinum:
below the plane, it is
subdivided into:
1. Anterior mediastinum: in
front of pericardium
2. Middle mediastinum:
contains heart &
pericardium
3. Posterior mediastinum:
behind pericardium
SUPERIOR MEDIASTINUM
BOUNDARIES:
◼ Anterior: manubrium
sterni
◼ Posterior: Upper 4
thoracic vertebrae
◼ Superior: Plane of
thoracic inlet
◼ Inferior: Horizontal
plane
◼ On each side: Pleura
◼
CONTENTS
◼ FROM BEHIND
FORWARD:
1. Esophagus
2. Trachea
3. Arch of aorta & its 3
branches:
1. Brachiocephalic, left
common carotid & left
subclavian arteries
4. Right & left
brachiocephalic veins &
superior vena cava
5. Thymus gland
◼ OTHER CONTENTS:
◼ Nerves:
◼ Right & left vagus
◼ Right & left phrenic
◼ Right & left sympathetic
trunks
◼ Left recurrent laryngeal
◼ Lymphatic structures:
◼ Thoracic duct
◼ Lymph nodes
◼
ANTERIOR MEDIASTINUM
◼ BOUNDARIES
◼ Anterior
▪ Sternum
▪ Rib
◼ Posterior
▪ Pericardial sac
▪ Aorta
▪ Brachiocephalic
vessels
CONTENTS
◼ Thymus gland
◼ Branches of internal
thoracic vessels
◼ Fat
◼ Lymph nodes
POSTERIOR MEDIASTINUM
◼ BOUNDARIES:
◼ Anterior:
▪ Pericardium & diaphragm
◼ Posterior:
▪ Lower 8 thoracic
vertebrae
◼ Superior:
▪ Horizontal plane
◼ Inferior:
▪ Diaphragm
◼ On each side:
▪ Pleura
CONTENTS
◼ Esophagus (most
anterior structure)
◼ Thoracic duct
◼ Right & left vagus
◼ Right & left sympathetic
trunks & their branches
(splanchnic nerves)
◼ Descending aorta
◼ Azygos & hemiazygos
veins
◼ Lymph nodes
◼
MIDDLE MEDIASTINUM
◼ CONTENTS:
◼ Pericardium & heart
◼ Arteries: ascending Phrenic
aorta, pulmonary nerve
trunk
◼ Veins: lower half of
superior vena cava,
terminations of
inferior vena cava &
pulmonary veins
◼ Nerves: phrenic
◼ Lymph nodes
BRACHIOCEPHALIC VEIN
(SUPERIOR MEDIASTINUM)
◼ FORMATION:
▪ Internal jugular
▪ Subclavian vein
◼ END:
▪ Both veins unite to form S.V.C.
◼ RIGHT VEIN:
▪ Right phrenic nerve
▪ Right pleura & lung,
▪ Its tributaries in thorax:
▪ Right 1st posterior intercostal vein,
▪ Right internal thoracic vein
▪ Right lymphatic duct
◼ LEFT VEIN:
▪ Manubrium
▪ Thymus gland
▪ Posteriorly to branches of arch of aorta,
▪ Its tributaries in thorax:
▪ Left 1st posterior intercostal vein,
▪ Left superior intercostal vein,
▪ Left internal thoracic vein,
▪ Thoracic duct
◼
SUPERIOR VENA CAVA:
(SUPERIOR & MIDDLE MEDIASTINUM)
◼ FORMATION:
▪ Brachiocephalic veins,
behind lower border of
right 1st costal cartilage
◼ END:
▪ Right atrium behind
right 3rd costal cartilage
◼ TRIBUTARIES:
▪ Azygos vein
◼
AZYGOS VEIN: (POSTERIOR
MEDIASTINUM)
◼ ORIGIN:
▪ Right ascending lumbar & subcostal
veins (passes through aortic opening of
diaphragm)
◼ END:
▪ Arch above the root of right lung & ends
in S.V.C.
▪ Opposite lower border of tT4
◼ RELATIONS:
▪ Anterior: esophagus
▪ Posterior: thoracic vertebra
▪ Right: right pleura & lung
▪ Left: thoracic duct
◼ TRIBUTARIES:
▪ Superior & inferior hemiazygos veins,
▪ Right superior intercostal vein,
▪ Right posterior intercostal veins (from
4th to 11th),
▪ Right bronchial veins,
▪ Esophageal & pericardial veins
◼
INFERIOR HEMIAZYGOS:
(POSTERIOR MEDIASTINUM)
◼ ORIGIN:
▪ Left ascending lumbar &
subcostal veins (passes
through left crus of
diaphragm)
◼ END:
▪ Azygos vein, opposite
T8
◼ TRIBUTARIES:
▪ Left posterior
intercostal veins (9th to
11th),
▪ Esophageal veins
◼
SUPERIOR HEMIAZYGOS:
(POSTERIOR MEDIASTINUM)
◼ ORIGIN:
▪ Left posterior intercostal
veins (4th to 8th)
◼ END:
▪ Azygos vein, opposite T7
◼ TRIBUTARIES:
▪ Left bronchial veins
◼ INFERIOR VENA CAVA:
(Posterior mediastinum)
◼ END:
▪ Vena caval opening of
diaphragm & opens into right
atrium behind right 6th costal
cartilage
◼
ARTERIES
AORTA
ASCENDING AORTA:
(MIDDLE MEDIASTINUM)
◼ ORIGIN:
▪ Left ventricle opposite
lower border of left 3rd
costal cartilage
◼ END:
▪ Ascends upward,
forward & to the right &
continues as arch of
aorta
◼ BRANCHES:
▪ Right & left coronary
arteries
ARCH OF AORTA:
(SUPERIOR MEDIASTINUM)
◼ ORIGIN:
▪ Ascending aorta, opposite
upper border of right 2nd
costal cartilage
◼ COURSE & RELATIONS:
▪ Ascends upward backward &
to the left (behind
manubrium & in front of
trachea) then curves
backward (to the left of
trachea) then finally curves
downward
◼ TERMINATION:
▪ Descending aorta, opposite
lower border of T4
BRANCHES OF ARCH OF AORTA:
(SUPERIOR MEDIASTINUM)
◼ BRACHIOCEPHALIC:
▪ Ascends upward & to the
right
▪ Right common carotid &
right subclavian arteries
◼ LEFT COMMON
CAROTID:
▪ Ascends upward & to the
left
▪ Enters the neck
◼ LEFT SUBCLAVIAN:
▪ Ascends upward
▪ Arches over apex of left
lung to enter neck
DESCENDING AORTA:
(POSTERIOR MEDIASTINUM)
◼ ORIGIN:
▪ Continuation of arch of aorta
◼ TERMINATION:
▪ Aortic opening of diaphragm
(opposite T12)
▪ Abdominal aorta
◼ RELATIONS:
▪ Anterior: esophagus
▪ Posterior: thoracic vertebrae
▪ Right: thoracic duct
▪ Left: left pleura & lung
◼ BRANCHES:
▪ Posterior intercostal (from 3rd to
11th), subcostal, bronchial,
esophageal, pericardial arteries
◼
PULMONARY TRUNK
(MIDDLE MEDIASTINUM)
◼ ORIGIN:
▪ Upper part of right ventricle,
behind sternal end of left 3rd
costal cartilage
◼ COURSE:
▪ Ascends upward & to the left
& divides (at lower border of
T4) into:
▪ Right pulmonary: runs behind
ascending aorta & S.V.C to enter
root of right lung
▪ Left pulmonary: runs in front of
desending aorta to enter root of
left lung
◼
TRACHEA
(SUPERIOR MEDIASTINUM)
◼ BEGINNING:
▪ Continuation of larynx
◼ TERMINATION:
▪ Bifurcates into 2 bronchi, opposite lower
border of T4
◼ RELATIONS:
▪ Anterior: arch of aorta, brachiocephalic &
left common carotid arteries, left
brachiocephalic vein
▪ Posterior: left recurrent laryngeal nerve,
esophagus
▪ Right: right vagus nerve, azygous vein
▪ Left: arch of aorta, left subclavian artery,
left vagus nerve, left phrenic nerve
◼ NERVE SUPPLY:
▪ Sympathetic trunks & vagus
◼ BLOOD SUPPLY:
▪ Inferior thyroid vessels
◼ LYMPHATIC DRAINAGE:
▪ Pretracheal & paratracheal
◼ OTHER CONTENTS:
◼ Nerves:
◼ Right & left vagus
◼ Right & left phrenic
◼ Right & left sympathetic
trunks
◼ Left recurrent laryngeal
◼ Lymphatic structures:
◼ Thoracic duct
◼ Lymph nodes
◼
ESOPHAGUS
(SUPERIOR MEDIASTINUM)
◼ BEGINNING:
▪ Continuation of pharynx,
opposite C6
◼ TERMINATION:
▪ Passes through esophageal
opening of diaphragm (opposite
T10) & joins stomach
◼ RELATIONS:
▪ Anterior: left recurrent
laryngeal nerve, trachea, left
common carotid artery
▪ Posterior: thoracic vertebrae
▪ Right: right pleura & lung
▪ Left: thoracic duct, left pleura &
lung
ESOPHAGUS
(POSTERIOR MEDIASTINUM)
◼ Anterior:
▪ Pericardium, separating it from left
atrium
◼ Posterior:
▪ Thoracic duct, descending aorta, azygos
vein
◼ Right:
▪ Right pleura & lung, thoracic duct,
azygos vein
◼ Left:
▪ Descending aorta, left pleura & lung
◼ NERVE SUPPLY:
▪ As trachea
◼ ARTERIAL SUPPLY:
▪ Descending aorta
◼ VENOUS DRAINAGE:
▪ Azygos & hemiazygos
◼ LYMPHATIC DRAINAGE:
▪ Posterior mediastinal lymph nodes
◼
THORACIC DUCT
(POSTERIOR MEDIASTINUM)
◼ ORIGIN:
▪ Upper end of cysterna chyli
(opposite L1 & L2)
◼ COURSE:
▪ Passes through aortic opening
of diaphragm, ascends in
posterior mediastinum to enter
root of neck
◼ END:
▪ In left brachiocephalic vein
◼ RELATIONS:
▪ Anterior: esophagus
▪ Posterior: thoracic vertebrae
▪ Right: azygos vein
▪ Left: descending aorta
◼
NERVES
PHRENIC NERVES
(SUPERIOR & MIDDLE MEDIASTINUM)
◼ ORIGIN:
▪ Anterior rami of C3,4,5
◼ COURSE & RELATIONS IN
THORAX:
◼ LEFT:
▪ Descends to the left side of: arch
aorta, pericardium
◼ RIGHT:
▪ Descends to the right side of: right
brachiocephalic vein, S.V.C.,
pericardium, I.V.C.
◼ BRANCHES:
▪ Motor branches to: diaphragm
▪ Sensory branches from:
▪ Diaphragmatic pleura
▪ Fibrous pericardium & parietal layer
of serous pericardium
▪ Peritoneum covering central part of
undersurface of diaphragm
◼
VAGUS NERVES:
(SUPERIOR & POSTERIOR
MEDIASTINUM)
◼ ORIGIN:
▪ 10th cranial nerve
◼ COURSE & RELATIONS IN
THORAX:
◼ RIGHT:
▪ Trachea, behind root of right lung
(pulmonary plexus), behind
esophagus (esophageal plexus),
passes through esophageal opening
of diaphragm to reach posterior
surface of stomach
◼ LEFT:
▪ Arch aorta, behind root of left lung
(pulmonary plexus), in front of
esophagus (esophageal plexus),
passes through esophageal opening
of diaphragm to reach anterior
surface of stomach
◼
THORACIC PART OF SYMPATHETIC TRUNKS
(SUPERIOR & POSTERIOR MEDIASTINUM)
◼ BEGINNING:
▪ The cervical part continues
as thoracic part
◼ TERMINATION:
▪ The thoracic part continues
as lumbar part
◼ COURSE:
▪ In upper part of thorax:
descend in front of heads of
ribs
▪ In lower part of thorax:
descend on the sides of
bodies of vertebrae
◼ GANGLIA:
▪ Usually 11
