MISTLEY JANE 1

ANTERIOR AND POSTERIOR MEDIASTINUM In a pattern that will be more evident in the abdomen,
the branches of the descending aorta arise and course
POSTERIOR MEDIASTINUM: within three vascular planes (Fig. 1.72):
i the posterior part of the inferior mediastinum An anterior, midline plane of unpaired visceral
s IS LOCATED: branches to the gut (embryonic digestive tube) and
a INFERIOR: to the transverse thoracic plane its derivatives (A in Fig. 1.72 inset).
h ANTERIOR: to the T5T12 vertebrae Lateral planes of paired visceral branches serving
i POSTERIOR: to the pericardium and diaphragm viscera other than the gut and its derivatives (B).
g BETWEEN: the parietal pleura of the two lungs Posterolateral planes of paired (segmental) parietal
POSTERIOR MEDIASTINUM CONTAINS: branches to the body wall (C).
h
thoracic aorta ESOPHAGEAL ARTERIES:
l thoracic duct and lymphatic trunks in the thorax
y posterior mediastinal lymph nodes the unpaired visceral branches of the anterior
m azygos and hemi-azygos veins vascular plane
o esophagus and esophageal nerve plexus usually two, but there may be as many as five.
b Some authors also include the thoracic sympathetic BRONCHIAL ARTERIES:
trunks and thoracic splanchnic nerves: The paired visceral branches of the lateral plane are
i
however, these structures lie lateral to the REPRESENTED IN THE THORAX
l vertebral bodies and are not within the posterior LEFT BRONCHIAL ARTERY:
e mediastinal compartment or space per se. Arise directly from the aorta
r Although the right and left bronchial arteries
eTHORACIC AORTA may arise directly from the aorta most
i
g is the continuation of the arch of the aorta commonly only the paired left bronchial arteries
s BEGINS: on the left side of the inferior border of the do so;
i
a body of the T4 vertebra and RIGHT BRONCHIAL ARTERIES:
o
h DESCENDS: in the posterior mediastinum on the left arise indirectly as branches of a right posterior
n sides of the T5T12 vertebrae. intercostal artery (usually the 3rd).
i
g As it descends, the thoracic aorta approaches the
median plane and displaces the esophagus to the
h
right.
l LIES POSTERIOR: to the root of the left lung,
y pericardium, and esophagus.
m IT TERMINATES ANTERIOR: (with a name change to
o abdominal aorta) to the inferior border of the T12
b vertebra and
ENTERS: the abdomen through the aortic hiatus in the
i
diaphragm
l The thoracic duct and azygos vein:
e ascend on its right side and accompany it through
r this hiatus.
e THORACIC AORTIC PLEXUS
g Surrounded by an autonomic nerve network
i
o
n

NINE POSTERIOR INTERCOSTAL ARTERIES:

the paired parietal branches of the thoracic aorta
that arise posterolaterally
that supply all but the upper two intercostal spaces
and the subcostal arteries (Fig. 1.72).

CLINICAL ANATOMY | ANTERIOR AND POSTERIOR MEDIASTINUM

 MISTLEY JANE 2
The latter vessels arise from the thoracic aorta but AORTIC ARCH COMPRESSION:
course below the diaphragm. is most evident in a postero-anterior (PA) radiograph
They are in series with the posterior intercostal arteries. after a barium swallow
Exceptions to this pattern include the: BRONCHIAL IMPRESSION:
SUPERIOR PHRENIC ARTERIES: is more evident in lateral views
paired parietal branches that pass No constrictions are visible in the empty esophagus;
anterolaterally to the superior surface of the however, as it expands during filling, the structures
diaphragm (which is actually facing posteriorly noted above compress its walls.
at this level owing to the convexity of the
diaphragm), where they anastomose with the THORACIC DUCT AND LYMPHATIC TRUNKS
i
musculophrenic and pericardiacophrenic THORACIC DUCT:
branches of the internal thoracic artery.
s is the largest lymphatic channel in the body.
PERICARDIAL BRANCHES: a In the posterior mediastinum, it lies on the:
unpaired branches that arise anteriorly but, h Anterior aspect of the bodies of the inferior 7
instead of passing to the gut, send twigs to the i thoracic vertebrae.
pericardium. g The thoracic duct conveys most lymph of the body to
The same is true for the small mediastinal the venous system that from:
h
arteries supply the lymph nodes and other the lower limbs
tissues of the posterior mediastinum.
l pelvic cavity
y abdominal cavity
m left upper limb
o and left side of the thorax
b head
i neck
All lymph except that from the right superior
l
quadrant.
e The thoracic duct originates from:
r the cisterna chili (chyle cistern) in the abdomen
e and
g ascends through the aortic hiatus in the
i diaphragm
The duct is usually thin walled and dull white.
o
Often it is beaded because of its numerous
n valves.
IT ASCENDS IN: the posterior mediastinum among
On its left: thoracic aorta on its left
On its right: the azygous vein
Anteriorly: esophagus
Posteriorly: vertebral bodies
AT THE LEVEL OF THE T4, T5, OR T6 VERTEBRA:
the thoracic duct crosses to the left
ESOPHAGUS
i POSTERIOR: to the esophagus, and
DESCENDS INTO: the posterior mediastinum from the
s ASCENDS: into the superior mediastinum.
superior mediastinum, passing posterior to and to the
The thoracic duct receives branches:
a right of the arch of the aorta and posterior to the
from the middle and superior intercostal spaces
h pericardium and left atrium.
of both sides through several collecting trunks.
i The esophagus constitutes:
It also receives branches from posterior
the primary posterior relationship of the base of the
g mediastinal structures.
heart.
h Near its termination, the thoracic duct often
It then deviates to the left and passes through the
l receives:
esophageal hiatus in the diaphragm at the level of the
y Jugular
T10 vertebra, anterior to the aorta.
Subclavian and
m The esophagus may have three impressions, or
bronchomediastinal lymphatic trunks (although
o constrictions, in its thoracic part.
any or all these vessels may terminate
b These may be observed as narrowings of the lumen
independently).
in oblique chest radiographs that are taken as barium
i The thoracic duct usually empties into the venous
is swallowed.
l system near the union of the left internal jugular and
The esophagus is compressed by three structures:
e subclavian veinsthe left venous angle or origin of
the arch of the aorta
the left brachiocephalic vein but it may open into the
r the left main bronchus
left subclavian vein.
e the diaphragm
g The first two impressions occur in close proximity.
i CLINICAL ANATOMY | ANTERIOR AND POSTERIOR MEDIASTINUM
 MISTLEY JANE 3
IT ARCHES OVER: the superior aspect of the root
of the right lung to join the SVC, similar to the way
the arch of the aorta passes over the root of the
left lung.
In addition to the posterior intercostal veins, the
azygos vein communicates with the vertebral venous
plexuses that drain the back, vertebrae, and
structures in the vertebral canal.
The azygos vein also receives the mediastinal,
esophageal, and bronchial veins

HEMI-AZYGOS VEIN:
arises on the left side by the junction of the left
subcostal and ascending lumbar veins.
It ascends on the left side of the vertebral column,
posterior to the thoracic aorta as far as the T9
vertebra.
Here it crosses to the right, posterior to the aorta,
thoracic duct, and esophagus, and joins the azygos
VESSELS AND LYMPH NODES OF POSTERIOR vein.
i
MEDIASTINUM
sPOSTERIOR MEDIASTINAL LYMPH NODES: The hemi-azygos vein receives the inferior three:
a Lie posterior to the pericardium, where they are posterior intercostal veins
h related to the esophagus and thoracic aorta. the inferior esophageal veins, and
several small mediastinal veins.
i There are several nodes posterior to the inferior
g part of the esophagus and more (up to eight) anterior
and lateral to it.
h
The posterior mediastinal lymph nodes receive lymph
l from:
y esophagus
m posterior aspect of the pericardium
o diaphragm
b middle posterior intercostal spaces
i Lymph from the nodes drains to:
the right or left venous angles via the right
l lymphatic duct or the thoracic duct.
e
r AZYGOS SYSTEM OF VEINS:
e on each side of the vertebral column
g Drains the:
i Back
thoracoabdominal walls
o
mediastinal viscera
n The azygos system exhibits much variation in its
ACCESSORY HEMI-AZYGOS VEIN:
origin, course, tributaries, and anastomoses.
BEGINS AT: the medial end of the 4th or 5th
The azygos vein (G., azygos, unpaired) and its main
intercostal space and
tributary, the hemi-azygos vein:
DESCENDS ON: the left side of the vertebral
Usually arise from roots arising from the
column from T5 through T8
posterior aspect of the IVC and/or renal vein,
It receives tributaries from:
respectively, which merge with the ascending
veins in the 4th8th intercostal spaces
lumbar veins.
and sometimes from the left bronchial veins
IT CROSSES OVER: the T7 or T8 vertebra,
AZYGOS VEIN:
POSTERIOR TO: the thoracic aorta and thoracic
forms a collateral pathway between the SVC and IVC
duct, where it joins the azygos vein.
Drains blood from the posterior walls of the thorax
Sometimes the accessory hemi-azygos vein joins the
and abdomen.
hemi-azygos vein and opens with it into the azygos
IT ASCENDS IN: the posterior mediastinum,
vein.
passing close to the right sides of the bodies of the
The accessory hemi-azygos is frequently connected
inferior 8 thoracic vertebrae.
to the left superior intercostal vein.

CLINICAL ANATOMY | ANTERIOR AND POSTERIOR MEDIASTINUM

 MISTLEY JANE 4
LEFT SUPERIOR INTERCOSTAL VEIN: In infants and children:
which drains the 1st3rd intercostal spaces The anterior mediastinum contains the inferior part
may communicate with the accessory hemi- of the thymus.
azygos vein In unusual cases, this lymphoid organ may extend to
however, it drains primarily into the left the level of the 4th costal cartilages.
brachiocephalic vein
SURFACE ANATOMY OF HEART AND MEDIASTINAL
i
NERVES OF POSTERIOR MEDIASTINUM VISCERA
i
The sympathetic trunks and their associated ganglia s THE HEART AND GREAT VESSELS
s form a major portion of the autonomic nervous system. a are approximately in the middle of the thorax,
a THORACIC SYMPATHETIC TRUNKS: h surrounded:
h are in continuity with the cervical and lumbar i LATERALLY AND POSTERIORLY: by the lungs
i sympathetic trunks. g ANTERIORLY: by the sternum and
The thoracic trunks lie against the heads of the ribs the central part of the thoracic cage
g h
in the superior part of the thorax, the The borders of the heart are variable and depend on the
h costovertebral joints in the midthoracic level, and l position of the diaphragm and the build and physical
l the sides of the vertebral bodies in the inferior part y condition of the person.
y of the thorax. m The outline of the heart can be traced on the anterior
m LOWER THORACIC SPLANCHNIC NERVES: o surface of the thorax by using the following guidelines:
o Also known as greater, lesser, and least splanchnic b THE SUPERIOR BORDER:
b nerves. corresponds to a line connecting the inferior
i
Are part of the abdominopelvic splanchnic nerves: border of the 2nd left costal cartilage to the
i l
because they supply viscera inferior to the superior border of the 3rd right costal
l diaphragm. e cartilage.
e They consist of presynaptic fibers from: r THE RIGHT BORDER:
r the 5th through the 12th sympathetic ganglia, e corresponds to a line drawn from the 3rd right
e which pass through the diaphragm and synapse g costal cartilage to the 6th right costal cartilage;
g in prevertebral ganglia in the abdomen. this border is slightly convex to the right.
i
They supply sympathetic innervation for most of the THE INFERIOR BORDER:
i o
abdominal viscera. corresponds to a line drawn from the inferior
o n end of the right border to a point in the 5th
n intercostal space close to the left MCL; the left
end of this line corresponds to the location of
the apex of the heart and the apex beat.
THE LEFT BORDER:
Corresponds to a line connecting the left ends of
the lines representing the superior and inferior
borders.
The valves are located posterior to the sternum;
however, the sounds produced by them are projected
to the areas
pulmonary (P)
aortic (A)
mitral (M)
tricuspid (T)
where the stethoscope may be
ANTERIOR MEDIASTINUM placed to avoid intervening bone.
i the smallest subdivision of the mediastinum APEX BEAT:
s LIES BETWEEN: the body of the sternum is the impulse that results from the apex of the
a ANTERIORLY: the transversus thoracis muscles heart being forced against the anterior thoracic wall
h POSTERIORLY: pericardium when the left ventricle contracts.
It is continuous with: The location of the apex beat (mitral area, M) varies
i
the superior mediastinum at the sternal angle and is in position and may be located in the 4th or 5th
g intercostal spaces, 610 cm from the AML (anterior
limited inferiorly by the diaphragm.
h median line).
The anterior mediastinum consists of:
l loose connective tissue (sternopericardial ligaments)
y fat
m lymphatic vessels
o a few lymph nodes and
b branches of the internal thoracic vessels
i
l CLINICAL ANATOMY | ANTERIOR AND POSTERIOR MEDIASTINUM
 MISTLEY JANE 5
AUSCULTATORY AREAS ANOMALIES OF ARCH OF AORTA
i Clinicians interest in the surface anatomy of the heart The most superior part of the arch of the aorta is usually
s and cardiac valves results from their need to listen to approximately 2.5 cm inferior to the superior border of
a valve sounds. the manubrium, but it may be more superior or inferior.
h The five areas (two areas are for the pulmonary valve) Sometimes the arch curves over the root of the right
i are as wide apart as possible so that the sounds produced lung and passes inferiorly on the right side, forming a
g at any given valve may be clearly distinguished from those right arch of the aorta.
produced at other valve. In some cases, the abnormal arch, after passing over the
h
Blood tends to carry the sound in the direction of its root of the right lung, passes posterior to the esophagus
l flow; consequently, each area is situated superficial to to reach its usual position on the left side.
y the chamber or vessel into which the blood has passed Less frequently, a double arch of the aorta forms a
m and in a direct line with the valve orifice. vascular ring around the esophagus and trachea.
o A trachea that is compressed enough to affect breathing
b may require surgical division of the vascular ring.
i
ANEURYSM OF ASCENDING AORTA
l The distal part of the ascending aorta:
e receives a strong thrust of blood when the left
r ventricle contracts.
e Because its wall is not yet reinforced by fibrous
g pericardium (the fibrous pericardium blends with the
aortic adventitia at the beginning of the arch), an
i
aneurysm (localized dilation) may develop.
o
An aortic aneurysm is evident on a chest film (radiograph
n of the thorax) or an MR angiogram as an enlarged area of
the ascending aorta silhouette.
Individuals with an aneurysm usually complain of chest
pain that radiates to the back.
The aneurysm may exert pressure on the trachea,
esophagus, and recurrent laryngeal nerve, causing
VARIATIONS OF GREAT ARTERIES difficulty in breathing and swallowing.
i
s
BRANCHES OF ARCH OF AORTA COARCTATION OF AORTA
a The usual pattern of branches of the arch of the aorta the arch of the aorta or thoracic aorta has an abnormal
h is present in approximately 65% of people. narrowing (stenosis) that diminishes the caliber of the
i Variations in the origin of the branches of the arch are aortic lumen, producing an obstruction to blood flow to
g fairly common. the inferior part of the body.
27% of people: the left common carotid artery originates The most common site for a coarctation is near the
h
from the brachiocephalic trunk. ligamentum arteriosum.
l 2.5% of people: A brachiocephalic trunk fails to form, in When the coarctation is inferior to this site (postductal
y these cases each of the four arteries (right and left coarctation):
m common carotid and subclavian arteries) originate a good collateral circulation usually develops between
o independently from the arch of the aorta. the proximal and distal parts of the aorta through
b 5% of people: The left vertebral artery originates from the intercostal and internal thoracic arteries.
the arch of the aorta This type of coarctation is compatible with many years of
i
1.2% of people: Both right and left brachiocephalic life because the collateral circulation carries blood to
l trunks originate from the arch the thoracic aorta inferior to the stenosis.
e A retro-esophageal right subclavian artery: The collateral vessels may become so large that they
r sometimes arises as the last (most-left-sided) cause notable pulsation in the intercostal spaces and
e branch of the arch of the aorta. erode the adjacent surfaces of the ribs, which is visible
g The artery crosses posterior to the esophagus to in radio graphs of the thorax.
reach the right upper limb and may compress the
i
esophagus, causing difficulty in swallowing INJURY TO RECURRENT LARYNGEAL NERVES
o
(dysphagia). The recurrent laryngeal nerves supply all intrinsic
n An accessory artery to the thyroid gland, the thyroid muscles of the larynx, except one.
imaartery (L. arteria thyroidea ima), may arise from the Consequently, any investigative (diagnostic) procedure
arch of the aorta or the brachiocephalic artery. (e.g., mediastinotomy) or disease process in the superior
mediastinum may injure these nerves and affect the
voice.
Because the left recurrent laryngeal nerve winds around
the arch of the aorta and ascends between the trachea

CLINICAL ANATOMY | ANTERIOR AND POSTERIOR MEDIASTINUM


and esophagus, it may be involved in a bronchogenic or
esophageal carcinoma, enlargement of mediastinal lymph
nodes, or an aneurysm of the arch of the aorta.
In the latter condition, the nerve may be stretched by
the dilated arch.
BLOCKAGE OF ESOPHAGUS
The impressions produced in the esophagus by adjacent
structures are of clinical interest because of the slower
passage of substances at these sites.
The impressions indicate where swallowed foreign
objects are most likely to lodge and where a stricture
may develop, e.g., after the accidental drinking of a
caustic liquid such as lye.
LACERATION OF THORACIC DUCT
The thoracic duct is thin walled and usually dull white in
living persons.
However it may be colorless, making it difficult to
identify.
Consequently, it is vulnerable to inadvertent injury during
investigative and/ or surgical procedures in the posterior
mediastinum.
Laceration of the thoracic duct during an accident or lung
surgery results in lymph escaping into the thoracic cavity
at rates ranging from 75 to 200 mL per hour.
Lymph or chyle from the lacteals of the intestine may
also enter the pleural cavity, producing chylothorax. This
fluid may be removed by a needle tap or by thoracentesis;
in some cases it may be necessary to ligate (tie off) the
thoracic duct.
The lymph then returns to the venous system by other
lymphatic channels that join the thoracic duct superior
to the ligature.
VARIATIONS OF THORACIC DUCT
are common because the superior part of the duct
represents the original left member of a pair of
lymphatic vessels in the embryo.
Sometimes two thoracic ducts are present for a short
distance.
ALTERNATE VENOUS ROUTES TO HEART
The azygos, hemi-azygos, and accessory hemi-azygos
veins:
offer alternate means of venous drainage from the
thoracic, abdominal, and back regions when
obstruction of the IVC occurs.
In some people, an accessory azygos vein parallels the
azygos vein on the right side.
Other people have no hemi-azygos system of veins.
A clinically important variation, although uncommon, is
when the azygos system receives all the blood from the
IVC except that from the liver.
In these people, the azygos system drains nearly all
the blood inferior to the diaphragm, except from the
digestive tract.
If obstruction of the SVC occurs superior to the entrance of
the azygos vein, blood can drain inferiorly into the veins of the
abdominal wall and return to the right atrium through the azygos
venous system and the IVC.
MISTLEY JANE 6
AGE CHANGES IN THYMUS
The thymus is a prominent feature of the superior mediastinum
during infancy and childhood.
In some infants, the thymus may compress the trachea.
The thymus plays an important role in the development
and maintenance of the immune system.
As puberty is reached, the thymus begins to diminish in relative
size.
By adulthood, it is usually replaced by adipose tissue and is often
scarcely recognizable; however, it continues to produce T-
lymphocytes.
AORTIC ANGIOGRAPHY
To radiographically visualize the arch of the aorta and the
branches arising from it, a long, narrow catheter is passed into
the ascending aorta via the femoral or brachial artery in the
inguinal or elbow region, respectively.
Under fluoroscopic control, the tip of the catheter is placed just
inside the opening of a coronary artery
An aortic angiogram can be made by injecting radiopaque
contrast material into the aorta and into openings of the
arteries arising from the arch of the aorta.
RADIOGRAPHY OF MEDIASTINUM
The heart casts most of the central radiopaque shadow in PA
projections, but the separate chambers of the heart are not
distinguishable.
Knowledge of the structures forming the cardiovascular shadow
or silhouette is important because changes in the shadow may
indicate anomalies or functional disease.
In PA radiographs (AP views), the borders of the cardiovascular
shadow are as follows:
Right border, right brachiocephalic vein, SVC, right atrium,
and IVC.
Left border, terminal part of the arch of aorta, pulmonary
trunk, left auricle, and left ventricle.
The left inferior part of the cardiovascular shadow presents the
region of the apex.
The typical anatomical apex, if present, is often inferior to the
shadow of the diaphragm.
Three main types of cardiovascular shadows occur, depending
primarily on body type or habitus:
Transverse type, observed in obese persons, pregnant
women, and infants.
Oblique type, characteristic of most people.
Vertical type, present in people with narrow chests.
CT AND MRI OF MEDIASTINUM
CT and MRI are commonly used to examine the thorax.
CT is sometimes combined with mammography to examine the
breasts.
Before CT scans are taken, an iodide contrast material is given
intravenously.
Because breast cancer cells have an unusual affinity for iodide,
they become recognizable.
MRI is usually better for detecting and delineating soft tissue
lesions.
It is especially useful for examining the viscera and lymph nodes
of the mediastinum and roots of the lungs, by means of both
planar and reconstructed images.
Transverse (axial) CT and MR scans are always oriented to show
how a horizontal section of a patients body lying on an
examination table would appear to the physician who is at the
patients feet.
Therefore, the top of the image is anterior, and the left lateral
edge of the image represents the right lateral surface of the
patients body. Data from CT and MR scans can be graphically
reconstructed by the computer as transverse, sagittal, oblique,
or coronal sections of the body.
CLINICAL ANATOMY | ANTERIOR AND POSTERIOR MEDIASTINUM