THE MEDIASTINUM

Is a broad central partition that separates two laterally placed pleural sacs

It contains the thymus gland, the pericardial sac, the heart, the trachea, and the major arteries and veins
It serves as a passageway for the oesophagus, thoracic duct, and various components of the nervous system It is subdivided into several smaller regions.

Cross-section of the thorax showing the position of the mediastinum.

Lateral view of the mediastinum.

SUBDIVIONS OF THE MEDIASTINUM A transverse plane extending from the sternal angle to the IV disc of T4 and T5 separates the mediastinum into Superior and Inferior mediastinum The pericardial sac further divides the inferior mediastinum into: Anterior, Middle, Posterior mediastinum

Subdivisions of the mediastinum.

THE MIDDLE MEDIASTINUM Is centrally located in the thoracic cavity and contains the pericardium, heart Structures Heart and pericardium origins of the great vessels: pulmonary trunk, ascending aorta The inferior half of the SVC enters the fibrous pericardium to enter the right atrium. At the level of T8 the IVC enters the fibrous pericardium after passing thru the central tendon of the diaphragm. Short segment of the pulmonary veins are within the pericardial sac.

Sagittal section of the pericardium.

Pericardium

Is a fibroserous sac surrounding the heart and roots of the great vessels. It consist of the :
Fibrous pericardium Serous Pericardium The fibrous pericardium is the outer layer and is tough connective tissue The serous pericardium is thin and consist of two layers: the parietal and visceral layer The parietal layer- lines the inner surface of the fibrous, Visceral layer (epicardium) adheres to the heart and forms its outer layer. The space created by the two layers of the serous pericardium contains a small amount of fluid-pericardial cavity.

Phrenic nerves and pericardiacophrenic vessels.

Major vessels within the middle mediastinum. A. Anterior view. B. Posterior view.

THE SUPERIOR MEDIASTINUM Is posterior to the manubrium and anterior to the first four vertebral bodies Superiorly: oblique line passing from the jugular notch to the superior border of T1 Inferiorly: transverse plane passing from the sternal angle to IV disc of T4 and T5 Laterally: mediastinal part of the parietal pleura on either side Structures: Thymus Right and left brachiocephalic veins Left superior intercostal vein SVC Arch of aorta Oesophagus Phrenic and vagus nerves Left recurrrent laryngeal nerve Thoracic duct Small nerves, blood vessels and lymphatics

The thymus is the most anterior component of the superior mediastinum. Lying posterior to the sternum. Superiorly it extends into the neck and inferiorly to the anterior mediastinum over the pericardial sac. Involved in development of the immune system, large structure in child which begins to atrophy after puberty.

Thymus.

Right and left brachiocephalic veins: form on each side as junction between subclavian and internal jugular veins. The left crosses the midline to the right to form the superior vena cava Superior vena cava: Begins at the lower edge of the right first costal cartilage and terminates at the right third costal cartilage where it drains into the right atrium. It receives the azygos vein before entering the pericardial sac.

Arch of the aorta: thoracic portion aorta is divided into ascending aorta, arch, thoracic part of the descending aorta. Only the arch is in the superior mediastinum. Begins from the ascending aorta coming from the pericardial sac courses upwards, backwards and to the left at the vertebral level T4/T5. Initially anteriorly and then lateral to the trachae.

Three branches arise from the arch and are crossed by the left brachiocephalic vein: brachiocephalic trunk, left common carotid, left subclavian artery.

Ligamentum arteriosum: important in embryonic circulation where its is patent(ductus arteriosum). It connects the pulmonary trunk to aorta bypassing the lung. Soon after birth it closes and forms the ligamentum arteriosum.

 Vagus nerves: Passes thru the superior and posterior mediastinum before entering the abdominal cavity. The right vagus nerve lies between the right brachiocephalic vein and brachiolicephalic trunk and descends on the lateral surface of the trachae and then posterior to the root of the right lung to reach the oesophagus.

Right and left phrenic nerves: arise from C3-C5 spinal nerves and descend in the thorax to supply motor and sensory innervation to diaphragm Thoracic duct: major lymphatic vessel in body passes thru posterior portion of superior mediastinum.

Left vagus nerve: posterior to the left brachiocephalic vein between the left common carotid and subclavian arteries . It descends and passes posterior to the root of the left lung to reach the oesophagus. It gives off the left recurrent laryngeal nerve which can be seen inferior to the arch of the aorta lateral to the ligamentum arteriosum.

Trachae and oesophagus: palpable at the jugular notch, posterior to it is the oesophagus which is anterior to the vertebral column. As these structures passed in the superior mediastinum they are crossed by the azygos vein on the right and the arch of the aorta on the left. The trachae bifurcates into right and left principle bronchus at T4/T5 whereas the oesophaus continues in the posterior mediastinum.

POSTERIOR MEDIASTINUM Is posterior to the pericardial sac and anterior to the vertebral bodies at mid and lower thoracic vertebrae. Superiorly: transverse plane passing at sternal angle to IV disc between T4 and T5 Inferiorly: diaphragm Laterally:mediastinal parts of the parietal pleura Structures: Oesophagus Thoracic aorta Azygos system of veins Thoracic duct Sympathetic trunks Thoracic splanchnic nerves

Oesophagus: muscular tube begins at inferior border of cricoid cartilage and ends at cardiac opening of stomach at T11. Descends on vertebral bodies in midline position. It passes in the oesophaeal hiatus , an opening in the muscular part of the diaphragm at vertebral level T10.

Thoracic aorta: begins at the lower edge of T4 and ends anterior to the lower edge of T12 passing thru aortic hiatus posterior to diaphragm.

Azygos system of veins: consist of longitudinal vessels on each side of the body that drains blood from the body wall into the superior vena cava. Major veins: azygos vein on the right hemiazygos and accessory on the left
The azygos vein: Begins at L1 or L2 junction between Right ascending lumbar and subcostal vein. Enters thorax thru aortic hiatus ascends in posterior mediastinum. At T4 it arches over root of right lung to drain into the SVC

Right superior intercostal vein

Thoracic duct: Principal channel thru which most of the lymph is returned to the venous system. It begins in the abdomen as sacular dilatation: cisternal chyli. It extends from the vertebra L2 to root of neck. Enters thorax thru aortic hiatus. Ascends upwards in posterior mediastinum and at T5 moves to the left. Empties into jxn between left subclavian and left internal jugular vein.

Thoracic portion of sympathetic trunks.

Thoracic portion of sympathetic trunks.

Sympathetic trunks: Important component of sympathetic part of the ANS. There are 11 or 12 ganglia which are connected via white and gray rami communicantes to thoracic spinal nerves. Throughout their course the trunks are covered by parietal pleura. Medial branches of the sympathetic trunks-greater(thoracic ganglia 5-9) , lesser(9-10/10-11) and least(12) splanchnic nerves contain preganglionic sympathetic fibres.

ANTERIOR MEDIASTINUM

Posterior to the body of the sternum and anterior to the pericardial sac.

Contains portion of thymus gland, fat, sternopericardial ligaments, branches from internal thoracic vessels