Learning Objectives
? Identify the divisions of the mediastinum and describe
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their contents.? Describe the gross anatomy of structures in
mediastinum.
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? Describe the anatomy of nerves in the mediastinum.
? Correlate this knowledge to clinical conditions.
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Boundaries of mediastinumThoracic inlet
Sternal Angle
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sternum
Thoracic vertebra
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Thoracic ouletTS: Mediastinum
CS: Mediastinum
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Mediastinum
? Bulky septum
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between thepleural cavities
& lungs
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Extends-
? Root of the
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neck todiaphragm
? From the
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sternum to
vertebral
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columnDivisions of mediastinum
? Divided by an imaginary horizontal plane from
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the sternal angle to the intervertebral discbetween 4th & 5th vertebra in to
? superior mediastinum
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? Inferior mediastinum ?Anterior Middle Posterior
DIVISIONS OF MEDIASTINUM
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Boundaries Of Superior Mediastinum
BOUNDARIES:
? Anterior: manubrium sterni
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? Posterior: Upper 4 thoracic vertebrae? Superior: Plane of thoracic inlet
? Inferior: Horizontal plane
? On each side: Pleura
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Superior mediastinum
SUPERIOR MEDIASTINUM
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SUPERIOR MEDIASTINUMLEFT
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RIGHTSuperior mediastinum
? Posterior to the sternum & anterior to the
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bodies of first four thoracic vertebraSuperior mediastinum
CONTENTS:
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? FROM BEHIND FORWARD:
1.Esophagus
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2.Trachea3.Arch of aorta & its 3 branches: brachiocephalic,
left common carotid & left subclavian arteries
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4.Right & left brachiocephalic veins & superior vena
cava
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5.Thymus glandOther Contents of superior mediastinum
Nerves:
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1. Right & left vagus
2. Right & left phrenic
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3. Right & leftsympathetic trunks
4. Left recurrent
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laryngeal
Lymphatic structures:
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1. Thoracic duct2. Lymph nodes
Thymus
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? Asymmetric bilobed gland
? Upper extent may reach as high as thyroid
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gland? Involved in early development of immune
system
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? Large in children
? Atrophies after puberty
Brachiocephalic veins
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?Located immediately
posterior to thymus
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?Formed at the jn. of IJ& subclavian veins.
? Begins post to clavicle
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?Tributaries: vertebral,
first post. Intercostal,
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int. thoracic, inf.Thyroid, thymic veins
Left superior intercostal vein
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? Drains upper two
or three
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intercostal veins,left bronchial
veins & left
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pericardiophrenic
veins
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? Drains in to leftbrachiocephalic
veins
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Superior vena cava
? Vertically oriented
? Begins posterior
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to the lower edge
of first costal
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cartilage? terminates at the
lower border of
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right third costal
cartilage
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Arch of aorta & it's branches? Begins when
ascending aorta
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emerges from
pericardial sac
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? Terminates on left sideof vertebral level
between Th 4th - 5th
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Branches-
Brachiocephalic trunk
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Left CCALeft subclavian
Thyroid ima
Trachea
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? Midline structure
? Present anterior to
esophagus
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? Swallowing, breathing,
disease & specialized
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instrumentation causesshift of trachea
? divides just inferior to
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sternal angle (T3- T4)
into Right & Left principal
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bronchusVagus nerve
Right Vagus
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? lies between rightbrachiocephalic
vein & trunk
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? Descends
posteriorly to the
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root of Right lungto reach
esophagus
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? Gives branches to
esophagus,
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cardiac plexus &pulmonary plexus
Left Vagus nerve
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? Lies between Lt CCA &
Lt subclavian artery
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? Pass posterior to theroot of lung to reach the
esophagus
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? Gives branches to
esophagus, cardiac &
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pulmonary plexus? Also gives Lt recurrent
laryngeal nerve- arise at
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inferior margin of arch of
aorta, winds around the
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aorta & reaches thegroove between
esophagus & trachea
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Left recurrent laryngeal nerve
? arise at inferior
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margin of arch ofaorta, winds around
the aorta & reaches
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the groove between
esophagus &
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tracheaPhrenic nerve
? Right Phrenic ?enters
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lateral to Right Vagus& beginning of Right
brachiocephalic vein
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? continues inferiorly on
the Right side of sup
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vena cava, onentering middle
mediastinum
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descends along the
Rt side of pericardial
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sac anterior to the Rtlung root
? leaves the thorax with
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inferior vena cava
Left phrenic nerve
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? enters similar toRight Phrenic nerve
? Lateral to Vagus & Lt
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brachiocephalic vein
? Descends on left
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lateral surface ofarch of aorta
? Passes superficial to
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Lt vagus & superior
intercostal vein
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Left phrenic nerve? In middle
mediastinum lies on
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the Lt side of
pericardial sac
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anterior to root of Ltlung
? Pierces the
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diaphragm near the
apex of the heart
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Thoracic duct? Major lymphatic vessel
of the body
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? Enters sup.
mediastinum from
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below at the level ofT4/5
? continues through the
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superior med. posterior
to arch of aorta
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between the esophagus& Lt pleura
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Anterior MediastinumLies ant. to pericardium
Boundaries:
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Anterior: body of sternumPosterior: pericardium
superior: imaginary line
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separating sup. &
inf.mediastinum
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Infreior: diaphragmLateral: mediastinal pleura
Anterior mediastinum
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Thymus
contains:
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Lymph nodesfat
Thymus
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Located in anteriormediastinum.
Develops from endoderm
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of 3rd pharyngeal pouchPresent in childhood,
involutes in adults
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Blood supplyArterial :i nt. Mammary arteries
Venous: internal thoracic veins
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Lymphatic drainage: lower
cervical, int. Mammary and hilar
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nodesEsophagus
? Starts at the C6th &
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terminates at cardiacopening of stomach
(T12)
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? Descends anterior to
vertebral bodies in
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midline? Crossed laterally by the
azygos vein on the right
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side & arch of aorta on
the left side
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Posterior MediastinumBOUNDARIES:
? Anterior: Pericardium & diaphragm
? Posterior: Lower 8 thoracic vertebrae
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? Superior: Horizontal plane? Inferior: Diaphragm
? On each side: Pleura
Posterior Mediastinum
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? CONTENTS:
1. Esophagus (most anterior structure)
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2. Thoracic duct3. Right & left vagus
4. Descending aorta
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5. Azygos & hemiazygos veins
6. Right & left sympathetic trunks & their
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branches (splanchnic nerves)7. Lymph nodes
POSTERIOR MEDIASTINUM
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POSTERIOR MEDIASTINUMPOSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM
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POSTERIOR MEDIASTINUM
MIDDLE MEDIASTINUM
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? CONTENTS:
1. Pericardium & heart
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2. Arteries: ascending aorta, pulmonary trunk3. Veins: lower half of superior vena cava,
terminations of inferior vena cava & pulmonary
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veins
4. Nerves: phrenic
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5. Lymph nodesMediastinum
VEINS
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BRACHIOCEPHALIC: (Superior mediastinum)
? FORMATION: by union of internal jugular & subclavian vein
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(behind medial end of clavicle)? END: Both veins unite to form S.V.C.
? RIGHT VEIN: shorter & has a vertical course, related lateral y to
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right phrenic nerve & right pleura & lung, its tributaries in thorax:
right 1st posterior intercostal vein, right internal thoracic vein,
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right lymphatic duct? LEFT VEIN: longer & has an oblique course, related anteriorly to
manubrium & thymus gland, & posteriorly to branches of arch of
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aorta, its tributaries in thorax: left 1st posterior intercostal vein,
left superior intercostal vein, left internal thoracic vein, thoracic
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ductVEINS
SUPERIOR VENA CAVA: (Superior & middle mediastinum)
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? FORMATION: by union of brachiocephalic veins, behind lower border of
right 1st costal cartilage
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? END: opens into right atrium behind right 3rd costal cartilage? TRIBUTARIES: azygos vein
AZYGOS & HEMIAZYGOS VEINS
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VEINS
AZYGOS VEIN: (Posterior mediastinum)
?
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ORIGIN: by union of right ascending lumbar & subcostal veins
(passes through aortic opening of diaphragm)
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?END: forms an arch above the root of right lung & ends in S.V.C.
opposite lower border of T4
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?
RELATIONS:
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1. Anterior: esophagus2. Posterior: thoracic vertebra
3. Right: right pleura & lung
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4. Left: thoracic duct
?
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TRIBUTARIES: superior & inferior hemiazygos veins, rightsuperior intercostal vein, right posterior intercostal veins (from
4th to 11th), right bronchial veins, esophageal & pericardial veins
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VEINS
INFERIOR HEMIAZYGOS: (Posterior
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mediastinum)?ORIGIN: by union of left ascending lumbar
& subcostal veins (passes through left crus
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of diaphragm)
?END: into azygos vein, opposite T8
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?TRIBUTARIES: left posterior intercostalveins (9th to 11th), esophageal veins
VEINS
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SUPERIOR HEMIAZYGOS: (Posterior mediastinum)
? ORIGIN: by left posterior intercostal veins (4th to 8th)
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? END: into azygos vein, opposite T7? TRIBUTARIES: left bronchial veins
INFERIOR VENA CAVA: (Posterior mediastinum)
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? END: passes through vena caval opening of diaphragm& opens into right atrium behind right 6th costal
cartilage
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ArA te
ORT rAi:
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?ASCEND e
IN s
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G AORTA: (Middle mediastinum)
1. ORIGIN: at the base of left ventricle opposite lower border of left 3rd
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costal cartilage2. END: ascends upward, forward & to the right & continues as arch of
aorta
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3. BRANCHES: right & left coronary arteries
Ar
? te
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ARrCieH sOF AORTA: (Superior mediastinum)
1. ORIGIN: continuation of ascending aorta, opposite upper border of
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right 2nd costal cartilage2. COURSE & RELATIONS: ascends upward backward & to the left
(behind manubrium & in front of trachea) then curves backward (to
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the left of trachea) then final y curves downward
3. TERMINATION: continues as descending aorta, opposite lower border
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of T4Ar
?
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teBRArNiCHeESs OF ARCH OF AORTA: (Superior mediastinum)1. BRACHIOCEPHALIC: ascends upward & to the right (behind
left brachiocephalic vein & in front of trachea) & divides
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into right common carotid & right subclavian arteries
(behind right sternoclavicular joint)
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2. LEFT COMMON CAROTID: ascends upward & to the left (tothe left side of brachiocephalic artery) & enters the neck
(behind left sternoclavicular joint)
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3. LEFT SUBCLAVIAN: ascends upward (behind left common
carotid artery, in front of esophagus, to the left side of
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trachea), arches over apex of left lung to enter neckAr
DES te
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CENDI rNieG AO sRTA: (Posterior mediastinum)
?
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ORIGIN: continuation of arch of aorta
?
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TERMINATION: passes through aortic opening ofdiaphragm (opposite T12) & continues as abdominal aorta
?
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RELATIONS:
1. Anterior: esophagus
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2. Posterior: thoracic vertebrae3. Right: thoracic duct
4. Left: left pleura & lung
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?
BRANCHES: posterior intercostal (from 3rd to 11th),
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subcostal, bronchial, esophageal, pericardial arteriesAr
PUL te
MON rARiYe TRsUNK (Middle mediastinum)
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? ORIGIN: from upper part of right ventricle, behind
sternal end of left 3rd costal cartilage
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? COURSE: ascends upward & to the left & divides (atlower border of T4) into:
1. Right pulmonary: runs behind ascending aorta &
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S.V.C to enter root of right lung
2. Left pulmonary: runs in front of desending aorta to
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enter root of left lungT
? RAC
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BEGIN HNIN EA
G: continuation of larynx, opposite C6
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? TERMINATION: bifurcates into 2 bronchi, opposite lower border
of T4
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? RELATIONS: (in superior mediastinum)1. Anterior: arch of aorta, brachiocephalic & left common carotid
arteries
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2. Posterior: left recurrent laryngeal nerve, esophagus
3. Right: right vagus nerve
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4. Left: arch of aorta, left subclavian artery? NERVE SUPPLY: sympathetic trunks & vagus
? BLOOD SUPPLY: inferior thyroid vessels
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? LYMPHATIC DRAINAGE: pretracheal & paratracheal
ESOP
? BEGINNI H
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NG: AG
contin UuatiSon of pharynx, opposite C6
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? TERMINATION: passes through esophageal opening of diaphragm(opposite T10) & joins stomach
? RELATIONS: (in superior mediastinum)
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1. Anterior: left recurrent laryngeal nerve, trachea, left subclavian artery
2. Posterior: thoracic vertebrae
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3. Right: right pleura & lung4. Left: thoracic duct, left pleura & lung
ESOP?RELATIHONAGS: (inU pSosterior mediastinum)
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1.Anterior: pericardium, separating it from left atrium
2.Posterior: thoracic duct, descending aorta, azygos vein
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3.Right: right pleura & lung4.Left: descending aorta, left pleura & lung
? NERVE SUPPLY: as trachea
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? ARTERIAL SUPPLY: descending aorta
? VENOUS DRAINAGE: azygos & hemiazygos
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? LYMPHATIC DRAINAGE: posterior mediastinal lymphnodes
THORACIC DUCT
? ORIGIN: from upper end of cysterna chyli (opposite
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L1 & L2)
? COURSE: passes through aortic opening of
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diaphragm, ascends in posterior mediastinum(behind esophagus) & in superior mediastinum (to
the left of esophagus) to enter root of neck
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? END: in left brachiocephalic vein
? RELATIONS: ( in posterior mediastinum)
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1. Anterior: esophagus2. Posterior: thoracic vertebrae
3. Right: azygos vein
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4. Left: descending aorta
THORACIC DUCT
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TRIBUTARIES:? It drains lymph from both sides of the body below
the diaphragm through cysterna chyli
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? It drains lymph from left half of the body above
diaphragm through:
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1. Left jugular lymph trunk: drains left side of head &neck
2. Left subclavian lymph trunk: drains left upper limb
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3. Left bronchomediastinal lymph trunk: drains left
side of thorax
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RIGHT LYMPHATIC DUCT? ORIGIN: formed by union of:
1. Right jugular lymph trunk: drains right
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side of head & neck
2. Right subclavian lymph trunk: drains
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right upper limb3. Right bronchomediastinal lymph trunk:
drains right side of thorax
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? END: in right brachiocephalic vein
NERVES
PHRENIC NERVES: (Superior & middle mediastinum)
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?
ORIGIN: anterior rami of C3,4,5
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?COURSE & RELATIONS IN THORAX:
1. RIGHT: descends to the right side of: right brachiocephalic vein,
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S.V.C., pericardium, I.V.C.
2. LEFT: descends to the left side of: arch aorta, pericardium
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?BRANCHES:
1. Motor branches to: diaphragm
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2. Sensory branches from:
?
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Mediastinal & central part of diaphragmatic pleura?
Fibrous pericardium & parietal layer of serous pericardium
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?
Peritoneum covering central part of undersurface of diaphragm
NERVES
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? VAGUS NERVES: (Superior & posterior mediastinum)? ORIGIN: 10th cranial nerve
? COURSE & RELATIONS IN THORAX:
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1. RIGHT: descends to the right side of: trachea, behind
root of right lung (pulmonary plexus), behind
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esophagus (esophageal plexus), passes throughesophageal opening of diaphragm to reach posterior
surface of stomach
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2. LEFT: descends to the left side of: arch aorta, behind
root of left lung (pulmonary plexus), in front of
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esophagus (esophageal plexus), passes throughesophageal opening of diaphragm to reach anterior
surface of stomach
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NERVES
BRANCHES IN THORAX:
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? BOTH VAGI: to lungs & esophagus? RIGHT VAGUS: to heart
? LEFT VAGUS: left recurrent laryngeal nerve:
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curves below arch of aorta, behind ligamentum
arteriosum, ascends in groove between trachea
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& esophagus to reach the neck. It supplies: heart,trachea, esophagus (in thorax) & larynx (in neck)
NERVES
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THORACIC PART OF SYMPATHETIC TRUNKS: (Superior &posterior mediastinum)
? BEGINNING: the cervical part continues as thoracic
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part by passing in front of neck of first rib
? TERMINATION: the thoracic part continues as lumbar
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part by passing behind medial arcuate ligament? COURSE:
1. In upper part of thorax: descend in front of heads of
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ribs
2. In lower part of thorax: descend on the sides of
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bodies of vertebrae? GANGLIA: usual y 11 (1st thoracic ganglion fuses with
inferior cervical ganglion forming stel ate ganglion)
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NERVES
?
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BRANCHES:1. Rami communicantes: each ganglion receives a
white ramus (preganglionic) & gives a grey ramus
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(postganglionic) to corresponding thoracic spinal
nerve
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2. Visceral branches (postganglionic) to thoracic organs(from upper 5 ganglia): to heart, lungs, esophagus,
descending aorta
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3. Visceral branches (preganglionic) to abdominal
organs:
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? Greater splanchnic nerve (from 5th to 9th ganglia)? Lesser splanchnic nerve (from 10th 7 11th ganglia)
? Lowest splanchnic nerve (from 12th ganglion)
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Nerves in mediastinum
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? The right vagus nerve descends in
the thorax, first posterolateral to the
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brachiocephalic artery then lateralto the trachea
? Passes behind the root of the right
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lung and assists in the formation of
the pulmonary plexus.
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? On leaving the plexus, the vaguspasses onto the posterior surface of
the esophagus and takes part in the
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formation of the esophageal
plexus.
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? It then passes through theesophageal opening of the
diaphragm.
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Nerves in mediastinum
? The left vagus nerve descends in
the thorax between the left
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common carotid and the left
subclavian arteries
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? It then crosses the left side of theaortic arch
? The vagus then turns backward
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behind the root of the left lung and
assists in the formation of the
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pulmonary plexus.? On leaving the plexus, the vagus
passes onto the anterior surface of
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the esophagus and takes part in
the formation of the esophageal
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plexus.Nerves in mediastinum
? The right phrenic nerve
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descends in the thorax along theright side of the right
brachiocephalic vein and the
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superior vena cava .
? It passes in front of the root of
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the right lung and runs along theright side of the pericardium, which
separates the nerve from the right
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atrium.
? It then descends on the right side
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of the inferior vena cava to t`hediaphragm.
? Its terminal branches pass through
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the caval opening in the
diaphragm to supply the central
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part of the peritoneum on its underaspect.
Nerves in mediastinum
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? The left phrenic nerve descendsin the thorax along the left side of
the left subclavian artery.
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? It crosses the left side of the aortic
arch and here crosses the left side
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of the left vagus nerve.? It passes in front of the root of the
left lung and then descends over
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the left surface of the pericardium,
which separates the nerve from
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the left ventricle.? On reaching the diaphragm, the
terminal branches pierce the
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muscle and supply the central part
of the peritoneum on its under
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aspect.anatomical
Acc. To felson
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Clinical correlations? Deflection of Mediastinum
?If air enters the pleural
cavity (a condition called
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pneumothorax), the lung
on that side immediately
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collapses and themediastinum is displaced to
the opposite side.
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?patient's being breathless
and in a state of shock; on
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examination, the tracheaand the heart are found to
be displaced to the opposite
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side
Clinical correlations
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? Mediastinitis?Deep infection of the neck spread readily into the thorax,
producing a mediastinitis.
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?Penetrating wounds of the chest involving the esophagusmay produce a mediastinitis.
Clinical correlations
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? Mediastinal Tumors or Cysts
?Enlargement of mediastinal tumor
may compress the left recurrent
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laryngeal nerve, producing
paralysis of the left vocal fold.
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?An expanding cyst or tumor canpartially occlude the superior vena
cava, causing severe congestion
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of the veins of the upper part of
the body.
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?Other pressure effects can beseen on the sympathetic trunks,
phrenic nerves, and sometimes
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the trachea, main bronchi, and
esophagus.
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Clinical correlations? Mediastinoscopy
?diagnostic procedure by which
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tracheobronchial lymph nodesare obtained without opening the
pleural cavities.
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?A small incision is made in the
midline in the neck just above
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the suprasternal notch, andthe superior mediastinum is
explored down to the region of
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the bifurcation of the trachea.
?The procedure can be used to
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determine the diagnosis anddegree of spread of carcinoma
of the bronchus.
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Summary
? Mediastinum: definition
? Extend and sub
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divisions? Contents
? Nerves passing thorax
? Clinical correlations
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