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Expansion of the superior shadow of the mediastinum on x-ray. The structure of the mediastinum in children

Definition of the concept

X-ray examination played a very important role in the diagnosis of mediastinal diseases. Before the discovery of X-rays, this area containing vital organs was almost inaccessible for study, since classical methods of clinical examination (inspection, palpation, percussion, auscultation) are ineffective and do not provide timely diagnosis.

The lack of connection with the external environment and any secretions available for research also made it difficult to study the condition of the mediastinum. The introduction of the X-ray method into clinical medicine marked the beginning of a detailed study of this area in normal and pathological conditions.

The mediastinum is a space bounded anteriorly by the sternum and medial segments of the anterior ribs, posteriorly by the spine and the inner ends of the posterior ribs, and laterally by the mediastinal pleura.

The lower border of the mediastinum is the diaphragm, but there is no upper border: through the upper aperture of the chest, the mediastinum communicates widely with the neck region.

Research methods

For the diagnosis and differential diagnosis of mediastinal diseases, a number of techniques, both basic and additional, are used: multi-projection fluoroscopy and radiography, multi-projection tomography, including transverse computed tomography, kymography, pneumomediastinography, pneumopericardium, esophageal contrast, angiocardiography, aortography, cavography, azygography, mammariography, lymphography , puncture biopsy under X-ray control.

"Differential X-ray diagnostics
diseases of the respiratory system and mediastinum",
L.S.Rozenshtrauch, M.G.Winner

One of the reasons for the expansion of the median shadow may be an aneurysm of the great vessels, in particular the aorta. It occurs most often with syphilis, atherosclerosis, fungal diseases and traumatic injuries. Based on their shape, aneurysms are classified into spindle-shaped, cylindrical, spherical and saccular. A special form is dissecting aneurysms. Atherosclerotic aneurysms are usually not very large and have a cylindrical and fusiform shape. Syphilitic aneurysms can reach...

In most cases, it is expanded in the areas adjacent to the aneurysm. The exception is small aneurysms, as well as fungal and traumatic ones, in which the size of the aorta can be normal. Shape and size of the heart. With large aneurysms, especially the sinus of Valsalva and the ascending aorta, aortic insufficiency is often observed, changing the configuration of the heart and causing its dilation. Ripple. Only in…

Aneurysms of the ascending aorta cause a local semi-oval expansion of the median shadow to the right. When the aneurysm is large enough, the trachea and esophagus are displaced to the left. Compression of the right main bronchus leads to hypoventilation of the lung. There may be signs of fluid in the pleural cavity due to compression in the area of the azygos vein. When the phrenic nerve is damaged, paresis of the right dome of the diaphragm with its paradoxical movement is observed. Often...

Tomogram in direct projection Aneurysm of the left branch of the aortic arch, which caused atelectasis of the left lung. Characteristic stump of the left main bronchus. Aneurysms of the aortic arch manifest themselves with various radiological symptoms, which depend on the size of the aneurysm and the characteristics of its relationship with neighboring organs. With an aneurysm of the right half of the aortic arch, an additional shadow appears along the right contour of the median shadow directly below the collarbone, and...

The aneurysm of the descending aorta is projected in the frontal projection against the background of the left lung, and in the lateral projection - in the posterior mediastinum. They often have a spindle-shaped shape, the contrasted esophagus shifts to the right. When positioned low, they are covered by the shadow of the heart and are not visible in direct projection. If pulsation is preserved, kymography provides significant assistance in diagnosing an aortic aneurysm. In the most difficult times for...

In this not so rare variant of development (one case per 2000 people), a local expansion of the mediastinal shadow is detected along the right contour of the median shadow at the level of the aortic arch, which often causes diagnostic difficulties. This becomes of practical importance especially in older people, when the sclerotic right aorta and the left subclavian artery extending from it compress the esophagus located between them...

Computer tomogram One node of such a tumor is located in the spinal canal, the other is in the posterior mediastinum, in the costovertebral groove. The first node arises from the roots or membranes of the spinal cord. Not fitting into the tight space of the spinal canal, the tumor extends beyond its limits, causing expansion of the corresponding intervertebral foramen. The second node, developing in more favorable conditions, can reach...

Neurogenic tumors of the posterior mediastinum often have to be differentiated from a number of other pathological formations. Melting of all tumor tissue, with the exception of the most peripheral parts, turns it into a kind of cyst. Enclosed posterior paramediastinal pleurisy is characterized by obtuse angles formed by its shadow and the chest wall. A multi-projection study reveals a shadow of varying shape and intensity. Moorings outside the localization are found in the pleural cavity...

Local expansion of the median shadow may be caused by a group of enlarged lymph nodes that have merged with each other and form an irregular tumor-shaped formation of various sizes. Such a conglomerate becomes edge-forming most often in the paratracheal region on the right, but sometimes it can be located in other parts of the mediastinum. The causes of these accumulations of enlarged lymph nodes can be various processes, the main ones being...

Signs of polycyclicity, characteristic of clusters of enlarged lymph nodes, usually cannot be detected, which is associated, on the one hand, with caseation of the tissue of the nodes, and on the other, with the compaction of the mediastinal pleura covering them. If calcium salts deposited in the thickness of the lymph nodes form sufficiently large accumulations, the shadow of the conglomerate becomes heterogeneous due to high-intensity darkening against its background...

Definition of the concept

The mediastinum is a space bounded in front by the sternum and the medial segments of the anterior ribs, in the back by the spine and the inner ends of the posterior ribs, and on the sides by the mediastinal pleura.

The lower border of the mediastinum is the diaphragm, but there is no upper border: through the upper aperture of the chest, the mediastinum communicates widely with the neck region.

Research methods

"Differential X-ray diagnostics
diseases of the respiratory system and mediastinum",
L.S.Rozenshtrauch, M.G.Winner

The aneurysm of the descending aorta is projected in a direct projection against the background of the left lung, and in a lateral projection - in the posterior mediastinum. They often have a spindle-shaped shape, the contrasted esophagus shifts to the right. When positioned low, they are covered by the shadow of the heart and are not visible in direct projection. If pulsation is preserved, kymography provides significant assistance in diagnosing an aortic aneurysm. In the most difficult times for...

Neurogenic tumors usually have a dense consistency and are well encapsulated. They can reach large sizes; their weight reaches 3 - 4 kg. Tumors arising from nerve trunks most often have one neurovascular pedicle. Neoplasms originating from the sympathetic ganglia may have 2 - 3 legs or more. In 90% of cases, neurogenic tumors are located in the posterior mediastinum,…

For the most part, these tumors are projected against the background of the pulmonary fields, simulating intrapulmonary formations. There are many known cases of diagnostic errors in this area, which led to tactical errors when surgeons planned to remove tumors or cysts of the lungs, but during the operation they turned out to be neurogenic tumors of the posterior mediastinum. X-ray in lateral projection Neurogenic tumor of the paravertebral space. The tumor projects onto…

Neurogenic tumor of the paravertebral space Plain radiograph (a) and radiograph under diagnostic pneumothorax (b). The lung is collapsed, the tumor has not moved. Thinning and marginal usuration of nearby ribs, as well as vertebral bodies, are not evidence of tumor malignancy. This may be a consequence of the pressure of an expansively growing benign tumor. At the same time, not only the phenomena of chalisteresis occur in the bones, but also true...

Allows you to identify not only the subtleties of pathological processes in the chest, but also to study the effect of the disease on surrounding tissues (within the cutting ability of the method).

When analyzing an X-ray image, it is necessary to understand that the image is formed by diverging beams of x-rays, therefore the obtained sizes of objects do not correspond to the actual ones. As a result, radiology specialists analyze an extensive list of darkening, clearing and other radiological symptoms before issuing a conclusion.

How to correctly interpret lung x-rays

In order for the interpretation of lung x-rays to be correct, an analysis algorithm must be created.

In classic cases, specialists study the following features of the image:

quality of execution;
shadow picture of the chest organs (pulmonary fields, soft tissues, skeletal system, location of the diaphragm, mediastinal organs).

Quality assessment involves identifying features of placement and mode that may affect the interpretation of the x-ray picture:

Asymmetrical body position. It is assessed by the location of the sternoclavicular joints. If it is not taken into account, rotation of the thoracic vertebrae can be detected, but this will be incorrect.
The hardness or softness of the image.
Additional shadows (artifacts).
The presence of concomitant diseases affecting the chest.
Completeness of coverage (a normal x-ray of the lungs should include the apices of the lung fields above and the costophrenic sinuses below).
In a correct photograph of the lungs, the shoulder blades should be located outward from the chest, otherwise they will create distortions when assessing the intensity of radiological symptoms (clearing and darkening).
Clarity is determined by the presence of single-contour images of the anterior segments of the ribs. If there is dynamic blurring of their contours, it is obvious that the patient was breathing during exposure.
The contrast of an x-ray is determined by the presence of color shades of black and white. That is, when deciphering, it is necessary to compare the intensity of the anatomical structures that produce darkening with those that create clearing (pulmonary fields). The difference between shades indicates the level of contrast.

It is also necessary to take into account possible image distortions when examining a person under different directions of X-rays (see figure).

Figure: distorted image of a ball when examined with a direct beam (a) and with an oblique position of the receiver (b)

Protocol for describing a chest x-ray by a doctor

The protocol for decoding the chest X-ray begins with the description: “ on the presented radiograph of the OGK in direct projection" The direct (posterior-anterior or anteroposterior) projection involves taking an x-ray with the patient standing with his face or back to the beam tube with a central path of rays.

We continue the description: “ in the lungs without visible focal and infiltrative shadows" This standard phrase indicates the absence of additional shadows caused by pathological conditions. Focal shadows occur when:

tumors;
occupational diseases (silicosis, talcosis, asbestosis).

Infiltrative darkening indicates diseases accompanied by inflammatory changes in the lungs. These include:

pneumonia;
edema;
helminthic infestations.

The pulmonary pattern is not deformed, clear– such a phrase indicates the absence of disturbances in the blood supply, as well as pathogenetic mechanisms causing vascular deformation:

circulation disturbances in the small and large circles;
cavitary and cystic X-ray negative formations;
stagnation.

The roots of the lungs are structural, not expanded– this description of the OGK image indicates that in the area of the roots the radiologist does not see additional shadows that can change the course of the pulmonary artery or enlarge the lymph nodes of the mediastinum.

Poor structure and deformation of the roots of the lungs is observed with:

sarcoidosis;
enlarged lymph nodes;
mediastinal tumors;
stagnation in the pulmonary circulation.

If mediastinal shadow without features, which means that the doctor did not identify additional formations coming out from behind the sternum.

The absence of “plus shadows” on a direct x-ray of the lungs does not mean the absence of tumors. It should be understood that the X-ray image is summative and is formed based on the intensity of many anatomical structures that are superimposed on each other. If the tumor is small and not from a bone structure, it overlaps not only the sternum, but also the heart. In such a situation, it cannot be identified even on a side image.

The diaphragm is not changed, the costophrenic sinuses are free – the final stage of the descriptive part of deciphering an X-ray image of the lungs.

All that remains is the conclusion: “ in the lungs without visible pathology».

Above we have given a detailed description of a normal lung x-ray so that readers have an idea of what the doctor sees in the image and what the protocol for his conclusion is based on.

Below is an example of a transcript if a patient has a lung tumor.

Description of an X-ray of the lungs with a tumor

Schematic representation of a node in the S3 segment of the left lung

An overview p-gram of the chest organs visualizes a nodular formation in the upper lobe of the left lung (segment S3) against the background of a deformed pulmonary pattern about 3 cm in diameter, polygonal in shape with wavy clear contours. From the node a path is traced to the left root and cords to the interlobar pleura. The structure of the formation is heterogeneous, which is due to the presence of centers of decay. The roots are structural, the right one is somewhat expanded, probably due to enlarged lymph nodes. The cardiac shadow is without features. The sinuses are free, the diaphragm is not changed.

Conclusion: X-ray picture of peripheral cancer in S3 of the left lung.

Thus, in order to decipher a chest x-ray, the radiologist has to analyze many symptoms and reunite them into a single picture, which leads to the formation of a final conclusion.

Features of lung field analysis

Correct analysis of lung fields creates opportunities to identify many pathological changes. The absence of darkening and clearing does not yet exclude lung diseases. However, to correctly interpret a chest image (CH), the doctor must know the numerous anatomical components of the X-ray symptom “pulmonary field”.

Features of the analysis of pulmonary fields on an x-ray:

the right margin is wide and short, the left is long and narrow;
the median shadow is physiologically expanded to the left due to the heart;
For correct description, the pulmonary fields are divided into 3 zones: lower, middle and upper. Similarly, 3 zones can be distinguished: internal, middle and external;
the degree of transparency is determined by air and blood filling, as well as the volume of parenchymal lung tissue;
the intensity is influenced by the superposition of soft tissue structures;
in women, the image may be obscured by the mammary glands;
the individuality and complexity of the pulmonary pattern requires highly qualified physicians;
Normally, the pulmonary pleura is not visible. Its thickening is observed during inflammation or tumor growth. The pleural sheets are more clearly visualized on a lateral radiograph;
each lobe consists of segments. They are distinguished based on the special structure of the bronchovascular bundle, which branches separately in each lobe. There are 10 segments in the right lung, 9 in the left lung.

Thus, interpreting lung x-rays is a complex task that requires extensive knowledge and long-term practical experience. If you have an x-ray that needs to be described, please contact our radiologists. We'll be happy to help!

Almost every person has health problems, it is important to be as attentive as possible to your well-being, noting any problems that arise, so that you can timely contact a specialist who will not only conduct a full diagnosis, but also prescribe the therapy necessary in your case to get rid of the problem. Sometimes situations occur when, in case of pain in a certain part of the body or when other unpleasant symptoms appear, fluoroscopy or some other examination is prescribed, and a specialist makes a diagnosis that is unclear to you. Let's look in this material at what an expansion of the mediastinal shadow on an x-ray could mean and whether it is worth panicking in this case.

What is the mediastinum

First, let's look at what the mediastinum is to understand what we're talking about. In fact, this term covers a whole complex of internal organs located between the pleural cavities of the human body. The mediastinum is limited in front by the sternum, and in the back by the spine. There is practically no restriction from above, and from below it is represented by a diaphragm. Experts note that all organs related to the mediastinum are surrounded by fatty tissue.

Reasons for shadow expansion

Enlargement or displacement of the mediastinum on radiographs is a very serious symptom. In the vast majority of cases, it warns of the development of any serious problems in the mediastinum, for example, cancerous tumors. Mediastinal formations can be detected only with the help of instrumental diagnostic methods, among which radiography, computed tomography and magnetic resonance imaging stand out. The last two methods are distinguished by their extremely high information content, but also by their enormous cost. In most cases, an x-ray can show everything you need, and it is completely free, but only a specialist has the right to decide on the choice of diagnostic procedure; in some cases, the full picture of the condition of the mediastinal organs may not be revealed using a conventional x-ray.

Important! Only the most dangerous and severe situations will be described below. In some cases, errors are possible during the diagnostic process, due to which the shadow magnification will be incorrect. Certain other disorders may also develop, so all situations should be assessed on an individual basis by a qualified professional.

Intrathoracic struma

One of the possible problems that can be identified using x-rays is the intrathoracic struma. This term refers to a formation that appears above the collarbone, pushing aside and significantly narrowing the trachea. Let us immediately mention that this problem, in which the shadow of the mediastinum shifts, cannot always be identified only with the help of a conventional x-ray, because for proper differentiation sometimes other methods are required. Specialists strive to clarify the state of the intrathoracic string during the swallowing process. Thus, the shadows are shifted upward.

As for the symptoms of intrathoracic struma, that is, its clinical manifestations in which this problem should be suspected, it almost never helps to identify this tumor. The fact is that the patient will suffer from shortness of breath and many other typical symptoms.

Aortic aneurysm

An aortic aneurysm can be considered an incredibly serious disorder. As for its diagnosis, there should be no difficulties with the diffuse form of this problem. If the aneurysm protrudes in the form of a sac, that is, local expansion is observed, it becomes quite difficult to differentiate it from a tumor for obvious reasons. Only an experienced specialist can evaluate the pulsation, because in some cases it can be transmitted to tumor formations. There are some diagnostic rules, let's look at them briefly.

According to the Thoma-Kinböck rule, limited aortic aneurysms of a syphilitic nature are most often accompanied by expansion of this large vessel along its entire length. With syphilitic mesaortitis, everything is quite ambiguous, since the Wasserman reaction does not give an accurate result. The risk of developing an aneurysm increases with diagnosed aortic insufficiency, which can be caused by syphilitic aneurysms of various types.

According to the Oliver-Cardarelli symptom, in the presence of pronounced expansion in the area of the aortic arch and when the expansion is placed on the bronchial tree, significant lowering of the trachea will be observed during pulse beats. As for ambiguous and difficult situations, they should be clarified using a lateral radiograph, then many inaccuracies and ambiguities can be resolved.

Pay attention! At more advanced stages of the aneurysm, it will be extremely difficult to confuse it with other problems, since you will be able to note patterns appearing on the ribs or even vertebrae. The fact is that, most likely, they will definitely not be present in other disorders associated with the mediastinum.

Tumors

Tumors should also be treated with the utmost seriousness and responsibility, since even benign neoplasms can result in dire consequences.

Lymphosarcoma (malignant neoplasms) often appears as an isolated tumor of a mediastinal nature, and in most situations they are already accompanied by pronounced manifestations:

significant acceleration of ROE;
mild anemia;
stagnation of blood flow, which is characterized by significant expansion of the veins, as well as various types of problems associated with the heart.

But in this case, it is impossible to make a diagnosis only based on the mentioned manifestations; it is imperative to carry out a biopsy of the lymph node under the collarbone, which will help resolve all ambiguous cases.

Lymphosarcomatosis is practically no different from lymphogranulomatosis on X-ray; specialists will not be able to determine the type of malignant tumor using this examination, so you should pay attention to the general condition of the patient and conduct other examinations. It is best to start with a blood test, since changes in them will definitely be observed in both cases.

Swelling abscess, phlegmon

If a mediastinal tumor develops, and the patient also experiences a febrile state, then one should not forget about the possibility of developing an abscess, and mediastinal phlegmon often appears. It should be noted that these problems have different manifestations. If edema abscesses can be difficult to distinguish from tumors, then mediastinal phlegmons are absolutely always accompanied by severe symptoms and serious disorders (for example, leukocytosis).

In abscess tuberculosis, the appearance of abscesses is observed after primary infection of the hilar lymph nodes. This problem can occur extremely slowly at the very beginning, and the disease will gradually break into the nearest organs. It is worth noting that with this problem, very often inexperienced doctors make an erroneous diagnosis - lymphogranulomatosis. The way out of this situation is the same lymph node biopsy, which allows you to easily find out the real cause of the disorders.

We should not forget that in some cases lymphogranulomatosis is combined with tuberculosis, but a complication of this kind can be observed only at the most advanced stages.

Pay attention! Only qualified, experienced doctors can analyze images to identify the problem, as this is a rather complex process even for them. If a specialist has doubts, additional and more accurate diagnostic procedures are required, for example, the previously mentioned computed tomography or MRI.

Pneumomediastinography - what is it?

Many have heard that gas is sometimes pumped into the mediastinal organs, but not everyone knows what this is for and when it is used. In fact, in such cases we are most often talking about pneumomediastinography, that is, an X-ray examination of a given part of the body, for which the mentioned gas is a contrast. Note that by the word “gas” experts most often mean air or pure oxygen, but anything else can be used.

The introduction occurs through a puncture, after which the specialist must position the patient in a certain way (the goal is to ensure that gas accumulates in the mediastinum). The radiographs themselves are taken at least 2 hours after its administration.

Experts consider pneumomediastinography one of the most valuable methods for diagnosing malignant and benign neoplasms. It can be used in various situations, on which many features of the examination will depend, but gas is always used.

Pay attention! Pneumomediastinography can only be performed in a hospital, since after the examination the patient needs careful monitoring for 2 days or even longer, depending on the situation.

It is worth understanding that diagnostics of this kind are prescribed only in cases where ordinary x-rays are not effective, that is, with its help, specialists were unable to identify the problem and prescribe competent therapy.

Mediastinal surgery, one of the youngest branches of surgery, has received significant development due to the development of issues of anesthesia, surgical techniques, diagnosis of various mediastinal processes and neoplasms. New diagnostic methods make it possible not only to accurately establish the localization of a pathological formation, but also make it possible to evaluate the structure and structure of the pathological focus, as well as obtain material for pathomorphological diagnosis. Recent years have been characterized by the expansion of indications for surgical treatment of mediastinal diseases, the development of new highly effective, low-traumatic treatment methods, the introduction of which has improved the results of surgical interventions.

Classification of mediastinal disease.

Mediastinal injuries:

1. Closed trauma and wounds of the mediastinum.

2. Damage to the thoracic lymphatic duct.

Specific and nonspecific inflammatory processes in the mediastinum:

1. Tuberculous adenitis of the mediastinum.

2. Nonspecific mediastinitis:

A) anterior mediastinitis;

B) posterior mediastinitis.

According to the clinical course:

A) acute non-purulent mediastinitis;

B) acute purulent mediastinitis;

B) chronic mediastinitis.

Mediastinal cysts.

1. Congenital:

A) coelomic pericardial cysts;

B) cystic lymphangitis;

B) bronchogenic cysts;

D) teratomas

D) from the embryonic embryo of the foregut.

2. Purchased:

A) cysts after hematoma in the pericardium;

B) cysts formed as a result of the disintegration of a pericardial tumor;

D) mediastinal cysts arising from the border areas.

Mediastinal tumors:

1. Tumors arising from the organs of the mediastinum (esophagus, trachea, large bronchi, heart, thymus, etc.);

2. Tumors arising from the walls of the mediastinum (tumors of the chest wall, diaphragm, pleura);

3. Tumors arising from the tissues of the mediastinum and located between organs (extraorgan tumors). Tumors of the third group are true tumors of the mediastinum. They are divided according to histogenesis into tumors of nervous tissue, connective tissue, blood vessels, smooth muscle tissue, lymphoid tissue and mesenchyme.

A. Neurogenic tumors (15% of this location).

I. Tumors arising from nervous tissue:

A) sympathoneuroma;

B) ganglioneuroma;

B) pheochromocytoma;

D) chemodectoma.

II. Tumors arising from nerve sheaths.

A) neuroma;

B) neurofibroma;

B) neurogenic sarcoma.

D) schwannomas.

D) ganglioneuromas

E) neurilemmomas

B. Connective tissue tumors:

A) fibroma;

B) chondroma;

B) osteochondroma of the mediastinum;

D) lipoma and liposarcoma;

D) tumors arising from blood vessels (benign and malignant);

E) myxomas;

G) hibernomas;

E) tumors from muscle tissue.

B. Tumors of the thymus gland:

A) thymoma;

B) thymus cysts.

D. Tumors from reticular tissue:

A) lymphogranulomatosis;

B) lymphosarcoma and reticulosarcoma.

E. Tumors from ectopic tissues.

A) substernal goiter;

B) intrathoracic goiter;

B) adenoma of the parathyroid gland.

The mediastinum is a complex anatomical formation located in the middle of the thoracic cavity, enclosed between the parietal layers, spinal column, sternum and lower diaphragm, containing fiber and organs. The anatomical relationships of the organs in the mediastinum are quite complex, but knowledge of them is mandatory and necessary from the standpoint of the requirements for providing surgical care to this group of patients.

The mediastinum is divided into anterior and posterior. The conventional boundary between them is the frontal plane drawn through the roots of the lungs. In the anterior mediastinum there are: the thymus gland, part of the aortic arch with branches, the superior vena cava with its sources (brachiocephalic veins), the heart and pericardium, the thoracic part of the vagus nerves, the phrenic nerves, the trachea and the initial sections of the bronchi, nerve plexuses, lymph nodes. In the posterior mediastinum there are: the descending aorta, azygos and semi-gypsy veins, the esophagus, the thoracic part of the vagus nerves below the roots of the lungs, the thoracic lymphatic duct (thoracic region), the border sympathetic trunk with the splanchnic nerves, nerve plexuses, lymph nodes.

To establish a diagnosis of the disease, localization of the process, its relationship to neighboring organs, in patients with mediastinal pathology, it is first necessary to conduct a full clinical examination. It should be noted that the disease in the initial stages is asymptomatic, and pathological formations are an accidental finding during fluoroscopy or fluorography.

The clinical picture depends on the location, size and morphology of the pathological process. Typically, patients complain of pain in the chest or heart area, interscapular area. Pain is often preceded by a feeling of discomfort, expressed in a feeling of heaviness or foreign formation in the chest. Shortness of breath and difficulty breathing are often observed. When the superior vena cava is compressed, cyanosis of the skin of the face and upper half of the body and their swelling may be observed.

When examining the mediastinal organs, it is necessary to conduct thorough percussion and auscultation and determine the function of external respiration. Important during the examination are electro- and phonocardiographic studies, ECG data, and X-ray studies. Radiography and fluoroscopy are carried out in two projections (direct and lateral). When a pathological focus is identified, tomography is performed. The study, if necessary, is supplemented with pneumomediastinography. If the presence of a substernal goiter or an aberrant thyroid gland is suspected, ultrasound examination and scintigraphy with I-131 and Tc-99 are performed.

In recent years, when examining patients, instrumental research methods have been widely used: thoracoscopy and mediastinoscopy with biopsy. They allow a visual assessment of the mediastinal pleura, partly the mediastinal organs, and collection of material for morphological examination.

Currently, the main methods for diagnosing mediastinal diseases, along with radiography, are computed tomography and nuclear magnetic resonance.

Features of the course of individual diseases of the mediastinal organs:

Damage to the mediastinum.

Frequency - 0.5% of all penetrating chest wounds. Damage is divided into open and closed. Features of the clinical course are caused by bleeding with the formation of a hematoma and compression of organs, vessels and nerves.

Signs of mediastinal hematoma: slight shortness of breath, mild cyanosis, swelling of the neck veins. X-ray shows darkening of the mediastinum in the area of the hematoma. Often a hematoma develops against the background of subcutaneous emphysema.

When the vagus nerves are imbibited by blood, vagal syndrome develops: respiratory failure, bradycardia, deterioration of blood circulation, and confluent pneumonia.

Treatment: adequate pain relief, maintaining cardiac activity, antibacterial and symptomatic therapy. With progressive mediastinal emphysema, puncture of the pleura and subcutaneous tissue of the chest and neck with short and thick needles is indicated to remove air.

When the mediastinum is injured, the clinical picture is complemented by the development of hemothorax and hemothorax.

Active surgical tactics are indicated for progressive impairment of external respiratory function and ongoing bleeding.

Damage to the thoracic lymphatic duct can occur with:

1. closed chest injury;
2. knife and gunshot wounds;
3. during intrathoracic operations.

As a rule, they are accompanied by a severe and dangerous complication: chylothorax. If conservative therapy is unsuccessful, surgical treatment is required within 10-25 days: ligation of the thoracic lymphatic duct above and below the injury, in rare cases, parietal suturing of the duct wound, implantation into the azygos vein.

Inflammatory diseases.

Acute nonspecific mediastinitis- inflammation of the mediastinal tissue caused by a purulent nonspecific infection.

Acute mediastinitis can be caused by the following reasons.

Open mediastinal injuries.
1. Complications of operations on the mediastinal organs.
2. Contact spread of infection from adjacent organs and cavities.
3. Metastatic spread of infection (hematogenous, lymphogenous).
4. Perforation of the trachea and bronchi.
5. Perforation of the esophagus (traumatic and spontaneous rupture, instrumental damage, damage by foreign bodies, tumor disintegration).

The clinical picture of acute mediastinitis consists of three main symptom complexes, the varying severity of which leads to a variety of its clinical manifestations. The first symptom complex reflects the manifestations of severe acute purulent infection. The second is associated with the local manifestation of a purulent focus. The third symptom complex is characterized by the clinical picture of damage or disease that preceded the development of mediastinitis or was its cause.

General manifestations of mediastinitis: fever, tachycardia (pulse - up to 140 beats per minute), chills, decreased blood pressure, thirst, dry mouth, shortness of breath up to 30 - 40 per minute, acrocyanosis, agitation, euphoria with transition to apathy.

With limited posterior mediastinal abscesses, the most common symptom is dysphagia. There may be a dry barking cough up to suffocation (involvement of the trachea), hoarseness (involvement of the recurrent nerve), as well as Horner's syndrome - if the process spreads to the sympathetic nerve trunk. The patient's position is forced, semi-sitting. There may be swelling in the neck and upper chest. On palpation there may be crepitus due to subcutaneous emphysema, as a result of damage to the esophagus, bronchus or trachea.

Local signs: chest pain is the earliest and most persistent sign of mediastinitis. The pain intensifies when swallowing and throwing the head back (Romanov's symptom). The localization of pain mainly reflects the localization of the abscess.

Local symptoms depend on the location of the process.

Anterior mediastinitis	Posterior mediastinitis
Chest pain	Chest pain radiating into the interscapular space
Increased pain when tapping the sternum	Increased pain with pressure on the spinous processes
Increased pain when tilting the head - Gehrke's symptom	Increased pain when swallowing
Pastiness in the sternum area	Pastosity in the area of the thoracic vertebrae
Symptoms of compression of the superior vena cava: headache, tinnitus, cyanosis of the face, swelling of the veins of the neck	Symptoms of compression of the paired and semi-gypsy veins: dilatation of the intercostal veins, effusion in the pleura and pericardium
With CT and NMR - a darkened zone in the projection of the anterior mediastinum	With CT and NMR - a darkened zone in the projection of the posterior mediastinum
X-ray - shadow in the anterior mediastinum, presence of air	X-ray - shadow in the posterior mediastinum, presence of air

When treating mediastinitis, active surgical tactics are used, followed by intensive detoxification, antibacterial and immunostimulating therapy. Surgical treatment consists of providing optimal access, exposing the injured area, suturing the rupture, draining the mediastinum and pleural cavity (if necessary) and applying a gastrostomy tube. Mortality in acute purulent mediastinitis is 20-40%. When draining the mediastinum, it is best to use the method of N.N. Kanshin (1973): drainage of the mediastinum with tubular drainages, followed by fractional rinsing with antiseptic solutions and active aspiration.

Chronic mediastinitis divided into aseptic and microbial. Aseptic include idiopathic, posthemorrhagic, coniotic, rheumatic, dysmetabolic. Microbial diseases are divided into nonspecific and specific (syphilitic, tuberculous, mycotic).

What is common to chronic mediastinitis is the productive nature of inflammation with the development of sclerosis of the mediastinal tissue.

Idiopathic mediastinitis (fibrous mediastinitis, mediastinal fibrosis) is of greatest surgical importance. In a localized form, this type of mediastinitis resembles a tumor or mediastinal cyst. In the generalized form, mediastinal fibrosis is combined with retroperitoneal fibrosis, fibrous thyroiditis and orbital pseudotumor.

The clinical picture is determined by the degree of compression of the mediastinal organs. The following compartment syndromes are identified:

Superior vena cava syndrome
Pulmonary vein compression syndrome
Tracheobronchial syndrome
Esophageal syndrome
Pain syndrome
Nerve compression syndrome

Treatment of chronic mediastinitis is mainly conservative and symptomatic. If the cause of mediastinitis is determined, its elimination leads to a cure.

Mediastinal tumors. All clinical symptoms of various mediastinal mass formations are usually divided into three main groups:

1. Symptoms from the mediastinal organs, compressed by the tumor;

2. Vascular symptoms resulting from compression of blood vessels;

3. Neurogenic symptoms developing due to compression or sprouting of nerve trunks

Compression syndrome manifests itself as compression of the mediastinal organs. First of all, the brachiocephalic and superior vena cava veins are compressed - superior vena cava syndrome. With further growth, compression of the trachea and bronchi is noted. This is manifested by cough and shortness of breath. When the esophagus is compressed, swallowing and passage of food are impaired. When the tumor of the recurrent nerve is compressed, phonation disturbances, paralysis of the vocal cord on the corresponding side. When the phrenic nerve is compressed, the paralyzed half of the diaphragm stands high.

When the borderline sympathetic trunk is compressed, Horner's syndrome causes drooping of the upper eyelid, narrowing of the pupil, and retraction of the eyeball.

Neuroendocrine disorders manifest themselves in the form of joint damage, heart rhythm disturbances, and disturbances in the emotional-volitional sphere.

The symptoms of tumors are varied. The leading role in making a diagnosis, especially in the early stages before the appearance of clinical symptoms, belongs to computed tomography and x-ray methods.

Differential diagnosis of mediastinal tumors themselves.

		Location		Content		Malignancy	Density
Teratoma	The most common tumor of the mediastinum	Anterior mediastinum	Significant	Mucous membrane, fat, hair, organ rudiments	Slow		Elastic
Neurogenic	Second most common	Posterior mediastinum	Significant	Homogeneous	Slow			Fuzzy
Connective tissue	Third most common	Various, most often anterior mediastinum	Various	Homogeneous	Slow
Lipoma, hibernoma		Various	Various	Mixed structure	Slow			Fuzzy
Hemangioma, lymphangioma		Various						Fuzzy

Thymomas (tumors of the thymus) are not classified as mediastinal tumors themselves, although they are considered together with them due to the peculiarities of localization. They can behave both benign and malignant tumors, giving metastases. They develop either from epithelial or lymphoid tissue of the gland. Often accompanied by the development of myasthenia gravis. The malignant variant occurs 2 times more often, is usually very severe and quickly leads to the death of the patient.

Surgical treatment is indicated:

with an established diagnosis and suspicion of a tumor or mediastinal cyst;
for acute purulent mediastinitis, foreign bodies in the mediastinum causing pain, hemoptysis or suppuration in the capsule.

The operation is contraindicated if:

established distant metastases to other organs or cervical and axillary lymph nodes;
compression of the superior vena cava with transition to the mediastinum;
persistent paralysis of the vocal cord in the presence of a malignant tumor, manifested by hoarseness;
dissemination of a malignant tumor with the occurrence of hemorrhagic pleurisy;
the general serious condition of the patient with symptoms of cachexia, hepatic-renal failure, pulmonary and heart failure.

It should be noted that when choosing the scope of surgical intervention in cancer patients, one should take into account not only the growth pattern and extent of the tumor, but also the general condition of the patient, age, and the condition of vital organs.

Surgical treatment of malignant tumors of the mediastinum gives poor results. Hodgkin's disease and reticulosarcoma respond well to radiation treatment. For true mediastinal tumors (teratoblastomas, neuromas, connective tissue tumors), radiation treatment is ineffective. Chemotherapy methods for the treatment of malignant true tumors of the mediastinum are also ineffective.

Purulent mediastinitis requires emergency surgical intervention as the only way to save the patient, regardless of the severity of his condition.

To expose the anterior and posterior mediastinum and the organs located there, various surgical approaches are used: a) complete or partial longitudinal dissection of the sternum; b) transverse dissection of the sternum, in which both pleural cavities are opened; c) both the anterior and posterior mediastinum can be opened through the left and right pleural cavity; d) diaphragmotomy with and without opening the abdominal cavity; e) opening the mediastinum through an incision in the neck; f) the posterior mediastinum can be penetrated extrapleurally from behind along the lateral surface of the spine with resection of the heads of several ribs; g) the mediastinum can be entered extrapleurally after resection of the costal cartilages at the sternum, and sometimes with partial resection of the sternum.

Rehabilitation. Work ability examination.

Clinical examination of patients

To determine the ability of patients to work, general clinical data are used with a mandatory approach to each person examined. During the initial examination, it is necessary to take into account clinical data, the nature of the pathological process - disease or tumor, age, complications from the treatment, and in the presence of a tumor - possible metastasis. It is common to be placed on disability before returning to professional work. For benign tumors after radical treatment, the prognosis is favorable. The prognosis for malignant tumors is poor. Tumors of mesenchymal origin are prone to relapses followed by malignancy.

Subsequently, the radicality of the treatment and complications after treatment are important. Such complications include lymphostasis of the extremities, trophic ulcers after radiation treatment, and disturbances in the ventilation function of the lungs.

Security questions

1. Classification of mediastinal diseases.
2. Clinical symptoms of mediastinal tumors.
3. Methods for diagnosing mediastinal tumors.
4. Indications and contraindications for surgical treatment of tumors and mediastinal cysts.
5. Operative approaches to the anterior and posterior mediastinum.
6. Causes of purulent mediastinitis.
7. Clinic of purulent mediastinitis.
8. Methods for opening ulcers with mediastinitis.
9. Symptoms of esophageal rupture.

10. Principles of treatment of esophageal ruptures.

11. Causes of damage to the thoracic lymphatic duct.

12. Chylothorax clinic.

13. Causes of chronic mediastinitis.

14. Classification of mediastinal tumors.

Situational tasks

1. A 24-year-old patient was admitted with complaints of irritability, sweating, weakness, and palpitations. Ill for 2 years. The thyroid gland is not enlarged. Basic exchange +30%. A physical examination of the patient did not reveal any pathology. An X-ray examination reveals a rounded formation 5x5 cm with clear boundaries in the anterior mediastinum at the level of the second rib on the right, the lung tissue is transparent.

What additional studies are needed to clarify the diagnosis? What is your tactic in treating a patient?

2. Patient, 32 years old. Three years ago I suddenly felt pain in my right arm. She was treated with physiotherapy - the pain decreased, but did not go away completely. Subsequently, I noticed a dense, lumpy formation on the right side of the neck in the supraclavicular region. At the same time, the pain in the right side of the face and neck intensified. At the same time I noticed a narrowing of the right palpebral fissure and a lack of sweating on the right side of the face.

Upon examination, a dense, lumpy, immobile tumor and an expansion of the superficial venous section of the upper half of the body in front were discovered in the right clavicular region. Slight atrophy and decreased muscle strength in the right shoulder girdle and upper limb. Dullness of percussion sound over the apex of the right lung.

What kind of tumor can you think of? What additional research is needed? What's your tactic?

3. Patient, 21 years old. She complained of a feeling of pressure in her chest. Radiologically, on the right, an additional shadow is adjacent to the upper part of the mediastinal shadow in front. The outer contour of this shadow is clear, the inner one merges with the shadow of the mediastinum.

What disease can you think of? What is your tactics in treating the patient?

4. Over the past 4 months, the patient has developed vague pain in the right hypochondrium, accompanied by increasing dysphagic changes. An X-ray examination on the right revealed a shadow in the right lung, which is located behind the heart, with clear contours about 10 cm in diameter. The esophagus at this level is compressed, but its mucous membrane is not changed. Above the compression there is a long delay in the esophagus.

What is your presumptive diagnosis and tactics?

5. A 72-year-old patient immediately after fibrogastroscopy developed substernal pain and swelling in the neck area on the right.

What complication can you think of? What additional studies will you perform to clarify the diagnosis? What is your tactics and treatment?

6. Sick 60 years. A day ago in the hospital, a fish bone was removed at level C 7. After which swelling appeared in the neck area, temperature up to 38°, abundant salivation, palpation on the right began to detect an infiltrate of 5x2 cm, painful. X-ray signs of phlegmon of the neck and expansion of the mediastinal body from above.

What is your diagnosis and tactics?

1. To clarify the diagnosis of intrathoracic goiter, it is necessary to carry out the following additional examination methods: pneumomediastinography - in order to clarify the topical location and size of tumors. Contrast study of the esophagus - to identify dislocation of mediastinal organs and displacement of tumors during swallowing. Tomographic examination - to identify narrowing or pushing aside of the vein by a neoplasm; scanning and radioisotope study of thyroid function with radioactive iodine. Clinical manifestations of thyrotoxicosis determine the indications for surgical treatment. Removal of a retrosternal goiter in this location is less traumatic to be carried out using a cervical approach, following the recommendations of V.G. Nikolaev to cross the sternohyoid, sternothyroid, and sternocleidomastoid muscles. If there is a suspicion of fusion of the goiter with surrounding tissues, transthoracic access is possible.

2. You can think about a neurogenic tumor of the mediastinum. Along with a clinical and neurological examination, radiography in direct and lateral projections, tomography, pneumomediastinography, diagnostic pneumothorax, angiocardiopulmography is necessary. In order to identify disorders of the sympathetic nervous system, the Linara diagnostic test is used, based on the use of iodine and starch. The test is positive if, during sweating, starch and iodine react, taking on a brown color.

Treatment of a tumor that causes compression of nerve endings is surgical.

3. You can think about a neurogenic tumor of the posterior mediastinum. The main thing in diagnosing a tumor is to establish its exact location. Treatment consists of surgical removal of the tumor.

4. The patient has a tumor of the posterior mediastinum. The most likely neurogenic character. The diagnosis can be clarified by a multifaceted X-ray examination. At the same time, it is possible to identify the interest of neighboring authorities. Considering the location of the pain, the most likely cause is compression of the phrenic and vagus nerves. Treatment is surgical, in the absence of contraindications.

5. One can think about iatrogenic rupture of the esophagus with the formation of cervical mediastinitis. After an X-ray examination and X-ray contrast examination of the esophagus, an urgent operation is indicated - opening and drainage of the rupture zone, followed by sanitation of the wound.

6. The patient has perforation of the esophagus with subsequent formation of phlegmon of the neck and purulent mediastinitis. Treatment is surgical opening and drainage of neck phlegmon, purulent mediastinotomy with subsequent sanitation of the wound.

All parts of the mediastinum are closely connected to each other by fissures and sinuses, so inflammatory processes easily become widespread.

The fiber surrounding the mediastinal organs in children is loose and tender, and therefore the mediastinum is more pliable and elastic. All parts of the mediastinum are closely connected to each other by fissures and sinuses, so inflammatory processes easily become widespread.

The mediastinum in newborns and infants is larger than in adults, occupying almost 1/3 of the volume of the chest cavity. A significant part of the anterior mediastinum in newborns and infants is occupied by the thymus gland.

The thymus gland, glandula thymus, consists of two lobes enclosed in a connective tissue capsule. In front it is adjacent to the posterior surface of the sternum, in the back it is in contact with the ascending aorta, the superior vena cava and the pulmonary trunk, on the right and left the mediastinal pleura separates it from the lungs. The shape of the thymus gland is varied: pyramidal, triangular or oval. The width of the gland ranges from 3.3 to 10.8 cm, the thickness reaches 1 cm. The upper edge of the gland is located 1-1.5 cm above the manubrium of the sternum, the lower one reaches the anterior sections of the bodies of the III-IV ribs, in rare cases - up to diaphragm. Its weight in newborns is 4.2% of the total body weight.

By the time the child is born, the transverse size of the thymus gland is greater than its length and anteroposterior size.

In the first 2-3 years, the growth of the gland is especially rapid, and then slows down. After puberty, the thymus gland usually atrophies and is replaced by connective and fatty tissue.

X-ray examination in a direct projection does not identify the thymus gland, which does not extend outward from large vessels. When the gland is eccentrically located, one of its lobes becomes edge-forming in the upper part of the median shadow, usually on the right (Fig. 232).

Rice. 232. Radiographs of the organs of the chest cavity in the direct posterior and right lateral projections. Shape options,

the size and position of the thymus gland in children of the first year of life.

With thymic hyperplasia, it pushes the layers of the mediastinal pleura outward. The thymus gland forms a uniform, intense darkening with distinct outer contours. The latter can be unevenly convex, sometimes with noticeable polycyclicity, rectilinear or even concave.

As a rule, the shape of the contours and the length of the shadow are asymmetrical. The lower pole of the gland merges with the cardiovascular bundle, overlapping its corresponding sections; sometimes the shadow of the gland reaches the diaphragm. Often the lower pole of the gland is rounded or pointed, the shadow of which is wedge-shaped and resembles mediastinal-interlobar pleurisy. In addition to the location of the gland in the edge-forming section, it is possible that it is wedged between the ascending aorta and the superior vena cava. In this case, the thymus gland shifts the superior vena cava to the right, thereby increasing the width of the median shadow at the level of the vascular bundle. To clarify the size and position of the thymus gland, X-ray examination in the lateral projection is crucial.

On a radiograph in a lateral projection, the thymus gland is located at the level of the upper part of the retrosternal spaces a, merging with the shadow of the heart and large vessels.

With hyperplasia, the thymus gland, spreading anteriorly and downward, fills, to a greater or lesser extent, the anterior mediastinum and creates a uniform, medium-intensity shadow with a fairly clear inferoanterior contour at the level of the retrosternal space.

Knowledge of the anatomical and radiological variants of the shape, position and size of the thymus gland is of practical importance, since the shadow of the gland can be the cause of diagnostic errors, simulating enlarged lymph nodes, a mediastinal tumor, encysted mediastinal pleurisy and other pathological processes.

The hyperplastic thymus gland, in contrast to the tumor and pathologically changed lymph nodes of the anterior mediastinum, is characterized by the absence of clinical manifestations. It remains relatively constant in size in the coming months of radiological observation. As the child ages, there is a gradual decrease in the gland.

With age, as the diaphragm descends and the size of the thymus gland decreases, the size of the chest cavity increases, and the mediastinum decreases. In this regard, in an x-ray image in a direct projection, the median shadow becomes narrower relative to the transverse size of the chest, and in a lateral projection, the retrosternal space appears wider and more transparent.

Tags: age characteristics, thymus, aorta, direct projection, transverse size
Start of activity (date): 02/22/2017 12:58:00
Created by (ID): 645
Key words: age-related features, thymus, aorta, direct projection

The mediastinum is also divided into top floor(located above the tracheal bifurcation) and ground floor(located below the tracheal bifurcation). Or the mediastinum is divided into three floors:

Upper- above the level of the V thoracic vertebra
Average- located at the level from the V thoracic vertebra (located approximately at the level of the tracheal bifurcation) to the VIII thoracic vertebra
Lower- below the level of the VIII thoracic vertebra

The most common radiological sign of the presence of a neoplasm in the mediastinum is extension of the median shadow. At the same time, on the radiograph in a direct projection, smoothing of the arches formed normally by the aorta and the cardiac shadow is noted. The expansion of the mediastinum is also accompanied by the formation of “protrusions” (additional shadows of a semicircular, semi-oval or irregular shape) along the contour of the mediastinum (on one or both sides), the wide base of which merges with the median shadow (Figure 1, 2). The contours of the extended median shadow are clear and even, and in the case of development malignant neoplasms- fuzzy and lumpy.

Figure 1. Neoplasm in the mediastinum (schematic image of a radiograph in frontal and lateral projections). In this image, the tumor belongs to the anterior mediastinum

Figure 2. Mediastinal mass. A - expansion of the mediastinal shadow to the left in the middle floor, caused by a neoplasm (see arrow). B- radiograph of another patient: the image shows an expansion of the mediastinal shadow with a polycyclic contour to the right in the upper floor; there is also an expansion (to a lesser extent) of the mediastinal shadow to the left (see arrows)

The “belonging” of a pathological shadow to the mediastinum can be established in the following way: if on a radiograph in a direct projection one mentally extends the contours of the shadow to a full circle or oval, then the “center” of the shadow will be located outside the pulmonary field, in the mediastinum (Figure 3), and the “corners” “between the contour of the mediastinum and the shadow of the neoplasm there will be blunt. Also, shadows caused by neoplasms in the mediastinum do not correspond to the lobes and segments of the lung and can be projected onto several lobes at the same time (like other extrapulmonary formations, for example, encysted effusions; see article). It is necessary to pay attention to the fact that these signs do not “work” in all cases (for example, with neurogenic tumors that are localized in the posterior mediastinum near the shadow of the spine, the “center” of the shadow of the tumor is often projected not onto the mediastinum, but onto the pulmonary field).

Figure 3. Difference in projection of the tumor shadow (schematic image of a radiograph in direct projection). A- projection of the neoplasm into the mediastinum; B- intrapulmonary formation

On a lateral radiograph, an additional shadow may be detected in the corresponding part of the mediastinum, but it is not always clearly visualized, especially if the tumor is localized in the upper mediastinum. It is necessary to pay due attention to the analysis of the retrosternal space - in case of damage to the anterior mediastinum, it is obscured. If changes in the mediastinum are determined only on an X-ray in a direct projection, and pathological changes are not reliably detected on a X-ray in a lateral projection, the patient must undergo additional X-ray CT examination.

The most common mediastinal neoplasms

The expansion of the upper mediastinum is often caused by an enlargement of the thyroid gland - an intrathoracic goiter, which on a radiograph in a direct projection is defined as an expansion of the upper floor of the mediastinum due to an additional semi-oval or semi-circular shadow with usually clear and even contours, the base of which merges with the shadow of the mediastinum. Often this expansion of the mediastinal shadow occurs to the right, since the aortic arch deflects the goiter to the right (Figure 4), however, the mediastinal shadow can expand in both directions (Figure 5), especially if the goiter is large (Figure 6).

Figure 4. Intrathoracic goiter. A - X-ray in direct projection: the mediastinum in the upper floor is expanded to the right due to an additional formation with a clear and even contour (see arrow); the formation significantly displaces the trachea to the left (see pointers). B- radiograph in the right lateral projection: the goiter (see arrows) is located behind the trachea - in the posterior mediastinum

Figure 5. Intrathoracic goiter. The expansion of the mediastinum in the upper floor in both directions is determined, the contours of the shadow are clear and even (see arrows)

Figure 6. Large intrathoracic goiter. The goiter expands the mediastinal shadow in both directions; trachea is displaced to the right (see arrows)

When the goiter is located in the upper floor of the posterior mediastinum, the trachea usually shifts forward, which can be determined on a lateral radiograph. In some cases, the shadow of the goiter is not clearly visualized on the lateral projection image. In some cases, the shadow of the expanded upper mediastinum continues upward into the shadow of the soft tissues of the neck. Calcifications (clumpy, or in the form of diffuse calcification or a rim) may also be observed in the structure of the goiter. Note that intrathoracic goiter often causes compression of the superior vena cava, narrowing and displacement of the esophagus and trachea (Figure 7).

Figure 7. Displacement of the contrasted esophagus and trachea to the left by intrathoracic goiter. The shadow of the mediastinum is expanded due to the goiter to the right in the upper section (see arrow)

Lipomas

Lipomas are often localized in the anterior mediastinum, in the lower floor. Mediastinal lipoma on x-ray is usually defined as an irregularly rounded formation adjacent to the heart, anterior chest wall and diaphragm. In some cases, the shadow of a lipoma can merge with the cardiac shadow, thereby “simulating” an increase in the size of the heart.

Abdominomediastinal lipomas

So-called abdominomediastinal lipomas are found quite often. In fact, this is not a neoplasm, but a prolapse of fatty preperitoneal tissue into the mediastinum through slits in the diaphragm. The X-ray picture of abdominomediastinal lipomas is characterized by additional semicircular, semioval or irregularly shaped shadows in the lower floor of the anterior mediastinum, localized in the area of the cardiophrenic sinuses, often on the right. On a radiograph in a direct projection, abdominomediastinal lipomas are adjacent to the cardiac shadow and diaphragm; An x-ray in a lateral projection reveals obtuse “angles” formed by this lipoma with the diaphragm and the anterior chest wall (Figure 8, 9).

Figure 8. Abdominomediastinal lipoma (schematic illustration)

Figure 9. Abdominomediastinal lipoma in the right cardiophrenic sinus. A - radiograph in frontal projection, B - radiograph in right lateral projection

Coelomic pericardial cysts

Coelomic pericardial cysts have radiographic features similar to abdominomediastinal lipomas, but are less common and are localized in the cardiophrenic sinuses. On a radiograph, coelomic pericardial cysts are defined as a semicircular or semioval shadow. Experts note that on the X-ray in the lateral projection, the “angles” formed by the coelomic cyst with the diaphragm and the anterior chest wall are sharp (Figure 10, 11).

Figure 10. Coelomic pericardial cyst (schematic illustration)

Figure 11. Coelomic pericardial cyst. A - enlarged fragment of a radiograph in a direct projection: on the right, in the projection of the cardiophrenic sinus, a poorly visible additional semi-oval shadow with an even contour is determined (see arrow). B- radiograph in the right lateral projection: the shadow of the cyst above the diaphragm is clearly visible, located not strictly in the cardiophrenic sinus, but slightly posteriorly (see arrows)

Accurate differential diagnosis of abdominal-mediastinal lipomas and coelomic pericardial cysts can be made possible by performing RCT (RCT allows one to identify both an accumulation of adipose tissue and a cyst with fluid contents). Often, additional shadows are found in the cardiophrenic sinuses due to moorings(massive fibrous layers on the pleura). Mooring lines are characterized by less convex contours, and their shape is similar to triangular (see article and)

Timoma

Thymoma is a tumor of the thymus gland. On a radiograph, thymoma is usually found in the anterior mediastinum, in the middle floor. Thymoma forms a pear-shaped or oval-shaped shadow with smooth, sometimes wavy contours. Experts believe that on an X-ray in a direct projection, benign thymomas usually expand the mediastinal shadow in only one direction, and on a X-ray in a lateral projection, the shadow may not be detected, since the thymoma has a flat configuration and has a low shadow intensity. Malignant thymomas are often identified on a lateral radiograph; the contours of the shadow of malignant thymoma are fuzzy and lumpy. The X-ray picture of malignant thymomas resembles lymphoma (see article).

Teratodermoid formations

Teratodermoid formations include teratoma And dermoid cysts- neoplasms of the mediastinum, formed as a result of disturbances in the development of tissues and organs during embryonic development, which contain tissues that are not characteristic of this anatomical region. On a radiograph, such formations are localized in the anterior mediastinum, in the middle floor (rarely in the upper floor) in the form of an additional shadow with a clear and even contour. In teratodermoid formations, calcifications, adipose tissue, a cystic component with liquid content, and bone inclusions (bone fragments, teeth) can be detected. When performing conventional radiography, such inclusions are rarely detected, that is, in most cases it is impossible to differentiate teratodermoid formations from other mediastinal neoplasms. Dermoid cysts sometimes break into the esophagus or bronchus (in this case, a horizontal liquid/gas level is detected in the formation on an x-ray). If teratodermoid formations are malignant, the contours of the shadow have fuzzy, bumpy contours; however, the exact nature of the formation can only be determined by performing a biopsy and further histological examination of the resulting biopsy.

Cysts

Cysts in the mediastinum may be bronchogenic(bronchial origin) and enterogenous(occur due to disruption of the digestive canal). Sometimes these types of cysts can only be differentiated by histological analysis. It is often very difficult to detect mediastinal cysts during routine radiography, since the shadows of these cysts may not extend beyond the contour of the midline. As a rule, mediastinal cysts are filled with contents (on an x-ray they are determined in the form of oval or rounded homogeneous shadows), and in the wall of bronchogenic cysts calcifications of the “shell” type can be detected.

Bronchogenic cysts often localized in the central mediastinum, in the upper or middle floor, near or under the tracheal bifurcation, and also close to the main bronchi. In this case, the radiograph shows in a limited area an expansion of the median shadow with a clear arc-shaped contour.

Enterogenous cysts often located in the posterior mediastinum (more precisely, in that part of the posterior mediastinum that is located anterior to the spine - in Holtzknecht's space), in the lower floor, close to the esophagus.

Mediastinal cysts can compress and displace the trachea and esophagus. If the cyst breaks into the esophagus, bronchus or trachea, the x-ray shows a thin-walled cavity with a horizontal level of liquid/gas contents.

Neurogenic tumors

Neurogenic tumors form in the mediastinum from the sheaths of peripheral nerves ( neurofibroma, schwannoma), as well as from the sympathetic and parasympathetic ganglia ( neuroblastomas, ganglioneuromas). Such neoplasms are localized in the paravertebral space - the costovertebral groove - traditionally belong to the posterior mediastinum and can be found in any floor (upper, middle, lower).

On an x-ray, neurogenic tumors are identified as additional shadows of an oval (semi-oval) or round (semi-circular) shape with clear, even contours. In the later stages of tumor development, the contours of the shadow may become unclear and uneven (lumpy). In some neurogenic tumors, calcifications may be detected. In addition to the expansion of the median shadow, an additional shadow is detected on radiographs in frontal and lateral projections, which is visualized against the background of the spine or adjacent to the spine. It is sometimes difficult to differentiate neurogenic tumors from intrapulmonary neoplasms, since when a neurogenic tumor grows towards the lung, it projects predominantly onto the pulmonary field. Neurogenic tumors can also cause changes in adjacent bone structures - deformation and usuration of the ribs and vertebrae due to pressure, expansion of the intervertebral foramina.

If a mass formation of the mediastinum is suspected, the patient must be prescribed an RCT to clarify the location and structure of the formation (the presence of fluid, inert tissue, calcifications, adipose tissue, cystic component in the formation), determine the signs of a malignant process, and detect enlarged lymph nodes in the mediastinum.

Other causes of widening of the mediastinal shadow

Esophageal diverticula

Diverticula of the esophagus occur in any part of the esophagus and can cause widening of the median shadow. "Cervical" (Zenker's) diverticula esophagus are localized in the upper part of the mediastinum. Diagnosis of diverticula by radiography requires contrast examination of the esophagus.

Aortic aneurysm

Aortic aneurysm may cause expansion of the median shadow. With an aneurysm of the ascending aorta, the median shadow expands to the right; with an aneurysm of the descending aorta, the median shadow expands to the left (Figure 12, 13)

Figure 12. Aneurysm of the descending aorta (see arrow). A- radiograph in direct projection; B- radiograph in the left lateral projection.

Figure 13. Aneurysm of the descending aorta. A - X-ray in direct projection: there is a significant expansion of the median shadow to the left due to the aorta. B- radiograph in the left lateral projection: the expansion of the entire descending aorta is determined

Note that an aneurysm of the descending aorta in its lower section (above the diaphragm) on an x-ray can simulate changes in the lung (additional round formation) or a hiatal hernia (see Figure 14).

Figure 14. Aneurysm of the descending aorta located supradiaphragmatically. A - X-ray in direct projection: in the lower part of the mediastinum is expanded to the left due to an additional shadow, which is partially defined behind the heart (see arrow). B- radiograph in the left lateral projection: an additional shadow is identified above the diaphragm, which is a “continuation” of the shadow of the descending aorta (see arrows)

Please note that on an x-ray, aortic dissection is not always identified as dilation of the aorta, since in some cases dissection occurs in the absence of an aortic aneurysm. An existing aortic aneurysm can also be complicated by dissection. If aortic dissection is suspected, the patient should undergo multispiral CT with angiography.

Abnormalities in the location of the aorta, such as a right-lying aorta, can cause the median shadow to expand to the right. In this case, the aortic arch and descending aorta in a typical place (along the left contour of the median shadow) are not determined, since they are located on the right (Figure 15)

Figure 15. Right aorta. A - X-ray in direct projection: in the upper part, the expansion of the mediastinal shadow to the right is determined, in a typical location on the left, the aortic arch is not visualized. B- radiograph in the right lateral projection: the aortic arch is identified behind the trachea (see arrow)

Hiatal hernia

Large hiatal hernias can cause widening of the median shadow in the lower part. On a lateral X-ray, such hernias are revealed behind the shadow of the heart in the form of additional round-shaped formations (rarely irregularly rounded) with clear contours. As a rule, they determine the horizontal level of the contents that is in the stomach; less often, this level is not determined. Diagnosis of hiatal hernia is carried out by contrast examination of the esophagus and stomach (Figure 16).

Figure 16. Intrathoracic location of the stomach. A - X-ray in direct projection: in the lower part of the mediastinum, an expansion of the mediastinal shadow to the right is determined (see arrow). B- radiograph in the right lateral projection: an additional shadow behind the heart is determined (see arrows); This is a somewhat atypical picture, since the liquid/gas level typical for the stomach is not visualized. IN- contrast study of the stomach: the stomach is almost completely located towards the chest cavity (this is due to the “short esophagus”)

Figure 17. Expansion of the mediastinum due to a giant aneurysm of the aberrant subclavian artery on the right

Figure 18. A - X-ray taken in the supine position: the expansion of the mediastinal shadow in the upper part to the right is determined. B- X-ray of the same patient in a standing position: the mediastinal shadow is not widened

– a group of morphologically heterogeneous neoplasms located in the mediastinal space of the chest cavity. The clinical picture consists of symptoms of compression or germination of a mediastinal tumor into neighboring organs (pain, superior vena cava syndrome, cough, shortness of breath, dysphagia) and general manifestations (weakness, fever, sweating, weight loss). Diagnosis of mediastinal tumors includes x-ray, tomographic, endoscopic examination, transthoracic puncture or aspiration biopsy. Treatment of mediastinal tumors is surgical; for malignant neoplasms it is supplemented with radiation and chemotherapy.

ICD-10

C38.1 C38.2 C38.3 D15.2

General information

Tumors and cysts of the mediastinum account for 3-7% in the structure of all tumor processes. Of these, in 60-80% of cases benign tumors of the mediastinum are detected, and in 20-40% - malignant (mediastinal cancer). Mediastinal tumors occur with equal frequency in men and women, mainly at the age of 20-40 years, i.e., in the most socially active part of the population. Tumors of mediastinal localization are characterized by morphological diversity, the likelihood of primary malignancy or malignancy, the potential threat of invasion or compression of vital mediastinal organs (respiratory tract, great vessels and nerve trunks, esophagus), and technical difficulties of surgical removal. All this makes mediastinal tumors one of the pressing and most complex problems of modern thoracic surgery and pulmonology.

The anatomical space of the mediastinum is limited anteriorly by the sternum, retrosternal fascia and costal cartilages; behind - the surface of the thoracic spine, the prevertebral fascia and the necks of the ribs; on the sides - by the layers of the mediastinal pleura, below - by the diaphragm, and above - by a conventional plane passing along the upper edge of the manubrium of the sternum. Within the boundaries of the mediastinum are the thymus gland, upper sections of the superior vena cava, aortic arch and its branches, brachiocephalic trunk, carotid and subclavian arteries, thoracic lymphatic duct, sympathetic nerves and their plexuses, branches of the vagus nerve, fascial and cellular formations, lymph nodes, esophagus , pericardium, tracheal bifurcation, pulmonary arteries and veins, etc. In the mediastinum there are 3 floors (upper, middle, lower) and 3 sections (anterior, middle, posterior). The floors and sections of the mediastinum correspond to the localization of neoplasms emanating from the structures located there.

Classification of mediastinal tumors

All mediastinal tumors are divided into primary (initially arising in the mediastinal space) and secondary (metastases of tumors located outside the mediastinum).

Primary mediastinal tumors are formed from different tissues. According to their genesis, mediastinal tumors are divided into:

neurogenic neoplasms (neurinomas, neurofibromas, ganglioneuromas, malignant neuromas, paragangliomas, etc.)
mesenchymal neoplasms (lipomas, fibromas, leiomyomas, hemangiomas, lymphangiomas, liposarcoma, fibrosarcoma, leiomyosarcoma, angiosarcoma)
lymphoid neoplasms (lymphogranulomatosis, reticulosarcoma, lymphosarcoma)
dysembryogenetic neoplasms (teratomas, intrathoracic goiter, seminomas, chorionepitheliomas)
tumors of the thymus (benign and malignant thymomas).

Also in the mediastinum there are so-called pseudotumors (enlarged conglomerates of lymph nodes in tuberculosis and Beck's sarcoidosis, aneurysms of large vessels, etc.) and true cysts (coelomic pericardial cysts, enterogenic and bronchogenic cysts, hydatid cysts).

In the upper mediastinum, thymomas, lymphomas and substernal goiter are most often found; in the anterior mediastinum - mesenchymal tumors, thymomas, lymphomas, teratomas; in the middle mediastinum - bronchogenic and pericardial cysts, lymphomas; in the posterior mediastinum - enterogenous cysts and neurogenic tumors.

Symptoms of mediastinal tumors

The clinical course of mediastinal tumors is divided into an asymptomatic period and a period of severe symptoms. The duration of the asymptomatic course is determined by the location and size of mediastinal tumors, their nature (malignant, benign), growth rate, and relationships with other organs. Asymptomatic tumors of the mediastinum usually become a finding during preventive fluorography.

The period of clinical manifestations of mediastinal tumors is characterized by the following syndromes: compression or invasion of neighboring organs and tissues, general symptoms and specific symptoms characteristic of various neoplasms.

The earliest manifestations of both benign and malignant tumors of the mediastinum are chest pain caused by compression or growth of the tumor into the nerve plexuses or nerve trunks. The pain is usually moderately intense and can radiate to the neck, shoulder girdle, and interscapular area.

Tumors of the mediastinum with left-sided localization can simulate pain resembling angina pectoris. When a tumor compresses or invades the mediastinum of the borderline sympathetic trunk, Horner's symptom often develops, including miosis, ptosis of the upper eyelid, enophthalmos, anhidrosis and hyperemia of the affected side of the face. If you have pain in the bones, you should think about the presence of metastases.

Compression of the venous trunks is primarily manifested by the so-called superior vena cava syndrome (SVVC), in which the outflow of venous blood from the head and upper half of the body is disrupted. SVC syndrome is characterized by heaviness and noise in the head, headache, chest pain, shortness of breath, cyanosis and swelling of the face and chest, swelling of the neck veins, and increased central venous pressure. In case of compression of the trachea and bronchi, cough, shortness of breath, and wheezing occur; recurrent laryngeal nerve - dysphonia; esophagus – dysphagia.

General symptoms of mediastinal tumors include weakness, fever, arrhythmias, brady and tachycardia, weight loss, arthralgia, and pleurisy. These manifestations are more characteristic of malignant tumors of the mediastinum.

Some mediastinal tumors develop specific symptoms. Thus, with malignant lymphomas, night sweats and skin itching are observed. Mediastinal fibrosarcomas may be accompanied by a spontaneous decrease in blood glucose levels (hypoglycemia). Ganglioneuromas and neuroblastomas of the mediastinum can produce norepinephrine and epinephrine, which leads to attacks of arterial hypertension. Sometimes they secrete a vasointestinal polypeptide that causes diarrhea. With intrathoracic thyrotoxic goiter, symptoms of thyrotoxicosis develop. Myasthenia gravis is detected in 50% of patients with thymoma.

Diagnosis of mediastinal tumors

The variety of clinical manifestations does not always allow pulmonologists and thoracic surgeons to diagnose mediastinal tumors based on anamnesis and objective examination. Therefore, instrumental methods play a leading role in identifying mediastinal tumors.

A comprehensive x-ray examination in most cases allows one to clearly determine the location, shape and size of the mediastinal tumor and the extent of the process. Mandatory studies for suspected mediastinal tumors include chest X-ray, polyposition radiography, and radiography of the esophagus. X-ray data are clarified using chest CT, MRI or MSCT of the lungs.

Among the endoscopic diagnostic methods for mediastinal tumors, bronchoscopy, mediastinoscopy, and videothoracoscopy are used. When performing bronchoscopy, bronchogenic localization of tumors and tumor invasion of the mediastinum of the trachea and large bronchi are excluded. Also during the study, it is possible to perform a transtracheal or transbronchial biopsy of a mediastinal tumor.

In some cases, samples of pathological tissue are taken through transthoracic aspiration or puncture biopsy, performed under ultrasound or x-ray guidance. The preferred methods of obtaining material for morphological research are mediastinoscopy and diagnostic thoracoscopy, which allow biopsy under visual control. In some cases, there is a need to perform a parasternal thoracotomy (mediastinotomy) for revision and biopsy of the mediastinum.

If there are enlarged lymph nodes in the supraclavicular region, a pre-scaling biopsy is performed. In case of superior vena cava syndrome, CVP is measured. If lymphoid tumors of the mediastinum are suspected, a bone marrow puncture with myelogram examination is performed.

Treatment of mediastinal tumors

In order to prevent malignancy and the development of compression syndrome, all mediastinal tumors should be removed as early as possible. For radical removal of mediastinal tumors, thoracoscopic or open methods are used. When the tumor is located retrosternally and bilaterally, longitudinal sternotomy is predominantly used as a surgical approach. For unilateral localization of the mediastinal tumor, an anterolateral or lateral thoracotomy is used.

Patients with a severe general somatic background can undergo transthoracic ultrasound aspiration of a mediastinal tumor. In case of a malignant process in the mediastinum, radical extended removal of the tumor is performed or

4. Tumors of the mediastinum / Shepetko M.N., Prokhorov A.V., Labunets I.N. – 2012.

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Competent decoding makes it possible to identify not only the subtleties of pathological processes in the chest, but also to study the effect of the disease on surrounding tissues (within the cutting ability of the method).

How to correctly interpret lung x-rays

In order for the interpretation of lung x-rays to be correct, an analysis algorithm must be created.

In classic cases, specialists study the following features of the image:

quality of execution;
shadow picture of the chest organs (pulmonary fields, soft tissues, skeletal system, location of the diaphragm, mediastinal organs).

Quality assessment involves identifying features of placement and mode that may affect the interpretation of the x-ray picture:

Asymmetrical body position. It is assessed by the location of the sternoclavicular joints. If it is not taken into account, rotation of the thoracic vertebrae can be detected, but this will be incorrect.
The hardness or softness of the image.
Additional shadows (artifacts).
The presence of concomitant diseases affecting the chest.
Completeness of coverage (a normal x-ray of the lungs should include the apices of the lung fields above and the costophrenic sinuses below).
In a correct photograph of the lungs, the shoulder blades should be located outward from the chest, otherwise they will create distortions when assessing the intensity of radiological symptoms (clearing and darkening).
Clarity is determined by the presence of single-contour images of the anterior segments of the ribs. If there is dynamic blurring of their contours, it is obvious that the patient was breathing during exposure.
The contrast of an x-ray is determined by the presence of color shades of black and white. That is, when deciphering, it is necessary to compare the intensity of the anatomical structures that produce darkening with those that create clearing (pulmonary fields). The difference between shades indicates the level of contrast.

It is also necessary to take into account possible image distortions when examining a person under different directions of X-rays (see figure).

Figure: distorted image of a ball when examined with a direct beam (a) and with an oblique position of the receiver (b)

Protocol for describing a chest x-ray by a doctor

tumors;
occupational diseases (silicosis, talcosis, asbestosis).

Infiltrative darkening indicates diseases accompanied by inflammatory changes in the lungs. These include:

pneumonia;
edema;
helminthic infestations.

The pulmonary pattern is not deformed, clear– such a phrase indicates the absence of disturbances in the blood supply, as well as pathogenetic mechanisms causing vascular deformation:

circulation disturbances in the small and large circles;
cavitary and cystic X-ray negative formations;
stagnation.

Poor structure and deformation of the roots of the lungs is observed with:

sarcoidosis;
enlarged lymph nodes;
mediastinal tumors;
stagnation in the pulmonary circulation.

If mediastinal shadow without features, which means that the doctor did not identify additional formations coming out from behind the sternum.

The absence of “plus shadows” on a direct x-ray of the lungs does not mean the absence of tumors. It should be understood that the X-ray image is summative and is formed based on the intensity of many anatomical structures that are superimposed on each other. If the tumor is small and not from a bone structure, it overlaps not only the sternum, but also the heart. In such a situation, it cannot be identified even on a side image.

The diaphragm is not changed, the costophrenic sinuses are free – the final stage of the descriptive part of deciphering an X-ray image of the lungs.

All that remains is the conclusion: “ in the lungs without visible pathology».

Above we have given a detailed description of a normal lung x-ray so that readers have an idea of what the doctor sees in the image and what the protocol for his conclusion is based on.

Below is an example of a transcript if a patient has a lung tumor.

Description of an X-ray of the lungs with a tumor

Schematic representation of a node in the S3 segment of the left lung

Conclusion: X-ray picture of peripheral cancer in S3 of the left lung.

Thus, in order to decipher a chest x-ray, the radiologist has to analyze many symptoms and reunite them into a single picture, which leads to the formation of a final conclusion.

Features of lung field analysis

Features of the analysis of pulmonary fields on an x-ray:

the right margin is wide and short, the left is long and narrow;
the median shadow is physiologically expanded to the left due to the heart;
For correct description, the pulmonary fields are divided into 3 zones: lower, middle and upper. Similarly, 3 zones can be distinguished: internal, middle and external;
the degree of transparency is determined by air and blood filling, as well as the volume of parenchymal lung tissue;
the intensity is influenced by the superposition of soft tissue structures;
in women, the image may be obscured by the mammary glands;
the individuality and complexity of the pulmonary pattern requires highly qualified physicians;
Normally, the pulmonary pleura is not visible. Its thickening is observed during inflammation or tumor growth. The pleural sheets are more clearly visualized on a lateral radiograph;
each lobe consists of segments. They are distinguished based on the special structure of the bronchovascular bundle, which branches separately in each lobe. There are 10 segments in the right lung, 9 in the left lung.

Mediastinal tumors and cysts are a large and heterogeneous group of neoplasms. Neoplasms in the mediastinum can form from tissues and organs that are normally located there, as well as from tissues that are displaced into the mediastinum due to disorders of embryonic development. This article briefly discusses only the formations that are of greatest importance in a doctor’s practice. For convenience of presentation, this article discusses pathological disorders in the mediastinal lymph nodes and some other disorders.

Clinical signs of mediastinal tumors and cysts can be different and depend on the size, nature (benign or malignant), and location of the tumor. Some mediastinal tumors do not show any clinical signs (for example, mediastinal cysts) and are detected during a preventive examination. In other cases, patients may complain of shortness of breath, cough, and chest pain. So, thymoma(tumor of the thymus) can be combined with myasthenia gravis. With malignant neoplasms, the patient complains of weakness and a sharp decrease in body weight. In the case of the development of large mediastinal neoplasms, superior vena cava compression syndrome(cyanosis of the upper half of the body, shortness of breath, dilation of the veins of the upper extremities and neck), and symptoms of compression of the esophagus and upper respiratory tract may also be observed. Recurrent nerve damage manifests itself dysphagia(impaired swallowing), damage to the phrenic nerves accompanied by relaxation of the diaphragm, and if the process involves sympathetic trunk, arises Horner's syndrome(ptosis, miosis, enophthalmos). In addition, symptoms of spinal cord damage may occur. Suppuration of mediastinal cysts causes inflammatory syndrome, increased body temperature.

Today, in the diagnosis of mediastinal formations, the leading role is played by X-ray computed tomography (XCT), and the task of traditional radiography is to detect changes in the X-ray picture that are suspicious for mediastinal pathology.

First of all, we need to consider some issues of the anatomy of the mediastinum. A detailed description of the anatomy of the mediastinum can be found in manuals on RCT; in traditional radiography, a somewhat simplified scheme is used.

On a lateral radiograph, the mediastinum is divided into 3 sections:

Anterior mediastinum- from the posterior surface of the sternum to the anterior surface of the aorta and heart
Central mediastinum- formed by the heart, aorta and aortic arch, trachea, the roots of the lungs also belong to the central mediastinum
Posterior mediastinum- located behind the posterior surface of the heart and behind the trachea, also includes the descending aorta and esophagus

Upper- above the level of the V thoracic vertebra
Average- located at the level from the V thoracic vertebra (located approximately at the level of the tracheal bifurcation) to the VIII thoracic vertebra
Lower- below the level of the VIII thoracic vertebra

Figure 1. Neoplasm in the mediastinum (schematic image of a radiograph in frontal and lateral projections). In this image, the tumor belongs to the anterior mediastinum

Figure 3. Difference in projection of the tumor shadow (schematic image of a radiograph in direct projection). A- projection of the neoplasm into the mediastinum; B- intrapulmonary formation

The most common mediastinal neoplasms

Figure 5. Intrathoracic goiter. The expansion of the mediastinum in the upper floor in both directions is determined, the contours of the shadow are clear and even (see arrows)

Figure 6. Large intrathoracic goiter. The goiter expands the mediastinal shadow in both directions; trachea is displaced to the right (see arrows)

Lipomas

Abdominomediastinal lipomas

Figure 8. Abdominomediastinal lipoma (schematic illustration)

Figure 9. Abdominomediastinal lipoma in the right cardiophrenic sinus. A - radiograph in frontal projection, B - radiograph in right lateral projection

Coelomic pericardial cysts

Figure 10. Coelomic pericardial cyst (schematic illustration)

Timoma

Teratodermoid formations

Cysts

Neurogenic tumors

Other causes of widening of the mediastinal shadow

Esophageal diverticula

Aortic aneurysm

Figure 12. Aneurysm of the descending aorta (see arrow). A- radiograph in direct projection; B- radiograph in the left lateral projection.

Note that an aneurysm of the descending aorta in its lower section (above the diaphragm) on an x-ray can simulate changes in the lung (additional round formation) or a hiatal hernia (see Figure 14).

Hiatal hernia

Figure 17. Expansion of the mediastinum due to a giant aneurysm of the aberrant subclavian artery on the right