What organs are located in the anterior mediastinum? Mediastinal tumor: classification, forms and localizations, symptoms, how to treat

Mediastinumis a complex of organs bounded in front by the manubrium and the body of the sternum, behind by the bodies of the thoracic vertebrae, on the sides by the mediastinal pleura, below by the diaphragm, above by a conventional plane passing through the superior thoracic aperture. There is practically no upper border due to the passage of large vessels and nerves, the esophagus and trachea, as well as due to the direct communication of the retrovisceral and pretracheal tissue spaces of the neck with the tissue of the anterior and posterior mediastinum.

By the frontal plane passing through the posterior surface of the roots of the lungs, the mediastinum is conventionally divided into anterior and posterior.

Rice. 43. View of the mediastinum from the right pleural cavity.
The right side of the chest and the right lung were removed.

IN anterior mediastinum are located: the heart, surrounded by the pericardium, and above it (from front to back) the thymus gland (or replacing it fatty tissue), brachiocephalic and superior vena cava, terminal section of the azygos vein, phrenic nerves, lymph nodes, ascending aorta, aortic arch with arteries branching from it, pulmonary trunk, arteries and veins, trachea and main bronchi.

In the posterior mediastinum there are: the thoracic aorta, esophagus, azygos and semi-gyzygos veins, thoracic duct, thoracic part sympathetic trunk, lymph nodes. The vagus nerves in the upper thoracic cavity are located in the anterior mediastinum, from where they travel down and back to the esophagus and pass into the posterior mediastinum.

In the mediastinum, in addition to the large arteries listed above, numerous smaller arteries pass to the organs, vessels, nerves and lymph nodes of the mediastinum. Outflow venous blood from the organs of the mediastinum it proceeds through veins of the same name as the arteries into the brachiocephalic, superior vena cava, azygos, semi-gyzygos and accessory semi-zygos veins.

The outflow of lymph from the mediastinal organs and lungs is carried out into numerous anterior and posterior mediastinal nodes, pulmonary nodes located near the tracheobronchial tree - all these are nodes of the visceral group. The latter are associated with the parietal, or parietal, nodes located in front (nodi lymphatici parasternales) and behind (intercostal and paravertebral nodes).

Rice. 44. View of the vessels, nerves and organs of the mediastinum from the side of the right pleural cavity.

Same as in fig. 43. In addition, the mediastial and diaphragmatic pleura and part of the mediastinal tissue were removed.

Lymph nodes located near the tracheobronchial tree are represented by several groups: inside the lungs - nodi lymphatici pulmonales; at the gates of the lungs - nodi lymphatici broncho-pulmonales; along the surface of the main bronchi in the pulmonary roots - nodi lymphatici tracheobronchiales superiores; under the bifurcation of the trachea between the initial sections of the main bronchi - nodi lymphatici tracheobronchiales inferiores (bifurcation nodes); along the trachea - nodi lymphatici tracheales, consisting of laterotracheal, paratracheal and retrotracheal nodes.

Right laterotracheal The lymph nodes, among 3-6, are located to the right of the trachea behind the superior vena cava along the arch of the azygos vein to the subclavian artery. The left laterotracheal nodes, including 4-5, lie along the left recurrent laryngeal nerve. Non-permanent retrotracheal nodes are located on the path of the lymphatic vessels, through which lymph from the lower tracheobronchial nodes flows into the right laterotracheal nodes. Most of the efferent vessels from the left laterotracheal nodes, to which the flow of lymph from the left lung, trachea and esophagus are directed, are also directed to the upper right laterotracheal nodes, obliquely crossing the trachea. A smaller part of the efferent vessels of these nodes flows into the cervical part of the thoracic duct or approaches the lower deep cervical nodes. Thus, the right laterotracheal nodes are the main lymph station of both lungs, trachea and esophagus. From them arises a single or double right posterior truncus bronchomediastinalis, running upward and laterally behind the right brachiocephalic and internal jugular veins, and sometimes behind the brachiocephalic trunk, right common carotid or subclavian arteries. This lymphatic trunk flows into the truncus jugularis or into one of the lower deep cervical nodes, less often into the truncus suhclavius ​​or into a vein.

The posterior mediastinal lymph nodes (nodi lymphatici mediastinales poste-riores) are paraesophageal (2-5 nodes), interaortoesophageal (1-2 nodes), located at the level of the lower pulmonary veins, and non-permanent nodes near the diaphragm near the aorta and esophagus. The presence of numerous connections between the mediastinal nodes and the possibility (under certain conditions) of lymph flow in the same vessels in opposite directions create extensive collateral pathways that connect through the mediastinal nodes the initial and final sections of the thoracic duct, the thoracic duct and the right lymphatic duct or its roots, nodes of the chest cavity and nodes of the lower parts of the neck.

The nerves of the mediastinum are a complex single complex, consisting of intra-organ and extra-organ nerve formations(nerve endings, nodes, plexuses, individual nerves and their branches). The phrenic, vagus, sympathetic and spinal nerves take part in the innervation of the mediastinal organs.

The phrenic nerves (pp. phrenici) are branches of the cervical plexus and are directed to the thoraco-abdominal barrier through the anterior mediastinum (Fig. 44, 46).

Right phrenic nerve in upper section The mediastinum lies between the beginning of the subclavian vein and artery, located lateral to the vagus nerve. Below, along the entire length to the diaphragm, from the outside the nerve is adjacent to the mediastinal pleura, from the inside - to the lateral surface of the right brachiocephalic and superior
vena cava, pericardium and lateral surface of the inferior vena cava.

The left phrenic nerve is initially located between the left subclavian vein and artery. Below, all the way to the diaphragm, on the lateral side, the nerve is adjacent to the left mediastinal pleura. On the medial side of the nerve are located: the left common carotid artery, the aortic arch and the left side surface pericardium. At the apex of the heart, the nerve enters the diaphragm. When ligating the ductus botallus, the left phrenic nerve serves as a guide for incision of the mediastinal pleura. The incision is made 1-1.5 cm behind the nerve. From the phrenic nerves in the mediastinum, sensory branches extend to the pleura, thymus, brachiocephalic and superior vena cava, internal mammary artery, pericardium, pulmonary veins, visceral pleura and pleura of the root of the lung.

The right vagus nerve penetrates the chest cavity, located along the anterior surface of the initial part of the right subclavian artery and behind the right brachiocephalic vein. Heading down backward and medially inward from the mediastinal pleura, the nerve obliquely crosses the brachiocephalic trunk and trachea from the outside and lies behind the root of the right lung, where it approaches the esophagus and then runs along its posterior or posterolateral surface.

The left vagus nerve enters the chest cavity, located lateral to the left common carotid artery, anterior to the left subclavian artery, posterior to the left brachiocephalic vein and mediastinal pleura. Heading down and back, the nerve crosses the aortic arch and lies behind the root of the left lung and anterior to the descending aorta, then deviates to the medial side, approaches the esophagus and lies on its anterior or left anterolateral surface.

Rice. 45. View of the mediastinum from the left pleural cavity. The left side of the chest and the left lung were removed.

In the upper part of the mediastinum, both vagus nerves are single trunks. At the level of the roots of the lungs, and sometimes above or below them, both nerves are divided into 2-3, and sometimes more, branches, which, connecting with each other, form the plexus oesophageus around the esophagus. In the lower part of the thoracic esophagus, the branches of the plexus merge to form the anterior and posterior chords (truncus vagalis anterior and posterior), passing together with the esophagus through the hiatus oesophageus of the diaphragm. These trunks are most often single, but can be double, triple, or consist of a larger (up to 6) number of branches.

Numerous branches arise from the vagus nerves in the chest cavity. The right recurrent laryngeal nerve (n. laryngeus recurrens dexter) starts from the vagus nerve at the lower edge of the subclavian artery and, going around it from below and behind, goes to the neck. The level of origin of the nerve may descend into the chest cavity with age, reaching in some cases the lower edge of the brachiocephalic trunk.

The left recurrent laryngeal nerve (n. laryngeus recurrens sinister) arises from n. vagus at the level of the lower edge of the aortic arch, lateral to the ligament arteriosus. Having circled the aortic arch behind the ligament arteriosus in the direction from the outside to the inside, the nerve lies in the tracheoesophageal groove and goes up.

Below the origin of the recurrent nerves from the vagus nerves, usually over a distance of 3-4 cm, branches extend to the esophagus (2-6), trachea, and heart (cardiaci inferiores). Numerous branches to the esophagus, lungs (from 5 to 20 on the right and from 5 to 18 on the left), pericardium, and aorta extend from the esophageal plexus and mainly to the esophagus - from the anterior and posterior chords in esophageal hiatus diaphragm.

Thoracic division of the sympathetic nervous system. The sympathetic trunk most often consists of 9-11 ganglia thoracica, connected by rr. interganglionares. The number of nodes can decrease to 5-6 (merging nodes) or increase to 12-13 (dispersion). The upper thoracic node in 3/4 of cases merges with the lower cervical node, forming a stellate node. rr depart from the nodes and internodal branches to the thoracic nerves. communicantes. The number of connecting branches (up to 6), their thickness (from 0.1 to 2 mm) and length (up to 6-8 cm) are very variable. Numerous visceral branches, which are part of the nerve plexuses of the anterior and posterior mediastinum, depart ventrally from the border trunk. The largest visceral branches are the splanchnic nerves.

Rice. 46. ​​View of the vessels, nerves and organs of the mediastinum from the side of the left pleural cavity. The same as in Fig. 45. In addition, the mediastinal and diaphragmatic pleura and part of the mediastinal tissue were removed.

The greater celiac nerve (n. splanchnicus major) is formed by 1-8 (usually 2-4) visceral branches (roots) extending from V, VI-XI thoracic nodes and internodal branches. The right celiac nerve is formed more often a large number roots than the left one. The largest main root (usually the upper one) arises from the VI or VII node. Heading forward, down and medially along the lateral surface of the spinal column, the roots gradually connect with each other and form the large splanchnic nerve, which penetrates the retroperitoneal space through a gap in the peduncle of the diaphragm and enters the solar plexus. The lesser celiac nerve (n. splanchnicus minor) is formed by 1-4 (usually one) roots from the IX-XI thoracic nodes. The lowest celiac nerve (n. splanchnicus imus) is found on the left more often (in 72% of cases) than on the right (in 61.5% of cases). It is formed more often by one root extending from the X-XII thoracic nodes. Both small and the lowest splanchnic nerves are located lateral to the greater splanchnic nerve and penetrate through the diaphragm into the retroperitoneal space, where they enter the renal or celiac plexus. Both sympathetic trunks are located on the heads of the 6-7 upper ribs; below this level they gradually deviate forward and run along the lateral surface of the vertebral column column. The trunks are separated from the pleural cavity by the parietal pleura, a layer of fiber and the intrathoracic fascia. A. intercostalis suprema is adjacent to the trunk on the lateral side. The posterior intercostal arteries and veins cross the trunk from the posteromedial surface, and the azygos and semi-gypsy veins lie anterior and medial to the border trunks .

Rice. 47. Lymphatic vessels and mediastinal nodes.

The greater celiac nerve on the right crosses the azygos vein and lies in front or medially of it on the anterior surface of the spinal column, on the left it crosses the accessory azygos vein and goes down between it and the aorta. Through the crus of the diaphragm, the sympathetic trunk passes lateral and somewhat posterior to the splanchnic nerves.

Nerve plexuses of the mediastinum1. The nerves described above and their branches, as well as cardiac nerves sympathetic trunks and the cardiac branches of the vagus nerves, penetrating the mediastinum from the side of the neck, take part in the formation of the nerve plexuses of the anterior and posterior mediastinums. In the anterior mediastinum, an extensive cardiopulmonary plexus is formed, located around the aorta and on the anterior surfaces of the roots of the lungs. The superficial part of this plexus lies on the anterior surface of the aortic arch, its large branches and the root of the left lung.

The plexus is formed by: left nn. cardiaci cervicales superior, medius and inferior from the corresponding cervical sympathetic nodes, nn. cardiaci thoracici from the thoracic nodes, rr. cardiaci superiores and inferiores from the left vagus nerve and separate non-permanent branches from the right superior cardiac nerves and branches. The branches of the plexus innervate the pericardium, the left pulmonary artery, the superior left pulmonary vein, the wall of the aortic arch, and partly thymus gland and the left brachiocephalic vein.

The deep part of the cardiopulmonary plexus, more developed than the superficial one, is located between the aorta and trachea and along the anterior surface of the root of the right lung, located mainly on the right pulmonary artery and the right main bronchus. The plexus is formed by the right and left cardiac nerves of the cervical and thoracic sympathetic nodes, the cardiac branches of the vagus and recurrent laryngeal nerves. The branches of the plexus are directed to the pericardium, the right pulmonary artery and superior pulmonary vein, the wall of the aortic arch, the right main and upper lobe bronchi, and the pulmonary pleura. Non-permanent branches go to the right brachiocephalic and superior vena cava and to the left main bronchus.

The cardiopulmonary plexus includes many small nerve ganglia, the largest of which, the Wriesberg node, lies on the anterior surface of the aortic arch. Another nodule is located in connective tissue between the aortic arch and the pulmonary trunk, at the site of its division into the right and left pulmonary arteries. Branches from the vagus nerve and sympathetic trunk approach the nodule and 3-7 branches extend to the pulmonary trunk.

The intraorgan plexuses of the heart (plexus cardiacus) and lungs (plexus pulmonalis) originate from the superficial and deep parts of the cardiopulmonary plexus. The superficial and deep sections of the plexus are connected to each other by numerous connections. In turn, the plexus as a whole connects with the nerve plexuses of the posterior mediastinum. These features of the innervation of the organs of the thoracic cavity are confirmed every day in the clinic - damage or injury to any part of the plexus leads to disruption of the function of not one, but a number of organs innervated by the plexuses.

The plexuses of the posterior mediastinum form the vagus nerves and branches of the borderline sympathetic trunks. In the posterior mediastinum there are nerve plexuses near the esophagus and near the vessels (azygos and semi-gypsy veins, aorta, thoracic duct), located on the anterior and lateral surfaces of the spinal column.

The esophageal plexus (plexus oesophageus), formed by the branches of the vagus nerves and sympathetic trunks, lies in the tissue around the esophagus from the level of the trachea bifurcation to the diaphragm. Branches from the thoracic sympathetic nodes and internodal branches to the esophageal plexus extend from the stellate to the X thoracic node; branches from the large splanchnic nerves may also enter the plexus. Branches extend from the plexus to the esophagus, lungs, aorta, pericardium and other plexuses of the posterior mediastinum.

Rice. 48. View of the chest, back and neck areas in a horizontal cut. View from above
The cut was made directly above the sternoclavicular joint.

The prevertebral plexus is formed by the visceral branches of the thoracic sympathetic trunk, as well as branches arising from the large splanchnic nerves. The upper 5-6 thoracic nodes give off more visceral branches compared to the lower ones. Going forward, down and medially, the visceral branches connect even before approaching the organs, and on the thoracic aorta, azygos and semi-gyzygos veins and the thoracic duct they form plexuses, of which the largest and most well-defined is the plexus aorticus thoracicus. It connects the branches of the right and left sympathetic trunks. Branches extend from the plexus to the vessels of the posterior mediastinum, esophagus, and lungs. Branches from 2-5 upper thoracic nodes are directed to the lung. These branches are usually united into one trunk, which is connected to the esophageal plexus and is directed along the bronchial artery to the posterior surface of the root of the lung. If there are two sympathetic branches to the root of the lung, the second branch originates either from the underlying thoracic nodes (up to DVI) or from the thoracic aortic plexus.

Related materials:

There are several approaches to dividing our body into sections. Clear boundaries of organs and systems, as well as their totality, help doctors more accurately navigate the body, prescribing treatment, describing any malfunctions and pathologies. At the same time, doctors, regardless of their profile, use the same terms to refer to specific areas of the body. So the zone that is localized in the middle and in the upper part of the body can be called the sternum. However, medical specialists call it the mediastinum. Today we will talk about the mediastinum, mediastinal tumors, mediastinal nodes, what is its anatomy, where is it located.

Structure

To more accurately describe the location of pathologies and plan correction methods, the mediastinum is divided into upper and lower, as well as anterior, posterior and middle.

The anterior part of this area is limited on the front side by the sternum, and behind by the brachiocephalic vessels, as well as the pericardium and brachiocephalic trunk. The thoracic veins pass inside this space; in addition, the thymus gland, in other words the thymus gland, is located in it. It is in front of the mediastinum that the thoracic artery and lymph nodes go. The middle part of the region under consideration includes the heart, hollow, brachiocephalic, diaphragmatic, pulmonary veins. In addition, it includes the brachiocephalic trunk, aortic arch, trachea, main bronchi, and pulmonary arteries. As for the posterior mediastinum, it is limited by the trachea, as well as the pericardium from the frontal area, and the spine from the posterior side. This part includes the esophagus and the descending aorta, in addition it includes the hemizygos and azygos vein, and the thoracic lymphatic duct. The posterior mediastinum also contains lymph nodes.

The upper zone of the mediastinum consists of all the anatomical structures located above upper limit pericardium, represented by the upper aperture of the sternum, as well as a line extending from the angle of the chest and intervertebral disc Th4-Th5.

As for the lower mediastinum, it is limited by the upper edges of the diaphragm and pericardium.

Mediastinal tumors

Various tumor-like formations can develop in the mediastinum area. At the same time, neoplasms of this organ include not only true formations, but also those cysts and tumor-like ailments that have a different etiology, location, and other course of the disease. Any neoplasm of this type originates from tissues of different origins; they are united solely by their location. In this case, doctors consider:

Neoplasm Clinic

Tumor formations are usually found in young and middle-aged people. age group, regardless of gender. As practice shows, mediastinal diseases often do not indicate themselves; they can only be detected during preventive studies. At the same time, there are some symptoms that can indicate such disorders and which need to be paid attention to.

So, tumor formations inside the mediastinum often make themselves felt by mild painful sensations that can radiate towards the neck, shoulder area and between the shoulder blades. In the event that the formation grows inside the borderline sympathetic trunk, the patient’s pupils dilate, drooping of the eyelid and retraction may be observed eyeball.

Damage to the recurrent laryngeal nerve often makes itself felt by hoarseness in the voice. Classic symptoms tumor formations are painful sensations in the chest area, as well as a feeling of heaviness in the head. In addition, shortness of breath may occur, cyanosis, swelling of the face, and disturbances in the passage of food through the esophagus may occur.

If tumor diseases reach an advanced stage of development, the patient experiences a noticeable increase in body temperature, as well as severe weakness. In addition, arthralgia, irregular heart rhythms, and some swelling of the extremities are observed.

Lymph nodes of the mediastinum

As mentioned above, there are many lymph nodes located inside the mediastinum. The most common lesion of these organs is lymphadenopathy, which can develop against the background of metastases of carcinoma, lymphoma, as well as some non-tumor diseases, for example, sarcoidosis, tuberculosis, etc.

In addition to changes in the size of the lymph nodes, lymphadenopathy makes itself felt by fever, as well as excessive sweating. In addition, severe weight loss occurs, hepatomegaly and splenomegaly develop. The diseases provoke frequent infections of the upper respiratory tract in the form of tonsillitis, various types of sore throat and pharyngitis.

In some cases, lymph nodes can be affected in isolation, and sometimes tumors grow into other organs.

Elimination of tumor diseases and other problems with the mediastinum is carried out according to generally accepted standards of therapeutic influence.

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Meaning of the word mediastinum

mediastinum in the crossword dictionary

Dictionary of medical terms

mediastinum (mediastinum, PNA, JNA; septum mediastinale, BNA)

part of the thoracic cavity located between the right and left pleural sacs, bounded in front by the sternum, behind by the thoracic spine, below by the diaphragm, above by the superior aperture of the chest.

Explanatory dictionary of the Russian language. D.N. Ushakov

mediastinum

mediastinum, plural no, cf.

The space between the spine and the sternum, in which the heart, aorta, bronchi and other organs are located (anat.).

trans. A barrier, an obstacle that prevents communication between two parties (book). :Abolish the districts, which are turning into an unnecessary mediastinum between the region and the districts: Stalin (report of the Central Committee at the XVI Congress of the All-Union Communist Party (Bolsheviks), 1930).

Explanatory dictionary of the Russian language. S.I.Ozhegov, N.Yu.Shvedova.

mediastinum

I, Wed. (specialist.). The place in the middle part of the chest cavity where the heart, trachea, esophagus, and nerve trunks are located.

adj. mediastinal, -aya, -oe.

Encyclopedic Dictionary, 1998

mediastinum

in anatomy - part of the thoracic cavity in mammals and humans, in which the heart, trachea and esophagus are located. In humans, the mediastinum is bounded laterally by the pleural sacs (they contain the lungs), below by the diaphragm, in front by the sternum and behind by the spine.

Mediastinum

anatomical region in the human chest cavity, limited in front by the sternum, behind by the thoracic spine, on the sides by the pleura and surfaces of the lungs, below by the diaphragm (see Thoracic obstruction); The upper limit is considered to be a conventional horizontal line passing along the upper edge of the sternum. There are anterior and posterior lungs, separated by the roots of the lungs. The anterior S. contains the heart with the pericardial sac (pericardium), the ascending part of the aorta and its arch with the arterial vessels extending from them, the pulmonary trunk, the superior and inferior vena cava, the pulmonary veins, and the phrenic nerves. In the posterior S. there are the thoracic part of the descending aorta and its branches, the esophagus, the azygos and semi-gypsy veins, the thoracic lymphatic duct, and the vagus and celiac nerves. Closed injuries to S.'s organs occur due to bruises, chest compressions, and sternum fractures. When the lungs or bronchi are damaged and air accumulates, emphysema of the lungs and compression of its organs develop. Open injuries to the lungs are combined with damage to the lungs and often to the abdominal organs. The treatment of these injuries is surgical. The most common diseases of S. are mediastinitis, retrosternal location of enlarged thyroid gland, cysts and tumors of S.’s organs, damage to S.’s lymph nodes, for example, with lymphogranulomatosis.

Lit.: Petrovsky B.V., Surgery of the mediastinum, M., 1960; Elizarovsky S.I., Kondratyev G.I., Atlas “Surgical anatomy of the mediastinum”, M., 1961; Golbert Z. V., Lavnikova G. A., Tumors and cysts of the mediastinum, M., 1965.

Wikipedia

Mediastinum

Mediastinum - anatomical space in the middle parts of the chest cavity. The mediastinum is limited by the sternum and spine. The mediastinal organs are surrounded by fatty tissue. The pleural cavities are located on the sides of the mediastinum.

Examples of the use of the word mediastinum in the literature.

When examining the chest organs, they are clearly visible mediastinum, great vessels, heart, as well as lungs and lymph nodes.

And it is clear that in these variants and details one can encounter more and more genuine aberrations than in its seed, for the perception of which by the Indian people teleological forces worked for many centuries, spending incredible work on weakening many of its representatives mediastinum between daytime consciousness and deep memory - a repository of memories of the paths of the soul until the moment of its last incarnation.

The reason is inflammatory process, accumulation of mucus, pus, blood in the respiratory tract, compression of the bronchi by enlarged lymph nodes, displacement of organs mediastinum.

Fiber inflammation mediastinum, is most often caused by a purulent nonspecific infection.

It is most often located in the subcutaneous fatty tissue, in the area of ​​the shoulder blades, on the shoulders, limbs, in the retroperitoneal space, mediastinum and etc.

The air accumulated in the pleural cavity compresses the lung and displaces mediastinum in a healthy direction.

Danger open pneumothorax is that when breathing air enters and leaves the pleura, which infects the pleura and leads to balloting mediastinum, irritation of nerve endings and a decrease in the respiratory surface of the lungs.

The contrast between the murder and the blue sky made me feel cruel mediastinum between these two shores, where all principles, images, emotions and premonitions flowed like a chaotic waterfall, knowing no barriers.

The sparkling robot, visibly embodying the countless wealth of its owner, pulled back the silk cover, revealing to all eyes a mirror-polished golden figurine of a naked young man, who was plunging a double-edged sword into the very mediastinum defeated word mill.

Spread of phlegmon of the neck to the anterior and posterior mediastinum often leads to death.

So adults in the war were accustomed to it through everyday life, but for Ivan this mediastinum did not have.

The professor, with a serious look, as if he was doing something very important, determined the limits of his stupidity, the degree of displacement mediastinum etc.

Everyday life, everyday life, everyday life could be like this mediastinum, adaptation of the body to the merciless climate of war.

The flow of ion gas covered them with a dense curtain inside a gravitational oasis in the very mediastinum cluster - a safe haven in which they intended to rest before returning to Coruscant.

The little thymus, the tiny gland of my unborn son, the all-powerful ruler of the immune system, tirelessly destroyed the tumor in my mediastinum, suffocated and crushed the tumor in the lung, drove the cancer away from me.

In the section on diseases of the mediastinum, usually only diseases of the lymph nodes, tissue, and partly the mediastinal pleura are considered, mainly from the point of view of the compression phenomena they cause; purulent mediastinitis is primarily of surgical interest.
When considering the symptoms of compression, it is advisable to conditionally divide the mediastinum (minus the main organs - the heart and cardiac membrane) into upper, posterior, anterior. The upper mediastinum contains the aortic arch, thoracic (lymphatic) duct, esophagus, vagus, sympathetic, phrenic nerve; posterior descending aorta, lower part of the trachea, main bronchi, lower part of the esophagus, vena cava (superior and lower), thoracic duct, vagus, sympathetic, phrenic nerve; anterior - mainly the thymus gland.
Severe, even fatal signs of compression can be caused in the mediastinum (as well as in the brain) by any tumor (in the broad sense of the word), not only malignant, but even benign and inflammatory.
The most common complaints with compression of the mediastinal organs are shortness of breath, cough with sputum, change in voice, pain, dysphagia; Objective signs include impaired local circulation with edema, roundabout circulation, local cyanosis, etc.
Shortness of breath is most often caused by compression of the trachea or bronchi, stagnation of blood in the lungs, including due to compression of the pulmonary veins at the point where they flow into the heart, compression of the recurrent nerve, etc.
It should be imagined that in the origin of shortness of breath in diseases of the mediastinum, the neuroreflex effect on the part of the respiratory tract receptors, as well as vascular baroreceptors, etc., is of primary importance.
Congestive cough, the formation of roundabout venous circulation and other mediastinal compression signs are of the same origin. Representing the manifestation of adaptive mechanisms for the restoration of various aspects of impaired organ activity, shortness of breath, cough, etc., at the same time, often achieve excessive Strength; in these cases, it is advisable to strive to alleviate them.

Shortness of breath develops in several periods - first only after physical stress or in case of excitement, then it becomes
constant, is inspiratory or also expiratory in nature, often accompanied by stridor (with compression of the trachea); as the disease progresses, orthopnea takes on the character, the patient cannot lie down, shortness of breath greatly disrupts sleep; It is not so rare that death occurs from strangulation.

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The cough is often paroxysmal, convulsive or whooping cough-like in nature when irritated by enlarged lymph nodes or when the process spreads to the mucous membrane of the tracheal bifurcation. Cough can also be a consequence of congestive or inflammatory bronchitis, irritation of the vagus nerve. The cough, like the voice, may be hoarse, weak or silent, with a special hue from swelling or paralysis vocal cords(with compression of the recurrent nerve). The cough is initially dry or with sputum, mucous from excessive secretion and retention of mucus or mucopurulent, sometimes, with the development of bronchiectasis from compression of the bronchus, very copious. Often the sputum is stained with blood (congestion, bronchiectasis, rupture of blood vessels).
Particularly painful are pains that occur either in the form of attacks radiating to the neck or arm due to pressure on the brachial plexus or in the form of a feeling of numbness or pressure in one arm.
Difficulty swallowing (dysphagia) rarely reaches the degree that is observed with diseases of the esophagus itself.
When the superior vena cava or its main branches are compressed, swelling of the cervical tissue and shoulder girdle is observed in the form of a cape and upper limbs, even swelling of the face, or one right or left arm. Blood from the superior vena cava system penetrates into the inferior
through the veins of the anterior wall of the body or mainly through the deeply embedded azygos and semi-gypsy vein (if they have escaped compression); with unilateral compression of the subclavian vein, collaterals lead from this side of the chest to the collectors of the superior vena cava of the opposite side; Due to swelling of the veins of the orbit and swelling of the tissue, bulging eyes may develop. Small skin veins on the face and chest are dilated. Superficially located veins have the appearance of blue-purple, “leech” cords. Venous stagnation is accompanied by extremely sharp local cyanosis due to stretching of the veins and slow blood outflow.
Disruption of blood flow through the arterial trunks is observed less frequently, mainly with an aortic aneurysm.
An objective examination reveals other signs of compression of the mediastinal organs: uneven pupils or complete compression syndrome of the upper cervical sympathetic nerve with miosis, eye retraction, drooping eyelid, sweating and facial hyperemia on the affected side, persistently recurrent herpes zoster on the chest simultaneously with intercostal neuralgia due to compression of the roots, high standing of the diaphragm and other signs
unilateral paralysis of the phrenic nerve, effusion into the pleural cavity as a result of accumulation of the contents of the milk vessels - chylothorax with compression of the thoracic (lymphatic) duct. Compression of the bronchus produces the usual symptoms of bronchial obstruction up to massive atelectasis.
Other mediastinal signs are characteristic of mediastino-pericarditis: multicostal systolic retraction in the atrium, lack of forward movement of the lower part of the sternum during inspiration due to fusion with the spine, paradoxical pulse, systolic retraction of the laryngeal cartilage.
X-ray examination easily establishes congestion in the lungs, obstruction of the esophagus (when contrast is given), high standing and paralysis of the diaphragm on the left or right side, displacement of the trachea (ascertained and clinically), atrophy of the vertebral bodies, leading to transverse myelitis; examination with a laryngeal mirror - paralysis of the plus ligaments.
Signs of the disease itself that causes compression are easily detected, for example, enlarged lymph nodes in the neck or in the mediastinum (with lymphogranulomatosis, etc.), signs of mediastinal pleurisy, aortic aneurysm, mitral stenosis (causing compression of the lower laryngeal nerve in the case of a sharp increase in the left atrium), scarring tuberculous process with calcification, etc.

Mediastinum I Mediastinum

part of the chest cavity, bounded in front by the sternum and behind by the spine. Covered with intrathoracic fascia, on the sides - with mediastinal pleura. From above, the border of S. is the upper aperture of the chest, from below -. The mediastinum contains the pericardium, large vessels, the trachea and main vessels, the esophagus, and the thoracic duct ( rice. 12 ).

The mediastinum is conventionally divided (along the plane passing through the trachea and main bronchi) into anterior and posterior. In the anterior are the Thymus, the right and left brachiocephalic and superior vena cava, the ascending part and (Aorta), its branches, the Heart and the Pericardium, in the posterior are the thoracic part of the aorta, the esophagus, the vagus nerves and sympathetic trunks, their branches, unpaired and semi-unpaired veins, Thoracic duct. In the anterior S. there are upper and lower sections (the lower one contains the heart). The loose tissue surrounding the organs communicates at the top through the anterior S. with the previsceral cellular tissue space of the neck, through the posterior - with the retrovisceral cellular tissue space of the neck, at the bottom through the holes in the diaphragm (along the para-aortic and peri-esophageal cellular tissue) - with the retroperitoneal cellular tissue. Between the fascial sheaths of organs and vessels of the S., interfascial gaps and spaces are formed, filled with fiber, forming fiber spaces: pretracheal - between the trachea and the aortic arch, in which the posterior thoracic aortic plexus is located; retrotracheal - between the trachea and the esophagus, where the paraesophageal and posterior mediastinal lie; left tracheobronchial, where the aortic arch, left vagus and left upper tracheobronchial lymph nodes are located; the right tracheobronchial, which contains the azygos, right vagus nerve, and right upper tracheobronchial lymph nodes. Between the right and left main bronchi there is an interbronchial, or bifurcation, space with the lower tracheobronchial lymph nodes located in it.

Blood supply is provided by the branches of the aorta (mediastinal, bronchial, esophageal, pericardial); The outflow of blood occurs into the azygos and semi-amygos veins. Lymphatic vessels conduct lymph to the tracheobronchial (upper and lower), peritracheal, posterior and anterior mediastinal, prepericardial, lateral pericardial, prevertebral, intercostal, perithoracic lymph nodes. S. is carried out by the thoracic aortic nerve plexus.

Research methods. In most cases, it is possible to identify S.’s pathology based on the results clinical trial and standard fluorography (Fluorography), as well as using radiography (X-ray) of the chest. In case of swallowing disorders, it is advisable to use radiopaque and endoscopic examination esophagus. Angiography (angiography) is sometimes used to visualize the superior and inferior vena cava, aorta, and pulmonary trunk. Computed X-ray tomography and nuclear magnetic resonance imaging have great potential, which are the most informative methods for diagnosing mediastinal diseases. If a pathology of the thyroid gland (retrosternal) is suspected, a radionuclide scan is indicated. For morphological verification of the diagnosis, mainly for S. tumors, endoscopic methods are used (bronchoscopy (Bronchoscopy) with transtracheal or transbronchial puncture, thoracoscopy, mediastinoscopy), transthoracic puncture, mediastinotomy. During mediastinoscopy, the anterior S. is examined using a mediastinoscope inserted after mediastinotomy. is surgery, which can be used for diagnostic purposes.

Developmental defects. Among the malformations of S., the most common are pericardial cysts (coelomic), dermoid cysts, bronchogenic cysts, and enterogenic cysts. Pericardial cysts are usually thin-walled and filled with clear fluid. As a rule, they are asymptomatic and are an incidental finding during X-ray examination. Bronchogenic cysts are localized near the trachea and large bronchi and can cause respiratory tract problems, resulting in dryness, shortness of breath, and stridor. Enterogenous cysts are localized near the esophagus and can ulcerate with subsequent perforation and the formation of fistulas with the esophagus, trachea, and bronchi. developmental defects S. operational. favorable with timely treatment.

Damage. There are closed and open injuries to the S. Closed injuries to the S. occur with bruises and compression of the chest, fractures of the sternum, or general contusions and are characterized by the formation of a hematoma in the tissue of the S. Clinically, they are manifested by moderate chest pain, shortness of breath, mild cyanosis, and slight swelling of the neck veins. from small vessels stops spontaneously. Bleeding from larger vessels is accompanied by the formation of an extensive hematoma and the spread of blood through the tissue C. When the vagus nerves are imbibed by blood, a syndrome characterized by pronounced violation breathing, circulatory disorders, development of bilateral pneumonia. S. hematomas lead to mediastinitis or mediastinal abscess. Closed S. injuries due to trauma to hollow organs are often complicated by Pneumothorax and Hemothorax. If the trachea or large bronchi, less often the lungs and esophagus, are damaged in S., mediastinal or pneumomediasticum penetrates and develops. A small amount of air is localized within the S., and when it enters in significant quantities, the air can spread through the cellular spaces beyond the S. In this case, extensive subcutaneous emphysema develops and unilateral or bilateral emphysema is possible. Widespread mediastinal emphysema is accompanied by pressing pain in the chest, shortness of breath and cyanosis. Deteriorates sharply general state patient, are often observed in the subcutaneous tissue of the face, neck and upper chest, disappearance of cardiac dullness, weakening of heart sounds. confirms the accumulation of gas in the tissue of the S. and neck.

Open injuries to the chest are often associated with injuries to other organs of the chest. Injuries to the thoracic trachea and main bronchi simultaneously with the great vessels (aortic arch, superior vena cava, etc.) usually lead to fatal outcome at the scene of the incident. If he remains alive, then respiratory distress, coughing attacks with the release of foamy blood, mediastinal emphysema, and pneumothorax occur. A sign of injury to the trachea and large bronchi may be air escaping through the wound when exhaling. Penetration of the chest from the front and left side should raise suspicion for a possible heart attack (Heart). The thoracic esophagus is rarely isolated, is accompanied by mediastinal emphysema, and purulent Mediastinitis and Pleurisy quickly develop. thoracic duct (thoracic duct) are more often detected several days or even weeks later and are characterized by increasing effusion pleurisy. Pleural fluid (chyle), in the absence of blood, resembles milk in color and, in a biochemical study, contains an increased amount of triglycerides.

The scope of first aid for wounds of S.'s organs is usually small, the application of aseptic, toilet of the upper respiratory tract, according to indications - the administration of painkillers and oxygen.

When performing emergency medical measures for open wounds of S.'s organs, it is necessary to adhere to the following sequence: toilet of the respiratory tract, sealing of the chest cavity and trachea, pleural cavity, subclavian or jugular vein.

Sealing the chest cavity is mandatory in cases of open pneumothorax. Temporary sealing is achieved by applying a bandage with a sterile cotton-gauze pad that completely covers the wound opening. Oilcloth, cellophane, polyethylene or other impenetrable material is placed on top. The bandage is fixed far beyond the edges with a tiled application of strips of adhesive plaster. It is advisable to bandage the arm to the affected side of the chest. For small cut wounds You can match their edges and fix them with adhesive tape.

In case of breathing problems, an “Ambu” type bag or any portable breathing apparatus is used for artificial ventilation of the lungs (Artificial lung). You can start mechanical ventilation with mouth-to-mouth or mouth-to-mouth breathing, and then perform tracheal intubation (see Intubation).

Pleural puncture is necessary if there are signs of internal tension pneumothorax. It is performed in the second intercostal space in front with a thick needle with a wide lumen or trocar to ensure free air from the pleural cavity. The needle is either temporarily connected to a plastic or rubber tube with a valve at the end.

In case of the rarely observed rapid development of tense mediastinal emphysema, emergency cervical surgery is indicated - the skin above the jugular notch with the creation of a duct behind the sternal tissue into tissue C.

All victims and wounded will be hospitalized in specialized surgical departments. Transportation should be carried out by a specialized resuscitation machine. It is preferable to transport the victim in a semi-sitting position. The accompanying document indicates the circumstances of the injury, its clinical symptoms and a list of treatment measures taken.

In the hospital after examination and necessary examination the issue of further treatment tactics is being resolved. If the patient's condition is closed damage S. improves, limited to rest, symptomatic therapy and prescribing antibiotics to prevent infectious complications.

The scope of surgical interventions for open injuries of the chest is quite wide - treatment of a chest wound up to complex operations on the organs of the chest cavity. Indications for urgent thoracotomy are injuries to the heart and large vessels, trachea, large bronchi and lungs with bleeding, tension pneumothorax, injuries to the esophagus, diaphragm, progressive deterioration of the patient’s condition in case of an unclear diagnosis. When deciding on surgery, it is necessary to take into account the damage, the degree of functional impairment and the effect of conservative measures.

Diseases. Inflammatory diseases of S. - see Mediastinitis. Relatively often a retrosternal goiter is detected. A “diving” retrosternal goiter is distinguished, most of which is located in the S., and the smaller one is on the neck (protrudes when swallowing); the retrosternal goiter itself, localized entirely behind the sternum (its upper pole is palpable behind the notch of the manubrium of the sternum); intrathoracic, located deep in the S. and inaccessible for palpation. “Diving” goiter is characterized by periodically occurring asphyxia, as well as symptoms of compression of the esophagus (). With retrosternal and intrathoracic goiter, symptoms of compression of large vessels, especially veins, are noted. In these cases, swelling of the face and neck, swelling of the veins, hemorrhages in the sclera, dilation of the veins of the neck and chest are detected. in these patients it is increased, headaches, weakness, and shortness of breath are observed. To confirm the diagnosis, radionuclide with 131 I is used, but the negative results of this study do not exclude the presence of a so-called cold colloidal node. The retrosternal and intrathoracic goiter can become malignant, so its early radical removal is necessary.

Tumors S. are observed equally often in men and women; found predominantly in young and mature age. Most of them are congenital neoplasms. Benign tumors of S. significantly prevail over malignant ones.

Clinical symptoms of benign neoplasms of S. depend on many factors - the growth rate and size of the tumor, its location, the degree of compression of adjacent anatomical formations, etc. During the course of neoplasms of S., two periods are distinguished - an asymptomatic period with clinical manifestations. Benign tumors develop asymptomatically for a long time, sometimes years and even decades.

There are two main syndromes in S.'s pathology - compression and neuroendocrine. Compression syndrome cause a significant increase in pathological formation. It is characterized by a feeling of fullness and pressure, dull pain behind the sternum, shortness of breath, cyanosis of the face, swelling of the neck, face, dilatation of the saphenous veins. Then signs of dysfunction of certain organs appear as a result of their compression.

There are three types of compression symptoms: organ (compression of the heart, trachea, main bronchi, esophagus), vascular (compression of the brachiocephalic and superior vena cava, thoracic duct, displacement of the aorta) and neurogenic (compression with impaired conductivity of the vagus, phrenic and intercostal nerves, sympathetic trunk).

Neuroendocrine syndrome is manifested by damage to joints, reminiscent of large and tubular bones. Observed various changes heart rate, angina.

Neurogenic tumors of the S. (neurinomas, neurofibromas, ganglioneuromas) often develop from the sympathetic trunk and intercostal nerves and are located in the posterior S. With neurogenic tumors, the symptoms are more pronounced than with all others benign formations C. There are pains in the chest, in the back, headaches, in some cases - sensory, secretory, vasomotor, pilomotor and trophic disorders on the skin of the chest from the side of the tumor location. Less commonly observed are Bernard-Horner syndrome, signs of compression of the recurrent laryngeal nerve, etc. Radiologically, neurogenic tumors are characterized by a homogeneous, intense oval or round shadow, closely adjacent to the spine.

Ganglioneuromas may have an hourglass shape if part of the tumor is located in the spinal canal and is connected by a narrow stalk to the tumor in the mediastinum. In such cases, signs of spinal cord compression, even paralysis, are combined with mediastinal symptoms.

Of the tumors of mesenchymal origin, lipomas are the most common, fibromas, hemangiomas, lymphangiomas are less common, and chondromas, osteomas and hibernomas are even less common.

Metastatic damage to the lymph nodes of S. is typical for lung cancer and esophagus, thyroid and breast cancer, seminoma and adenocarcinoma.

In order to clarify the diagnosis, the entire necessary complex is used diagnostic measures, however, the final establishment of the species malignant tumor is possible only after a biopsy of a peripheral lymph node, examination of pleural exudate, tumor puncture obtained by puncture through the chest wall or tracheal wall, bronchus or bronchoscopy, mediastinoscopy or parasternal mediastinotomy, thoracotomy as the final stage of diagnosis. Radionuclide research is carried out to determine the shape of the size, the extent of the tumor process, as well as the differential diagnosis of malignant and benign tumors, cysts and inflammatory processes.

In case of malignant tumors, the risk of surgery is determined by many factors, and primarily by the prevalence and morphological features of the process. Even partial removal malignant tumor S. improves the condition of many patients. In addition, a decrease in tumor mass creates favorable conditions for subsequent radiation and chemotherapy.

Contraindications to surgery are serious condition patient (extreme, severe hepatic, renal, pulmonary-heart failure, intractable therapeutic effects) or signs of obvious inoperability (the presence of distant metastases, a malignant tumor in the parietal pleura, etc.).

The prognosis depends on the shape of the tumor and the timeliness of treatment.

Bibliography: Blokin N.N. and Perevodchikova N.I. tumor diseases, M., 1984; Vagner E.A. breast injuries, M, 1981; Wagner E. A et al. bronchi, Perm, 1985; Vishnevsky A.A. and Adamyak A.A. Surgery of the mediastinum, M, 1977, bibliogr.; Elizarovsky S.I. and Kondratyev G.I. Surgical mediastinum, M., 1961, bibliogr.; Isakov Yu.F. and Stepanov E.A. and cysts of the thoracic cavity in children, M., 1975; Petrovsky B.V., Perelman M.I. and Koroleva N.S. Tracheobronchialnaya, M., 1978.

Rice. 1. Mediastinum (right view, mediastinal pleura, part of the costal and diaphragmatic pleura are removed, tissue and lymph nodes are partially removed): 1 - trunks brachial plexus(cut off); 2 - left subclavian artery and vein (cut off); 3 - superior vena cava; 4 - II rib; 5 - right phrenic nerve, pericardial diaphragmatic artery and vein; 6 - right pulmonary artery(cut off); 7 - pericardium; 8 - diaphragm; 9 - costal pleura (cut off); 10 - great splanchnic nerve; 11 - right pulmonary veins (cut off); 12 - posterior intercostal artery and vein; 13 - lymphatic; 14 - right bronchus; 15 - azygos vein; 16 - esophagus; 17 - right sympathetic trunk; 18 - right vagus nerve; 19 - trachea.

Rice. 2. Mediastinum (left view, mediastinal pleura, part of the costal and diaphragmatic pleura, as well as fiber have been removed): 1 - clavicle; 2 - left sympathetic trunk; 3 - esophagus; 4 - thoracic duct; 5 - left subclavian artery; 6 - left vagus nerve; 7 - thoracic aorta; 8 - lymph node; 9 - great splanchnic nerve; 10 - hemizygos vein; 11 - diaphragm; 12 - esophagus; 13 - left phrenic nerve, pericardial diaphragmatic artery and vein; 14 - pulmonary veins (cut off); 15 - left pulmonary artery (cut off); 16 - left common carotid artery; 17 - left brachiocephalic vein.