MEDIASTINUM

Lecture (4)
Last updated: March 2013
Hosam Eldeen Elsadig MBBS , [Link]
 Objectives:
2

 Basic anatomy, to identify:

 Boundaries, divisions and contents of mediastinum
 Clinical anatomy, to define:
 Benefits of venous central cathetrization.
 Surface anatomy, to identify:
 Planes that divide the mediastinum
 Structures at the level of sternal angle.

 Radiology, to identify:
 Aorta in normal sagittal MRI of the thorax
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Introduction: Lecture's map
3

 Mediastinum (definition and divisions).

 Superior.

 Inferior:

Anterior.
Middle.
Posterior.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 The mediastinum
4

 It is a midline space that forms a

partition.
 Boundaries:

Anteriorly: the sternum.

Posteriorly: the thoracic vertebrae.
Superiorly: root of the neck.
Inferiorly: diaphragm.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
Mediastinum

5 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

6 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
7 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 DIVISIONS
8

 According to line from :

Sternalangle (angle of Louis or
menobriosternal joint), anteriorly.
 To:
Lower border of T4 posteriorly .
Last updated: March 2013
Hosam Eldeen Elsadig MBBS, [Link].
9 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 DIVISIONS
10

Superior.
Inferior:

Anterior.
Middle.
Posterior.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Lecture's map
11

 Mediastinum (definition and divisions).

 Superior.

 Inferior:

Anterior.
Middle.
Posterior.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Superior Mediastinum
12

 Thymus.
 Great vessels.
 Arteries:
 Aorta and its branches.
 Pulmonary trunk.

 Veins: Superior Vena cava and its tributaries.

 Trachea.
 Oesophagus.
 Nerves.
 Phrenic: spinal nerve.
 Vagus: cranial nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Superior Mediastinum

13 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Thymus

Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

14 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 The thymus
15

It is a primary lymphoid organ.

Function: production of T-
Lymphocytes.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Thymus

Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

16 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 The thymus
17

 It lies posterior to the

manubrium and extends into the
anterior mediastinum, anterior
to the fibrous pericardium.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 The thymus is highly active in early part of life

18 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 The thymus
19

 Arterial supply: The anterior intercostal arteries.

 Venous drainage into:

 The left brachiocephalic

 Internal thoracic.

 Inferior thyroid veins.

 The lymphatics end in:

 The parasternal lymph nodes.
 Brachiocephalic lymph nodes.

 Tracheobronchial lymph nodes.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Superior Mediastinum
20

 Thymus.
 Great vessels.
 Arteries:
 Aorta and its branches.
 Pulmonary trunk.

 Veins: Superior Vena cava and its tributaries.

 Trachea.
 Oesophagus.
 Nerves.
 Phrenic: spinal nerve.
 Vagus: cranial nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Aorta and its branches

Image from: Agur, Anne M.R.; Dalley, Arthur F. Grant’s Atlas of Human Anatomy. 12th Ed. Lippincott Williams & Wilkins; 2009.

21 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

Parts of
Aorta

 Ascending.
 Arch of the aorta.
 Descending .
 Abdominal aorta.

Image from: Richard [Link], Wayne Vogl,Adam [Link], GRAYS anatomy for students, Elsevier Inc. 2007

22 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Aorta: Relations to angle of Lois plane

23 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Aorta: Relations to pulmonary trunk

Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

24 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Branches of the Aorta
25

 In order from anterior to posterior:

Brachiocephalic trunk.
(brachium+cephalic)
Left common carotid.
Left subclavian artery.
(sub = below , clavian: from clavicle)
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
Branches of
the Aorta
26 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Ligamentum arteriosum
27

 Developmentally: it was a patent

vessel (ductus arteriosus) connecting
the pulmonary trunk with the arch of
aorta.
 The vessel closes soon after birth.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 MRI
sagittal
section:
aorta
Image from: Torsten B. Moeller; Emil Reif. Pocket Atlas of Sectional Anatomy. 3rd edition. Germany by Appl Aprinta Druck, Wemding; 2005
28 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Superior Mediastinum
29

 Thymus.
 Great vessels.
 Arteries:
 Aorta and its branches.
 Pulmonary trunk.

 Veins: Superior Vena cava and its tributaries.

 Trachea.
 Oesophagus.
 Nerves.
 Phrenic: spinal nerve.
 Vagus: cranial nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Pulmonary Trunk
30

 It is an artery.
 Carries deoxygenated blood from

the right ventricle of the heart into

the lungs.
 Divisions:

Right and left pulmonary arteries.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Pulmonary Trunk

Image from: Agur, Anne M.R.; Dalley, Arthur F. Grant’s Atlas of Human Anatomy. 12th Ed. Lippincott Williams & Wilkins; 2009.

31 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Pulmonary Trunk: relations to the trachea

Image from: Agur, Anne M.R.; Dalley, Arthur F. Grant’s Atlas of Human Anatomy. 12th Ed. Lippincott Williams & Wilkins; 2009.

32 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Pulmonary Trunk: relations to aorta

33 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Superior Mediastinum
34

 Thymus.
 Great vessels.
 Arteries:
 Aorta and its branches.
 Pulmonary trunk.

 Veins: Superior Vena cava and its tributaries.

 Trachea.
 Oesophagus.
 Nerves.
 Phrenic: spinal nerve.
 Vagus: cranial nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Superior Vena Cava
35

 Brings the blood back from the

thorax, upper limbs, head and neck
into the heart.
 Tributaries:

Right brachiocephalic vein.

Left brachiocephalic vein.
Azygos vein.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Image from: Agur, Anne M.R.; Dalley, Arthur F. Grant’s Atlas of Human Anatomy. 12th Ed. Lippincott Williams & Wilkins; 2009.

36 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Think about this
37

The left
brachiocephalic vein
is longer than the
right one.
Why?
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Clinical note: venous central lines
38

 Large systemic veins are used to

establish central venous access for:
 Diagnosis: administering large
amounts of fluid, drugs, and blood.
 Treatment: in conditions like renal
dialysis.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Superior Mediastinum
39

 Thymus.
 Great vessels.
 Arteries:
 Aorta and its branches.
 Pulmonary trunk.

 Veins: Superior Vena cava and its tributaries.

 Trachea.
 Oesophagus.
 Nerves.
 Phrenic: spinal nerve.
 Vagus: cranial nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Trachea
40

It is a tube made of smooth

muscles and cartilage.
Extends from C6 to T4.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

  Blood supply.
Branches from the aorta.
 Innervation.
Vagus nerve.
41 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Relations:
the trachea
descends
anterior to
the
esophagus

42 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Relations: the
trachea divides into
right and left
bronchi (bronchus)
at the level of
sternal angle.

43 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

Relations, the left
bronchus lies :
•Posterior to the
bifurcation of the
pulmonary trunk.
•Anterior to the
descending
aorta.

44 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Anatomical relations (Trachea)
45

The arch of aorta on the left.

The arch of azygos on the right.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

46 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Superior Mediastinum
47

 Thymus.
 Great vessels.
 Arteries:
 Aorta and its branches.
 Pulmonary trunk.

 Veins: Superior Vena cava and its tributaries.

 Trachea.
 Oesophagus.
 Nerves.
 Phrenic: spinal nerve.
 Vagus: cranial nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Esophagus (oesophagus)
48

It is a muscular tube.

Extends from C6 to T10.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

The upper part of
the esophagus is
posterior to the
trachea.
The lower part is
deviated a little to
the left to run
anterior to the
descending aorta.
Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

49 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

50 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

51

 Blood supply.
Branches from aorta
(esophageal arteries)
 Innervation.
Vagus nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Superior Mediastinum
52

 Thymus.
 Great vessels.
 Arteries:
 Aorta and its branches.
 Pulmonary trunk.

 Veins: Superior Vena cava and its tributaries.

 Trachea.
 Oesophagus.
 Nerves.
 Phrenic: spinal nerve.
 Vagus: cranial nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Phrenic Nerve
53

 Spinal nerve.
 Roots are C3,4 and 5.

 Runs anterior to the roots of the lung.

 Supplies the diaphragm.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Image from: Richard [Link], Wayne Vogl,Adam [Link], GRAYS anatomy for students, Elsevier Inc. 2007
54 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Superior Mediastinum
55

 Thymus.
 Great vessels.
 Arteries:
 Aorta and its branches.
 Pulmonary trunk.

 Veins: Superior Vena cava and its tributaries.

 Trachea.
 Oesophagus.
 Nerves.
 Phrenic: spinal nerve.
 Vagus: cranial nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Vagus Nerve
56

 Cranial nerve.
 Passes posterior to the roots of the lung.

 Gives an important branches at this

area.
Recurrent laryngeal nerves (right and
left).
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Image from: Richard [Link], Wayne Vogl,Adam [Link], GRAYS anatomy for students, Elsevier Inc. 2007
57 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Recurrent laryngeal nerves
58

 The right recurrent laryngeal nerve:

 Hooks around the right subclavian artery.
 The left recurrent laryngeal nerve:
 Passes inferior to the arch of the aorta,
immediately lateral to the ligamentum
arteriosum.
 Both nerves ascend to the larynx in the
groove between the trachea and the
esophagus.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Left recurrent laryngeal nerve

59 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 About Nerves
60

 Origin
(nuclei for cranial nerves and spinal
cord segment for spinal nerves).
 Course or pathway.

 Destination.

 Type of innervation.

(Sensory and motor)

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Superior Mediastinum
61

 Thymus.
 Great vessels.
 Arteries:
 Aorta and its branches.
 Pulmonary trunk.

 Veins: Superior Vena cava and its tributaries.

 Trachea.
 Oesophagus.
 Nerves.
 Phrenic: spinal nerve.
 Vagus: cranial nerve.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Lecture's map
62

 Mediastinum (definition and divisions).

 Superior.

 Inferior:

Anterior.
Middle.
Posterior.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Posterior Mediastinum
63

 Azygos system of veins.

 Continuation of the oesophagus.

 Thoracic duct.

 Descending thoracic aorta.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

64 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Azygos System
65

Azygos vein.
Hemiazygos.

Accessory hemiazygos.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

66 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

67 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
68 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

69 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Thoracic Duct
70

 Largest lymphatic vessel.

 Starts at cisterna chyli.

 Ends at the junction of the left subclavian

and left internal jugular viens.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Image from: Richard [Link], Wayne Vogl,Adam [Link], GRAYS anatomy for students, Elsevier Inc. 2007

71 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Thoracic Duct
72

 Drains the lymph from:

 Lower limbs.
 Pelvis.
 Abdomen.
 Left upper limb.
 Left side of the thorax, head, and neck.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Thoracic Duct

Imafe from: Johannes [Link]; Chihiro Yokochi; Elke Lütjen-Drecoll. Color atlas of anatomy. 7th edition. Lippincott Williams & Wilkins 2011
73 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Branches of the aorta in posterior mediastinum

74 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Identify
the
following
structures

Imafe from: Johannes [Link]; Chihiro Yokochi; Elke Lütjen-Drecoll. Color atlas of anatomy. 7th edition. Lippincott Williams & Wilkins 2011
75 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Answer for the previous image
76

Imafe from: Johannes [Link]; Chihiro Yokochi; Elke Lütjen-Drecoll. Color atlas of anatomy. 7th edition. Lippincott Williams & Wilkins 2011

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Surface anatomy: planes

Image from: Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins; 2006.

77 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Surface anatomy: identifying structures in the
superior mediastinum

78 Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 In the previous image
79

 On each side, the internal jugular and subclavian

veins join to form the brachiocephalic veins behind
the sternal ends of the clavicles near the
sternoclavicular joints.
 The left brachiocephalic vein crosses from left to right
behind the manubrium of sternum.
 The brachiocephalic veins unite to form the superior
vena cava behind the lower border of the costal
cartilage of the right first rib.
 The arch of aorta begins and ends at the transverse
plane between the sternal angle anteriorly and
vertebral level TIV/V posteriorly.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Lecture's map
80

 Mediastinum (definition and divisions).

 Superior.

 Inferior:

Anterior.
Middle.
Posterior.

Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013

 Please try to answer this question
81

 The lymph from the following organ

is not drained by thoracic duct :
A. Right hand.
B. Urinary bladder.
C. Stomach.
D. Left lung.
E. Liver.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 Please try to answer this question
82

 The left recurrent laryngeal nerve

hooks around:
A. The aorta.
B. The left brachiocephalic vein.
C. The rigth subclavian artery.
D. The pulmonary trunk.
E. The common carotid artery.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013
 References
83

 [Link], LAST‘S anatomy regional and applied, 9th Ed. Churchill livingstone; 1997
 Richard [Link], Wayne Vogl,Adam [Link], GRAYS anatomy for students, Elsevier Inc. 2007
 Harold Ellis, Clinical Anatomy,Applied anatomy for students and junior doctors, 11th Ed, Blackwell
Publishing Ltd, 2006
 Richard [Link], Clinical Anatomy by Regions, 8th Ed. Lippincott Williams & Wilkins.
 Moore, Keith L.; Dalley, Arthur F, Clinically Oriented Anatomy, 5th Ed. Lippincott Williams & Wilkins;
2006.
 Agur, Anne M.R.; Dalley, Arthur F. Grant’s Atlas of Human Anatomy. 12th Ed. Lippincott Williams &
Wilkins; 2009.
 Elaine N. Marieb, R.N.; Patricia Brady Wilhelm ; Jon Mallatt. Human anatomy. 6th edition, Pearson
Education, Inc. ; 2012
 Johannes [Link]; Chihiro Yokochi; Elke Lütjen-Drecoll. Color atlas of anatomy. 7th edition. Lippincott
Williams & Wilkins 2011
 Torsten B. Moeller; Emil Reif. Pocket Atlas of Sectional Anatomy. 3rd edition. Germany by Appl
Aprinta Druck, Wemding; 2005
 Acland's video Atlas of Human Anatomy, Robert [Link] M.D , FRCS.
 Abraham's et al , McMinn clinical atlas.
Hosam Eldeen Elsadig MBBS, [Link]. Last updated: March 2013