Mediastinum

Strictly speaking, the mediastinum is the partition between the lungs and includes the mediastinal pleura. However, the term is commonly applied to the region between the two pleural sacs bounded anteriorly by the sternum and posteriorly by the thoracic vertebral column and extending vertically from the thoracic inlet to the diaphragm. For descriptive purposes, this region is arbitrarily divided into superior and inferior mediastina, and the latter is subdivided into anterior, middle and posterior parts. The plane of division into superior and inferior mediastina crosses the manubriosternal joint and the lower surface of the fourth thoracic vertebra (Fig. 55.1). Detailed accounts of some mediastinal contents are also included with descriptions of the respiratory organs (see Ch. 57) and the heart (see Ch. 56).

Fig. 55.1 The major divisions of the mediastinum (see text for further details). Note that not all mediastinal contents are
depicted.

SUBDIVISIONS OF THE MEDIASTINUM SUPERIOR MEDIASTINUM The superior mediastinum lies between the manubrium sterni and the upper four thoracic vertebrae (see Fig. 55.19AC). It is bounded below by the sternal plane, above by the plane of the thoracic inlet, and laterally by the mediastinal pleurae. It contains the lower ends of sternohyoid, sternothyroid and longus colli; thymic remnants; the internal thoracic arteries and veins, the brachiocephalic veins and the upper half of the superior vena cava, the aortic arch, the brachiocephalic, left common carotid and subclavian arteries and the left superior intercostal vein; the right and left vagi and phrenic nerves, the left recurrent laryngeal nerve, the cardiac nerves and the superficial part of the cardiac plexus; the trachea, oesophagus and thoracic duct. It also contains the paratracheal, brachiocephalic and tracheobronchial lymph nodes associated with their named structures. INFERIOR MEDIASTINUM Anterior mediastinum The anterior mediastinum lies between the sternal body and pericardium (see Fig. 55.19D,E). It narrows above the fourth costal cartilages, where the pleural sacs come close to each other, and contains loose connective tissue, the sternopericardial ligaments, a few lymph nodes and the mediastinal branches of the internal thoracic artery. The anterior mediastinum may sometimes contain part of the thymus gland or its degenerated remains. Middle mediastinum The middle mediastinum is the broadest part of the inferior mediastinum (see Fig. 55.19D,E). It contains the pericardium, the heart and the ascending aorta; the lower half of the superior vena cava receiving the azygos venous arch posteriorly; the tracheal bifurcation and both main bronchi; the pulmonary trunk and right and left pulmonary arteries and veins; the right and left phrenic nerves; the deep part of the cardiac plexus; the tracheobronchial lymph nodes. Posterior mediastinum The posterior mediastinum is bounded anteriorly by the bifurcation of the trachea, pulmonary vessels, pericardium and the posterior part of the upper surface of the diaphragm (see Fig. 55.19D,E). Posteriorly, it is bounded by the vertebral column, from the lower border of the fourth to the twelfth thoracic vertebrae, and on each side by the mediastinal pleura. It contains the descending thoracic aorta and the azygos, hemiazygos and accessory azygos veins; the right and left sympathetic chains, the splanchnic nerves and the right and left vagi; the oesophagus; the thoracic duct and posterior mediastinal lymph nodes.

Fig. 55.19 Transverse section of the thorax, obtained by CT. A, At the level of the junction of the first rib. 1.
Manubrium.2. Right brachiocephalic artery. 3. Right brachiocephalic vein. 4. Trachea. 5. Scapula. 6. Left brachiocephalic vein. 7. Left common carotid artery. 8. Left subclavian artery. 9. Oesophagus. B, Through the lower portion of the third thoracic vertebra. 1. Brachiocephalic vein. 2. Pretracheal space. 3. Trachea. 4. Oesophagus. 5. Pectoralis major. 6. Combined brachiocephalic artery and left subclavian artery (normal variant). 7. Left subclavian artery. 8. Scapula. C, Through the middle of the fourth thoracic vertebra and aortic arch. 1. Anterior junction. 2. Superior vena cava. 3. Pretracheal space. 4. Trachea. 5. Arch of aorta. 6. Oesophagus. 7. Scapula. D, At the upper border of the sixth thoracic vertebra, below the carina at the level of the pulmonary trunk and the right main pulmonary artery. 1. Ascending aorta. 2. Superior vena cava.3. Right pulmonary artery. 4. Right main bronchus. 5. Subcarinal space. 6. Oesophagus 7. Azygos vein. 8. Trunk of pulmonary artery. 9. Superior branch of left pulmonary vein. 10. Left main bronchus. 11. Inferior branch of left pulmonary artery. 12. Descending aorta. E, Through the lower portion of the seventh thoracic vertebra, passing through the aortic root. 1. Aortic root. 2. Left atrium. 3. Oesophagus. 4. Azygos vein. 5. Right ventricular outflow tract. 6. Left inferior pulmonary vein. 7. Descending aorta.

MEDIASTINAL COMMUNICATIONS WITH THE NECK Anatomical pathways exist between the oral cavity and the thorax via the parapharyngeal space and other fascial planes of the neck. The parapharyngeal space is more likely to be infected than any of the other potential tissue spaces in the head and neck: infection can pass from this space to the retropharyngeal and pretracheal spaces and so reach the superior mediastinum, from where it can track down into the anterior part of the inferior mediastinum (see Ch. 28).