Anterior and posterior mediastinum. Borders of the posterior mediastinum

A tumor of the mediastinum is a relatively rare pathology. According to statistics, formations of this area are found in no more than 6-7% of cases of all human tumors. Most of them are benign, only a fifth of them are initially malignant.

Among patients with mediastinal neoplasms, there are approximately the same number of men and women, and the predominant age of the diseased is 20-40 years, that is, the most active and young part of the population suffers.

From the point of view of morphology, tumors of the mediastinal region are extremely heterogeneous, but almost all of them, even benign in nature, are potentially dangerous due to the possible compression of surrounding organs. In addition, the peculiarity of localization makes them difficult to remove, which is why they appear to be one of the most difficult problems in thoracic surgery.

Most people who are far from medicine have a very vague idea of what the mediastinum is and what organs are located there. In addition to the heart, structures of the respiratory system, large vascular trunks and nerves, the lymphatic apparatus of the chest, which can give rise to all kinds of formations, are concentrated in this area.

The mediastinum (mediastinum) is a space, the anterior part of which is formed by the sternum, the anterior sections of the ribs, covered from the inside by the retrosternal fascia. The posterior mediastinal wall is the anterior surface of the spinal column, the prevertebral fascia, and the posterior segments of the ribs. The lateral walls are represented by sheets of the pleura, and from below the mediastinal space is closed by the diaphragm. The upper part does not have a clear anatomical boundary; it is an imaginary plane running through the upper end of the sternum.

Within the mediastinum are the thymus, the superior segment of the superior vena cava, the aortic arch and arterial vascular lines originating from it, the thoracic lymphatic duct, nerve fibers, fiber, the esophagus passes behind, the heart is located in the middle zone in the pericardial sac, the zone of division of the trachea into bronchi, pulmonary vessels.

In the mediastinum, the upper, middle and lower floors are distinguished, as well as the anterior, middle and posterior parts. To analyze the extent of the tumor, the mediastinum is conditionally divided into upper and lower halves, the boundary between which is the upper part of the pericardium.

In the posterior mediastinum, growth of neoplasia from lymphoid tissue (), neurogenic tumors, metastatic cancers of other organs is characteristic. In the anterior mediastinal region, lymphoma and teratoid tumors, mesenchymomas from connective tissue components are formed, while the risk of malignancy of neoplasia of the anterior mediastinum is higher than in other departments. Lymphomas, cystic cavities of bronchogenic and dysembryogenetic genesis, and other cancers are formed in the middle mediastinum.

Tumors of the upper mediastinum are thymomas, lymphomas and intrathoracic goiter, as well. Thymomas, bronchogenic cysts are found on the middle floor, and pericardial cysts and fatty neoplasms are found in the lower mediastinal region.

Classification of mediastinal neoplasia

The tissues of the mediastinum are extremely diverse, so tumors in this area are united only by a common location, otherwise they are diverse and have different sources of development.

Tumors of the mediastinal organs are primary, that is, initially growing from the tissues of this area of the body, as well as secondary - metastatic nodes of cancers of another localization.

Primary mediastinal neoplasias are distinguished by histogenesis, that is, the tissue that became the ancestor of the pathology:

Neurogenic -, ganglioneuroma - grow from peripheral nerves and nerve ganglia;
Mesenchymal -, fibroma, etc.;
Lymphoproliferative - Hodgkin's disease, lymphoma, lymphosarcoma;
Dysontogenetic (formed in violation of embryonic development) - teratoma, chorionepithelioma;
- neoplasia of the thymus.

Mediastinal neoplasms are mature and immature, while mediastinal cancer is not quite the right wording, given the sources of its origin. Cancer is called epithelial neoplasia, and formations of connective tissue genesis and teratoma are found in the mediastinum. Cancer in the mediastinum is possible, but it will be secondary, that is, it will arise as a result of metastasis of carcinoma of another organ.

Thymomas- These are tumors of the thymus that affect people 30-40 years old. They make up about a fifth of all mediastinal tumors. There are malignant thymoma with a high degree of invasion (germination) of the surrounding structures, and benign. Both varieties are diagnosed with approximately equal frequency.

Disembryonic neoplasia- also not uncommon in the mediastinum, up to a third of all teratomas are malignant. They are formed from embryonic cells that have remained here since fetal development, and contain components of epidermal and connective tissue origin. Usually pathology is detected in adolescents. Immature teratomas grow actively, metastasize to the lungs and nearby lymph nodes.

Favorite localization of tumors neurogenic origin- nerves of the posterior mediastinum. Carriers can be vagus and intercostal nerves, spinal membranes, sympathetic plexus. They usually grow without causing any concern, but the spread of neoplasia into the spinal canal can provoke compression of the nervous tissue and neurological symptoms.

Tumors of mesenchymal origin- the widest group of neoplasms, diverse in structure and source. They can develop in all departments of the mediastinum, but more often in the anterior part. Lipomas - benign tumors of adipose tissue, usually unilateral, can spread up or down the mediastinum, penetrate from the anterior to the posterior region.

Lipomas have a soft texture, due to which the symptoms of compression of neighboring tissues do not occur, and the pathology is detected by chance during examination of the chest organs. A malignant analogue - liposarcoma - is rarely diagnosed in the mediastinum.

Fibromas are formed from fibrous connective tissue, grow asymptomatically for a long time, and the clinic is called upon reaching a large size. They can be multiple, of different shapes and sizes, have a connective tissue capsule. Malignant fibrosarcoma grows rapidly and provokes the formation of an effusion in the pleural cavity.

Hemangiomas Tumors from the vessels are quite rare in the mediastinum, but usually affect its anterior part. Neoplasms from the lymphatic vessels - lymphangiomas, hygromas - are usually found in children, form nodes, can grow into the neck, causing displacement of other organs. Uncomplicated forms are asymptomatic.

Mediastinal cyst- This is a tumor-like process, which is a rounded cavity. The cyst is congenital and acquired. Congenital cysts are considered a consequence of a violation of embryonic development, and their source can be the tissue of the bronchus, intestines, pericardium, etc. - bronchogenic, enterogenic cystic formations, teratomas. Secondary cysts form from the lymphatic system and tissues that are normally present here.

Symptoms of mediastinal tumors

For a long time, the tumor of the mediastinum is able to grow hidden, and the signs of the disease appear later, when the surrounding tissues are compressed, their germination, and metastasis begins. In such cases, pathology is detected during examination of the chest organs for other reasons.

Location, volume and degree of differentiation of the tumor determine the duration of the asymptomatic period. Malignant neoplasms grow faster, so the clinic appears earlier.

The main signs of tumors of the mediastinum include:

Symptoms of compression or invasion of neoplasia into surrounding structures;
General changes;
specific changes.

The main manifestation of the pathology is considered pain syndrome, which is associated with the pressure of the neoplasm or its invasion into the nerve fibers. This feature is characteristic not only for immature, but also for completely benign tumor processes. Pain disturbs on the growth side of the pathology, not too intense, pulling, can be given to the shoulder, neck, interscapular region. With left-sided pain, it can be very similar to that of angina pectoris.

An increase in soreness in the bones is considered an unfavorable symptom, which most likely indicates possible metastasis. For the same reason, pathological fractures are possible.

Characteristic symptoms appear when nerve fibers are involved in tumor growth:

Eyelid droop (ptosis), retraction of the eye and dilated pupil on the side of neoplasia, sweating disorder, fluctuations in skin temperature indicate the involvement of the sympathetic plexus;
Hoarseness of voice (laryngeal nerve affected);
An increase in the level of the diaphragm during the germination of the phrenic nerves;
Disorders of sensitivity, paresis and paralysis during compression of the spinal cord and its roots.

One of the symptoms of compression syndrome is the narrowing of the venous lines by a tumor, more often the superior vena cava, which is accompanied by difficulty in venous outflow from the tissues of the upper body and head. Patients in this case complain of noise and a feeling of heaviness in the head, increasing with bending over, soreness in the chest, shortness of breath, swelling and cyanosis of the skin of the face, expansion and congestion of the cervical veins with blood.

The pressure of the neoplasm on the airways provokes coughing and shortness of breath, and compression of the esophagus is accompanied by dysphagia, when it is difficult for the patient to eat.

Common signs of tumor growth are weakness, decreased performance, fever, sweating, weight loss, which indicate the malignancy of the pathology. The progressive increase in the tumor causes intoxication with the products of its metabolism, which is associated with joint pain, edematous syndrome, tachycardia, and arrhythmias.

Specific symptoms characteristic of certain types of neoplasms of the mediastinum. For example, lymphosarcomas cause skin itching, sweating, and fibrosarcomas occur with episodes of hypoglycemia. Intrathoracic goiter with elevated hormone levels is accompanied by signs of thyrotoxicosis.

Symptoms of a mediastinal cyst associated with the pressure that it exerts on neighboring organs, so the manifestations will depend on the size of the cavity. In most cases, cysts are asymptomatic and cause no discomfort to the patient.

With the pressure of a large cystic cavity on the mediastinal contents, shortness of breath, cough, swallowing disorders, a feeling of heaviness and pain in the chest may occur.

Dermoid cysts, which are the result of intrauterine development disorders, often give symptoms of cardiac and vascular disorders: shortness of breath, cough, pain in the heart, increased heart rate. When the cyst is opened, a cough appears in the lumen of the bronchus with sputum, in which hair and fat are distinguishable.

Dangerous complications of cysts are their ruptures with an increase in pneumothorax, hydrothorax, and the formation of fistulas in the chest cavities. Bronchogenic cysts can suppurate and lead to hemoptysis when opened into the lumen of the bronchus.

Thoracic surgeons and pulmonologists are more likely to encounter mediastinal tumors. Given the variety of symptoms, the diagnosis of mediastinal pathology presents significant difficulties. To confirm the diagnosis, radiography, MRI, CT, as well as endoscopic procedures (broncho- and mediastinoscopy) are used. A biopsy allows the final verification of the diagnosis.

Video: lecture on the diagnosis of tumors and cysts of the mediastinum

Treatment

Surgical operation is recognized as the only true method of treatment for tumors of the mediastinum. The sooner it is carried out, the better the prognosis for the patient. In benign formations, an open intervention is performed with complete excision of the neoplasia growth site. In the case of a malignant process, the most radical removal is indicated, and depending on the sensitivity to other types of antitumor treatment, chemotherapy and radiation therapy are prescribed, either alone or in combination with surgery.

When planning a surgical intervention, it is extremely important to choose the right approach, which will give the surgeon the best view and space for manipulation. The probability of recurrence or progression of the pathology depends on the radicalness of the removal.

Radical removal of neoplasms of the mediastinal region is performed by thoracoscopy or thoracotomy - anterior-lateral or lateral. If the pathology is located retrosternally or on both sides of the chest, a longitudinal sternotomy with a dissection of the sternum is considered preferable.

Videothoracoscopy- a relatively new method of treating a tumor of the mediastinum, in which the intervention is accompanied by minimal surgical trauma, but at the same time, the surgeon has the opportunity to examine the affected area in detail and remove the altered tissues. Videothoracoscopy makes it possible to achieve high treatment results even in patients with serious background pathology and a small functional reserve for further recovery.

In severe concomitant diseases that complicate the operation and anesthesia, palliative treatment is performed in the form of tumor removal by means of ultrasound by transthoracic access or partial excision of tumor tissues to decompress mediastinal formations.

Video: lecture on surgery for mediastinal tumors

Forecast in mediastinal tumors is ambiguous and depends on the type and degree of tumor differentiation. With thymomas, cysts, retrosternal goiter, mature connective tissue neoplasia, it is favorable, provided they are removed in a timely manner. Malignant tumors not only compress and germinate organs, disrupting their function, but also actively metastasize, which leads to an increase in cancer intoxication, the development of serious complications and the death of the patient.

The author selectively answers adequate questions from readers within his competence and only within the limits of the OncoLib.ru resource. Face-to-face consultations and assistance in organizing treatment are not currently provided.

The mediastinum is an anatomical space, the middle region of the chest. The mediastinum is bounded anteriorly by the sternum and posteriorly by the spine. On the sides of this organ are the pleural cavities.

For various purposes (surgical intervention, planning of radiation therapy, description of the localization of pathology), the mediastinum, in accordance with the scheme proposed by Twining in 1938, is divided into upper and lower, as well as anterior, posterior and middle sections.

Anterior, middle, posterior mediastinum

The anterior mediastinum is bounded anteriorly by the sternum, and posteriorly by the brachiocephalic veins, pericardium, and brachiocephalic trunk. In this space are the internal thoracic veins, the thoracic artery, the mediastinal lymph nodes and the thymus - the thymus gland.

The structure of the middle mediastinum: heart, vena cava, brachiocephalic veins and brachiocephalic trunk, aortic arch, ascending aorta, diaphragmatic veins, main bronchi, trachea, pulmonary veins and arteries.

The posterior mediastinum is bounded by the trachea and pericardium in the anterior part, and in the posterior by the spine. In this part of the body are the esophagus, descending aorta, thoracic lymphatic duct, semi-unpaired and unpaired veins, as well as the posterior lymph nodes of the mediastinum.

Superior and inferior mediastinum

All anatomical structures that lie above the upper edge of the pericardium belong to the superior mediastinum: its boundaries are the superior aperture of the sternum and the line drawn between the angle of the chest and the intervertebral disc Th4-Th5.

The inferior mediastinum is limited by the upper edges of the diaphragm and pericardium and, in turn, is also divided into anterior, middle and posterior parts.

Classification of neoplasms of the mediastinum

Neoplasms of the organ are considered not only true tumors of the mediastinum, but also tumor-like diseases and cysts that are different in etiology, localization and course of the disease. Each of the neoplasms of the mediastinum comes from tissues of different origin, uniting only by anatomical boundaries. They are divided into:

Tumors of the mediastinum are detected mainly in young and middle age with the same frequency, both in men and women. Despite the fact that diseases of the mediastinum may not manifest themselves for a long time and be detected only in a preventive study, there are several symptoms that characterize violations of this anatomical space:

Non-intense pain, localized at the site of neoplasms and radiating to the neck, shoulder, interscapular region;
Pupil dilation, drooping of the eyelid, retraction of the eyeball - can occur if the tumor grows into the borderline sympathetic trunk;
Hoarseness of voice - originates from damage to the recurrent laryngeal nerve;
Heaviness, noise in the head, shortness of breath, chest pain, cyanosis and swelling of the face, swelling of the veins of the chest and neck;
Violation of the passage of food through the esophagus.

In the late stages of mediastinal diseases, an increase in body temperature, general weakness, arthralgic syndrome, heart rhythm disturbance, and swelling of the extremities are observed.

Mediastinal lymphadenopathy

Lymphadenopathy or an increase in the lymph nodes of this organ are observed with metastases of carcinoma, lymphomas, as well as some non-tumor diseases (sarcoidosis, tuberculosis, etc.).

The main symptom of the disease is a generalized or localized enlargement of the lymph nodes, however, mediastinal lymphadenopathy may have such additional manifestations as:

Increased body temperature, sweating;
weight loss;
Frequent infection of the upper respiratory tract (tonsillitis, pharyngitis, tonsillitis);
Hepatomegaly and splenomegaly.

The defeat of the lymph nodes, characteristic of lymphomas, can be isolated, or combine the germination of tumors in other anatomical structures (trachea, blood vessels, bronchi, pleura, esophagus, lungs).

21.02.2017

The mediastinum, mediastinum, is a part of the chest cavity, delimited at the top by the upper chest opening, below by the diaphragm, in front by the sternum, behind by the spinal column, from the sides by the mediastinal pleura.

Mediastinum, mediastinum - part of the chest cavity, delimited at the top by the upper chest opening, below - by the diaphragm, in front - by the sternum, behind - by the spinal column, from the sides - by the mediastinal pleura. The mediastinum contains vital organs and neurovascular bundles. The organs of the mediastinum are surrounded by loose fatty tissue, which communicates with the tissue of the neck and retroperitoneal space, and through the fiber of the roots - with the interstitial tissue of the lungs. The mediastinum separates the right and left pleural cavities. Topographically, the mediastinum is a single space, but for practical purposes it is divided into two sections: the anterior and posterior mediastinum, mediastinum anterius et posterius.

The border between them corresponds to a plane close to the frontal, and runs at the level of the posterior surface of the trachea and the roots of the lungs (Fig. 229).

Rice. 229. Topographic ratios in the mediastinum (left view according to V. N. Shevkunenko)

1 - esophagus; 2 - vagus nerve; 3 - thoracic lymphatic duct; 4 - aortic arch; 5 - left recurrent nerve; 6 - left pulmonary artery; 7 - left bronchus; 8 - semi-unpaired vein; 9 - sympathetic trunk; 10 - diaphragm; 11 - pericardium; 12 - thoracic aorta; 13 - pulmonary veins; 14 - pericardial-phrenic arteries and vein; 15 - vrisberg knot; 16 - pleura; 17 - phrenic nerve; 18 - left common carotid artery; 19 - left subclavian artery.

In the anterior mediastinum are located: the heart and pericardium, the ascending aorta and its arch with networks, the pulmonary trunk and its branches, the superior vena cava and brachiocephalic veins; bronchial arteries and veins, pulmonary veins; trachea and bronchi; the thoracic part of the vagus nerves, lying above the level of the roots; phrenic nerves, lymph nodes; in children, in the hyoid gland, and in adults, the adipose tissue that replaces it.

In the posterior mediastinum are located: the esophagus, descending aorta, inferior vena cava, unpaired and semi-unpaired veins, thoracic lymphatic duct and lymph nodes; the thoracic part of the vagus nerves, which lies below the roots of the lungs; border sympathetic trunk together with celiac nerves, nerve plexuses.

The lymph nodes of the anterior and posterior mediastinum anastomose with each other and with the lymph nodes of the neck and retroperitoneal space.

Taking into account the peculiarities of the location of individual anatomical formations and pathological processes, in particular the lymph nodes, in practical work it is accepted to divide the anterior mediastinum into two sections: the anterior, actually retrosternal space, and the posterior, called the middle mediastinum, which houses the trachea and its surrounding lymph nodes. The boundary between the anterior and middle mediastinum is the frontal plane drawn along the anterior wall of the trachea. In addition, a conventionally drawn horizontal plane passing at the level of the tracheal bifurcation, the mediastinum is divided into upper and lower.

The lymph nodes. According to the International Anatomical Nomenclature, the following groups of lymph nodes are distinguished: tracheal, upper and lower tracheobronchial, bronchopulmonary, pulmonary, anterior and posterior mediastinal, peristernal, intercostal and diaphragmatic. However, for practical purposes, given the different localization of individual groups of lymph nodes in the corresponding sections of the mediastinum and the characteristics of regional lymphatic outflow, we consider it appropriate to use the classification of intrathoracic lymph nodes proposed by Rouviere and supplemented by D. A. Zhdanov.

According to this classification, parietal (parietal) and visceral (visceral) lymph nodes are distinguished. The parietal are located on the inner surface of the chest wall between the internal thoracic fascia and the parietal pleura, the visceral - dense adjacent to the mediastinal organs. Each of these groups in turn consists of separate subgroups of nodes, the name and location of which are presented below.

Parietal lymph nodes. 1. Anterior, parasternal, lymph nodes (4-5) are located on both sides of the sternum, along the internal thoracic blood vessels. They receive lymph from the mammary glands and the anterior chest wall.

The posterior, paravertebral, lymph nodes are located under the parietal pleura along the lateral and anterior surfaces of the vertebrae, below the level of the VI thoracic vertebra.

The intercostal lymph nodes are located along the furrows of the II - X ribs, each of them contains from one to six nodes.

The posterior intercostal nodes are constant, the lateral nodes are less constant.

The peristernal, perivertebral and intercostal lymph nodes receive lymph from the chest wall and anastomose with the lymph nodes of the neck and retroperitoneal space.

Internal lymph nodes. In the anterior mediastinum, several groups of lymph nodes are distinguished.

The upper prevascular lymph nodes are arranged in three chains:

a) prevenous - along the superior vena cava and right brachiocephalic vein (2-5 knots);

b) preaortocarotid (3-5 nodes) begin with a node of the arterial ligament, cross the aortic arch and continue to the top, the lobar carotid artery;

c) the transverse chain (1-2 nodes) is located along the left brachiocephalic vein.

Preascular lymph nodes receive lymph from the neck, partly from the lungs, thyroid gland
and hearts.

Lower diaphragmatic - consist of two groups of nodes:

a) prepericardial (2-3 nodes) are located behind the body of the sternum and the xiphoid process at the point of attachment of the diaphragm to the seventh costal cartilage;

b) lateropericardial (1-3 nodes) on each side are grouped above the diaphragm, along the lateral surfaces of the pericardium; the right nodes are more permanent and are located next to the inferior vena cava.

The lower diaphragmatic nodes receive lymph from the anterior sections of the diaphragm and partly from the liver.

The following groups of lymph nodes are located in the middle mediastinum.

Peritracheal lymph nodes (right and left) lie along the right and left walls of the trachea, non-permanent (posterior) - posterior to it. The right chain of peritracheal lymph nodes is located behind the superior vena cava and brachiocephalic veins (3-6 nodes). The lowest node of this chain is located directly above the confluence of the unpaired vein with the superior vena cava and is called the node of the unpaired vein. On the left, the peritracheal group consists of 4-5 small nodes and is closely adjacent to the left in the recurrent nerve. The lymph nodes of the left and right peritracheal circuits anastomose.

Traxeo - bronchial (1-2 nodes) are located in the outer corners formed by the trachea and main bronchi. The right and left tracheobronchial lymph nodes are mainly adjacent to the anterolateral surfaces of the trachea and main bronchi.

Bifurcation nodes (3-5 nodes) are located in the interval between the bifurcation of the trachea and the pulmonary veins, mainly along the lower wall of the right main bronchus.

Broncho - pulmonary lie in the region of the roots of the lungs, in the corners of the division of the main, lobar and segmental broncho. In relation to the lobar bronchi, the upper, lower, anterior and posterior bronchopulmonary nodes are distinguished.

The nodes of the pulmonary ligaments are unstable, located between the sheets of the pulmonary ligament.

Intrapulmonary nodes are located along the segmental bronchi, arteries, at the corners of their branching into subsegmental branches.

The lymph nodes of the middle mediastinum receive lymph from the lungs, trachea, larynx, pharynx, esophagus, thyroid gland, and heart.

There are two groups of lymph nodes in the posterior mediastinum.

1.0 coloesophageal (2-5 knots in) placed along the lower esophagus.

2. Interortoesophageal (1-2 nodes) along the descending aorta at the level of the lower pulmonary veins.

The lymph nodes of the posterior mediastinum receive lymph from the esophagus and partly from the abdominal organs.

Lymph from the lungs and mediastinum is collected by the efferent vessels, which fall into the thoracic lymphatic duct (ductus thoracicus), flowing into the left brachiocephalic vein.

Normally, the lymph nodes are small (0.3-1.5 cm). Bifurcation lymph nodes reach 1.5-2 cm.

tags: mediastinum
Start of activity (date): 21.02.2017 11:14:00
Created by (ID): 645
Keywords: mediastinum, pleura, interstitial tissue

Mediastinal surgery, one of the youngest branches of surgery, has received significant development due to the development of anesthetic management, surgical techniques, and diagnostics of various mediastinal processes and neoplasms. New diagnostic methods allow not only to accurately determine the localization of a pathological formation, but also make it possible to assess the structure and structure of the pathological focus, as well as to obtain material for pathological 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 diseases of the mediastinum.

Mediastinal injuries:

1. Closed trauma and injuries 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.

By clinical course:

A) acute non-purulent mediastinitis;

B) acute purulent mediastinitis;

C) chronic mediastinitis.

Mediastinal cysts.

1. Congenital:

A) coelomic cysts of the pericardium;

B) cystic lymphangitis;

C) bronchogenic cysts;

D) teratoma

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 collapse of the pericardial tumor;

D) mediastinal cysts emanating from the border areas.

Tumors of the mediastinum:

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

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

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

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

I. Tumors originating from the nervous tissue:

A) sympathoneuroma;

B) ganglioneuroma;

B) pheochromocytoma;

D) chemodectoma.

II. Tumors arising from nerve sheaths.

A) neuroma;

B) neurofibroma;

C) neurogenic sarcoma.

D) schwannomas.

D) ganglioneuromas

E) neurilemmomas

B. Connective tissue tumors:

A) fibroma;

B) chondroma;

C) osteochondroma of the mediastinum;

D) lipoma and liposarcoma;

E) tumors emanating from the vessels (benign and malignant);

E) myxomas;

G) hibernomas;

E) tumors from muscle tissue.

B. Tumors of the thymus:

A) thymoma;

B) cysts of the thymus gland.

D. Tumors from the reticular tissue:

A) lymphogranulomatosis;

B) lymphosarcoma and reticulosarcoma.

E. Tumors from ectopic tissues.

A) retrosternal goiter;

B) intrasternal goiter;

C) adenoma of the parathyroid gland.

The mediastinum is a complex anatomical formation located in the middle of the chest cavity, enclosed between the parietal sheets, the spinal column, the sternum and below the diaphragm, containing fiber and organs. The anatomical relationships of the organs in the mediastinum are quite complex, but their knowledge is obligatory 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 conditional boundary between them is the frontal plane drawn through the roots of the lungs. In the anterior mediastinum are located: the thymus gland, part of the aortic arch with branches, the superior vena cava with its origins (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 are located: the descending part of the aorta, the unpaired and semi-unpaired 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 celiac nerves, nerve plexuses, lymph nodes.

To establish the diagnosis of the disease, the localization of the process, its relationship to neighboring organs, in patients with mediastinal pathology, it is first necessary to conduct a complete 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. Usually patients complain of pain in the chest or heart area, interscapular region. Often, pain is preceded by a feeling of discomfort, expressed in a feeling of heaviness or a foreign mass in the chest. Often there is shortness of breath, shortness of breath. With compression of the superior vena cava, cyanosis of the skin of the face and upper half of the body, their swelling can be observed.

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

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

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

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

Mediastinal injury.

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

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

With imbibition of the blood of the vagus nerves, a vagal syndrome develops: respiratory failure, bradycardia, worsening of blood circulation, pneumonia of a confluent nature.

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

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

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

Damage to the thoracic lymphatic duct can be caused by:

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 of chylothorax. With unsuccessful conservative therapy for 10-25 days, surgical treatment is necessary: ligation of the thoracic lymphatic duct above and below the damage, in rare cases, parietal suturing of the duct wound, implantation in an unpaired vein.

Inflammatory diseases.

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

Acute mediastinitis can be caused by the following reasons.

Open injuries of the mediastinum.
1. Complications of operations on the organs of the mediastinum.
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 injury, damage by foreign bodies, tumor decay).

The clinical picture of acute mediastinitis consists of three main symptom complexes, the different 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.

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

With limited abscesses of the posterior mediastinum, dysphagia is the most common symptom. There may be a dry barking cough up to suffocation (involvement in the process 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 position of the patient is forced, semi-sitting. There may be swelling of 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 constant sign of mediastinitis. The pain is aggravated by swallowing and tilting the head back (Romanov's symptom). The localization of pain mainly reflects the localization of the abscess.

Local symptoms depend on the localization of the process.

Anterior mediastinitis	Posterior mediastinitis
Pain behind the sternum	Pain in the chest radiating to the interscapular space
Increased pain when tapping on the sternum	Increased pain with pressure on the spinous processes
Increased pain when tilting the head - Gercke's symptom	Increased pain when swallowing
Pastosity in the sternum	Pastosity in the region 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-unpaired veins: dilation of the intercostal veins, effusion in the pleura and pericardium
CT and NMR - blackout zone in the projection of the anterior mediastinum	CT and NMR - blackout zone in the projection of the posterior mediastinum
X-ray - a shadow in the anterior mediastinum, the presence of air	X-ray - a shadow in the posterior mediastinum, the presence of air

In the treatment of mediastinitis, active surgical tactics are used, followed by intensive detoxification, antibacterial and immunostimulating therapy. Surgical treatment consists in the implementation of optimal access, exposure of the injured area, suturing of the gap, drainage of the mediastinum and pleural cavity (if necessary) and the imposition of a gastrostomy. Mortality in acute purulent mediastinitis is 20-40%. When draining the mediastinum, it is best to use the technique of N.N. Kanshin (1973): drainage of the mediastinum with tubular drains, followed by fractional washing with antiseptic solutions and active aspiration.

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

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

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

The clinic is due to the degree of compression of the mediastinal organs. The following compression syndromes are identified:

superior vena cava syndrome
Compression syndrome of the pulmonary veins
Tracheobronchial syndrome
Esophageal syndrome
Pain syndrome
Nerve compression syndrome

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

Tumors of the mediastinum. All clinical symptoms of various volumetric formations of the mediastinum are usually divided into three main groups:

1. Symptoms from the organs of the mediastinum, squeezed by the tumor;

2. Vascular symptoms resulting from vascular compression;

3. Neurogenic symptoms that develop due to compression or germination of nerve trunks

Compression syndrome is manifested by compressed organs of the mediastinum. First of all, the veins of the brachiocephalic and superior vena cava are compressed - the syndrome of the superior vena cava. With further growth, compression of the trachea and bronchi is noted. This is manifested by coughing and shortness of breath. When the esophagus is compressed, swallowing and the passage of food are disturbed. When a tumor of the recurrent nerve is compressed, phonation is disturbed, paralysis of the vocal cord on the corresponding side. With compression of the phrenic nerve - high standing of the paralyzed half of the diaphragm.

With compression of the borderline sympathetic trunk of Horner's syndrome - drooping of the upper eyelid, constriction of the pupil, retraction of the eyeball.

Neuroendocrine disorders are manifested in the form of damage to the joints, heart rhythm disturbances, disorders of the emotional-volitional sphere.

Symptoms of tumors are varied. The leading role in the diagnosis, especially in the early stages before the onset of clinical symptoms, belongs to computed tomography and X-ray method.

Differential diagnosis of mediastinal tumors proper.

		Location		Content		malignancy	Density
Teratoma	Most common mediastinal tumor	Anterior mediastinum	Significant	Mucous, fat, hair, organ rudiments	Slow		elastic
neurogenic	Second in frequency	Posterior mediastinum	Significant	homogeneous	Slow			Fuzzy
Connective tissue	Third in frequency	Various, more 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 proper, although they are considered together with them due to localization features. They can behave both as benign and as malignant tumors, giving metastases. They develop either from the epithelial or from the lymphoid tissue of the gland. Often accompanied by the development of myasthenia gravis (Miastenia gravis). The malignant variant occurs 2 times more often, usually proceeds very hard and quickly leads to the death of the patient.

Surgical treatment is indicated:

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

The operation is contraindicated in:

established distant metastases to other organs or cervical and axillary lymph nodes;
compression of the superior vena cava with the transition to the mediastinum;
persistent paralysis of the vocal cord in the presence of a malignant tumor, manifested by hoarseness of voice;
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 in choosing the volume of surgical intervention in oncological patients, one should take into account not only the nature of the growth and prevalence of the tumor, but also the general condition of the patient, age, and the state of vital organs.

Surgical treatment of malignant tumors of the mediastinum gives poor results. Radiation treatment responds well to lymphogranulomatosis and reticulosarcoma. With true tumors of the mediastinum (teratoblastomas, neurinomas, connective tissue tumors), radiation treatment is ineffective. Chemotherapeutic methods of treatment of malignant true tumors of the mediastinum are also ineffective.

Purulent mediastinitis requires emergency surgery 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 operational approaches are used: a) full or partial longitudinal dissection of the sternum; b) transverse dissection of the sternum, while both pleural cavities are opened; c) both the anterior and posterior mediastinum can be opened through the left and right pleural cavities; d) diaphragmotomy with and without opening of the abdominal cavity; e) opening of 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 near the sternum, and sometimes with partial resection of the sternum.

Rehabilitation. Employability examination.

Clinical examination of patients

To determine the working capacity of patients, general clinical data are used with a mandatory approach to each examined person. During the initial examination, it is necessary to take into account clinical data, the nature of the pathological process - the disease or tumor, age, complications from the treatment, and in the presence of a tumor - and possible metastasis. Transfer to disability before return to professional work is usual. In benign tumors after their radical treatment, the prognosis is favorable. In malignant tumors, the prognosis is poor. Tumors of mesenchymal origin tend to develop relapses with subsequent malignancy.

In the future, the radical nature of the treatment, complications after treatment are important. Such complications include lymphostasis of the extremities, trophic ulcers after radiation treatment, impaired ventilation function of the lungs.

test questions

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

10. Principles of treatment of ruptures of the esophagus.

11. Causes of damage to the thoracic lymphatic duct.

12. Clinic of chylothorax.

13. Causes of chronic mediastinitis.

14. Classification of tumors of the mediastinum.

Situational tasks

1. A 24-year-old patient was admitted with complaints of irritability, sweating, weakness, and palpitations. Sick for 2 years. The thyroid gland is not enlarged. Main exchange +30%. Physical examination of the patient revealed no pathology. An X-ray examination in the anterior mediastinum at the level of the II rib on the right determines the formation of a rounded shape 5x5 cm with clear boundaries, the lung tissue is transparent.

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

2. The patient is 32 years old. Three years ago, she suddenly felt pain in her right arm. She was treated with physiotherapy - the pain decreased, but did not completely disappear. Subsequently, she noticed a dense, bumpy formation on the right side of the neck in the supraclavicular region. At the same time, the pain in the right half of the face and neck increased. Then she noticed a narrowing of the right palpebral fissure and the absence of sweating on the right half of the face.

On examination in the right clavicular region, a dense, tuberous, immobile tumor was found and an expansion of the superficial venous section of the upper half of the body in front. Slight atrophy and decreased muscle strength of the right shoulder girdle and upper limb. Dullness of percussion sound above the apex of the right lung.

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

3. The patient is 21 years old. She complained of a feeling of pressure in her chest. X-ray on the right to the upper part of the mediastinal shadow adjoins an additional 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 strategy in treating the patient?

4. During the last 4 months, the patient developed vague pain in the right hypochondrium, accompanied by increasing dysphagic changes. 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 is compressed at this level, but its mucosa is not changed. Above compression, there is a long delay in the esophagus.

Your presumptive diagnosis and tactics?

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

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

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

What is your diagnosis and tactics?

1. To clarify the diagnosis of intrasternal 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 - in order to identify the dislocation of the mediastinal organs and the displacement of tumors during swallowing. Tomographic examination - in order to identify the narrowing or displacement of the vein by the neoplasm; scanning and radioisotope study of thyroid functions with radioactive iodine. Clinical manifestations of thyrotoxicosis determine the indications for surgical treatment. Removal of the retrosternal goiter in this localization is less traumatic to carry out by cervical access, following the recommendations of V. G. Nikolaev to cross the sternohyoid, sternothyroid, sternocleidomastoid muscles. If there is a suspicion of the presence of fusion of the goiter with the surrounding tissues, transthoracic access is possible.

2. You can think of a neurogenic tumor of the mediastinum. Along with a clinical and neurological examination, radiography in frontal and lateral projections, tomography, pneumomediastinography, diagnostic pneumothorax, and angiocardiopulmography are 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 reacted, taking on a brown color.

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

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

4. A patient has a tumor in the posterior mediastinum. Most likely neurogenic. The diagnosis allows you to clarify a multifaceted x-ray examination. At the same time, the interest of neighboring organs can be identified. Given the localization of pain, the most likely cause is compression of the phrenic and vagus nerves. Surgical treatment, in the absence of contraindications.

5. You can think of an iatrogenic rupture of the esophagus with the formation of cervical mediastinitis. After 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 debridement of the wound.

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

The mediastinum is a collection of organs, nerves, lymph nodes and vessels that are located in the same space. In front, it is limited by the sternum, on the sides - by the pleura (the membrane surrounding the lungs), behind - by the thoracic spine. From below, the mediastinum is separated from the abdominal cavity by the largest respiratory muscle - the diaphragm. There is no border from above, the chest smoothly passes into the space of the neck.

Classification

For greater convenience of studying the organs of the chest, its entire space was divided into two large parts:

anterior mediastinum;

The front, in turn, is divided into upper and lower. The boundary between them is the base of the heart.

Also in the mediastinum, spaces filled with fatty tissue are isolated. They are located between the sheaths of vessels and organs. These include:

retrosternal or retrotracheal (superficial and deep) - between the sternum and the esophagus;
pretracheal - between the trachea and the aortic arch;
left and right tracheobronchial.

Borders and major organs

The border of the posterior mediastinum in front is the pericardium and trachea, behind - the anterior surface of the bodies of the thoracic vertebrae.

The following organs are located within the anterior mediastinum:

heart with a bag surrounding it (pericardium);
upper respiratory tract: trachea and bronchi;
thymus or thymus;
phrenic nerve;
the initial part of the vagus nerves;
two departments of the largest vessel of the body - part and arc).

The posterior mediastinum includes the following organs:

the descending part of the aorta and the vessels extending from it;
the upper part of the gastrointestinal tract - the esophagus;
part of the vagus nerves, located below the roots of the lungs;
thoracic lymphatic duct;
unpaired vein;
semi-unpaired vein;
abdominal nerves.

Features and anomalies of the structure of the esophagus

The esophagus is one of the largest organs of the mediastinum, namely its posterior part. Its upper border corresponds to the VI thoracic vertebra, and the lower one corresponds to the XI thoracic vertebra. This is a tubular organ that has a wall consisting of three layers:

mucous membrane inside;
muscle layer with annular and longitudinal fibers in the middle;
serous membrane outside.

The esophagus is divided into cervical, thoracic and abdominal parts. The longest of them is the chest. Its dimensions are approximately 20 cm. At the same time, the cervical region is about 4 cm long, and the abdominal region is only 1-1.5 cm.

Esophageal atresia is the most common malformation of the organ. This is a condition in which the named part of the alimentary canal does not pass into the stomach, but ends blindly. Sometimes atresia forms a connection between the esophagus and the trachea, which is called a fistula.

It is possible to form fistulas without atresia. These passages can occur with the respiratory organs, pleural cavity, mediastinum, and even directly with the surrounding space. In addition to congenital etiology, fistulas are formed after injuries, surgical interventions, cancerous and infectious processes.

Features of the structure of the descending aorta

Considering the anatomy of the chest, it should be disassembled - the largest vessel in the body. In the back of the mediastinum is its descending section. This is the third part of the aorta.

The entire vessel is divided into two large sections: thoracic and abdominal. The first of them is located in the mediastinum from the IV thoracic vertebra to the XII. To the right of it is an unpaired vein and on the left side is a semi-unpaired vein, in front - a bronchus and a heart bag.

Gives two groups of branches to the internal organs and tissues of the body: visceral and parietal. The second group includes 20 intercostal arteries, 10 on each side. Internal, in turn, include:

- most often there are 3 of them, which carry blood to the bronchi and lungs;
esophageal arteries - there are from 4 to 7 of them, supplying blood to the esophagus;
vessels supplying blood to the pericardium;
mediastinal branches - carry blood to the lymph nodes of the mediastinum and fatty tissue.

Features of the structure of the unpaired and semi-unpaired vein

The unpaired vein is a continuation of the right ascending lumbar artery. It enters the posterior mediastinum between the legs of the main respiratory organ - the diaphragm. There, on the left side of the vein is the aorta, spine and thoracic lymphatic duct. 9 intercostal veins flow into it on the right side, bronchial and esophageal veins. The continuation of the unpaired vein is the inferior vena cava, which carries blood from the whole body directly to the heart. This transition is located at the level of IV-V thoracic vertebrae.

The semi-unpaired vein is also formed from the ascending lumbar artery, only located on the left. In the mediastinum, it is located behind the aorta. After it comes to the left side of the spine. Almost all intercostal veins on the left flow into it.

Features of the structure of the thoracic duct

Considering the anatomy of the chest, it is worth mentioning the thoracic part of the lymphatic duct. This department originates in the aortic opening of the diaphragm. And it ends at the level of the upper thoracic aperture. First, the duct is covered by the aorta, then by the wall of the esophagus. The intercostal lymphatic vessels flow into it from both sides, which carry lymph from the back of the chest cavity. It also includes the broncho-mediastinal trunk, which collects lymph from the left side of the chest.

At the level of the II-V thoracic vertebrae, the lymphatic duct turns sharply to the left and then approaches the VII cervical vertebra. On average, its length is 40 cm, and the width of the lumen is 0.5-1.5 cm.

There are different variants of the structure of the thoracic duct: with one or two trunks, with a single trunk that bifurcates, straight or with loops.

Blood enters the duct through the intercostal vessels and esophageal arteries.

Features of the structure of the vagus nerves

The left and right vagus nerves of the posterior mediastinum are isolated. The left nerve trunk enters the space of the chest between two arteries: the left subclavian and the common carotid. The left recurrent nerve departs from it, enveloping the aorta and tending to the neck. Further, the vagus nerve goes behind the left bronchus, and even lower - in front of the esophagus.

The right vagus nerve is first placed between the subclavian artery and vein. The right recurrent nerve departs from it, which, like the left one, approaches the space of the neck.

The thoracic nerve gives off four main branches:

anterior bronchial - are part of the anterior pulmonary plexus along with the branches of the sympathetic trunk;
posterior bronchial - are part of the posterior pulmonary plexus;
to the heart bag - small branches carry a nerve impulse to the pericardium;
esophageal - form the anterior and posterior esophageal plexuses.

Mediastinal lymph nodes

All lymph nodes located in this space are divided into two systems: parietal and visceral.

The visceral system of lymph nodes includes the following formations:

anterior lymph nodes: right and left anterior mediastinal, transverse;
posterior mediastinal;
tracheobronchial.

Studying what is in the posterior mediastinum, it is necessary to pay special attention to the lymph nodes. Since the presence of changes in them is a characteristic sign of an infectious or cancerous process. The generalized increase is called lymphadenopathy. For a long time it can proceed without any symptoms. But a prolonged increase in lymph nodes eventually makes itself felt with such disorders:

weight loss;
lack of appetite;
increased sweating;
high body temperature;
angina or pharyngitis;
enlargement of the liver and spleen.

Not only medical workers, but also ordinary people should have an idea about the structure of the posterior mediastinum and the organs that are in it. After all, this is a very important anatomical formation. Violation of its structure can lead to serious consequences requiring the help of a specialist.