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Mediastinum

The mediastinum is the central compartment of the thoracic cavity, located between the left and right pleural sacs that enclose the lungs, and it contains vital structures such as the heart, major blood vessels, trachea, esophagus, and associated nerves and lymphatics.^[1] It extends longitudinally from the superior thoracic inlet at the base of the neck to the diaphragm inferiorly, serving as a protective passageway for cardiopulmonary and vascular elements between the neck, chest, and abdomen.^[1]^[2] Bounded anteriorly by the sternum, posteriorly by the vertebral column from T1 to T12, and laterally by the mediastinal pleura, the mediastinum occupies the midline of the thorax and measures approximately 8 cm in width in adults, with widening beyond this potentially indicating pathology.^[1]^[2] Traditionally divided into four compartments for anatomical study—superior, anterior, middle, and posterior—the mediastinum's organization reflects its role in housing and interconnecting key thoracic structures.^[1] An alternative three-compartment model proposed by the International Thymic Malignancy Interest Group (ITMIG) classifies it as prevascular, visceral, and paravertebral, aiding in clinical imaging and surgical approaches.^[2] The superior mediastinum, situated above the plane of the sternal angle (T4-T5), includes the thymus or its remnant, the aortic arch with its branches, the superior vena cava, trachea, esophagus, and phrenic and vagus nerves.^[1] The anterior mediastinum, anterior to the pericardium, primarily consists of loose connective tissue, fat, lymph nodes, and the thymus in younger individuals.^[1] In the middle mediastinum, the heart is enclosed within the pericardial sac, accompanied by the ascending aorta, pulmonary trunk, superior and inferior vena cavae, main bronchi, and portions of the trachea and phrenic nerves.^[1] The posterior mediastinum, behind the pericardium and extending to the diaphragm, contains the descending thoracic aorta, esophagus, azygos and hemiazygos veins, thoracic duct, vagus and splanchnic nerves, and sympathetic chains.^[1] These divisions underscore the mediastinum's critical function in supporting circulation, respiration, and lymphatic drainage while protecting against trauma.^[2]

Overview

Definition and Location

The mediastinum is defined as the central compartment of the thoracic cavity, situated between the pleural sacs of the lungs and extending from the thoracic inlet superiorly to the diaphragm inferiorly.^[1] This midline space occupies the thoracic region, separating the left and right lungs while housing essential structures such as the heart, major blood vessels, trachea, esophagus, thymus, and lymph nodes.^[3]^[4] The term and its anatomical conceptualization were described by Henry Gray in his 1858 publication Anatomy, Descriptive and Surgical, where it was portrayed as the interpleural space containing thoracic viscera excluding the lungs, positioned between the right and left pleurae in the median sagittal plane.^[5] Subsequent refinements to this definition have incorporated advancements in imaging modalities like computed tomography (CT), enabling more precise delineation of its compartments for clinical applications such as mass diagnosis and surgical planning.^[6] Functionally, the mediastinum serves to protect and support the thoracic viscera by providing a stable, connective tissue-enclosed passageway amid the dynamic respiratory movements of the surrounding lungs.^[2] It is conventionally divided into superior and inferior portions, with the latter further subdivided into anterior, middle, and posterior compartments, though modern imaging-based systems emphasize prevascular, visceral, and paravertebral zones for enhanced diagnostic utility.^[6]

Boundaries and Divisions

The mediastinum occupies the central compartment of the thoracic cavity, bounded anteriorly by the sternum and the costal cartilages from the second to the fourth ribs, which provide a rigid osseocartilaginous framework. Posteriorly, it is delimited by the vertebral column, encompassing the bodies of the thoracic vertebrae and the intervertebral discs from T1 to T12, forming a stable bony posterior wall. Laterally, the boundaries are defined by the parietal pleura of both lungs, which separate the mediastinum from the pleural cavities and allow for independent lung expansion.^[1]^[7] Superiorly, the mediastinum is demarcated by the plane of Louis, also known as the sternal angle or angle of Louis, which corresponds to the junction of the manubrium and body of the sternum at the level of the T4/T5 intervertebral disc; this transverse plane separates the superior mediastinum from the inferior mediastinum below. Inferiorly, the boundary is formed by the thoracic surface of the diaphragm, which domes upward to approximately the T12 vertebral level at its central tendon, marking the transition to the abdominal cavity. These boundaries enclose a dynamic space that accommodates vital thoracic structures while maintaining separation from adjacent compartments.^[1]^[7] The standard anatomical divisions of the mediastinum organize this space into the superior mediastinum, extending from the thoracic inlet down to the plane of Louis, and the inferior mediastinum, which spans from that plane to the diaphragm. The inferior mediastinum is further partitioned into three compartments: the anterior mediastinum, located between the sternum and the pericardium; the middle mediastinum, centered on the pericardial sac containing the heart; and the posterior mediastinum, situated between the pericardium and the vertebral column. These subdivisions are primarily conceptual, with the pericardium serving as the key physical landmark separating the anterior and middle from the posterior regions, though no complete septa exist across the entire space.^[1]^[7] This compartmental framework aids in clinical and surgical navigation by providing a standardized reference for localizing structures and pathologies within the thorax. Originating from 19th-century cadaveric dissections that emphasized gross anatomical landmarks, as initially outlined in seminal works like Henry Gray's Anatomy (1858), the divisions have evolved with advancements in imaging; modern CT-based classifications, such as the International Thymic Malignancy Interest Group (ITMIG) model introduced in 2014, refine these into three compartments (prevascular, visceral, and paravertebral) to better align with cross-sectional radiology and improve diagnostic precision.^[8]

Anatomy

Superior Mediastinum

The superior mediastinum is the uppermost compartment of the mediastinal space, serving as a critical passageway connecting the neck and thoracic cavity. It extends superiorly from the thoracic inlet to the transverse plane at the level of the sternal angle (angle of Louis) and the T4/T5 intervertebral disc, with lateral boundaries formed by the mediastinal pleurae, an anterior limit at the manubrium of the sternum, and a posterior boundary along the anterior surfaces of the upper four thoracic vertebrae.^[1]^[9] This region facilitates the transit of major neurovascular structures from the neck into the thorax, accommodating dynamic arrangements essential for systemic circulation and innervation. Key contents of the superior mediastinum include portions of several vital structures. The thymus gland occupies a central position, particularly in younger individuals, though it may involute with age. The upper segments of the trachea and esophagus traverse this space posteriorly, maintaining patency for air and food passage. The thoracic duct, the primary lymphatic vessel, ascends along the posterior aspect, draining lymph from the lower body into the venous system.^[1]^[10] Vascular elements dominate the superior mediastinum, with intricate arrangements supporting venous return and arterial distribution. The right and left brachiocephalic veins form by the union of the internal jugular and subclavian veins posterior to the sternoclavicular joints; the left brachiocephalic vein, longer at approximately 6-7 cm, crosses midline anterior to the aortic arch to join the right, forming the superior vena cava, whose uppermost portion resides here. The aortic arch originates from the ascending aorta and gives rise to three major branches: the brachiocephalic trunk (supplying the right subclavian and common carotid arteries), the left common carotid artery, and the left subclavian artery, all branching within this compartment to deliver oxygenated blood to the head, neck, and upper limbs. The arch of the azygos vein also enters the superior vena cava at the right tracheobronchial angle.^[1]^[10]^[9] Neural components include the bilateral phrenic nerves (arising from C3-C5 roots), which descend anterior to the subclavian arteries and root of the lung to innervate the diaphragm and pericardium, and the vagus nerves (cranial nerve X), which course posteriorly to the brachiocephalic veins, giving off recurrent laryngeal branches and contributing to the cardiac, pulmonary, and esophageal plexuses. The sympathetic trunks lie posterolaterally, providing autonomic innervation to thoracic viscera.^[1]^[10]^[9] Lymphatic drainage in the superior mediastinum is mediated by paratracheal and tracheobronchial lymph nodes, which receive afferents from the lungs, trachea, and esophagus before channeling into the thoracic duct or right lymphatic duct.^[10] In clinical practice, magnetic resonance imaging (MRI) is particularly valuable for evaluating vascular anomalies in the superior mediastinum, such as malformations causing mass effect on adjacent structures; T2-weighted sequences reveal hyperintense lesions with flow voids, aiding precise diagnosis and surgical planning.^[11]

Anterior Mediastinum

The anterior mediastinum constitutes the smallest compartment of the inferior mediastinum, situated between the body of the sternum anteriorly and the pericardium posteriorly. It extends from the plane of the sternal angle (angle of Louis) superiorly to the diaphragm inferiorly, with lateral boundaries formed by the mediastinal pleurae and anterior limits including the transversus thoracis muscles and the fifth, sixth, and seventh left costal cartilages.^[12]^[1] This compartment primarily contains loose areolar connective tissue, which includes the sternopericardial ligaments, small fat deposits, and lymphatic structures such as anterior mediastinal lymph nodes that drain to the parasternal nodes along the internal thoracic vessels. The internal thoracic (mammary) arteries and veins course through this space, providing vascular supply to the anterior thoracic wall. Key among its contents is the thymus gland, whose main body resides here in children and adolescents but involutes with age, undergoing fatty replacement in adults; thymic remnants or vestigial tissue may persist.^[12]^[1]^[1] Embryologically, the thymus originates from endodermal thickenings in the third pharyngeal pouch around the sixth week of gestation, forming bilateral thymopharyngeal ducts that descend caudally and medially to fuse in the anterior mediastinum by the eighth week, with the ducts subsequently involuting. The gland reaches peak size at puberty before atrophying, often leaving only fatty or cystic remnants derived from embryonic structures like the ultimobranchial body. Variations include ectopic thymic tissue, which may occur along the descent path due to incomplete migration, such as in the neck or intrathyroidal locations, with a prevalence of up to 0.99% for intrathyroidal cases in pediatric populations; such anomalies are typically asymptomatic but can mimic masses on imaging.^[13]^[14]

Middle Mediastinum

The middle mediastinum constitutes the central division of the inferior mediastinum, encompassing the heart and its enveloping pericardium as primary structures. It is bounded anteriorly and posteriorly by the pericardium, laterally by the mediastinal pleura of the lungs, superiorly by the transverse plane from the sternal angle to the T4 vertebral level, and inferiorly by the superior surface of the diaphragm. This compartment extends from the plane of Louis (sternal angle) to the diaphragm base, forming a protective enclosure for vital cardiovascular elements.^[15]^[1] Central to the middle mediastinum is the heart, including all four chambers (right and left atria, right and left ventricles), positioned within the pericardium. The pericardium comprises an outer fibrous layer—a tough, inelastic connective tissue sac continuous with the diaphragm's central tendon and great vessels—and an inner serous layer, divided into parietal (lining the fibrous layer) and visceral (epicardium adhering to the heart) components. The narrow pericardial cavity between these serous layers contains 15–50 mL of lubricating fluid, enabling frictionless cardiac movement. The phrenic nerves traverse the pericardial surfaces laterally, providing sensory innervation to the pericardial layers.^[16]^[17]^[1] Pericardial recesses include the transverse and oblique sinuses, formed by serous pericardium reflections. The transverse sinus lies superior to the left atrium, posterior to the ascending aorta and pulmonary trunk, and anterior to the superior vena cava and atria, creating a passageway that separates great vessel outflows from inflows. The oblique sinus forms a J-shaped cul-de-sac posterior to the left atrium, bounded by the pulmonary veins anteriorly and the inferior vena cava inferiorly, extending between the visceral and parietal layers. These sinuses and the pericardial cavity represent potential spaces where fluid can accumulate, as in pericardial effusions, leading to increased intrapericardial pressure.^[17]^[16]^[18] Key vascular elements encompass the ascending aorta emerging from the aortic root at the left ventricular base, the pulmonary trunk arising from the right ventricular outflow tract and dividing into the pulmonary arteries, the lower segment of the superior vena cava, the superior portion of the inferior vena cava, and the azygos vein's arch crossing the right tracheobronchial region. The aortic root and pulmonary valve are situated centrally within the pericardial sac, optimizing hemodynamic efficiency. These vessels link to continuations from the superior mediastinum.^[19]^[15]^[1] Innervation of the middle mediastinum is biphasic, with parasympathetic input from vagus nerve branches forming the cardiac plexus to influence heart rate and conduction, and sympathetic supply from T1–T4 chain ganglia also via the cardiac plexus for acceleratory effects. The phrenic nerves (C3–C5 origins) provide additional somatic sensory fibers to the pericardium and motor supply to the diaphragm. Echocardiography offers detailed visualization of these structures, using views like parasternal long-axis (for aortic root and effusions), parasternal short-axis (for chambers and valves), apical four-chamber (for atrial and ventricular assessment), and subcostal (for inferior pericardium), where effusions manifest as echo-free spaces exceeding 15–35 mL.^[1]^[15]^[20]

Posterior Mediastinum

The posterior mediastinum is the compartment of the inferior mediastinum situated posterior to the pericardium and anterior to the vertebral column, extending superiorly from the plane of Louis (sternal angle at the T4/T5 intervertebral disc level) to the diaphragm inferiorly.^[21] Laterally, it is bounded by the mediastinal pleura, enclosing structures involved in vascular descent, esophageal transit, and lymphatic drainage.^[22] This region facilitates the passage of key conduits from the thorax to the abdomen, distinct from the cardiac focus of the adjacent middle mediastinum.^[23] Key contents of the posterior mediastinum include the thoracic portion of the esophagus, the descending thoracic aorta, the azygos system of veins (comprising the azygos vein, hemiazygos vein, and accessory hemiazygos vein), the thoracic duct, and neural elements such as the vagus nerves, sympathetic trunks, and splanchnic nerves.^[24] The descending thoracic aorta originates from the aortic arch at the T4/T5 level, courses posteriorly to the left of the vertebral column, and gives off branches including esophageal, bronchial, and posterior intercostal arteries before passing through the aortic hiatus at T12.^[25] The azygos system drains venous blood from the posterior thoracic and abdominal walls, with the azygos vein ascending on the right side to join the superior vena cava at T4, while the hemiazygos and accessory hemiazygos veins on the left cross midline to anastomose with it.^[21] The thoracic esophagus, approximately 20-25 cm in length, traverses the posterior mediastinum from the T1 level to the T10/T11 esophageal hiatus, featuring two physiological constrictions: at the broncho-aortic crossing (T4/T5 level), and at the diaphragmatic hiatus (T10).^[23] Its muscularis externa transitions from striated muscle in the upper third (innervated by somatic fibers via the vagus nerve) to smooth muscle in the lower two-thirds (controlled by autonomic fibers), enabling peristaltic propulsion.^[26] Arterial supply derives primarily from esophageal branches of the descending thoracic aorta in the middle third, supplemented by the inferior thyroid artery superiorly and left gastric artery inferiorly; venous drainage follows similar segmental patterns into the azygos system and portal vein.^[23] The vagus nerves (CN X) descend bilaterally, forming the esophageal plexus around the mid-thoracic esophagus to provide parasympathetic innervation, while the sympathetic trunks lie posterolaterally with greater and lesser splanchnic nerves (T5-T9 and T10-T12 origins, respectively) piercing the crura to reach abdominal viscera.^[27] The thoracic duct, the primary lymphatic vessel, originates from the cisterna chyli at the L1/L2 vertebral level in the abdomen, ascends through the aortic hiatus into the posterior mediastinum between the descending aorta and azygos vein, and courses posterior to the esophagus before arching laterally at T5 to drain into the left subclavian vein junction.^[28] It conveys lymph and chyle from approximately 75% of the body, including lipids absorbed from the intestines.^[29] Clinically, the posterior mediastinum's structures are prone to specific pathologies; for instance, portal hypertension can lead to esophageal varices in the lower thoracic esophagus due to portosystemic shunts via submucosal veins, risking rupture and hemorrhage.^[23] Injuries to the thoracic duct, often from trauma, surgery (e.g., esophageal or aortic procedures), or malignancy, may result in chylothorax, a chyle accumulation in the pleural space causing respiratory compromise.^[28]

Clinical Significance

Mediastinal Masses and Tumors

Mediastinal masses and tumors encompass a diverse group of neoplastic lesions arising within the mediastinal compartments, classified primarily as anterior (prevascular), middle (visceral), and posterior (paravertebral) based on the International Thymic Malignancy Interest Group (ITMIG) system. These lesions vary in etiology, with benign tumors often congenital or developmental in origin, such as teratomas, while malignant ones include thymic carcinomas and lymphomas, frequently linked to genetic alterations or lymphoid proliferation. Incidence is low overall, representing less than 1% of all tumors, but anterior compartment involvement predominates, accounting for approximately 60% of cases in adults.^[30]^[31]^[32] In the anterior mediastinum, common masses include thymomas, which comprise 20-50% of lesions and typically affect adults aged 40-60, often presenting as benign or low-grade malignancies associated with paraneoplastic syndromes like myasthenia gravis; teratomas, mature and benign in 70-80% of cases, arising from germ cell migration errors in young adults; thyroid goiters extending retrosternally; and lymphomas, particularly Hodgkin and non-Hodgkin types, which are malignant in nearly all instances and peak in younger patients. The "terrible T's" mnemonic highlights these thymic, teratoma, thyroid, and T-cell lymphoma entities as representative anterior pathologies. Middle mediastinal tumors are less common and often benign, including bronchogenic and pericardial cysts (50-60% of compartment masses), which are congenital foregut malformations, though malignant esophageal tumors like adenocarcinomas can occur. Posterior masses are dominated by neurogenic tumors, such as schwannomas and neurofibromas, which account for over 60% of lesions and are benign in 70% of cases, originating from neural crest derivatives; esophageal tumors, including gastrointestinal stromal tumors (GISTs), represent malignant subsets.^[30]^[31]^[32] Etiologically, benign masses like teratomas and neurogenic tumors often stem from embryonic remnants, while malignant ones, such as germ cell tumors in young adults (15-35 years) and thymic carcinomas, involve oncogenic drivers including TP53 mutations (prevalent in approximately 25-30% of thymic carcinoma cases, correlating with poor prognosis) and KIT mutations (found in 10-20% of thymic carcinomas and esophageal GISTs, enabling targeted therapies like imatinib). Many masses are asymptomatic, discovered incidentally on imaging, but symptomatic cases arise from compression of adjacent structures, leading to dyspnea (in 30-50% of large tumors), superior vena cava (SVC) syndrome (particularly with anterior lymphomas or thymomas), cough, or chest pain.^[30]^[31]^[33] Diagnosis relies on multimodal imaging and biopsy for confirmation and staging. Computed tomography (CT) is the initial modality for localization and characterization, revealing density patterns (e.g., fat in teratomas), while positron emission tomography-CT (PET-CT) assesses malignancy via FDG uptake, aiding lymphoma staging and distinguishing benign from malignant thymic lesions. CT-guided fine-needle aspiration biopsy provides tissue diagnosis in 80-90% of cases, though video-assisted thoracoscopic surgery (VATS) is preferred for anterior or equivocal lesions to avoid complications like pneumothorax. Staging follows Masaoka-Koga or TNM systems, with PET-CT crucial for detecting metastases in thymic carcinomas.^[30]^[31]^[32] Recent advances emphasize molecular profiling and targeted therapies. In thymic carcinomas, KIT mutations drive responsiveness to tyrosine kinase inhibitors, with response rates up to 50% in mutated subsets, while CYLD mutations may predict immunotherapy efficacy. Immunotherapy, particularly PD-1 inhibitors like pembrolizumab, has emerged in the 2020s for advanced thymic carcinoma post-platinum chemotherapy, showing objective response rates of 20-25% and progression-free survival of 4-6 months in phase II trials, though contraindicated in thymomas due to high (40-70%) immune-related adverse events like myositis. Combination approaches, such as avelumab with axitinib, yield higher response rates (up to 34%), highlighting ongoing shifts toward personalized treatment.^[33]^[34]^[35]

Widening and Shift

Widening of the mediastinum refers to an abnormal increase in the transverse diameter of the mediastinal silhouette on chest radiography, typically defined as greater than 8 cm measured at the level of the aortic knob on a posteroanterior (PA) view.^[36]^[37]^[38] The normal mediastinal width ranges from 6 to 8 cm in adults on a properly positioned PA chest X-ray (CXR), though measurements can vary slightly based on patient body habitus and inspiratory effort.^[39]^[40] This radiographic sign often prompts further evaluation, as it may indicate underlying pathology, but technical factors such as supine anteroposterior (AP) projections or poor inspiration can artifactually magnify the appearance.^[41]^[42] Common causes of mediastinal widening include vascular emergencies such as aortic dissection and thoracic aortic aneurysm, which expand the silhouette due to intramural hematoma or vessel dilatation.^[43]^[40]^[44] Traumatic injuries, particularly blunt aortic injury from deceleration mechanisms like motor vehicle collisions, lead to mediastinal hematoma and acute widening.^[43]^[45] Lymphadenopathy, often from reactive or neoplastic processes, can also contribute by enlarging mediastinal nodes, though this is distinguished from vascular causes via cross-sectional imaging.^[46]^[37] Mediastinal shift describes the deviation of central structures, such as the trachea or cardiac silhouette, from the midline on imaging, resulting from unequal intrathoracic pressures.^[47] This shift occurs away from the affected side in conditions like tension pneumothorax, where accumulating air increases ipsilateral pressure and compresses the contralateral lung.^[48]^[49] Large pleural effusions cause contralateral shift by mass effect, displacing the trachea and heart shadow.^[50] Lung collapse, such as from atelectasis or endobronchial obstruction, produces ipsilateral shift as volume loss pulls mediastinal structures toward the affected hemithorax.^[47]^[51] Diagnostic criteria for mediastinal widening on CXR involve measuring the horizontal distance from the right heart border to the left mediastinal margin at the aortic knob, with values exceeding 8 cm or more than one-third of the thoracic diameter considered abnormal, particularly on supine films.^[36]^[52] On computed tomography (CT), which provides superior anatomic detail, widening is assessed by evaluating mediastinal contours, vessel caliber, and tissue density; for instance, mediastinal fat typically measures -50 to -100 Hounsfield units (HU), while soft-tissue components range from 40 to 60 HU, aiding differentiation of hematoma (30-60 HU) from physiologic fat.^[39]^[53]^[30] Clinically, acute mediastinal widening correlates with life-threatening trauma, such as blunt aortic injury, where up to 80-90% of cases are fatal without prompt intervention, often detected within hours of deceleration trauma.^[54]^[55] Chronic widening is frequently linked to progressive aortic aneurysms, which may remain asymptomatic until rupture risk escalates, with diameters exceeding 5.5 cm indicating higher intervention thresholds per guidelines.^[56]^[44] By 2025, artificial intelligence (AI)-assisted tools have emerged to enhance detection of mediastinal widening on CXR, with algorithms like Lunit INSIGHT CXR achieving high sensitivity for abnormalities including widening, pneumothorax, and effusions, improving radiologist workflow in emergency settings.^[57]^[58] These deep learning models, trained on large datasets, localize widening with accuracy comparable to specialists, facilitating faster triage.^[59]^[60]

Infections and Inflammation

Infections and inflammation of the mediastinum encompass a range of conditions that can compromise vital thoracic structures, including acute and chronic forms of mediastinitis as well as granulomatous diseases like sarcoidosis. These processes often arise from direct spread of pathogens or systemic inflammatory responses, leading to significant morbidity if not promptly addressed. Acute mediastinitis, in particular, is a life-threatening emergency characterized by rapid progression, while chronic variants involve progressive fibrosis.^[61] Mediastinitis refers to inflammation or infection of the mediastinal tissues, divided into acute and chronic subtypes based on etiology and tempo. Acute mediastinitis most commonly occurs postoperatively following sternotomy for cardiac surgery, with an incidence of 0.5% to 2.5%, or as descending necrotizing mediastinitis originating from odontogenic infections in the oropharynx that spread via fascial planes. Chronic mediastinitis, often fibrosing, is typically triggered by granulomatous infections such as histoplasmosis, leading to scarring and compression of mediastinal structures over months to years.^[61]^[62]^[63] Pathophysiologically, acute forms are predominantly bacterial, with Staphylococcus aureus (including methicillin-resistant strains) accounting for 60% to 80% of postoperative cases due to surgical contamination, while polymicrobial infections involving anaerobes predominate in descending types. Fungal pathogens like Aspergillus are rarer but occur in immunocompromised patients, contributing to necrotizing tissue destruction and potential lymphatic spread through posterior mediastinal channels. In chronic fibrosing mediastinitis, Histoplasma capsulatum induces a granulomatous response that evolves into dense fibrosis, narrowing vascular and airway lumens.^[61]^[64] Symptoms of mediastinitis include high fever, retrosternal chest pain, dysphagia, and odynophagia, often accompanied by neck swelling in descending cases; respiratory distress and tachycardia may signal progression. Complications such as sepsis, mediastinal abscesses, and multiorgan failure are common, with mortality rates ranging from 20% to 40% in acute descending necrotizing mediastinitis despite intervention, and lower (1% to 14%) in postoperative variants.^[61]^[65]^[66] Treatment of acute mediastinitis emphasizes broad-spectrum intravenous antibiotics (e.g., vancomycin plus piperacillin-tazobactam) initiated empirically, followed by culture-guided adjustment, alongside urgent surgical drainage and debridement to remove necrotic tissue. For chronic fibrosing mediastinitis, management is supportive, with antifungal therapy (e.g., itraconazole for histoplasmosis) and potential stenting for symptomatic compression; corticosteroids may be used adjunctively in inflammatory flares. Early diagnosis via contrast-enhanced CT, which reveals mediastinal air-fluid collections or widening, is critical to improving outcomes.^[61]^[62]^[67] Beyond mediastinitis, sarcoidosis frequently manifests as mediastinal inflammation through noncaseating granulomatous lymphadenopathy, affecting over 90% of patients with pulmonary involvement and often presenting as bilateral hilar and right paratracheal enlargement on imaging. This granulomatous process, driven by macrophage and T-cell clusters, can cause cough, dyspnea, or chest discomfort in symptomatic cases (about 50%), though many remain asymptomatic; treatment involves glucocorticoids like prednisone (20-40 mg/day initially) for progressive disease to suppress inflammation.^[68]^[68] Purulent pericarditis represents another inflammatory condition with mediastinal extension, where bacterial infection (e.g., from Streptococcus or gram-negatives) spreads contiguously from mediastinal or pulmonary sources, leading to pus accumulation and widespread thoracic involvement. This rare entity carries high mortality due to its association with extensive mediastinal sepsis, managed with antibiotics and pericardial drainage, though outcomes remain poor without addressing the underlying source.^[69]^[69]

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[29]
Lymphatic Anatomy and Physiology - PMC - PubMed Central - NIH
The thoracic duct begins at the superior aspect of the cisterna chyli and travels cephalad ( Fig. 4 ). It ascends between the aorta and azygos vein laterally, ...Missing: L1 | Show results with:L1
[30]
A diagnostic approach to mediastinal masses in clinical practice - PMC
May 8, 2025 · This review discusses the most common mediastinal masses in adults, providing a practical approach to their differentiation mainly based on the predominant ...
[31]
Mediastinal Cancer - StatPearls - NCBI Bookshelf
The mediastinum is a cavity that separates the lungs from the other structures in the chest. Generally, mediastinum is divided into 3 main parts: anterior, ...
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Diagnosis, treatment, and management of mediastinal masses - PMC
Oct 27, 2025 · Mediastinal neoplasms are relatively rare tumors that require surgical or non-surgical treatment, and they harbor a wide variety of cell types.
[33]
Genomic insights into molecular profiling of thymic carcinoma
Jun 5, 2024 · Genomic insights into molecular profiling of thymic carcinoma: a narrative review ... thymic carcinoma who have KIT mutations. TET2 mutation is ...
[34]
Immunotherapy for Thymomas and Thymic Carcinomas
Immunotherapy is currently contraindicated outside of a clinical trial for patients with thymoma. Patients with thymic carcinoma receiving immunotherapy should ...
[35]
https://pubmed.ncbi.nlm.nih.gov/33248322/
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[PDF] Evaluation of the Widened Mediastinum
Widened mediastinum: Definition: A mediastinum measurement of ≥8 cm or >1/3rd the transthoracic distance at the level of the aortic knob on a supine AP film.
[37]
Widened mediastinum - WikEM
Oct 14, 2019 · Background. Diagnosed on plain radiography of the chest; Mediastinal width >8cm is abnormal; Potential causes include:.
[38]
Wide Mediastinum - FPnotebook
Mar 2, 2018 · Widened Mediastinum Criteria. Superior mediastinum >8 cm wide at the aortic knob (on PA View) OR; Mediastinum >33% of the transthoracic dstance ...
[39]
Widened Mediastinum - StatPearls - NCBI Bookshelf - NIH
A widened mediastinum is a feature often seen on a plain chest x-ray. When the mediastinum is greater than 6 to 8cm, depending on which source, it is noted to ...Definition/Introduction · Issues of Concern · Clinical Significance
[40]
Widened mediastinum at elderly: a challenge in the emergency ...
Dec 30, 2022 · A widened mediastinum is a feature often seen on a plain chest x-ray. When the mediastinum is greater than 6 to 8 cm, depending on which source, it is noted to ...
[41]
ABC of CXR Interpretation • LITFL • Examination Medicine
Mar 23, 2023 · Should have a width <8 cm on a PA CXR. A widened mediastinum can be associated with: AP CXR view, which magnifies the heart and mediastinal ...
[42]
Chest X-ray Abnormalities - Mediastinal abnormalities
Mediastinal widening. Widening of the mediastinum is most often due to technical factors such as patient positioning or the projection used.<|separator|>
[43]
Mediastinal widening (differential) | Radiology Reference Article
Feb 23, 2025 · The differential diagnoses for mediastinal widening include: traumatic aortic injury: look for asymmetric widening and blood attenuation.
[44]
Thoracic aortic aneurysm - Symptoms and causes - Mayo Clinic
Apr 18, 2025 · An aneurysm can occur anywhere in the body's main artery, called the aorta. Having an aortic aneurysm increases the risk of a tear in the aortic ...
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Widening of the Mediastinum - Radiology Key
Jun 12, 2019 · Widening of the mediastinum is a common observation that may be related to patient body habitus or atherosclerotic dilatation of the aorta and great vessels.
[46]
Mediastinal Mass (Tumor): Types, Symptoms, Causes & Treatment
This area, called the mediastinum, is surrounded by your breastbone in front, your spine in back and your lungs on each side. Your mediastinum contains your ...Overview · Middle Mediastinal Masses · Symptoms And CausesMissing: anatomy | Show results with:anatomy
[47]
Shift of the Mediastinum | Radiology Key
Jun 12, 2019 · Shift of the mediastinum indicates an imbalance of intrathoracic pressures. The mass effect of a large pleural effusion, pneumothorax, or intrathoracic mass ...
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Tension Pneumothorax - StatPearls - NCBI Bookshelf
Jul 7, 2025 · Tracheal deviation and mediastinal shift toward the contralateral side may be evident. Air release confirms the diagnosis upon inserting a large ...
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Tension Pneumothorax: What Is It, Causes, Signs ... - Osmosis
Mar 4, 2025 · Tension pneumothorax is a life-threatening condition caused by the continuous entrance and entrapment of air into the pleural space.
[50]
Mediastinal Shift: Sign of Malignant Pleural Effusion Diagnosis
This is clinically and radiologically detected by a shift in the trachea and heart to the side opposite to the pleural effusion. This is commonly seen in ...Missing: tension | Show results with:tension
[51]
Tracheal shift on CXR - Radiology at St. Vincent's University Hospital
In this case, the tracheal displacement is due to a massive right pleural effusion, opacifying almost the entire right hemithorax. This was a malignant pleural ...
[52]
How is the mediastinum measured on a chest X-ray (CXR) and what ...
Jul 30, 2025 · The most widely used criterion for a widened mediastinum on chest X-ray is a mediastinal width greater than 8 cm on a supine anteroposterior ...
[53]
Anterior Mediastinal Masses | AJR
On CT, however, a lipoma has characteristic homogeneous fat attenuation (usually −50 to −100 HU), no contrast enhancement, and well-defined margins. If the ...
[54]
Traumatic Aortic Injuries - StatPearls - NCBI Bookshelf
Mar 19, 2024 · Traumatic aortic injuries encompass a spectrum of potentially life-threatening conditions resulting from blunt or penetrating trauma to the aorta.
[55]
Current updates in acute traumatic aortic injury: radiologic diagnosis ...
Jun 30, 2022 · Acute traumatic aortic injuries are associated with substantial lethal outcome at the time of admission fatal in 80% to 90% of cases. These ...
[56]
2022 ACC/AHA Guideline for the Diagnosis and Management of ...
Nov 2, 2022 · The 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease provides recommendations to guide clinicians in the diagnosis, genetic evaluation ...
[57]
Artificial intelligence-assisted chest radiograph interpretation in Role ...
Oct 15, 2025 · INSIGHT CXR is a neural network-based software intended to assist radiologists in interpreting anteroposterior chest radiographs by detecting ...
[58]
Impact of AI Assistance in Pneumothorax Detection on Chest ... - NIH
Oct 19, 2025 · This software is designed to detect 10 common abnormalities (pneumothorax, mediastinal widening, pneumoperitoneum, nodule/mass ...
[59]
Artificial Intelligence Analysis of Chest Radiographs for Predicting ...
Aug 18, 2025 · The AI tool detects 10 types of abnormalities (atelectasis, calcification, cardiomegaly, consolidation, fibrosis, mediastinal widening, nodules, ...
[60]
AI- assisted detection for chest X- rays (AID- CXR): a multi - BMJ Open
In this study, we aim to evaluate the impact of one such tool (Lunit INSIGHT CXR) that can detect and localise ten common abnormalities on chest ...
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Mediastinitis - StatPearls - NCBI Bookshelf - NIH
Treatment for acute mediastinitis usually focuses on the early initiation of antibiotics and surgical debridement as necessary.[3][14][25] Antibiotics should ...
[62]
Acute Mediastinitis – Outcomes and Prognostic Factors of Surgical ...
The successful treatment of AM depends on the early diagnosis and rapid surgical management of this not so common disease, whereby the aim is to remove the ...Missing: symptoms | Show results with:symptoms
[63]
Acute mediastinitis, mediastinal granuloma, and chronic fibrosing ...
Jun 15, 2021 · Acute mediastinitis is a rare infection that carries high morbidity and mortality. They are complications seen most often with deep sternal wound infections.Missing: symptoms | Show results with:symptoms
[64]
Acute mediastinitis associated with tracheobronchial tuberculosis ...
Tuberculosis and fungal infections, such as histoplasmosis and aspergillosis, are the most common infections in chronic mediastinitis but rarely cause AM.
[65]
Acute Descending Mediastinitis: An Unusual Presentation - PMC
Jul 26, 2022 · Patients with acute descending mediastinitis can present with a wide spectrum of symptomatology including chills, high fever, tachycardia, dyspnea, ...
[66]
Descending necrotizing mediastinitis: key points to reduce the high ...
It is an uncommon disease with a mortality rate of about 20–40%. This high mortality is mainly attributed to delays in diagnosis and treatment and poor drainage ...
[67]
Descending necrotizing mediastinitis: etiopathogenesis, diagnosis ...
Formerly quite high mortality rates up to 40% decreased in recent years to an reported overall mortality rate of 17.5%, credited to the widespread use of ...
[68]
Clinical Manifestations, Diagnosis, and Treatment of Sarcoidosis
Aug 2, 2019 · Sarcoidosis is a systemic disease that can affect any organ, with the lungs and intrathoracic lymph nodes being the most frequently affected sites.
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Pericardial heart disease: its morphologic features and its causes
Purulent pericarditis with or without antibiotic treatment has a poor prognosis. It nearly always indicates a widespread infection of the mediastinum and lung.