Etienne Leroy Terquem – Pierre L’Her SPI / ISP Soutien Pneumologique International /...
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![Page 1: Etienne Leroy Terquem – Pierre L’Her SPI / ISP Soutien Pneumologique International / International Support for Pulmonology Mediastinal syndrome.](https://reader033.fdocuments.us/reader033/viewer/2022061404/5697bff41a28abf838cbd3d2/html5/thumbnails/1.jpg)
Etienne Leroy Terquem – Pierre L’HerSPI / ISP
Soutien Pneumologique International / International Support for Pulmonology
Mediastinal syndrome
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Mediastinum , anatomic recall
Space between the 2 lungs containing :
The heartThe big vessels (aorta, veina cava…)OesophagusNerves Nodes
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- correct inspiration : 9 posterior rib arches visible above the diaphragm (or 6 anterior rib arches above diaphragm )
-strictly front view :spinal line in the middle of the clavicle internal limits
Postero anterior incidence of the X ray beam
Adequat penetration / contrast
Technical conditions to make a good analysis of mediastinum on a CXR:
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This is a trap picture:
The first impression is that mediastinum is enlarged. It is wrong because in this case the CXR has not been made in
optimal condition: old woman with cyphoscoliosis and too
tired to stand up: cxr in decubitus position.
The consequency is a false enlargment of the
mediastinum with overlap of the 2 hilus areas
(notice that the position of the patient has been notified on the right edge of
the cxr)
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Is there a mediastinum enlargment?
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This a trap picture: false enlargment of the
mediastinum area, because non complete inspiration.
(only 7 posterior ribs arches visible above the
diaphragm. They should be minimum 9) .
The incidence is not strictly a front view
(the spinal cord line is not strictly in the middle of the clavicles internal limits) which contribute to false mediastinum enlargment
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Good quality CXR: - correct inspiration : 9 posterior rib arches visible above the diaphragm
(or 6 anterior rib arches above diaphragm )
-strictly front view :spinal line in the middle of the clavicle internal limits
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Partatracheal line
para-azygos line
para-oesophagus line
right paravertébral line
para-aortic line
Left paravertébral line
aorto-pulmonary line
Drawings and illustrations fromPr Daniel Jeanbourquin
Mediastinum lines
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Three of them are really important.
Right paratracheal line
Para-aortic line
Aorto pulmonary line
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Normal CXRTB adenopathy in the latero-tracheal area
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Adenopathy in aorto pulmonary window
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Bronchial cancer in contact with descending aorta (positive silhouette sign )
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Division of the mediastinum
The different compartments
(Felson classification)
For each compartment Specific etiologies
illustrations from Pr Daniel Jeanbourquin. France
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Anterior mediastinum
Middle mediastinum
Posterior mediastinum
Anterior edge of the trachea
Posterior edge of the heart
1 cm behind the anterior edge of
the vertebral body
Rib posterior arch
Posterior face of the sternum
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Superior mediastinum
Middle mediastinum
Inferior mediastinum
ANTERIOR MEDIASTINUM:Three tiers.
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Goitre
Lymphoma, thymoma
pleuro-péricardic cysts
ANTERIOR MEDIASTINUM
Endothoracic goitre LymphomaThymoma
germinal tumorsAscending aortic
aneuvrysm
Pleuro-pericardic cysts trans
diaphragmatic hernia
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GoitreANTERIOR MEDIASTINUM
superior tier Endothoracic goitre
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2
Application of the silhouette sign:The cervico-thoracic pass sign
1
2
1
2
1: The external and superior contours of the mediastinal opacity disappear above the
clavicles. This sign means that the opacity is anterior in the superior mediastinum
2: The superior edge of the opacity is visible in the pulmonary air above the
clavicles: the opacity is posterior
clavicle
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intrathoracic anterior goitre
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intrathoracic anterior goitre
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intrathoracic goitre
(compression of the trachea: main complication
of intra thoracic goiter)
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anterior intrathoracic goitre with tracheal compression
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anterior intrathoracic goitre with tracheal compression
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intrathoracic anterior goitre
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intrathoracic anterior goitre
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intrathoracic goitre(compression of the trachea)
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Posterior goitre Courtesy of Dr. Bellamy
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Posterior goitre Courtesy of Dr. Bellamy
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ANTERIOR MEDIASTINUM
MIDDLE TIER
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ANTERIOR MEDIASTINUM
Middle tier
Lymphoma
Thymoma
germinal tumours
Ascending aorta aneuvrysm
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Thymoma
Normal lateral view
Notice that the retro-sternal space is filled by the tumour
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Thymoma
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germinal tumour
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Man, 21 years old, worsening condition, asthenia, 38°C fever, weight loss (-5kg in 2 months), nocturnal sweating.
Notice the silhouette sign with heart (anterior mediastinum)And with the aortic arch ( extension to the middle mediastinum)
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Hodgkin’s disease
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Chest x-ray after chemotherapy
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Ascending aorta aneurysm
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Anterior mediastinuminferior tier
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pleuro-pericardic cysts
ANTERIOR MEDIASTINUM
Inferior tier
Pleuro-pericardic cysts
And trans diaphragmatic hernia
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Courtesy Dr L. Kalisa-Rwanda
Pleuro pericardial cyst
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Trans diaphragmatic hernia
(Morgani hiatus hernia)
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Middle mediastinum
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Middle mediastinum
ADENOPATHIES
-TUBERCULOSIS
-bronchial cancer
-lymphoma
-sarcoïdosis
bronchogenic cysts
Oesophageal pathology (hiatal hernia)
vascular lesions (aortic aneurysm)
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The most frequent
mediastinal mass is
ADENOPATHY
The most frequent etiology of adenopathy in countries with
high incidence of TB is TB
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trachea oesophagus
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right hilar and mediastinal adenopathy
tuberculous adenopathy
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Mediastinal enlargement suggesting adenopathies of superior mediastinum (normal x-ray image on the right)
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The most frequent localisations of TB adenopathies. In this area, lateral view is very usefull for diagnosis
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Lateral view is very usefull for diagnosis of mediastnum adenopathies in sub carena and inter tracheo bronchial areas
Rx normale
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Lateral view is very usefull for diagnosis of mediastnum adenopathies in sub carena and inter tracheo bronchial areas
Rx normale
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Right hilar adenopathy. Is there mediastinum associated adenopathies? Notice mediastinum enlargment
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Lateral view, previous case : hilar and mediastinum adenopathies.. On the right side normal lateral view. Lateral view is useful to confirm hilar and mediastinum adenopathies in the carena area. Notice partial atelectasis of the middle lobe .
Normal lateral view
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Normal chest x-rayAorto-pulmonary spaceAdenopathy
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Tuberculous adenopathy . Scannographic and endoscopic views
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Tuberculous adenopathies
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Tuberculous adenopathy with bronchial lesions
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Tuberculosis / HIV +
Tubeculous adenopathies are very frequent in cases of AIDS, and sometimes very bulky
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Here you see a CXR of TB/HIV co-infection: bulky bilateral adenopathies
(associated TB intra abdominal adenopathies)
Normal scan
Part 4 : tuberculous adenopathies
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Sarcoidosis In countries with high incidence of TB this CXR
would stongly suggest TB adenopathies
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Lateral view is very usefyll for diagnosis of hilar and mediastinum adenopathies
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But mediastinum adenopathies are not always tuberculous
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Bronchial carcinoma
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Bronchial carcinoma with superior vena cava syndrome
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Superior vena cava syndrome
Lyndon D. Wilson and coll New Eng. Med. Journal May 2007
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Small cell carcinoma bronchial cancer
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Bilateral adenopathies and left inferior opacity with retraction: probable left inferior atelectasis*: In adults the association of hilar adenopathies with atelectasis strongly
suggests bronchial cancer.
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Previous case Normal scan view
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After chemotherapy
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Young woman, 19 years old, Hodgkin’s disease.
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Young woman, 19 years old, Hodgkin’s disease.
normal view
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Bronchial cancer with hilar adenopathies
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Bronchogenic cysts10% of mediastinal tumours
embryology
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Bronchogenic cysts
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Bronchogenic cyst (courtesy of Dr. Bellamy )
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oesophageal diverticulum
Oesophagus pathology is not well
visible on CXR
If no scanner ,use baryte opacification
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Mega-oesophagus
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Aorta arch aneurysm
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Descending aorta aneurysm
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Descending aorta aneurysm
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Aneurysm of aortic arch and descending aorta
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Aneurysm of aortic arch and descending aorta
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Hiatal hernia: round opacity, in retro-cardiac situation, with a liquid level, disappearing in decubitus position
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Hiatal hernia
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Posterior mediastinum
Neurogenic tumours
and rachis pathology
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Neurogenic tumours Tumours of the nervous sheath (adults++): -Schwannoma (benign or very rarely malignant),
the most common - Neurofibroma Tumours of the nervous cells: -neuroblastoma, ganglioneuroblastoma
(children+++) -ganglioneuroma (adults) Tumours of the paraganglions: -paraganglioma
Malignant tumours: Adults: 1 to 4%
Children: 40 to 60%
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Neurogenic tumours
Courtesy Pr Jeanbourquin France
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Woman, 35 years old systematic radiologic examination
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Scanner and MRI: neurogenic tumour of the posterior mediastinum
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Pott’s disease: tuberculosis of para vertebra and psoas muscles and of vertebra corpus
1998 1999
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In cases of posterior mass, always look at the rachis and consider Pott’s disease.