Anterior mediastinum. Mediastinum, its boundaries, divisions, contents. Treatment of mediastinal tumors

The mediastinum is a part of the chest cavity, which is located between the pleural sacs (left and right), it is limited in front by the sternum, in the back by the spine, namely its thoracic region, the lower border of the mediastinum is the diaphragm, the upper one is the upper aperture of the chest (in other words, the mediastinum - this is a certain group of organs that is located between the mediastinal parts of the parietal pleura of the lungs). Conditionally allocate two divisions of the mediastinum : superior mediastinum and inferior mediastinum. The separation is carried out along a horizontal plane, this plane passes through the border between the handle and the body of the sternum and the gap between the fourth and fifth thoracic vertebrae (it is much easier to remember that the upper mediastinum is above the roots of the lungs, and the lower one is below).

• Anterior mediastinum located between the anterior part of the chest, as well as the anterior part of the pericardium. The anterior mediastinum includes the internal thoracic blood vessels (arteries and veins), as well as the anterior mediastinal, parasternal, and prepericardial lymph nodes.
• Middle mediastinum determined by the boundaries of the anterior surface and the posterior surface of the heart shirt. The middle mediastinum includes the heart and its pericardium, as well as intrapericardial sections of large blood vessels, pulmonary arteries and veins, main bronchi, nerves of the diaphragm, and lymph nodes.
• Posterior mediastinum located between the back of the pericardium and the spine itself. (It is much easier to say that in front of the heart is the anterior mediastinum, behind it is the posterior one, and the pericardial cavity, where the heart itself and something else is located, is the middle mediastinum). The posterior mediastinum includes part of the descending aorta, veins (semiazygous and azygous), lower elements of the esophagus and sympathetic trunks, thoracic lymphatic duct, vagus nerves, posterior mediastinal lymph nodes and prevertebral lymph nodes, as well as splanchnic nerves.

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.

The mediastinum is the area located between the pleural sacs. Bounded laterally by the mediastinal pleura, it extends from the superior thoracic inlet to the diaphragm and from the sternum to the spine. The mediastinum is potentially mobile and is normally kept in the middle position due to the balance of pressure in both pleural cavities. In rare cases, holes in the mediastinal pleura cause communication between the pleural sacs. In infants and young children, the mediastinum is extremely mobile, later it becomes more rigid, so that unilateral changes in pressure in the pleural cavity have a correspondingly less effect on it.

Fig.34. Divisions of the mediastinum.

Anatomists divide the mediastinum into 4 sections (Fig. 34). The lower border of the superior mediastinum is a plane drawn through the manubrium of the sternum and the IV thoracic vertebra. This arbitrary border runs below the aortic arch just above the tracheal bifurcation. The anatomical boundaries of the other compartments are shown in Table 18. Lesions with increasing volume in the mediastinum can shift the anatomical boundaries, so that the lesion, which usually occupies its own zone, can spread to others. Changes in a small congested upper mediastinum are especially prone to overstep arbitrary boundaries. However, in the norm, some formations extend to more than one department, for example, the thymus gland, which extends from the neck through the superior mediastinum to the anterior, the aorta and esophagus, located both in the superior and posterior mediastinum. The anatomic division of the mediastinum is of little clinical importance, but localization of lesions in the mediastinum provides valuable information in establishing the diagnosis (Table 19 and Figure 35). However, the diagnosis can rarely be established and even more rarely benign and malignant lesions can be distinguished before accurate histological data are obtained. In 1/5 of cases, tumors or cysts of the mediastinum may undergo malignant transformation.

Fig.35. Localization of tumors and cysts of the mediastinum on the lateral radiograph.

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. 1. closed chest injury;
2. 2. knife and gunshot wounds;
3. 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.

1. 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.

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:

1. superior vena cava syndrome
2. Compression syndrome of the pulmonary veins
3. Tracheobronchial syndrome
4. Esophageal syndrome
5. Pain syndrome
6. 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.

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:

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

The operation is contraindicated in:

1. established distant metastases to other organs or cervical and axillary lymph nodes;
2. compression of the superior vena cava with the transition to the mediastinum;
3. persistent paralysis of the vocal cord in the presence of a malignant tumor, manifested by hoarseness of voice;
4. dissemination of a malignant tumor with the occurrence of hemorrhagic pleurisy;
5. 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. 1. Classification of diseases of the mediastinum.
2. 2. Clinical symptoms of mediastinal tumors.
3. 3. Methods for diagnosing neoplasms of the mediastinum.
4. 4. Indications and contraindications for surgical treatment of tumors and cysts of the mediastinum.
5. 5. Operational access to the anterior and posterior mediastinum.
6. 6. Causes of purulent mediastinitis.
7. 7. Clinic of purulent mediastinitis.
8. 8. Methods of opening abscesses with mediastinitis.
9. 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.