Disease of Mediastinum and Pleura

Question 1

What are the:

Anterior

Lateral

Posterior

Superior

Inferior

borders of the mediastinum?

Answer 1

Anterior: Sternum

Lateral: Parietal Pleura (bilateral)

Posterior: Paravertebral gutters and ribs

Superior: Thoracic inlet

Inferior: Diaphragm

Question 2

Anatomically, what is located within the anterior superior compartment of the mediastinum?

Answer 2

Thymus gland

Aortic root and great vessels

Substernal thyroid and parathyroid tissue

Lymphatic vessels and nodes

Inferior aspect of trachea and esophagus

Question 3

What’s located within the middle compartment of the mediastinum?

Answer 3

Pericardial sac

Heart

Innominate veins and SVC

Trachea and major bronchi

Hila

Lymph nodes

Phrenic, upper vagus, and recurrent laryngeal nerves

Question 4

What’s located in the posterior compartment of the mediastinum?

Answer 4

Esophagus

Descending aorta

Hemiazygos and azygous veins

Thoracic duct

Lymph nodes

Vagus nerves

Sympathetic chain

Question 5

T or F?

An asymptomatic mass is benign 80% of the time,

a symptomatic mass is malignant 80% of the time.

Answer 5

False

Asymptomatic benign 80%,

symptomatic malignant 50% of time

Question 6

List some of the symtpoms associated with a symptomatic mediastinal mass

Answer 6

Fever, Anorexia, Weight loss

Endocrine syndromes

Autoimmune disorders (thymus related)

Question 7

In terms of mass location and symptoms in the mediastinum, how do children differ from adults?

Answer 7

Children: 65% are located posteriorly, 2/3rds are symptomatic

Adults: 65% are located anteriorly, 1/3rd are symptomatic

Question 8

What is the cause of B symptoms? What is being compressed?

Answer 8

Trick question.

The symptoms in B symptoms (night sweats, fevers, weight loss) are caused by the tumor releasing things out into the blood stream.

The tumor is not compressing any nerves or organs (which would cause symptoms)

Question 9

When doing physical exam for mediastinal masses, what is particularly important?

Answer 9

Weight loss

Blood pressure changes

Lymphadenopaty

The head, neck, upper extremities and chest exams.

Question 10

Why is CT better than CXR for looking at mediastinal masses?

Answer 10

You can tell if the mass is solid or fluid filled.

Differentiate between lymph structures or blood vessels

Question 11

Give the 4 terrible T’s of an anterior mediastinal mass differential?

Answer 11

Thymic neoplasm

Teratoma (germ cell tumor)

(Terrible) Lymphoma (Hodgkins or Non-Hodgkins)

Thyroid neoplasm

Question 12

What type of lesion comprises about 20% of middle compartment masses?

Answer 12

Cysts (fluid filled masses).

Remember that the middle compartment has a whole lot of stuff in it, so there’s lots of potential causes for masses there.

Question 13

What type of masses are most common in the posterior compartment? In who are these more common?

Answer 13

Tend to be masses involved with nerves (neurinomas, neurogenic tumors, etc).

More common in kids.

Question 14

For which compartment are the CBC markers Beta-HCG, alpha-fetoprotein, and Anti-acetylcholine receptor antibodies most indicative?

Are these markers the best method?

Answer 14

The anterior compartment (indicative of teratomas or thymomas).

Markers aren’t the best method, the best is to get a tissue sample (either through biopsies or surgical procedures)

Question 15

List the 4 major complications of mediastinal masses as presented in class.

Answer 15

1) Tracheal obstruction
2) SVC Syndrome (SVC compression)
3) Esophageal rupture
4) Vascular invasion (hemorrhage)

Question 16

What are the 2 components of the pleura, and which is associated with pain?

Where do the 2 components meet?

Answer 16

1) Visceral Pleura (lines the lung)
2) Parietal Pleura (lines the inner cavity)

The parieta pleura is associated with pain because it lines the cavity which is innervated.

They meet at the hilum of the lung.

Question 17

What are the 3 major disorders of the pleura?

Answer 17

1) Pneumothorax (air in the lungs)
2) Pleural effusion
3) Pleural based abnormalities

Question 18

What conditions are associated with spontaneous pneumothorax?

Answer 18

COPD

Interstitial Lung Diseases

Cystic Fibrosis

Lung Cancer

Question 19

What conditions are associated with traumatic pneumothorax (3 categories)?

Answer 19

1) Iatrogenic-complication of needle biopsy or central line
2) Barotrauma-intubation, mechanical ventilation
3) Trauma-penetrating or non-penetrating.

Question 20

What is the peak age for someone to have spontaneous pneumothorax?

Answer 20

Early 20s.

Usually occurs in someone with no precipitating events and no known lung diseases

Question 21

What are some of the hallmark clinical findings of someone with pneumothorax?

Answer 21

Acute chest pain, Dyspnea, Sense of doom/anxiety, cyanosis.

Percussion=hyper resonant

Decreased breath sounds

Decreased fremitus

Question 22

How should pneumothorax be treated?

Answer 22

Put them on 100% oxygen

Chest tube

Observation

Simple aspiration

Pleurodesis (adhese the 2 pleura)

Question 23

T or F?

Primary spontaneous pneumothorax is more dangerous than tension pneumothorax

Answer 23

False.

Tension pneumothorax is when intrapleural pressure exceeds atmospheric pressure and the lung collapses and becomes really small. The person is likely to die if you don’t intervene quickly.

Question 24

You’re in a plane crash on a deserted island. The person next to you all of a sudden can’t breath, and you realize they have tension pneumothorax. You realize you’re going to have to poke a hole in them to get the air out. Shoot! You forget where the neurovascular bundle is located on the ribs!! You don’t want to puncture that.. Should you go above or below the rib?

Answer 24

Above!

The neurovascular bundle runs along the bottom.

You’re a hero and you get tons of medals when you get home because you unknowingly saved the King of Nigeria.

Question 25

Pleural effusion is when the pleural fluid filling exceeds the drainage. Give some of the hallmarks of someone with pleural effusion.

Answer 25

Dry cough

Pleuritic chest pain (pain on inspiration)

Decreased breath sounds

Dullness to percussion

Question 26

What’s the difference between transudative and exudative pleural effusions?

Answer 26

Transudative=alteration in hydrostatic pressures that attract fluids (not protein rich)

Exudative=alterations in pleural permeability or rate of fluid removal (protein rich)

Question 27

Diagnostically, how do you differentiate between transudative and exudative effusions?

Answer 27

Perform a thoracentesis (extract pleural fluid) and look at the LDH_pl/LDH_ser and Prot_pl/Prot_ser ratios.

If the LDH ratio is

If the LDH ratio is >0.6 or the Prot ratio is >0.5 or LDH_pl is 2/3 upper limit normal for serum, it’s exudate (more protein)

These ratios are called Light’s Criteria.

Question 28

You perform a thoracentesis on a patient and find that the LDH ratio is 0.3 and the protein ratio is 0.6. How would you classify this effusion?

Answer 28

It would be an exudate effusion because the protein ratio is >0.5.

*Remember, to be considered transudate it has to satisfy BOTH, not just one or the other.

Thus, it’s easier to be EXUDATE than it is to be TRANSUDATE.

Question 29

What are the 3 most common differentials for transudate effusion?

Answer 29

Congestive Heart Failure

Cirrhosis with ascites

Nephrotic syndrome

Question 30

List some of the common causes for an exudative effusion

Answer 30

Infection

Cancer

Pulmonary Embolism

Connective Tissue Diseases

Post-MI syndrome

Question 31

What 3 conditions were listed under pleural abnormalities?

What is one type of exposure that was attributed to all 3?

Answer 31

1) Pleural Thickening
2) Pleural Plaques
3) Pleural Tumors

Asbestos exposure can lead to all of these (mesothelioma)