Disease of Mediastinum and Pleura Flashcards
What are the:
Anterior
Lateral
Posterior
Superior
Inferior
borders of the mediastinum?
Anterior: Sternum
Lateral: Parietal Pleura (bilateral)
Posterior: Paravertebral gutters and ribs
Superior: Thoracic inlet
Inferior: Diaphragm
Anatomically, what is located within the anterior superior compartment of the mediastinum?
Thymus gland
Aortic root and great vessels
Substernal thyroid and parathyroid tissue
Lymphatic vessels and nodes
Inferior aspect of trachea and esophagus
What’s located within the middle compartment of the mediastinum?
Pericardial sac
Heart
Innominate veins and SVC
Trachea and major bronchi
Hila
Lymph nodes
Phrenic, upper vagus, and recurrent laryngeal nerves
What’s located in the posterior compartment of the mediastinum?
Esophagus
Descending aorta
Hemiazygos and azygous veins
Thoracic duct
Lymph nodes
Vagus nerves
Sympathetic chain
T or F?
An asymptomatic mass is benign 80% of the time,
a symptomatic mass is malignant 80% of the time.
False
Asymptomatic benign 80%,
symptomatic malignant 50% of time
List some of the symtpoms associated with a symptomatic mediastinal mass
Fever, Anorexia, Weight loss
Endocrine syndromes
Autoimmune disorders (thymus related)
In terms of mass location and symptoms in the mediastinum, how do children differ from adults?
Children: 65% are located posteriorly, 2/3rds are symptomatic
Adults: 65% are located anteriorly, 1/3rd are symptomatic
What is the cause of B symptoms? What is being compressed?
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)
When doing physical exam for mediastinal masses, what is particularly important?
Weight loss
Blood pressure changes
Lymphadenopaty
The head, neck, upper extremities and chest exams.
Why is CT better than CXR for looking at mediastinal masses?
You can tell if the mass is solid or fluid filled.
Differentiate between lymph structures or blood vessels
Give the 4 terrible T’s of an anterior mediastinal mass differential?
Thymic neoplasm
Teratoma (germ cell tumor)
(Terrible) Lymphoma (Hodgkins or Non-Hodgkins)
Thyroid neoplasm
What type of lesion comprises about 20% of middle compartment masses?
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.
What type of masses are most common in the posterior compartment? In who are these more common?
Tend to be masses involved with nerves (neurinomas, neurogenic tumors, etc).
More common in kids.
For which compartment are the CBC markers Beta-HCG, alpha-fetoprotein, and Anti-acetylcholine receptor antibodies most indicative?
Are these markers the best method?
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)
List the 4 major complications of mediastinal masses as presented in class.
1) Tracheal obstruction
2) SVC Syndrome (SVC compression)
3) Esophageal rupture
4) Vascular invasion (hemorrhage)
What are the 2 components of the pleura, and which is associated with pain?
Where do the 2 components meet?
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.
What are the 3 major disorders of the pleura?
1) Pneumothorax (air in the lungs)
2) Pleural effusion
3) Pleural based abnormalities
What conditions are associated with spontaneous pneumothorax?
COPD
Interstitial Lung Diseases
Cystic Fibrosis
Lung Cancer
What conditions are associated with traumatic pneumothorax (3 categories)?
1) Iatrogenic-complication of needle biopsy or central line
2) Barotrauma-intubation, mechanical ventilation
3) Trauma-penetrating or non-penetrating.
What is the peak age for someone to have spontaneous pneumothorax?
Early 20s.
Usually occurs in someone with no precipitating events and no known lung diseases
What are some of the hallmark clinical findings of someone with pneumothorax?
Acute chest pain, Dyspnea, Sense of doom/anxiety, cyanosis.
Percussion=hyper resonant
Decreased breath sounds
Decreased fremitus
How should pneumothorax be treated?
Put them on 100% oxygen
Chest tube
Observation
Simple aspiration
Pleurodesis (adhese the 2 pleura)
T or F?
Primary spontaneous pneumothorax is more dangerous than tension pneumothorax
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.
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?
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.
Pleural effusion is when the pleural fluid filling exceeds the drainage. Give some of the hallmarks of someone with pleural effusion.
Dry cough
Pleuritic chest pain (pain on inspiration)
Decreased breath sounds
Dullness to percussion
What’s the difference between transudative and exudative pleural effusions?
Transudative=alteration in hydrostatic pressures that attract fluids (not protein rich)
Exudative=alterations in pleural permeability or rate of fluid removal (protein rich)
Diagnostically, how do you differentiate between transudative and exudative effusions?
Perform a thoracentesis (extract pleural fluid) and look at the LDHpl/LDHser and Protpl/Protser ratios.
If the LDH ratio is
If the LDH ratio is >0.6 or the Prot ratio is >0.5 or LDHpl is 2/3 upper limit normal for serum, it’s exudate (more protein)
These ratios are called Light’s Criteria.
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?
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.
What are the 3 most common differentials for transudate effusion?
Congestive Heart Failure
Cirrhosis with ascites
Nephrotic syndrome
List some of the common causes for an exudative effusion
Infection
Cancer
Pulmonary Embolism
Connective Tissue Diseases
Post-MI syndrome
What 3 conditions were listed under pleural abnormalities?
What is one type of exposure that was attributed to all 3?
1) Pleural Thickening
2) Pleural Plaques
3) Pleural Tumors
Asbestos exposure can lead to all of these (mesothelioma)
