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SMP - Cardiopulmonary Lab Practical > Dissection of the Posterior Mediastinum > Flashcards

Dissection of the Posterior Mediastinum Flashcards

1
Q

Boundaries of posterior mediastinum?

A
  1. Superiorly: sternal angle
  2. Inferiorly: diaphragm
  3. Laterally: mediastinal pleura
  4. Anteriorly: pericardial sac
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2
Q

6 major structures of the posterior mediastinum?

A
  1. Esophagus with its plexus (right and left)
  2. Thoracic aorta with its branches
  3. Azygos system of veins
  4. Thoracic duct and associated lymph nodes
  5. Sympathetic trunks
  6. Thoracic splanchnic nerves
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3
Q

Vertebral borders of esophagus?

A

C6 to T11

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4
Q

What is the esophagus?

A

Muscular tube

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5
Q

Pathway of esophagus in posterior mediastinum?

A

Anterior aspect of vertebrae in midline => anterior and to the left to be anterior to the thoracic aorta to enter the diaphragm

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6
Q

Vertebral level of esophagus passing through esophageal hiatus to enter diaphragm?

A

T10

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7
Q

Esophagus 2 attachments?

A
  1. Pharynx

2. Diaphragm

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8
Q

What is the right side of the esophagus covered by?

A

Mediastinal pleura

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9
Q

Position of thoracic duct in regards to esophagus in posterior mediastinum?

A
  • Inferior portion: right side

- Superior portion: left side

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10
Q

Position of aorta in regards to esophagus in posterior mediastinum?

A

Left

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11
Q

Position of right pulmonary artery and left main bronchus in regards to esophagus in posterior mediastinum?

A

Anterior

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12
Q

4 structures that are posterior to the esophagus at some point in the posterior mediastinum?

A
  1. Thoracic duct
  2. Hemiazygos veins
  3. Right posterior intercostal vessels
  4. Thoracic aorta (near diaphragm)
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13
Q

At what 4 locations can the esophagus be compresses/narrowed? What is at higher risk at these locations?

A
  1. Junction of esophagus and pharynx in the neck
  2. Aortic arch crossing over the esophagus in superior mediastinum
  3. Left main bronchus crossing over the esophagus in posterior mediastinum
  4. At esophageal hiatus in posterior mediastinum

Higher risk of swallowed objects getting lodged at these locations and if the object is corrosive it would cause more damage at these locations

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14
Q

What arteries do esophageal arteries arise from?

A
  1. Thoracic aorta
  2. Bronchial arteries
  3. Ascending branches of left gastric artery in abdomen
  4. Inferior thyroid artery
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15
Q

What veins do esophageal veins drain into?

A
  1. Azygos vein
  2. Hemiazygos vein
  3. Left gastric vein in abdomen
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16
Q

Lymphatic drainage of esophagus in posterior mediastinum?

A
  1. Posterior mediastinal lymph nodes

2. Left gastric lymph nodes (inferior 1/3rd)

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17
Q

Innervation of esophagus?

A

Branches from vagus nerves and sympathetic trunks

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18
Q

Innervation of striated muscle in superior portion of the esophagus?

A

Branchial efferents from vagus nerves

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19
Q

Innervation of smooth muscle fibers in inferior portion of the esophagus?

A

Preganglionic fibers that are parasympathetic visceral efferents and synapse in the myenteric and submucosal plexuses of the enteric NS in the esophageal wall

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20
Q

Sensory innervation of esophagus? Which ones are responsible for transmitting pain information to the CNS?

A

Visceral afferents in :

  1. Vagus nerves
  2. Sympathetic trunks***
  3. Splanchnic nerves***
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21
Q

Are the visceral afferents from the vagus nerves involved in the relay of pain recognition?

A

NOPE

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22
Q

What are the 2 trunks formed by the esophageal plexus?

A

Trunks formed by the esophageal plexus just above the diaphragm:

  1. Anterior vagal trunk on anterior surface of esophagus mainly from fibers from left vagus nerve
  2. Posterior vagal trunk on posterior surface of esophagus mainly from fibers from right vagus nerve

These continue through the diaphragm

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23
Q

To which lymph nodes does esophageal cancer spread?

A
  1. Lymph nodes in neck

2. Lymph nodes around celiac artery

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24
Q

Technique to assess site of esophageal cancer?

A

Endoscopy or barium swallow

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25
Q

Survival rate of esophageal rupture caught early? Untreated?

A

Caught early: 65%

Untreated: 0%

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26
Q

Where do esophageal ruptures occur typically? Treatment?

A

Lower third of esophagus on the left

Treatment: urgent surgical repair

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27
Q

Consequences of esophageal rupture?

A
  1. Sudden rise in intraluminal esophageal pressure produced by vomiting
  2. Uncoordination and failure of cricopharyngeus muscle to relax
  3. Large left pleural effusion that contains the gastric contents
  4. Subcutaneous emphysema (air gets into tissues under the skin)
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28
Q

Which lung is in contact with the esophagus?

A

Right lung

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29
Q

Vertebral levels of thoracic aorta?

A

T4 to T12

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30
Q

Pathway of thoracic aorta?

A

Left of midline => approaches midline and directly anterior to vertebrae inferiorly => aortic hiatus through diaphragm

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31
Q

7 branches of the thoracic aorta?

A
  1. Pericardial
  2. Bronchial
  3. Esophageal
  4. Mediastinal
  5. Posterior intercostal
  6. Superior phrenic
  7. Subcostal
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32
Q

What is the azygos system of veins?

A

Series of longitudinal vessels on each side of the body that drain blood from the body wall and move it superiorly to drain into SVC (but blood from viscera may also enter them)

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33
Q

Where are anastomoses found with the azygos system of veins?

A

With abdominal veins

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34
Q

Are the azygos veins connected from side to side?

A

YUP

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35
Q

What happens if the IVC is blocked?

A

Azygos system of veins will serve as an anastomotic pathway capable of returning blood from lower part of body to the heart

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36
Q

3 major veins of azygos system of veins?

A
  1. Azygos vein on right
  2. Hemiazygos vein on left
  3. Accessory hemiazygos vein on left
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37
Q

Pathway of azygos vein?

A

Arises in abdomen opposite L1 or L2 at junction between right ascending lumbar vein and right subcostal vein OR from IVC => aortic hiatus => posterior mediastinum to the right of the thoracic duct => arches anteriorly at T4 over root of right lung and right vagus nerve to drain into IVC before it enters pericardial sac

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38
Q

8 tributaries to azygos vein?

A
  1. Right superior intercostal vein
  2. 5th to 11th right posterior intercostal veins
  3. Hemiazygos vein
  4. Accessory hemiazygos vein
  5. Esophageal veins
  6. Mediastinal veins
  7. Pericardial veins
  8. Right bronchial veins
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39
Q

What is the superior intercostal vein formed by?

A

Junction of 2nd, 3rd, and 4th intercostal veins

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40
Q

Other name for hemiazygos vein?

A

Inferior hemiazygos vein

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41
Q

Pathway of hemiazygos vein?

A

Arises at junction between left ascending lumbar vein and left subcostal vein in abdomen (or either of those alone) => aortic hiatus => posterior mediastinum to left of thoracic duct to T9 => crosses vertebral column posterior to thoracic aorta, esophagus, and thoracic duct to enter azygos vein

42
Q

3 tributaries to hemiazygos vein?

A
  1. Lowest 4 or 5 left posterior intercostal veins
  2. Esophageal veins
  3. Mediastinal veins
43
Q

Pathway of accessory hemiazygos vein?

A

Descends from superior portion of posterior mediastinum on left side => crosses vertebral column at T8 to join azygos vein OR ends in hemiazygos vein OR connects to both

44
Q

Other name for accessory hemiazygos vein?

A

Superior hemiazygos vein

45
Q

To what does the accessory hemiazygos vein connect to sometimes superiorly?

A

Left superior intercostal vein

46
Q

2 tributaries to accessory hemiazygos vein?

A
  1. 4th to 8th left posterior intercostal veins

2. Left bronchial veins (sometimes)

47
Q

Which vein of the azygos system of veins often has a connection to the left renal vein?

A

Hemiazygos vein

48
Q

Pathway of thoracic duct?

A

Confluence of lymph trunks in abdomen forming a saccular dilation called the cisterna chyli => enters thorax posterior to aorta through aortic hiatus => posterior mediastinum to the right of midline between thoracic aorta and azygos vein and posterior to esophagus and anterior to vertebrae => moves to left of midline at T5 and enters superior mediastinum => through superior mediastinum => neck => left jugular trunk and left subclavian trunk (draining left neck/head and left upper limb) join the thoracic duct => empties into junction of left subclavian and left internal jugular veins

49
Q

Other name for cisterna chyli?

A

Chyle cistern

50
Q

What does the cisterny chyli drain?

A
  1. Abdominal viscera and walls
  2. Pelvis
  3. Perineum
  4. Lower limbs
51
Q

Vertebral level of thoracic duct?

A

L2 to root of neck

52
Q

5 tributaries to thoracic duct?

A
  1. Lymph trunks in abdomen
  2. Descending thoracic lymph trunks draining lower 6 or 7 intercostal spaces on both sides
  3. Upper intercostal lymph trunks draining upper LEFT 5 or 6 intercostal spaces
  4. Ducts from posterior mediastinal nodes
  5. Ducts from posterior diaphragmatic nodes
53
Q

Describe the sympathetic trunks of the posterior mediastinum.

A

2 parallel cords with 11 or 12 ganglia connected to adjacent thoracic spinal nerves by white and gray rami communicans

54
Q

How are sympathetic trunks numbered?

A

According to the thoracic spinal nerve with which they are associated

55
Q

Position of sympathetic trunks in superior portion of posterior mediastinum?

A

Anterior to neck of the ribs

56
Q

Position of sympathetic trunks in inferior portion of posterior mediastinum?

A

More medial than in superior portion of posterior mediastinum anterior to the lateral aspects of vertebral bodies

57
Q

How do the sympathetic trunks leave the thorax?

A

Pass posterior to the diaphragm under the median arcuate ligament OR through crura of diaphragm

58
Q

What are the sympathetic trunks covered by in the thorax?

A

Parietal pleura

59
Q

What are the 2 types of medial branches given off by the ganglia of the sympathetic trunks?

A
  1. Branches from upper 5 ganglia: postganglionic sympathetic fibers supplying thoracic viscera (small and contain visceral afferents)
  2. Branches from lower 7 ganglia: preganglionic sympathetic fibers supplying abdominal and pelvic viscera (large and contain visceral afferents) => forming the greater, lesser, and least splanchnic nerves
60
Q

Describe the pathway of the greater splanchnic nerve.

A

5th to 9th/10th thoracic ganglia => crus of diaphragm to abdomen => ends in celiac ganglion

61
Q

Describe the pathway of the lesser splanchnic nerve.

A

9th and 10th OR 10th and 11th thoracic ganglia => crus of diaphragm to abdomen => ends in aorticorenal ganglion

62
Q

Describe the pathway of the least splanchnic nerve.

A

12th thoracic ganglion => crus of diaphragm to abdomen => ends in renal plexus

63
Q

What is the crus of the diaphragm?

A

Refers to one of two (R and L) tendinous structures that extends below the diaphragm to the vertebral column

64
Q

Boundaries of anterior mediastinum?

A
  1. Superiorly: sternal angle
  2. Inferiorly: diaphragm
  3. Laterally: mediastinal pleura
  4. Anteriorly: sternum
  5. Posteriorly: middle mediastinum
65
Q

What is the major structure of the anterior mediastinum? Other contents?

A

Portion of the thymus

Other contents:

  1. Fat
  2. Connective tissue
  3. Lymph nodes
  4. Mediastinal branches of internal thoracic vessels
  5. Sternopericardial ligaments
66
Q

What kind of thoracic splanchnic innervates the adrenal glands?

A

Greater thoracic splanchnic

67
Q

Location of sympathetic trunks with regards to the intercostal arteries and veins?

A

Superficial to

68
Q

Can you find all 3 thoracic splanchnic in a cadaver?

A

Usually only greater, sometimes lesser, never the least

69
Q

Only part of posterior mediastinum that lymphatically drains to abdomen?

A

Inferior 1/3rd of esophagus

70
Q

What do we call the vagus nerves right before they become the anterior and posterior trunks on the esophagus?

A

Right and left vagal trunks

71
Q

What is the most posterior structure of the posterior mediastinum?

A

Thoracic duct

72
Q

What do we call the hole through which the IVC penetrates the diaphragm? Vertebral level?

A

Caval opening: T8

73
Q

What is dysphagia?

A

Difficulty swallowing

74
Q

Do intercostal nerves carry mainly myelinated neurons? Explain.

A

YUP

They carry:

  1. Somatic motor innervation to muscles of thoracic wall
  2. Somatic sensory innervation from skin and parietal pleura
  3. Postganglionic sympathetic fibers to periphery
75
Q

Are intercostal nerves protected by the inferior borders of the ribs?

A

YUP

76
Q

Where do the bronchial arteries branch from?

A

Thoracic aorta

77
Q

What does the greater splanchnic innervate?

A

Foregut and adrenal medulla

78
Q

What does the lesser splanchnic innervate?

A
  1. Midgut

2. Kidneys and upper ureters

79
Q

What does the least splanchnic innervate?

A

Renal plexus, which enters the kidneys on arterial branches to supply the vessels, Renal glomerulus, and tubules with branches to the ureteric plexus, the spermatic plexus and, on the right side, to the inferior vena cava

The ovarian plexus arises from the renal plexus, and is one of two sympathetic supplies distributed to the ovary and fundus of the uterus

80
Q

7 structures of the adult foregut?

A
  1. Esophagus (distal end)
  2. Stomach
  3. Duodenum (proximal half)
  4. Liver
  5. Gallbladder
  6. Pancreas
  7. Spleen
81
Q

8 structures of the adult midgut?

A
  1. Duodenum (distal half)
  2. Jejunum
  3. Ileum
  4. Cecum
  5. Appendix
  6. Ascending colon
  7. Hepatic flexure of colon
  8. Transverse colon (proximal two-thirds)
82
Q

5 structures of the adult hindgut?

A
  1. Distal third of the transverse colon
  2. Splenic flexure of colon
  3. Descending colon
  4. Sigmoid colon
  5. Rectum
83
Q

5 components of middle inferior mediastinum?

A
  1. Pericardium
  2. Heart
  3. Roots of great vessels
  4. Arch of the azygos vein
  5. Main bronchii
84
Q

Are all 11 physiological systems found in the mediastinum?

A

YUP

85
Q

What are esophageal varicosities? Most common cause? Why are these potentially lethal?

A

Enlarged esophageal veins associated with chronic alcoholism

Potentially lethal because they can burst causing severe hemorrhage

86
Q

Are the sympathetic trunks technically in the posterior mediastinum?

A

NOPE, because they are not between the R and L pleural cavities

87
Q

What kind of nerve fibers does the phrenic nerve carry?

A

Motor, sensory, and sympathetic nerve fibers

88
Q

Why does esophageal cancer cause anemia?

A

Tumors of the GIT are very friable and with the passage of digested material across the tumor, low-grade bleeding occurs causing anemia (usually asymptomatic)

89
Q

Describe the surgical procedure of esophageal resection to treat cancer. What is this called?

A

Transthoracic esophagectomy:

  1. Patient is placed in supine position
  2. Laparotomy (surgical incision of abdomen) to assess evidence of disease in abdominal cavity
  3. Stomach is mobilized with preservation of right gastric and gastro-omental arteries
  4. Short gastric vessels and left gastric vessels are divided
  5. Pyloromyotomy is performed (incision in stomach on the pylorus, the furthest part of the stomach that connects to the duodenum)
  6. Abdominal wound is closed
  7. Patient is placed in left lateral position
  8. Right posterolateral thoracotomy is performed through 5TH INTERCOSTAL SPACE
  9. Azygos vein divided to provide full access to the whole length of the esophagus
  10. Stomach is delivered through the diaphragmatic hiatus
  11. Esophagus is resected and stomach is anastomosed to the cervical esophagus
90
Q

How does esophageal cancer spread?

A

Submucosa or locoregional lymph nodes

91
Q

When are most esophageal cancers diagnosed? Survival rate?

A

Late

Survival rate: 25% 5-year survival rate

92
Q

Position of superior poles of kidneys?

A

Right: Anterior to rib 12

Left: Anterior to ribs 11 and 12

93
Q

What is the thoracic wall made of?

A

Posteriorly: 12 thoracic vertebrae
Laterally: 12 ribs + ICS muscles
Anteriorly: sternum

94
Q

T1 dermatome?

A

Medial forearm

95
Q

T2 dermatome?

A

Medial arm + 2nd ICS

96
Q

Sensory innervation of anterosuperior portion of the trunk?

A

Anterior ramus of C4 via supraclavicular branches of cervical plexus

97
Q

Dermatome over xiphoid process?

A

T6

98
Q

Dermatome over nipples?

A

T4

99
Q

Describe dermatomes T7 to T12.

A

They follow the contour of the ribs onto the anterior abdominal wall

100
Q

Dermatome of umbilicus?

A

T10

101
Q

Dermatomes of costal margin?

A

T5 to T9

SMP - Cardiopulmonary Lab Practical (11 decks)

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