Mediastinal Masses Flashcards by A B

Anatomy of the Mediastinum

A/P view

Superior = thoracic inlet

Inferior = diaphragm

Left and right = parietal pleura

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Anatomy of Mediastinum

Lateral view

anterior = Sternum

posterior = paravertebral gutters and ribs

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Anterior-Superior Compartment

1) thymus gland
2) aortic root and great vessels
3) substernal thyroid and parathyroid tissue
4) lymph vessels and nodes
5) inferior trachea and esophagus

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Middle Compartment

1) pericardial sac
2) heart
3) inominate veins and SVC
4) trachea and major bronchi
5) hila
6) lymph nodes
7) phrenic, upper vagus and recurrent laryngeal nerves

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Posterior compartment

lower vagus nerves

sympathetic chains

*** update

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Mediastinal Masses

__% of asymptomatic masses are benign

__ % of symptomatic masses are malignant

80%

50%

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Symptoms of mediastinal masses
Local

Systemic

Local =
1) compression of adjacent structures

2) invasion of adjacent structures

Systemic

1) fever, anorexia, weight loss
2) endocrine (thymus/thyroid)
3) autoimmune (thymus)

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Adults and children

ratio of anterior posterior middle mases

adults = 65% anterior
25% posterior
10% middle

Children
65% posterior
25% anterior

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Ddx of anterior mediastinal masses

terrible t

1) thyoma
2) teratoma = germ cell tumor
3) terrible lymphoma = hodgkin vs. non-hodgkin
4) thyroid tissue

Vascular = hematoma, aortic aneurysm

5) mesenchymal neoplasm
6) diaphragmatic hernia (Morgagni)
7) primary carcinoma

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Ddx of middle mediastinal masses

1) lymphadenopathy- around hill
2) developmental cysts
3) reactive and granulomatous inflamm (sarcoidosis)

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Ddx of posterior mediastinal masses

Peripheral Nerve (neurinomas)

neurogenic tumors

sympathetic ganglia cysts

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Symptoms assoc with obstruction of contiguous organs for mediastinal masses

1) dysphagia
2) SVC syndrome- compression of SVC = prevents venous return (erthyema of face and swelling and expansion of superficial skin veins)

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Symptoms in general with mediastinal masses

B symptoms
1) fever > 38 for 3 days

2) weight loss > 10% TBW in 6 months
3) drenching night sweats

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Physical exam with mediastinal masses

1) weight loss

2) lymphadenopathy

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Radiologic studies to order

what labs to get for diagnosis of mediastinal mass

1) CXR (can’t tell compartment from A/P)
2) CT scan

1) CBC with diff
2) beta-HCG, alpha-fetoprotein (assoc with germ cell tumors)

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Procedural tests for mediastinal mass

1) needle aspiration
- transbronchial needle asp
- percutaneous needle asp
- endoscopic US guided asp/bx

2) mediastinoscopy, thoracoscopy

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Complications of mediastinal masses

1) tracheal obstruction
2) SVC syndrome
3) Vascular invasion of thyroid cancers (hemorrhage)
4) esophageal rupture

Pleura

Define

2 single cell, continuous lining outer surface of lung, inner thoracic cavity

@ hilar root of lung

Disorders of the pleura

1) Pneumothorax

2) pleural effusion

Define pneumothorax

Types of pneumothorax

Air in pleural space

Spontaneous (primary = young, thin male, secondary = underlying chronic lung disease)

Traumatic (iatrogenic = procedure in hospital, non-iatrogenic = in public)

Causes of primary and secondary spontaneous pneumothorax

1) inherited follicular gene defects
2) COPD
3) PCP
4) MTb
5) necrotizing pneumonia
6) CF
7) ILDs
8) pneumoconiosis
9) Lung cancer

Traumatic Pneumothorax

Iatrogenic

Place central lines
(transthoracic needle aspiration)

Barotrauma

Trauma (penetrating vs. non-penetrating)

Symptoms of pneumothorax

1) acute onset chest pain (pleuritc on side of pneumothorax)
2) dyspnea
3) cough
4) anxiety
5) cyanosis (decr venous return or inadequate pulm reserve)
6) respiratory distress

Physical exam of pneumothorax

1) hyperresonant chest percussion
2) decr/absent breath sounds
3) decr fremitus
4) chest wall trauma (flail chest)
5) decr rib space

Radiology studies to order

1) CXR 2) CT chest 3) US can show absence of pleural slide

Treatment for small PTx

1) supplemental O2 (100%) and Nitrogen wash out so alveoli expand on their own 2) simple aspiration 3) tube thoracostomy (chest tube) 4) pleurodesis - develop inflame and scar btwn visceral and parietal pleura (>2 PTX or PTX not resolving)

Define tension pneumothorax

1) Incr PIP > atmospheric pressure throughout expiration and often during inspiration 2) causes shift in mediastinal structures AWAY FROM THE AIR 3) decr venous return, decr cardiac output

Signs and symptoms of tension pneumothorax

1) tachycardia = to compensate for decr venous return 2) hypotension 3) respiratory distres 4) cyanosis 5) profuse diaphoresis

Treatment of tension pneumothorax

1) don't wait for CXR 2) emergent insert 18 gauge angiocath in 2ICS mid clavicular 3) place chest tube if PTX confirmed

Define pleural effusion normal production of pleural fluid occurs when? assoc with?

1) normal production = 0.2-0.3 mL/kg 2) when rate of pleural fluid formation > drainage 3) assoc with both localized pleural disorders and systemic effect on pleura and LUPUS

Symptoms and signs of pleural effusion

1) dyspnea 2) pleuritic chest pain (if inflam like secondary to complicated PNA) 3) dry cough 4) decr breath sounds dullness to percussion decr tactile/vocal fremitus

CXR of pleural effusion

1) meniscus sign (fluid rises up along chest) | 2) dense opacity = absence of normal pulm markings

Transudative vs. exudative pleural effusion

Transudative = alterations in hydrostatic forces that affect fluid formation (acellular and NON-PROTEIN) Exudative = alterations in permeability of pleura/fluid removal (PROTEIN RICH)

Diagnosis of pleural effusion

1) thoracentesis | patient leaning up and over table to expand rib spaces

Light's Criteria for thoracentesis

Transudate = | LDH (pleural) / LDH (serum

Pleural fluid analysis

1) LDH + serum 2) Total protein (+ serum) (if you have infection --> low glucose and pH so must do surgical chest tube or deep cortication) 3) pH and glucose 4) WBC/RBC and diff 5) gram stain, culture 6) AFB/fungal stains 7) cytology for malignancy

Transudative PE

1) CHF 2) cirrhosis with ascites if have hydrohepatothorax pleural effusion --> don't put chest tube --> fluid will keep draining

Exudative PE

1) Infectious esp bacteira | 2) secondary to cancer

Pleural based abnormalities (3)

1) pleural thickening 2) pleural plaque 3) pleural tumors

vast majority of pleural tumors are ___ and ___

malignant and metastatic from lung and breast mesothelioma (years after heavy asbestos exposure)

Pleural plaques caused by?

1) chronic inflamm (granulomatous- histocytosis, sarcoidosis, lupus) 2) asbestos exposure (not malignant but pre-malignant)

How to determine pleural thickening etiology?

1) CT definition __ 1) inflame after infection (pneumonia, bacterial) 2) hemorrhage then calcification 3) prior treatment for effusion/PTX 4) occupational (asbestos) 5) Trauma 6) neoplasm