Mediastinal Masses

Question 1

Anatomy of the Mediastinum

A/P view

Answer 1

Superior = thoracic inlet

Inferior = diaphragm

Left and right = parietal pleura

Question 2

Anatomy of Mediastinum

Lateral view

Answer 2

anterior = Sternum

posterior = paravertebral gutters and ribs

Question 3

Anterior-Superior Compartment

Answer 3

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

Question 4

Middle Compartment

Answer 4

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

Question 5

Posterior compartment

Answer 5

lower vagus nerves

sympathetic chains

*** update

Question 6

Mediastinal Masses

__% of asymptomatic masses are benign

__ % of symptomatic masses are malignant

Answer 6

80%

50%

Question 7

Symptoms of mediastinal masses
Local

Systemic

Answer 7

Local =
1) compression of adjacent structures

2) invasion of adjacent structures

Systemic

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

Question 8

Adults and children

ratio of anterior posterior middle mases

Answer 8

adults = 65% anterior
25% posterior
10% middle

Children
65% posterior
25% anterior

Question 9

Ddx of anterior mediastinal masses

Answer 9

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

Question 10

Ddx of middle mediastinal masses

Answer 10

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

Question 11

Ddx of posterior mediastinal masses

Answer 11

Peripheral Nerve (neurinomas)

neurogenic tumors

sympathetic ganglia cysts

Question 12

Symptoms assoc with obstruction of contiguous organs for mediastinal masses

Answer 12

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

Question 13

Symptoms in general with mediastinal masses

Answer 13

B symptoms
1) fever > 38 for 3 days

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

Question 14

Physical exam with mediastinal masses

Answer 14

1) weight loss

2) lymphadenopathy

Question 15

Radiologic studies to order

what labs to get for diagnosis of mediastinal mass

Answer 15

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)

Question 16

Procedural tests for mediastinal mass

Answer 16

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

2) mediastinoscopy, thoracoscopy

Question 17

Complications of mediastinal masses

Answer 17

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

Question 18

Pleura

Define

Answer 18

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

@ hilar root of lung

Question 19

Disorders of the pleura

Answer 19

1) Pneumothorax

2) pleural effusion

Question 20

Define pneumothorax

Types of pneumothorax

Answer 20

Air in pleural space

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

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

Question 21

Causes of primary and secondary spontaneous pneumothorax

Answer 21

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

Question 22

Traumatic Pneumothorax

Iatrogenic

Answer 22

Place central lines
(transthoracic needle aspiration)

Barotrauma

Trauma (penetrating vs. non-penetrating)

Question 23

Symptoms of pneumothorax

Answer 23

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

Question 24

Physical exam of pneumothorax

Answer 24

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

Question 25

Radiology studies to order

Answer 25

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

Question 26

Treatment for small PTx

Answer 26

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)

Question 27

Define tension pneumothorax

Answer 27

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

Question 28

Signs and symptoms of tension pneumothorax

Answer 28

1) tachycardia = to compensate for decr venous return
2) hypotension

3) respiratory distres
4) cyanosis
5) profuse diaphoresis

Question 29

Treatment of tension pneumothorax

Answer 29

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

Question 30

Define pleural effusion
normal production of pleural fluid

occurs when?

assoc with?

Answer 30

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

Question 31

Symptoms and signs of pleural effusion

Answer 31

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

Question 32

CXR of pleural effusion

Answer 32

1) meniscus sign (fluid rises up along chest)

2) dense opacity = absence of normal pulm markings

Question 33

Transudative vs. exudative pleural effusion

Answer 33

Transudative = alterations in hydrostatic forces that affect fluid formation (acellular and NON-PROTEIN)

Exudative = alterations in permeability of pleura/fluid removal (PROTEIN RICH)

Question 34

Diagnosis of pleural effusion

Answer 34

1) thoracentesis

patient leaning up and over table to expand rib spaces

Question 35

Light’s Criteria for thoracentesis

Answer 35

Transudate =

LDH (pleural) / LDH (serum

Question 36

Pleural fluid analysis

Answer 36

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

Question 37

Transudative PE

Answer 37

1) CHF
2) cirrhosis with ascites

if have hydrohepatothorax pleural effusion –> don’t put chest tube –> fluid will keep draining

Question 38

Exudative PE

Answer 38

1) Infectious esp bacteira

2) secondary to cancer

Question 39

Pleural based abnormalities (3)

Answer 39

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

Question 40

vast majority of pleural tumors are ___ and ___

Answer 40

malignant and metastatic from lung and breast

mesothelioma (years after heavy asbestos exposure)

Question 41

Pleural plaques caused by?

Answer 41

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

Question 42

How to determine pleural thickening

etiology?

Answer 42

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