What are the mediastinal organs. Organs of the anterior mediastinum

Mediastinal surgery, one of the youngest branches of surgery, has received significant development due to the development of anesthetic management, surgical techniques, and diagnostics of various mediastinal processes and neoplasms. New diagnostic methods allow not only to accurately determine the localization of a pathological formation, but also make it possible to assess the structure and structure of the pathological focus, as well as to obtain material for pathological diagnosis. Recent years have seen an increase in indications for surgical treatment diseases of the mediastinum, the development of new highly effective low-traumatic treatment methods, the introduction of which has improved the results of surgical interventions.

Classification of diseases of the mediastinum.

• Mediastinal injuries:

1. Closed trauma and injuries of the mediastinum.

2. Damage to the thoracic lymphatic duct.

• Specific and non-specific inflammatory processes in the mediastinum:

1. Tuberculous adenitis of the mediastinum.

2. Nonspecific mediastinitis:

A) anterior mediastinitis;

B) posterior mediastinitis.

By clinical course:

A) acute non-purulent mediastinitis;

B) acute purulent mediastinitis;

C) chronic mediastinitis.

• Mediastinal cysts.

1. Congenital:

A) coelomic cysts of the pericardium;

B) cystic lymphangitis;

C) bronchogenic cysts;

D) teratoma

D) from the embryonic embryo of the foregut.

2. Purchased:

A) cysts after hematoma in the pericardium;

B) cysts formed as a result of the collapse of the pericardial tumor;

D) mediastinal cysts emanating from the border areas.

• Tumors of the mediastinum:

1. Tumors emanating from the organs of the mediastinum (esophagus, trachea, large bronchi, heart, thymus, etc.);

2. Tumors emanating from the walls of the mediastinum (tumors of the chest wall, diaphragm, pleura);

3. Tumors originating from the tissues of the mediastinum and located between organs (extraorganic tumors). Tumors of the third group are true tumors of the mediastinum. They are divided according to histogenesis into tumors from nervous tissue, connective tissue, blood vessels, smooth muscle tissue, lymphoid tissue and mesenchyme.

A. Neurogenic tumors (15% of this localization).

I. Tumors originating from the nervous tissue:

A) sympathoneuroma;

B) ganglioneuroma;

B) pheochromocytoma;

D) chemodectoma.

II. Tumors arising from nerve sheaths.

A) neuroma;

B) neurofibroma;

C) neurogenic sarcoma.

D) schwannomas.

D) ganglioneuromas

E) neurilemmomas

B. Connective tissue tumors:

A) fibroma;

B) chondroma;

C) osteochondroma of the mediastinum;

D) lipoma and liposarcoma;

E) tumors emanating from the vessels (benign and malignant);

E) myxomas;

G) hibernomas;

E) tumors from muscle tissue.

B. Tumors of the thymus:

A) thymoma;

B) cysts of the thymus gland.

D. Tumors from the reticular tissue:

A) lymphogranulomatosis;

B) lymphosarcoma and reticulosarcoma.

E. Tumors from ectopic tissues.

A) retrosternal goiter;

B) intrasternal goiter;

B) an adenoma thyroid gland.

The mediastinum is a complex anatomical formation located in the middle of the chest cavity, enclosed between the parietal sheets, the spinal column, the sternum and below the diaphragm, containing fiber and organs. The anatomical relationships of organs in the mediastinum are quite complex, but their knowledge is mandatory and necessary from the standpoint of the requirements for rendering surgical care this group of patients.

The mediastinum is divided into anterior and posterior. The conditional boundary between them is the frontal plane drawn through the roots of the lungs. In the anterior mediastinum are: thymus, part of the aortic arch with branches, superior vena cava with its origins (brachiocephalic veins), heart and pericardium, thoracic part of the vagus nerves, phrenic nerves, trachea and initial departments bronchi, nerve plexuses, lymph nodes. In the posterior mediastinum are located: the descending part of the aorta, the unpaired and semi-unpaired veins, the esophagus, the thoracic part of the vagus nerves below the roots of the lungs, the thoracic lymphatic duct (thoracic region), the border sympathetic trunk with the celiac nerves, the nerve plexuses, the lymph nodes.

To establish the diagnosis of the disease, the localization of the process, its relationship to neighboring organs, in patients with mediastinal pathology, it is first necessary to conduct a complete clinical examination. It should be noted that the disease in the initial stages is asymptomatic, and pathological formations are an accidental finding during fluoroscopy or fluorography.

The clinical picture depends on the location, size and morphology of the pathological process. Usually patients complain of pain in the chest or heart area, interscapular region. Often, pain is preceded by a feeling of discomfort, expressed in a feeling of heaviness or a foreign mass in the chest. Often there is shortness of breath, shortness of breath. With compression of the superior vena cava, cyanosis of the skin of the face and upper half of the body, their swelling can be observed.

When examining the mediastinal organs, it is necessary to conduct a thorough percussion and auscultation, determine the function external respiration. Important in the examination are electro- and phonocardiographic studies, ECG data, X-ray examination. Radiography and fluoroscopy are carried out in two projections (direct and lateral). If a pathological focus is detected, tomography is performed. The study, if necessary, is supplemented by pneumomediastinography. If a retrosternal goiter or aberrant thyroid is suspected, ultrasound and scintigraphy with I-131 and Tc-99 is performed.

AT last years when examining patients, instrumental research methods are widely used: thoracoscopy and mediastinoscopy with biopsy. They allow for a visual assessment of the mediastinal pleura, partly of the mediastinal organs, and to perform material sampling for morphological examination.

Currently, the main methods for diagnosing diseases of the mediastinum, along with radiography, are computed tomography and nuclear magnetic resonance.

Features of the course of certain diseases of the mediastinal organs:

Mediastinal injury.

Frequency - 0.5% of all penetrating chest injuries. Damage is divided into open and closed. Peculiarities clinical course are caused by bleeding with the formation of a hematoma and compression of organs, vessels and nerves by it.

Signs of mediastinal hematoma: slight shortness of breath, mild cyanosis, swelling of the jugular veins. When x-ray - darkening of the mediastinum in the area of ​​hematoma. Often a hematoma develops against the background of subcutaneous emphysema.

With imbibition of the blood of the vagus nerves, a vagal syndrome develops: respiratory failure, bradycardia, worsening of blood circulation, pneumonia of a confluent nature.

Treatment: adequate pain relief, maintenance of cardiac activity, antibacterial and symptomatic therapy. With progressive mediastinal emphysema, a puncture of the pleura and subcutaneous tissue of the chest and neck is indicated with short and thick needles to remove air.

When the mediastinum is injured, the clinical picture is supplemented by the development of hemothorax and hemothorax.

Active surgical tactics are indicated for progressive impairment of the function of external respiration and ongoing bleeding.

Damage to the thoracic lymphatic duct can be caused by:

1. 1. closed injury chest;
2. 2. knife and gunshot wounds;
3. 3. during intrathoracic operations.

As a rule, they are accompanied by severe and dangerous complication chylothorax. With unsuccessful conservative therapy for 10-25 days, surgical treatment is necessary: ​​ligation of the thoracic lymphatic duct above and below the damage, in rare cases, parietal suturing of the duct wound, implantation in an unpaired vein.

Inflammatory diseases.

Acute nonspecific mediastinitis- inflammation of the tissue of the mediastinum, caused by a purulent nonspecific infection.

Acute mediastinitis can be caused by the following reasons.

1. Open injuries of the mediastinum.
   1. Complications of operations on the organs of the mediastinum.
   2. Contact spread of infection from adjacent organs and cavities.
   3. Metastatic spread of infection (hematogenous, lymphogenous).
   4. Perforation of the trachea and bronchi.
   5. Perforation of the esophagus (traumatic and spontaneous rupture, instrumental injury, damage by foreign bodies, tumor decay).

The clinical picture of acute mediastinitis consists of three main symptom complexes, the different severity of which leads to a variety of its clinical manifestations. The first symptom complex reflects the manifestations of severe acute purulent infection. The second is associated with the local manifestation of a purulent focus. The third symptom complex is characterized by clinical picture injuries or diseases that preceded the development of mediastinitis or were its cause.

Common manifestations of mediastinitis: fever, tachycardia (pulse - up to 140 beats per minute), chills, decreased blood pressure, thirst, dry mouth, shortness of breath up to 30 - 40 per minute, acrocyanosis, agitation, euphoria with a transition to apathy.

With limited abscesses of the posterior mediastinum, the most common symptom is dysphagia. There may be a dry barking cough up to suffocation (involvement in the process of the trachea), hoarseness (involvement of the recurrent nerve), as well as Horner's syndrome - if the process spreads to the sympathetic nerve trunk. The position of the patient is forced, semi-sitting. There may be swelling of the neck and upper section chest. On palpation, there may be crepitus due to subcutaneous emphysema, as a result of damage to the esophagus, bronchus, or trachea.

Local signs: chest pain - the earliest and constant sign mediastinitis. The pain is aggravated by swallowing and tilting the head back (Romanov's symptom). The localization of pain mainly reflects the localization of the abscess.

Local symptoms depend on the localization of the process.

In the treatment of mediastinitis, active surgical tactics are used, followed by intensive detoxification, antibacterial and immunostimulating therapy. Surgical treatment consists in the implementation of optimal access, exposure of the injured area, suturing the gap, drainage of the mediastinum and pleural cavity (if necessary) and the imposition of a gastrostomy. Mortality in acute purulent mediastinitis is 20-40%. When draining the mediastinum, it is best to use the technique of N.N. Kanshin (1973): drainage of the mediastinum with tubular drains, followed by fractional washing with antiseptic solutions and active aspiration.

Chronic mediastinitis divided into aseptic and microbial. Aseptic ones include idiopathic, posthemorrhagic, coniotic, rheumatic, dysmetabolic. Microbial are divided into non-specific and specific (syphilitic, tuberculous, mycotic).

Common to chronic mediastinitis is the productive nature of inflammation with the development of sclerosis of the mediastinal tissue.

The greatest surgical value is idiopathic mediastinitis (fibrous mediastinitis, mediastinal fibrosis). With a localized form, this type of mediastinitis resembles a tumor or cyst of the mediastinum. In the generalized form, mediastinal fibrosis is combined with retroperitoneal fibrosis, fibrous thyroiditis, and orbital pseudotumor.

The clinic is due to the degree of compression of the mediastinal organs. The following compression syndromes are identified:

1. superior vena cava syndrome
2. Compression syndrome of the pulmonary veins
3. Tracheobronchial syndrome
4. Esophageal syndrome
5. Pain syndrome
6. compression syndrome nerve trunks

Treatment of chronic mediastinitis is mainly conservative and symptomatic. If the cause of mediastinitis is found out, its elimination leads to a cure.

Tumors of the mediastinum. All clinical symptoms various volumetric formations of the mediastinum are usually divided into three main groups:

1. Symptoms from the organs of the mediastinum, squeezed by the tumor;

2. Vascular symptoms resulting from vascular compression;

3. Neurogenic symptoms that develop due to compression or germination of nerve trunks

Compression syndrome is manifested by compressed organs of the mediastinum. First of all, the veins of the brachiocephalic and superior vena cava are compressed - the syndrome of the superior vena cava. With further growth, compression of the trachea and bronchi is noted. This is manifested by coughing and shortness of breath. When the esophagus is compressed, swallowing and the passage of food are disturbed. When a tumor of the recurrent nerve is compressed, phonation is disturbed, paralysis of the vocal cord on the corresponding side. With compression of the phrenic nerve - high standing of the paralyzed half of the diaphragm.

With compression of the border sympathetic trunk of Horner's syndrome - omission upper eyelid, pupillary constriction, retraction eyeball.

Neuroendocrine disorders are manifested in the form of damage to the joints, disorders heart rate, violations of the emotional-volitional sphere.

Symptoms of tumors are varied. The leading role in the diagnosis, especially in the early stages before the onset of clinical symptoms, belongs to computed tomography and radiological method.

Differential diagnosis of mediastinal tumors proper.

Thymomas (tumors of the thymus) are not classified as mediastinal tumors proper, although they are considered together with them due to localization features. They can behave both as benign and as malignant tumors, giving metastases. They develop either from the epithelial or from the lymphoid tissue of the gland. Often accompanied by the development of myasthenia gravis (Miastenia gravis). The malignant variant occurs 2 times more often, usually proceeds very hard and quickly leads to the death of the patient.

Surgical treatment is indicated:

1. with an established diagnosis and suspicion of a tumor or cyst of the mediastinum;
2. with acute purulent mediastinitis, foreign bodies mediastinum, causing pain, hemoptysis or suppuration in the capsule.

The operation is contraindicated in:

1. established distant metastases to other organs or cervical and axillary lymph nodes;
2. compression of the superior vena cava with the transition to the mediastinum;
3. persistent paralysis of the vocal cord in the presence of malignant tumor manifested by hoarseness of voice;
4. dissemination of a malignant tumor with the occurrence of hemorrhagic pleurisy;
5. the general serious condition of the patient with symptoms of cachexia, hepatic-renal failure, pulmonary and heart failure.

It should be noted that in choosing the volume of surgical intervention in oncological patients, one should take into account not only the nature of the growth and spread of the tumor, but also general state patient, age, condition of vital organs.

Surgical treatment of malignant tumors of the mediastinum gives poor results. Radiation treatment responds well to lymphogranulomatosis and reticulosarcoma. With true tumors of the mediastinum (teratoblastomas, neurinomas, connective tissue tumors), radiation treatment is ineffective. Chemotherapeutic methods of treatment of malignant true tumors of the mediastinum are also ineffective.

Purulent mediastinitis requires emergency surgery as the only way to save the patient, regardless of the severity of his condition.

To expose the anterior and posterior mediastinum and the organs located there, various operational approaches are used: a) full or partial longitudinal dissection of the sternum; b) transverse dissection of the sternum, while both pleural cavities are opened; c) both the anterior and posterior mediastinum can be opened through the left and right pleural cavities; d) diaphragmotomy with and without opening abdominal cavity; e) opening of the mediastinum through an incision in the neck; f) the posterior mediastinum can be penetrated extrapleurally from behind along the lateral surface of the spine with resection of the heads of several ribs; g) the mediastinum can be entered extrapleurally after resection of the costal cartilages near the sternum, and sometimes with partial resection of the sternum.

Rehabilitation. Employability examination.

Clinical examination of patients

To determine the working capacity of patients, general clinical data are used with a mandatory approach to each examined person. During the initial examination, it is necessary to take into account clinical data, the nature of the pathological process - the disease or tumor, age, complications from the treatment, and in the presence of a tumor - and possible metastasis. Transfer to disability before return to professional work is usual. In benign tumors after their radical treatment, the prognosis is favorable. In malignant tumors, the prognosis is poor. Tumors of mesenchymal origin tend to develop relapses with subsequent malignancy.

In the future, the radical nature of the treatment, complications after treatment are important. Such complications include lymphedema of the extremities, trophic ulcers after radiation treatment, violations of the ventilation function of the lungs.

test questions

1. 1. Classification of diseases of the mediastinum.
2. 2. Clinical symptoms of mediastinal tumors.
3. 3. Methods for diagnosing neoplasms of the mediastinum.
4. 4. Indications and contraindications for surgical treatment tumors and cysts of the mediastinum.
5. 5. Operational accesses into the anterior and posterior mediastinum.
6. 6. Causes of purulent mediastinitis.
7. 7. Clinic of purulent mediastinitis.
8. 8. Methods of opening abscesses with mediastinitis.
9. 9. Symptoms of rupture of the esophagus.

10. Principles of treatment of ruptures of the esophagus.

11. Causes of damage to the thoracic lymphatic duct.

12. Clinic of chylothorax.

13. Causes of chronic mediastinitis.

14. Classification of tumors of the mediastinum.

Situational tasks

1. A 24-year-old patient was admitted with complaints of irritability, sweating, weakness, and palpitations. Sick for 2 years. Thyroid not increased. Main exchange +30%. Physical examination of the patient revealed no pathology. An X-ray examination in the anterior mediastinum at the level of the II rib on the right determines the formation of a rounded shape 5x5 cm with clear boundaries, the lung tissue is transparent.

What additional studies are needed to clarify the diagnosis? What is your strategy in treating the patient?

2. The patient is 32 years old. Three years ago, she suddenly felt pain in her right arm. She was treated with physiotherapy - the pain decreased, but did not completely disappear. Subsequently, she noticed a dense, bumpy formation on the right side of the neck in the supraclavicular region. At the same time, the pain in the right half of the face and neck increased. Then she noticed a narrowing of the right palpebral fissure and the absence of sweating on the right half of the face.

On examination in the right clavicular region, a dense, tuberous, immobile tumor was found and an expansion of the superficial venous section of the upper half of the body in front. Slight atrophy and decreased muscle strength of the right shoulder girdle and upper limb. Dullness of percussion sound above the apex of the right lung.

What kind of tumor can you think of? What additional research is needed? What is your tactic?

3. The patient is 21 years old. She complained of a feeling of pressure in her chest. X-ray on the right to the upper part of the mediastinal shadow adjoins an additional shadow in front. The outer contour of this shadow is clear, the inner one merges with the shadow of the mediastinum.

What disease can you think of? What is your strategy in treating the patient?

4. During the last 4 months, the patient developed vague pain in the right hypochondrium, accompanied by increasing dysphagic changes. X-ray examination on the right revealed a shadow in the right lung, which is located behind the heart, with clear contours about 10 cm in diameter. The esophagus is compressed at this level, but its mucosa is not changed. Above compression, there is a long delay in the esophagus.

Your presumptive diagnosis and tactics?

5. A 72-year-old patient immediately after fibrogastroscopy developed retrosternal pain and swelling in the neck on the right.

What complication can you think of? What additional studies will you perform to clarify the diagnosis? What is your strategy and treatment?

6. Sick 60 years. A day ago, a fish bone at the level of C 7 was extracted in the hospital. After that, edema appeared in the neck, temperature up to 38 °, profuse salivation, an infiltrate of 5x2 cm, painful, began to be detected on palpation on the right. X-ray signs of phlegmon of the neck and the expansion of the body of the mediastinum from above.

What is your diagnosis and tactics?

1. To clarify the diagnosis of intrasternal goiter, it is necessary to carry out the following additional methods examinations: pneumomediastinography - in order to clarify the topical location and size of tumors. Contrast study of the esophagus - in order to identify the dislocation of the mediastinal organs and the displacement of tumors during swallowing. Tomographic examination - in order to identify the narrowing or displacement of the vein by the neoplasm; scanning and radioisotope study of thyroid functions with radioactive iodine. Clinical manifestations of thyrotoxicosis determine the indications for surgical treatment. Removal of the retrosternal goiter at this localization is less traumatic to carry out by cervical access, following the recommendations of V. G. Nikolaev to cross the sternohyoid, sternothyroid, sternocleidomastoid muscles. If there is a suspicion of the presence of fusion of the goiter with the surrounding tissues, transthoracic access is possible.

2. You can think of a neurogenic tumor of the mediastinum. Along with clinical and neurological examination radiography in frontal and lateral projections, tomography, pneumomediastinography, diagnostic pneumothorax, angiocardiopulmography are necessary. In order to detect disorders of the sympathetic nervous system a diagnostic Linara test is used, based on the use of iodine and starch. The test is positive if, during sweating, starch and iodine reacted, taking on a brown color.

Treatment of a tumor that causes compression of nerve endings is surgical.

3. You can think of a neurogenic tumor of the posterior mediastinum. The main thing in the diagnosis of a tumor is to establish its exact localization. Treatment consists of surgical removal of the tumor.

4. A patient has a tumor in the posterior mediastinum. Most likely neurogenic. The diagnosis allows you to clarify a multifaceted x-ray examination. At the same time, the interest of neighboring organs can be identified. Given the localization of pain, the most likely cause is compression of the phrenic and vagus nerves. Surgical treatment, in the absence of contraindications.

5. You can think of an iatrogenic rupture of the esophagus with the formation of cervical mediastinitis. After X-ray examination and X-ray contrast examination of the esophagus, an urgent operation is indicated - opening and drainage of the rupture zone, followed by debridement of the wound.

6. A patient has perforation of the esophagus with subsequent formation of neck phlegmon and purulent mediastinitis. Treatment is surgical opening and drainage of the phlegmon of the neck, purulent mediastinotomy, followed by debridement of the wound.

Mediastinum I Mediastinum

part of the thoracic cavity bounded anteriorly by the sternum and posteriorly by the spine. Covered with intrathoracic fascia, on the sides - mediastinal pleura. From above, the border of S. is the upper aperture of the chest, from below -. In the mediastinum are located the pericardium, large vessels and, trachea and main, esophagus, thoracic duct ( rice. 12 ).

The mediastinum is conditionally divided (along the plane passing through the trachea and main bronchi) into anterior and posterior. In the anterior are the Thymus gland, the right and left brachiocephalic and superior vena cava, the ascending part and (Aorta), its branches, the Heart and the Pericardium, in the posterior - the thoracic aorta, esophagus, vagus nerves and sympathetic trunks, their branches, unpaired and semi-unpaired vein, thoracic duct. In the anterior S., the upper and lower sections are distinguished (the heart is located in the lower). Loose, surrounding the organs, communicates above through the anterior S. with the previsceral cellular space of the neck, through the posterior - with the retrovisceral cellular space of the neck, below through the holes in the diaphragm (along the para-aortic and periesophageal tissue) - with the retroperitoneal tissue. Between the fascial sheaths of the organs and vessels of S., interfascial gaps and spaces are formed, filled with fiber that forms cellular spaces: pretracheal - between the trachea and the aortic arch, in which the posterior thoracic aortic plexus is located; retrotracheal - between the trachea and the esophagus, where the periesophageal and posterior mediastinal lie; left tracheobronchial, where the aortic arch, left vagus and left upper tracheobronchial lymph nodes are located; right tracheobronchial, in which there are unpaired, right vagus nerve, right upper tracheobronchial lymph nodes. Between the right and left main bronchi, an interbronchial, or bifurcation, space is determined with the lower tracheobronchial lymph nodes located in it.

The blood supply is provided by the branches of the aorta (mediastinal, bronchial, esophageal, pericardial); outflow of blood occurs in the unpaired and semi-unpaired veins. Lymphatic vessels conduct lymph to the tracheobronchial (upper and lower), paratracheal, posterior and anterior mediastinal, prepericardial, lateral pericardial, prevertebral, intercostal, perithoracic lymph nodes. S. is carried out by the thoracic aortic plexus.

Research methods. In most cases, it is possible to identify S.'s pathology based on the results clinical trial and standard x-rays (fluorography), as well as using x-rays (radiography) of the chest. In case of swallowing disorders, it is advisable to provide radiopaque and endoscopic studies of the esophagus. Angiography (Angiography) is sometimes used to visualize the superior and inferior vena cava, aorta, and pulmonary trunk. Computed X-ray Tomography and nuclear magnetic resonance imaging, which are the most informative methods for diagnosing diseases of the mediastinum, have great potential. If a pathology of the thyroid gland is suspected (retrosternal), a radionuclide Scan is indicated. For morphological verification of the diagnosis, mainly in S.'s tumors, endoscopic methods are used (bronchoscopy (Bronchoscopy) with transtracheal or transbronchial puncture, thoracoscopy, mediastinoscopy), transthoracic puncture, and mediastinotomy. At a mediastinoskopiya examine front S. by means of the mediastinoscope entered after a mediastinotomy. is a surgical operation that can be used for diagnostic purposes.

Malformations. Among the malformations of S., the most common are pericardial cysts (coelomic), dermoid cysts, bronchogenic and enterogenic cysts. Pericardial cysts are usually thin-walled and filled with clear fluid. They are usually asymptomatic and are an incidental finding on x-ray. Bronchogenic cysts are localized near the trachea and large bronchi, can cause airways, while dry, shortness of breath, stridor appear. Enterogenic cysts are localized near the esophagus, can ulcerate with subsequent perforation and the formation of fistulas with the esophagus, trachea, bronchi. malformations of S. operational. at timely treatment favorable.

Damage. There are closed and open injuries of S. Closed injuries of S. occur with bruises and compression of the chest, fractures of the sternum or general contusions and are characterized by the formation of a hematoma in the tissue of S. Clinically, they are manifested by moderate chest pain, shortness of breath, mild cyanosis and slight swelling of the jugular veins. from small vessels stops spontaneously. Bleeding from larger vessels is accompanied by the formation of an extensive hematoma and the spread of blood through fiber C. When the vagus nerves are imbibed by blood, a syndrome sometimes occurs, characterized by severe respiratory failure, circulatory disorders, and the development of bilateral pneumonia. S.'s hematoma leads to mediastinitis or mediastinal abscess. The closed damages of S. at an injury of hollow bodies are often complicated by Pneumothorax and Hemothorax. If the trachea or large bronchi are damaged, less often the lungs and esophagus in S., the mediastinal or pneumomediasticum penetrates and develops. A small amount of air is localized within S., and when it enters in significant quantities, air can spread through the cellular spaces beyond S. At the same time, extensive subcutaneous emphysema develops and unilateral or bilateral is possible. Widespread mediastinal emphysema is accompanied by pressing chest pains, shortness of breath and cyanosis. The general condition of the patient sharply worsens, often observed in subcutaneous tissue face, neck and upper chest, disappearance of cardiac dullness, weakening of heart tones. confirms the accumulation of gas in the tissue of S. and neck.

Open S.'s damages are quite often connected with injury of other organs of a thorax. Wounds of the thoracic trachea and main bronchi along with the main vessels (aortic arch, superior vena cava, etc.) usually lead to death at the scene. If he remains alive, then there are respiratory disorders, coughing fits with the release of foamy blood, mediastinal emphysema, pneumothorax. A sign of injury to the trachea and large bronchi may be the release of air through the wound on exhalation. Penetrating chest from the front and left should raise suspicion of possible heart(Heart). of the thoracic esophagus is rarely isolated, accompanied by mediastinal emphysema, purulent mediastinitis and pleurisy develop rapidly. thoracic duct (Thoracic duct) are more often detected after a few days or even weeks after and are characterized by increasing effusion pleurisy. The pleural fluid (chyle), in the absence of blood impurities, resembles milk in color and, in a biochemical study, contains an increased amount of triglycerides.

The volume of first aid for wounding S.'s organs is usually small, the imposition of aseptic, the toilet of the upper respiratory tract, according to indications - the introduction of painkillers and oxygen.

When performing emergency medical procedures for open wounds S.'s organs must adhere to the following sequence: toilet of the respiratory tract, sealing of the chest cavity and trachea, pleural cavity, subclavian or jugular vein.

Sealing of the chest cavity is mandatory in cases of open pneumothorax. Temporary sealing is achieved by applying a bandage with a sterile cotton-gauze pad that completely covers the wound opening. An oilcloth, cellophane, polyethylene or other impermeable layer is applied on top. The bandage is fixed far beyond the edges with a tiled overlay of strips of adhesive tape. It is advisable to bandage the hand to the affected side of the chest. At small cut wounds you can match their edges and fix with adhesive tape.

In case of respiratory disorders for artificial ventilation of the lungs (artificial lung), an Ambu-type bag or any portable breathing apparatus is used. You can start artificial ventilation of the lungs by breathing the mouth in or out of the mouth, and then carry out tracheal intubation (see Intubation).

Pleural puncture is necessary if there are signs of internal tension pneumothorax. It is produced in the second intercostal space in front with a thick needle with a wide lumen or a trocar to provide free air from the pleural cavity. The needle is either temporarily connected to a plastic or rubber tube with a valve at the end.

With a rarely observed rapid development of intense mediastinal emphysema, an emergency neck is shown - the skin above the jugular notch with the creation behind the sternal passage into the fiber C.

All the injured and wounded are hospitalized in specialized surgical departments. Transportation should be carried out by a specialized resuscitation machine. It is preferable to transport the victim in a semi-sitting position. The accompanying document indicates the circumstances of the injury, its clinical symptoms and a list of therapeutic measures taken.

In the hospital after examination and required examination the issue of further treatment tactics is being decided. If the condition of a patient with closed S.'s injury improves, they are limited to rest, symptomatic therapy and the appointment of antibiotics to prevent infectious complications.

The volume of surgical interventions for open injuries of S. is quite wide - treatment of a chest wound up to complex operations on the organs of the chest cavity. Indications for urgent thoracotomy are injuries to the heart and large vessels, trachea, large bronchi and lungs with bleeding, tension pneumothorax, injuries to the esophagus, diaphragm, progressive deterioration of the patient's condition in case of an unclear diagnosis. When deciding on an operation, it is necessary to take into account the damage, the degree functional disorders and the effect of conservative measures.

Diseases. Inflammatory diseases S. - see Mediastinitis. Relatively often retrosternal goiter is detected. Allocate a "diving" retrosternal goiter, most of which is located in the S., and the smaller one is on the neck (protrudes when swallowed); actually retrosternal goiter, localized entirely behind the sternum (its upper pole is palpable behind the notch of the sternum handle); intrathoracic, located deep in S. and inaccessible to palpation. A "diving" goiter is characterized by periodically occurring asphyxia, as well as symptoms of compression of the esophagus (). With retrosternal and intrathoracic goiter, symptoms of compression of large vessels, especially veins, are noted. In these cases, swelling of the face and neck, swelling of the veins, hemorrhages in the sclera, expansion of the veins of the neck and chest are detected. in these patients it is increased, headaches, weakness, shortness of breath are observed. To confirm the diagnosis, a radionuclide with 131 I is used, but the negative results of this study do not exclude the presence of the so-called cold colloidal node. Retrosternal and intrathoracic goiter can be malignant, so its early radical removal is mandatory.

Tumors Pages are observed equally often at men and women; occur predominantly in young and adulthood. Most of them are congenital neoplasms. Benign tumors of S. significantly prevail over malignant ones.

The clinical symptoms of benign neoplasms of S. depend on many factors - the growth rate and size of the tumor, its location, the degree of compression of neighboring anatomical formations, etc. During S.'s neoplasms, two periods are distinguished - an asymptomatic period with clinical manifestations. Benign tumors develop asymptomatically for a long time, sometimes years and even decades.

There are two main syndromes in S.'s pathology - compression and neuroendocrine. Compression syndrome is caused by a significant increase in pathological formation. It is characterized by a feeling of fullness and pressure, dull pain behind the sternum, shortness of breath, cyanosis of the face, swelling of the neck, face, dilatation of the saphenous veins. Then there are signs of dysfunction of certain organs as a result of their compression.

There are three types of compression symptoms: organ (and compression of the heart, trachea, main bronchi, esophagus), vascular (compression of the brachiocephalic and superior vena cava, thoracic duct, displacement of the aorta) and neurogenic (compression with impaired conduction of the vagus, phrenic and intercostal nerves, sympathetic trunk).

Neuroendocrine syndrome is manifested by joint damage resembling, as well as large and tubular bones. There are various changes in heart rate, angina pectoris.

Neurogenic tumors of S. (neurinomas, neurofibromas, ganglioneuromas) often develop from the sympathetic trunk and intercostal nerves and are located in the posterior S. With neurogenic tumors, the symptoms are more pronounced than with all other benign S. formations. There are pains behind the sternum, in the back, headaches , in some cases - sensitive, secretory, vasomotor, pilomotor and trophic disorders on the skin of the chest from the location of the tumor. Bernard-Horner syndrome, signs of compression of the recurrent laryngeal nerve, etc. are less commonly observed. Radiologically, neurogenic tumors are characterized by a homogeneous intense oval or rounded shadow, closely adjacent to the spine.

Ganglioneuromas may take the form hourglass if part of the tumor is located in the spinal canal and is connected by a narrow pedicle to the tumor in the mediastinum. In such cases, signs of compression are combined with mediastinal symptoms. spinal cord up to paralysis.

Of the tumors of mesenchymal origin, lipomas are most common, fibromas, hemangiomas, lymphangiomas are less common, chondromas, osteomas and hibernomas are even less common.

Metastatic lesion lymph nodes S. is typical for lung cancer and esophagus, thyroid and breast cancer, seminoma and adenocarcinoma.

In order to clarify the diagnosis, the entire necessary set of diagnostic measures is used, however, the final determination of the type of malignant tumor is possible only after a biopsy of the peripheral lymph node, examination of pleural exudate, tumor puncture obtained by puncture through the chest wall or the wall of the trachea, bronchus or bronchoscopy, mediastinoscopy or parasternal mediastinotomy , thoracotomy as the final stage of diagnosis. A radionuclide study is carried out to determine the shape of the size, the prevalence of the tumor process, as well as the differential diagnosis of malignant and benign tumors, cysts and inflammatory processes.

At malignant tumors S. to operation are defined by many factors, and first of all - prevalence and morphological features of process. Even partial removal of a malignant tumor of S. improves a condition of many patients. In addition, a decrease in tumor mass creates favorable conditions for subsequent radiation and chemotherapy.

Contraindications to surgery are the serious condition of the patient (extreme, severe hepatic, renal, pulmonary heart failure, not amenable to therapeutic effects) or signs of obvious inoperability (presence of distant metastases, a malignant tumor in the parietal pleura, etc.).

The prognosis depends on the form of the tumor and the timeliness of the treatment.

Bibliography: Blockin N.N. and Perevodchikova N.I. tumor diseases, M., 1984; Wagner E.A. chest injuries, M, 1981; Wagner E. A and other bronchi, Perm, 1985; Vishnevsky A.A. and Adamyak A.A. Surgery of the mediastinum, M, 1977, bibliogr.; Elizarovsky S.I. and Kondratiev G.I. Surgical mediastinum, M., 1961, bibliogr.; Isakov Yu.F. and Stepanov E.A. and cysts of the chest cavity in children, M., 1975; Petrovsky B.V., Perelman M.I. and Queen N.S. Tracheobronchial, M., 1978.

Rice. 1. Mediastinum (right view, mediastinal pleura, part of the costal and diaphragmatic pleura removed, fiber and lymph nodes partially removed): 1 - trunks of the brachial plexus (cut off); 2 - left subclavian artery and vein (cut off); 3 - superior vena cava; 4 - II rib; 5 - right phrenic nerve, pericardial phrenic artery and vein; 6 - right pulmonary artery (cut off); 7 - pericardium; 8 - diaphragm; 9 - costal pleura (cut off); 10 - large splanchnic nerve; 11 - right pulmonary veins (cut off); 12 - posterior intercostal artery and vein; 13 - lymphatic; 14 - right bronchus; 15 - unpaired vein; 16 - esophagus; 17 - right sympathetic trunk; 18 - right vagus nerve; 19 - trachea.

Rice. 2. Mediastinum (left view, mediastinal pleura, part of the costal and diaphragmatic pleura, as well as fiber removed): 1 - clavicle; 2 - left sympathetic trunk; 3 - esophagus; 4 - thoracic duct; 5 - left subclavian artery; 6 - left vagus nerve; 7 - thoracic aorta; 8 - lymph node; 9 - large splanchnic nerve; 10 - semi-unpaired vein; 11 - diaphragm; 12 - esophagus; 13 - left phrenic nerve, pericardial phrenic artery and vein; 14 - pulmonary veins (cut off); 15 - left pulmonary artery (cut off); 16 - left common carotid artery; 17 - left brachiocephalic vein.

1. Small medical encyclopedia. - M.: Medical Encyclopedia. 1991-96 2. First health care. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic Dictionary medical terms. - M.: Soviet Encyclopedia. - 1982-1984. - an obstacle, an obstacle that interferes with communication between the two sides (Ushakov) See ... Synonym dictionary

Modern Encyclopedia

In anatomy, the part of the thoracic cavity in mammals and humans, in which the heart, trachea and esophagus are located. In humans, the mediastinum is limited from the sides by pleural sacs (they contain the lungs), from below by the diaphragm, in front of the sternum and behind ... ... Big Encyclopedic Dictionary

mediastinum, mediastinum, pl. no, cf. 1. The space between the spine and the sternum, in which the heart, aorta, bronchi and other organs are located (anat.). 2. trans. An obstacle, an obstacle that interferes with the communication of the two sides (book). “…Abolish…… Explanatory Dictionary of Ushakov

MEDIASTINUM- MEDIASTUM, mediastinum (from Latin in me dio stans standing in the middle), the space located between the right and left pleural cavities and bounded laterally by the pleura mediastinalis, dorsally by the thoracic region of the spinal column by the necks of the ribs ... Big Medical Encyclopedia

Mediastinum- (anatomical), part of the thoracic cavity in mammals and humans, in which the heart, trachea and esophagus are located. In humans, the mediastinum is limited laterally by pleural sacs (they contain the lungs), from below by the diaphragm, in front by the sternum, behind ... ... Illustrated Encyclopedic Dictionary

MEDIASTINE, I, cf. (specialist.). A place in the middle part of the chest cavity, where the heart, trachea, esophagus, nerve trunks are located. | adj. mediastinal, oh, oh. Explanatory dictionary of Ozhegov. S.I. Ozhegov, N.Yu. Shvedova. 1949 1992 ... Explanatory dictionary of Ozhegov

- (mediastinum), the middle part of the thoracic cavity of mammals, in the swarm are the heart with large vessels, the trachea and the esophagus. Limited in front by the sternum, behind the thoracic spine, laterally by the pleura, below by the diaphragm; top, the border is considered ... Biological encyclopedic dictionary

- (mediastinum) the part of the pleura that runs from the anterior wall of the chest cavity to the back and is adjacent to the side of each lung with which they face each other. The space enclosed between these two layers of the pleura is called the mediastinal ... ... Encyclopedia of Brockhaus and Efron

Books

• Other Message, Vitaly Samoilov. Overcoming the seemingly invincible thickness of hypnotic sleep by a self-sufficient internal effort, opening the dark mediastinum of the darkened being in the heart of the vale, preparing the universal… electronic book

The mediastinum is an anatomical space, the middle region of the chest. The mediastinum is bounded anteriorly by the sternum and posteriorly by the spine. On the sides of this organ are the pleural cavities.

For various purposes ( surgical intervention, planning radiotherapy, descriptions of the localization of pathology) the mediastinum, in accordance with the scheme proposed by Twining in 1938, is divided into upper and lower, as well as anterior, posterior and middle sections.

Anterior, middle, posterior mediastinum

The anterior mediastinum is bounded anteriorly by the sternum, and posteriorly by the brachiocephalic veins, pericardium, and brachiocephalic trunk. In this space are the internal thoracic veins, the thoracic artery, the mediastinal lymph nodes and the thymus - the thymus gland.

The structure of the middle mediastinum: heart, vena cava, brachiocephalic veins and brachiocephalic trunk, aortic arch, ascending aorta, diaphragmatic veins, main bronchi, trachea, pulmonary veins and arteries.

The posterior mediastinum is bounded by the trachea and pericardium in the anterior part, and in the posterior by the spine. In this part of the body are the esophagus, descending aorta, thoracic lymphatic duct, semi-unpaired and unpaired veins, as well as the posterior lymph nodes of the mediastinum.

Superior and inferior mediastinum

All anatomical structures that lie above the upper edge of the pericardium belong to the superior mediastinum: its boundaries are the superior aperture of the sternum and the line drawn between the angle of the chest and intervertebral disc Th4-Th5.

The inferior mediastinum is limited by the upper edges of the diaphragm and pericardium and, in turn, is also divided into anterior, middle and posterior parts.

Classification of neoplasms of the mediastinum

Neoplasms of the organ are considered not only true tumors of the mediastinum, but also tumor-like diseases and cysts that are different in etiology, localization and course of the disease. Each of the neoplasms of the mediastinum comes from tissues of different origin, uniting only by anatomical boundaries. They are divided into:

Tumors of the mediastinum are detected mainly in young and middle age with the same frequency, both in men and women. Despite the fact that diseases of the mediastinum may not manifest themselves for a long time and be detected only on a preventive study, there are several symptoms that characterize violations of this anatomical space:

• Non-intense pain, localized at the site of neoplasms and radiating to the neck, shoulder, interscapular region;
• Pupil dilation, drooping of the eyelid, retraction of the eyeball - can occur if the tumor grows into the borderline sympathetic trunk;
• Hoarseness of voice - originates from damage to the recurrent laryngeal nerve;
• Heaviness, noise in the head, shortness of breath, chest pain, cyanosis and swelling of the face, swelling of the veins of the chest and neck;
• Violation of the passage of food through the esophagus.

In the late stages of mediastinal diseases, an increase in body temperature, general weakness, arthralgic syndrome, heart rhythm disturbance, and swelling of the extremities are observed.

Mediastinal lymphadenopathy

Lymphadenopathy or an increase in the lymph nodes of this organ are observed with metastases of carcinoma, lymphomas, as well as some non-tumor diseases (sarcoidosis, tuberculosis, etc.).

The main symptom of the disease is a generalized or localized enlargement of the lymph nodes, however, mediastinal lymphadenopathy may have such additional manifestations as:

• Increased body temperature, sweating;
• weight loss;
• Frequent infection of the upper respiratory tract (tonsillitis, pharyngitis, tonsillitis);
• Hepatomegaly and splenomegaly.

The defeat of the lymph nodes, characteristic of lymphomas, can be isolated, or combine the germination of tumors in other anatomical structures (trachea, blood vessels, bronchi, pleura, esophagus, lungs).

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Mediastinum- a complex anatomical and topographic region of the chest cavity. Its lateral borders are the right and left sheets of the mediastinal pleura, the posterior wall forms the thoracic spine, the anterior - the sternum, the lower edge limits the diaphragm. The mediastinum does not have an upper anatomical barrier, opening into the cellular space of the neck, and the upper edge of the sternum is considered its conditional boundary. The middle position of the mediastinum is maintained by intrapleural negative pressure, it changes with pneumothorax.

For convenience in determining the localization of pathological processes, the mediastinum is conditionally divided into anterior and posterior, upper, middle and lower. The boundary between the anterior and posterior mediastinum is the frontal plane, which passes through the center of the stem bronchi of the lung root. According to this division, the ascending aorta, the aortic arch with the innominate, left common carotid and left subclavian arteries, both innominate and superior vena cava, the inferior vena cava at the confluence with the right atrium, the pulmonary artery and veins, the heart with pericardium, thymus, phrenic nerves, trachea and mediastinal lymph nodes. In the posterior mediastinum are the esophagus, unpaired and semi-unpaired veins, thoracic lymphatic duct, vagus nerves, descending aorta with intercostal arteries, border trunk of sympathetic nerves on the right and left, lymph nodes.

All anatomical formations are surrounded by loose adipose tissue, which is separated by fascial sheets, and covered on the lateral surface by the pleura. Fiber is unevenly developed; it is especially well expressed in the posterior mediastinum, most weakly between the pleura and pericardium.

Organs of the anterior mediastinum

The aortic arch is thrown from front to back through the root of the left lung. The upper part of the arc is projected onto the handle of the sternum. From above, the left innominate vein adjoins it, from below - the transverse sinus of the heart, bifurcation pulmonary artery, left recurrent nerve, and obliterated ductus arteriosus. The pulmonary artery emerges from the conus arteriosus and lies to the left of the ascending aorta. The beginning of the pulmonary artery corresponds to the II intercostal space on the left.

The superior vena cava is formed as a result of the confluence of both innominate veins at the level of the II costal-sternal joint. Its length is 4-6 cm. It flows into the right atrium, where it passes partially intrapericardially.

The inferior vena cava enters the mediastinum through the aperture of the same name in the diaphragm. The length of the mediastinal part is 2-3 cm. It empties into the right atrium. Pulmonary veins exit two at a time from the gates of both lungs and flow into the left atrium.

The pectoral nerves depart from the cervical plexus and descend along the anterior surface of the anterior scalene muscle and penetrate into the chest cavity. The right thoracic nerve passes between the mediastinal pleura and the outer wall of the superior vena cava. The left one penetrates into the chest cavity anterior to the aortic arch and passes through the pericardio-pectoral arteries - branches of the internal intrathoracic artery.

The heart is mostly located in the left half of the chest, occupying the anterior mediastinum. On both sides it is limited by sheets of the mediastinal pleura. It distinguishes the base, apex and two surfaces - diaphragmatic and sternocostal.

Behind, according to the location of the spine, the esophagus with vagus nerves, the thoracic aorta are adjacent to the heart, the unpaired vein is on the right, the semi-aortic vein is on the left, and the thoracic duct is in the unpaired aortic sulcus. The heart is enclosed in a cardiac shirt - in one of the 3 closed serous sacs of the coelomic body cavity. The heart sac fuses with the tendinous part of the diaphragm to form the bed of the heart. At the top, the heart shirt is attached to the aorta, pulmonary artery and superior vena cava.

Embryological, anatomical, physiological and histological features of the thymus

The thymus gland is well developed in newborns and especially in children at the age of two. So, in newborns, iron is an average of 4.2% of body weight, and in 50 years and more - 0.2%. The weight of the gland in boys is somewhat greater than in girls.

In the post-pubertal period, the physiological involution of the thymus occurs, but its functioning tissue is preserved until old age.

The weight of the thymus gland depends on the degree of fatness of the subject (Hammar, 1926, etc.), as well as the constitution.

The size and dimensions of the thymus gland are variable and depend on age. This affects the anatomical and topographic relationships of the thymus gland and other organs. In children under 5 years of age, the upper edge of the gland protrudes from behind the handle of the sternum. Adults usually cervical region the thymus gland is absent and it occupies an intrathoracic position in the anterior mediastinum. It should be noted that in children under 3 years of age, the cervical part of the gland lies under the sternothyroid and sternohyoid muscles. Its posterior surface is adjacent to the trachea. These features should be taken into account during tracheostomy in children in order to avoid injury to the thymus gland and the innominate vein lying directly below it. The lateral surface of the thymus on the right is in contact with the jugular vein, the common carotid artery, vagus nerve, on the left - adjacent to the lower thyroid and common carotid arteries, vagus and less often - the recurrent nerve.

The thoracic part of the gland adjoins the posterior surface of the sternum, with its lower surface adjacent to the pericardium, the posterior one to the superior vena cava and left innominate vein, and a. anonymous. Below these formations, the iron is adjacent to the aortic arch. Its anterolateral parts are covered with pleura. In front, the gland is shrouded in a connective tissue sheet, which is a derivative of the cervical fascia. These bundles connect below with the pericardium. In the fascial bundles, muscle fibers are found that fan-shaped into the heart shirt and mediastinal pleura. In adults, the thymus gland is located in the anterior superior mediastinum and its syntopy corresponds to the thoracic part of the gland in children.

The blood supply of the thymus gland depends on the age, its size and, in general, on the functional state.

The source of arterial blood supply is a. raat-maria interna, a. thyreoidea inferior, a. anonyma and aortic arch.

Venous outflow is carried out more often into the left innominate vein, relatively less often into the thyroid and intrathoracic veins.

It is well known that up to 4 weeks of embryonic life, the thymus is a purely epithelial formation. In the future, the marginal zone is populated by small lymphocytes (thymocytes). Thus, as it develops, the thymus becomes a lymphoepithelial organ. The basis of the gland is a mesh epithelial formation reticulum, which is populated by lymphocytes. By 3 months of uterine life, peculiar concentric bodies appear in the gland, a specific structural unit of the thymus gland (V.I. Puzik, 1951).

The question of the origin of Hassal's bodies has long been debatable. Multicellular bodies of Gassall are formed by hypertrophy of the epithelial elements of the thymus reticulum. The morphological structure of the thymus gland is mainly represented by large transparent oval elongated epithelial cells, which can be of different sizes, colors and shapes, and small dark cells of the lymphoid series. The first make up the pulp of the gland, the second - mainly the bark. The cells of the medulla reach a higher level of differentiation than the cells of the cortex (Sh. D. Galustyan, 1949). Thus, the thymus gland is built from two genetically heterogeneous components - the epithelial network and lymphocytes, that is, it represents the lymphoepithelial system. According to Sh. D. Galustyan (1949), any damage leads to disruption of the connection between these elements that make up a single system (lymphoepithelial dissociation).

Embryogenesis data give no doubt that thymus is an endocrine gland. Meanwhile, numerous studies aimed at elucidating the physiological role of the thymus remained unsuccessful. Reaching its greatest development in childhood, the thymus gland, as the body grows and ages, undergoes physiological involution, which affects its weight, size and morphological structure (V.I. Puzik, 1951; Hammar, 1926, etc.). Experiments on animals with removed thymus gave conflicting results.

The study of the physiology of the thymus over the past decade has made it possible to come to important conclusions about its functional significance for the body. The role of the thymus gland in the adaptation of the organism under the influence of harmful factors was elucidated (E. 3. Yusfina, 1965; Burnet, 1964). Data have been obtained on the leading role of the thymus in immune responses (S. S. Mutin and Ya. A. Sigidin, 1966). It has been found that thymus is the most important source of new lymphocytes in mammals; thymic factor leads to lymphocytosis (Burnet, 1964).

The author believes that the thymus, apparently, serves as a center for the formation of "virgin" lymphocytes, whose progenitors do not have immunological experience, while in other centers where most of the lymphocytes are formed, they come from predecessors that already store something in their " immunological memory. Small lymphocytes play the role of carriers of immunological information. Thus, the physiology of the thymus remains largely unclear, but its importance for the body cannot be overestimated, which is especially evident in pathological processes.

K.T. Ovnatanyan, V.M. Kravets

All mediastinal tumors are an urgent problem for modern thoracic surgery and pulmonology, since such neoplasms are diverse in their morphological structure, they can be initially malignant or prone to malignancy. In addition, they always carry the potential risk of possible compression or invasion of vital organs ( Airways, vessels, nerve trunks or esophagus) and it is technically difficult to remove them surgically. In this article, we will introduce you to the types, symptoms, methods for diagnosing and treating mediastinal tumors.

Tumors of the mediastinum include a group of neoplasms located in the mediastinal space with different morphological structure. They are usually formed from:

• tissues of organs located within the mediastinum;
• tissues located between the organs of the mediastinum;
• tissues that appear with violations of intrauterine development of the fetus.

According to statistics, neoplasms of the mediastinal space are detected in 3-7% of cases of all tumors. At the same time, about 60-80% of them are benign, and 20-40% are cancerous. Such neoplasms are equally likely to develop in both men and women. Usually they are detected in people 20-40 years old.

A bit of anatomy

The mediastinum is located in the middle part of the chest and is limited by:

• sternum, costal cartilages and retrosternal fascia - in front;
• prevertebral fascia, thoracic spine and rib necks - behind;
• the upper edge of the handle of the sternum - from above;
• sheets of the medial pleura - on the sides;
• diaphragm from below.

In the region of the mediastinum are:

• thymus;
• esophagus;
• arch and branches of the aorta;
• upper sections of the superior vena cava;
• subclavian and carotid arteries;
• The lymph nodes;
• brachiocephalic trunk;
• branches of the vagus nerve;
• sympathetic nerves;
• thoracic lymphatic duct;
• tracheal bifurcation;
• pulmonary arteries and veins;
• cellular and fascial formations;
• pericardium etc.

In the mediastinum, to indicate the localization of the neoplasm, experts distinguish:

• floors - lower, middle and upper;
• departments - anterior, middle and posterior.

Classification

All tumors of the mediastinum are divided into primary, i.e., initially formed in it, and secondary - arising as a result of metastasis of cancer cells from other organs outside the mediastinal space.

Primary neoplasms can form from various tissues. Depending on this fact, the following types of tumors are distinguished:

• lymphoid - lympho- and reticulosarcomas, lymphogranulomas;
• thymomas - malignant or benign;
• neurogenic - neurofibromas, paragangliomas, neurinomas, ganglioneuromas, malignant neuromas, etc.;
• mesenchymal - leiomyomas, lymphangiomas, fibro-, angio-, lipo- and leiomyosarcomas, lipomas, fibromas;
• disembryogenetic - seminomas, teratomas, chorionepithelioma, intrathoracic goiter.

In some cases, pseudotumors can form in the mediastinal space:

• on large blood vessels;
• enlarged conglomerates of lymph nodes (with Beck's sarcoidosis or);
• true cysts (echinococcal, bronchogenic, enterogenic cysts or coelomic cysts of the pericardium).

As a rule, retrosternal goiter or thymomas are usually detected in the upper mediastinum, on average - pericardial or bronchogenic cysts, in the anterior - teratomas, lymphomas, thymomas, mesenchymal neoplasms, in the posterior - neurogenic tumors or enterogenic cysts.

Symptoms

As a rule, neoplasms of the mediastinum are detected in people 20-40 years old. During the course of the disease, there are:

• asymptomatic period - a tumor can be detected by chance during an examination for another disease or on fluorography images performed during routine examinations;
• the period of pronounced symptoms - due to the growth of the neoplasm, there is a violation in the functioning of the organs of the mediastinal space.

The duration of the absence of symptoms largely depends on the size and location of the tumor process, the type of neoplasm, the nature (benign or malignant), the growth rate and the relationship to the organs located in the mediastinum. The period of pronounced symptoms in tumors is accompanied by:

• signs of compression or invasion of the organs of the mediastinal space;
• specific symptoms characteristic of a particular neoplasm;
• general symptoms.

As a rule, with any neoplasm, the first sign of the disease is pain that occurs in the chest area. It is provoked by sprouting or compression of nerves or nerve trunks, is moderately intense and can be given to the neck, the area between the shoulder blades or shoulder girdle.

If the tumor is located on the left, then it causes, and with compression or germination of the borderline sympathetic trunk, it often manifests itself as Horner's syndrome, accompanied by redness and anhidrosis of half of the face (on the side of the lesion), drooping of the upper eyelid, miosis and enophthalmos (retraction of the eyeball in the orbit). In some cases, with metastatic neoplasms, pain in the bones appears.

Sometimes a tumor of the mediastinal space can compress the trunks of the veins and lead to the development of the syndrome of the superior vena cava, accompanied by a violation of the outflow of blood from the upper body and head. With this option, the following symptoms appear:

• sensations of noise and heaviness in the head;
• chest pain;
• dyspnea;
• swelling of the veins in the neck;
• increased central venous pressure;
• swelling and bluishness in the face and chest.

With compression of the bronchi, the following symptoms appear:

• cough;
• difficulty breathing;
• stridor breathing (noisy and wheezing).

When the esophagus is compressed, dysphagia appears, and when the laryngeal nerve is compressed, dysphonia appears.

Specific Symptoms

With some neoplasms, the patient has specific symptoms:

• with malignant lymphomas, itching is felt and sweating appears at night;
• with neuroblastomas and ganglioneuromas, the production of adrenaline and noradrenaline increases, leading to an increase in blood pressure, sometimes tumors produce a vasointestinal polypeptide that provokes diarrhea;
• with fibrosarcomas, spontaneous hypoglycemia (lowering blood sugar levels) can be observed;
• with intrathoracic goiter, thyrotoxicosis develops;
• with thymoma, symptoms appear (in half of patients).

General symptoms

Such manifestations of the disease are more characteristic of malignant neoplasms. They are expressed in the following symptoms:

• frequent weakness;
• feverish state;
• pain in the joints;
• pulse disorders (brady or tachycardia);
• signs.

Diagnostics

Pulmonologists or thoracic surgeons can suspect the development of a mediastinal tumor by the presence of the symptoms described above, but a doctor can make such a diagnosis with accuracy only on the basis of the results of instrumental examination methods. To clarify the location, shape and size of the neoplasm, the following studies may be prescribed:

• radiography;
• chest X-ray;
• x-ray of the esophagus;
• polypositional radiography.

A more accurate picture of the disease and the prevalence of the tumor process can be obtained:

• PET or PET-CT;
• MSCT of the lungs.

If necessary, some endoscopic examination methods can be used to detect tumors of the mediastinal space:

• bronchoscopy;
• videothoracoscopy;
• mediastinoscopy.

With bronchoscopy, specialists can exclude the presence of a tumor in the bronchi and the germination of the neoplasm in the trachea and bronchi. During such a study, a transbronchial or transtracheal tissue biopsy may be performed for subsequent histological analysis.

At a different location of the tumor for tissue sampling for analysis, aspiration puncture or transthoracic biopsy can be performed under the control of x-rays or ultrasound. The most preferred method for taking biopsy tissue is diagnostic thoracoscopy or mediastinoscopy. Such studies allow the sampling of material for research under visual control. Sometimes a mediastinotomy is performed to take a biopsy. With such a study, the doctor can not only take tissue for analysis, but also conduct an audit of the mediastinum.

If the examination of the patient reveals an increase in the supraclavicular lymph nodes, then he is prescribed a prescaled biopsy. This procedure consists in excision of palpable lymph nodes or an area of ​​fatty tissue in the area of ​​the angle of the jugular and subclavian veins.

With the likelihood of developing a lymphoid tumor, the patient undergoes a bone marrow puncture followed by a myelogram. And in the presence of superior vena cava syndrome, CVP is measured.

Treatment

Both malignant and benign tumors of the mediastinum should be surgically removed at the most early dates. This approach to their treatment is explained by the fact that they all carry a high risk of developing compression of surrounding organs and tissues and malignancy. Surgery is not indicated only for patients with malignant neoplasms in advanced stages.

Surgery

The choice of method of surgical removal of the tumor depends on its size, type, location, the presence of other neoplasms and the patient's condition. In some cases, and with sufficient equipment of the clinic, malignant or benign tumor can be removed using minimally invasive laparoscopic or endoscopic techniques. If it is impossible to use them, the patient undergoes a classic surgical operation. In such cases, a lateral or anterolateral thoracotomy is performed to access the tumor with its unilateral localization, and with a retrosternal or bilateral location, a longitudinal sternotomy is performed.

Patients with severe somatic diseases transthoracic ultrasonic aspiration of the tumor may be recommended to remove tumors. And in the case of a malignant process, an extended removal of the neoplasm is performed. At advanced stages of cancer, palliative excision of tumor tissues is performed to eliminate compression of the organs of the mediastinal space and alleviate the patient's condition.

Radiation therapy

The need for radiation therapy is determined by the type of neoplasm. Irradiation in the treatment of tumors of the mediastinum can be prescribed both before surgery (to reduce the size of the neoplasm) and after it (to destroy all cancer cells remaining after the intervention and prevent relapses).