MEDIASTINUM

AMEET KUMAR JHA

Asst. Professor
Pre-clinical Sciences
Texila American University
 Objective & Outcomes
Objectives:
To provide thorough knowledge & comprehension of Thorax and
Mediastinum
Outcomes:
Students should be able to:
1. Identify all bones in the thoracic region & discuss the role of any
associated tuberosities, grooves, etc.
2. Describe the muscles of the pectoral region.
3. Discuss the basic structure of the breast its neurovasculature &
lymphatic drainage.
4. Identify the boundaries that characterize the thoracic apertures &
the nerves innervating the thoracic structures.
5. Relate structures of the thorax with respect to adjacent structures.
6. Describe the contents of sup., post., middle & ant. Mediastinum.
 DEFINITION
• Mediastinum may be defined as the
space present between two pleural
sacs in the thorax.

• It is the space which contains almost

all the important structures of the
thorax except pleurae & lungs.
DIVISIONS OF MEDIASTINUM
DIVISIONS OF MEDIASTINUM
• It is divided by an imaginary horizontal plane
extending from sternal angle to lower border
of 4th thoracic vertebra into:
1. Superior mediastinum: above the plane
2. Inferior mediastinum: below the plane, it is
subdivided into:
• Anterior mediastinum: in front of pericardium

• Middle mediastinum: contains heart &

pericardium

• Posterior mediastinum: behind pericardium

 SUPERIOR MEDIASTINUM
• BOUNDARIES:
• Anterior: Manubrium sterni
• Posterior: Upper 4 thoracic vertebrae
• Superior: Plane of thoracic inlet
• Inferior: Horizontal plane
• On each side: Pleura
SUPERIOR MEDIASTINUM
SUPERIOR MEDIASTINUM
SUPERIOR MEDIASTINUM
 SUPERIOR MEDIASTINUM
• CONTENTS:
• FROM BEHIND FORWARD:
1.Esophagus
2.Trachea
3.Arch of aorta & its 3 branches:
brachiocephalic, left common carotid & left
subclavian arteries
4.Right & left brachiocephalic veins & superior
vena cava
5.Thymus gland
 SUPERIOR MEDIASTINUM

• OTHER CONTENTS:
• Nerves:
1. Right & left vagus
2. Right & left phrenic
3. Right & left sympathetic trunks
4. Left recurrent laryngeal
• Lymphatic structures:
1. Thoracic duct
2. Lymph nodes
POSTERIOR MEDIASTINUM

• BOUNDARIES:
• Anterior: Pericardium & diaphragm
• Posterior: Lower 8 thoracic vertebrae
• Superior: Horizontal plane
• Inferior: Diaphragm
• On each side: Pleura
POSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM
 POSTERIOR MEDIASTINUM
CONTENTS:
1. Esophagus (most anterior structure)
2. Thoracic duct
3. Right & left vagus
4. Descending aorta
5. Azygos & hemiazygos veins
6. Right & left sympathetic trunks & their
branches (splanchnic nerves)
7. Lymph nodes
 MIDDLE MEDIASTINUM
CONTENTS:
1. Pericardium & heart
2. Arteries: ascending aorta, pulmonary trunk
3. Veins: lower half of superior vena cava,
terminations of inferior vena cava &
pulmonary veins
4. Nerves: phrenic
5. Lymph nodes
 VEINS
• BRACHIOCEPHALIC: (Superior mediastinum)
• FORMATION: by union of internal jugular & subclavian vein
(behind medial end of clavicle)
• END: Both veins unite to form S.V.C.

• RIGHT VEIN: shorter & has a vertical course, related laterally to

right phrenic nerve & right pleura & lung, its tributaries in
thorax:
• right 1st posterior intercostal vein,
• right internal thoracic vein, right lymphatic duct

• LEFT VEIN: longer & has an oblique course, related anteriorly to

manubrium & thymus gland, & posteriorly to branches of arch
of aorta, its tributaries in thorax:
• left 1st posterior intercostal vein,
• left superior intercostal vein,
• left internal thoracic vein, thoracic duct
 VEINS

• SUPERIOR VENA CAVA: (Superior & middle

mediastinum)
• FORMATION: by union of brachiocephalic
veins, behind lower border of right 1st costal
cartilage
• END: opens into right atrium behind right 3rd
costal cartilage
• TRIBUTARIES: azygos vein
AZYGOS & HEMIAZYGOS VEINS
 VEINS
AZYGOS VEIN: (Posterior mediastinum)
• ORIGIN: by union of right ascending lumbar &
subcostal veins
• END: forms an arch above the root of right lung &
ends in S.V.C. opposite lower border of T4
• RELATIONS:
1. Anterior: esophagus
2. Posterior: thoracic vertebra
3. Right: right pleura & lung
4. Left: thoracic duct
• TRIBUTARIES: superior & inferior hemiazygos veins,
right superior intercostal vein, right posterior
intercostal veins (from 4th to 11th), right bronchial
veins, esophageal & pericardial veins
 VEINS
• HEMIAZYGOS VEIN: (Posterior mediastinum)

• ORIGIN: by union of left ascending lumbar &

subcostal veins (passes through left crus of
diaphragm)

• END: into azygos vein, opposite T8

• TRIBUTARIES: left posterior intercostal veins (9th

to 11th), esophageal veins
 VEINS
ACCESSORY HEMIAZYGOS: (Posterior mediastinum)

• ORIGIN: by left posterior intercostal veins (4th to 8th)

• END: into azygos vein, opposite T7
• TRIBUTARIES: left bronchial veins

INFERIOR VENA CAVA: (Posterior mediastinum)

• END: passes through vena caval opening of

diaphragm & opens into right atrium behind right
6th costal cartilage
 ARTERIES
AORTA:
• ASCENDING AORTA: (Middle mediastinum)

1. ORIGIN: at the base of left ventricle opposite

lower border of left 3rd costal cartilage

2. END: ascends upward, forward & to the right &

continues as arch of aorta

3. BRANCHES: right & left coronary arteries

 ARTERIES
ARCH OF AORTA: (Superior mediastinum)

1. ORIGIN: continuation of ascending aorta,

opposite upper border of right 2nd costal
cartilage
2. COURSE & RELATIONS: ascends upward
backward & to the left (behind manubrium &
in front of trachea) then curves backward (to
the left of trachea) then finally curves
downward
3. TERMINATION: continues as descending aorta,
opposite lower border of T4
 ARTERIES
BRANCHES OF ARCH OF AORTA: (Superior
mediastinum)
1. BRACHIOCEPHALIC: ascends upward & to the right
(behind left brachiocephalic vein & in front of
trachea) & divides into right common carotid & right
subclavian arteries (behind right sternoclavicular
joint)
2. LEFT COMMON CAROTID: ascends upward & to the
left (to the left side of brachiocephalic artery) &
enters the neck (behind left sternoclavicular joint)
3. LEFT SUBCLAVIAN: ascends upward (behind left
common carotid artery, in front of esophagus, to the
left side of trachea), arches over apex of left lung to
enter neck
 ARTERIES
DESCENDING AORTA: (Posterior mediastinum)
• ORIGIN: continuation of arch of aorta
• TERMINATION: passes through aortic opening of
diaphragm (opposite T12) & continues as abdominal
aorta
• RELATIONS:
1. Anterior: esophagus
2. Posterior: thoracic vertebrae
3. Right: thoracic duct
4. Left: left pleura & lung

• BRANCHES: posterior intercostal (from 3rd to 11th),

subcostal, bronchial, esophageal, pericardial arteries
 ARTERIES
PULMONARY TRUNK (Middle mediastinum)

• ORIGIN: from upper part of right ventricle, behind

sternal end of left 3rd costal cartilage

• COURSE: ascends upward & to the left & divides (at

lower border of T4) into:
1. Right pulmonary: runs behind ascending aorta & S.V.C
to enter root of right lung
2. Left pulmonary: runs in front of desending aorta to
enter root of left lung
 TRACHEA
• BEGINNING: continuation of larynx, opposite C6
• TERMINATION: bifurcates into 2 bronchi, opposite
lower border of T4

• RELATIONS: (in superior mediastinum)

1. Anterior: arch of aorta, brachiocephalic & left
common carotid arteries
2. Posterior: left recurrent laryngeal nerve, esophagus
3. Right: right vagus nerve
4. Left: arch of aorta, left subclavian artery
• NERVE SUPPLY: sympathetic trunks & vagus
• BLOOD SUPPLY: inferior thyroid vessels
• LYMPHATIC DRAINAGE: pretracheal & paratracheal
 ESOPHAGUS
• BEGINNING: continuation of pharynx, opposite
C6
• TERMINATION: passes through esophageal
opening of diaphragm (opposite T10) & joins
stomach

• RELATIONS: (in superior mediastinum)

1. Anterior: left recurrent laryngeal nerve,
trachea, left subclavian artery
2. Posterior: thoracic vertebrae
3. Right: right pleura & lung
4. Left: thoracic duct, left pleura & lung
 ESOPHAGUS
• RELATIONS: (in posterior mediastinum)
1.Anterior: pericardium, separating it from left
atrium
2.Posterior: thoracic duct, descending aorta,
azygos vein
3.Right: right pleura & lung
4.Left: descending aorta, left pleura & lung
• NERVE SUPPLY: as trachea
• ARTERIAL SUPPLY: descending aorta
• VENOUS DRAINAGE: azygos & hemiazygos
• LYMPHATIC DRAINAGE: posterior mediastinal
lymph nodes
 THORACIC DUCT
• ORIGIN: from upper end of cisterna chyli
(opposite L1 & L2)
• COURSE: passes through aortic opening of
diaphragm, ascends in posterior mediastinum
(behind esophagus) & in superior mediastinum
(to the left of esophagus) to enter root of neck
• END: in left brachiocephalic vein
• RELATIONS: ( in posterior mediastinum)
1. Anterior: esophagus
2. Posterior: thoracic vertebrae
3. Right: azygos vein
4. Left: descending aorta
 THORACIC DUCT contd..
• TRIBUTARIES:
• It drains lymph from both sides of the body
below the diaphragm through cysterna chyli
• It drains lymph from left half of the body
above diaphragm through:
1. Left jugular lymph trunk: drains left side of
head & neck
2. Left subclavian lymph trunk: drains left upper
limb
3. Left bronchomediastinal lymph trunk: drains
left side of thorax
 RIGHT LYMPHATIC DUCT
• ORIGIN: formed by union of:
1. Right jugular lymph trunk: drains right
side of head & neck
2. Right subclavian lymph trunk: drains right
upper limb
3. Right bronchomediastinal lymph trunk:
drains right side of thorax
• END: in right brachiocephalic vein
 NERVES
PHRENIC NERVES: (Superior & middle mediastinum)
• ORIGIN: anterior rami of C3,4,5
• COURSE & RELATIONS IN THORAX:
1. RIGHT: descends to the right side of: right
brachiocephalic vein, S.V.C., pericardium, I.V.C.
2. LEFT: descends to the left side of: arch aorta,
pericardium
• BRANCHES:
1. Motor branches to: diaphragm
2. Sensory branches from:
• Mediastinal & central part of diaphragmatic pleura
• Fibrous pericardium & parietal layer of serous
pericardium
• Peritoneum covering central part of undersurface of diaphragm
 NERVES
VAGUS NERVES: (Superior & posterior mediastinum)
• ORIGIN: 10th cranial nerve

• COURSE & RELATIONS IN THORAX:

1. RIGHT: descends to the right side of: trachea, behind
root of right lung (pulmonary plexus), behind
esophagus (esophageal plexus), passes through
esophageal opening of diaphragm to reach posterior
surface of stomach
2. LEFT: descends to the left side of: arch aorta, behind
root of left lung (pulmonary plexus), in front of
esophagus (esophageal plexus), passes through
esophageal opening of diaphragm to reach anterior
surface of stomach
 NERVES
• BRANCHES IN THORAX:

• BOTH VAGI: to lungs & esophagus

• RIGHT VAGUS: to heart
• LEFT VAGUS: left recurrent laryngeal nerve:
curves below arch of aorta, behind ligamentum
arteriosum, ascends in groove between trachea
& esophagus to reach the neck. It supplies:
heart, trachea, esophagus (in thorax) & larynx
(in neck)
 NERVES
• THORACIC PART OF SYMPATHETIC TRUNKS:
(Superior & posterior mediastinum)
• BEGINNING: the cervical part continues as thoracic
part by passing in front of neck of first rib
• TERMINATION: the thoracic part continues as lumbar
part by passing behind medial arcuate ligament
• COURSE:
1. In upper part of thorax: descend in front of heads of
ribs
2. In lower part of thorax: descend on the sides of bodies
of vertebrae
• GANGLIA: usually 11 (1st thoracic ganglion fuses with
inferior cervical ganglion forming stellate ganglion)
 NERVES
BRANCHES:

1. Rami communicantes: each ganglion receives a white

ramus (preganglionic) & gives a grey ramus
(postganglionic) to corresponding thoracic spinal
nerve
2. Visceral branches (postganglionic) to thoracic organs
(from upper 5 ganglia): to heart, lungs, esophagus,
descending aorta
3. Visceral branches (preganglionic) to abdominal
organs:
• Greater splanchnic nerve (from 5th to 9th ganglia)
• Lesser splanchnic nerve (from 10th 7 11th ganglia)
• Lowest splanchnic nerve (from 12th ganglion)
 QUESTIONS

The superior mediastinum is separated from the

inferior mediastinum by a transverse plane crossing
the:
A. ascending aorta and T3
B. brachiocephalic trunk and descending aorta
C. sternoxyphoid joint and T6
D. pulmonary vein and aortic arch
E. Manubriosternal joint and T4 vertebrae

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