Disease of Mediastinum and Pleura Flashcards Preview

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Flashcards in Disease of Mediastinum and Pleura Deck (65)
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What are the 3 compartments of the mediastinum?

Anterior (between sternum and pericardial sac)

Middle (from anterior pericardial sac to ventral surface of spine)

Posterior (spine and costovertebral gutters)


What resides in the anterior-superior compartment of the mediastinum? (5)

Thymus gland

Aortic root and great vessels

Substernal thyroid and parathyroid tissue

Lymphatic vessels and nodes

Inferior aspect of trachea and esophagus


What resides in the middle compartment of the mediastinum? (7)

1. Pericardial sac

2. Heart

3. Innominate veins and SVC

4. Trachea and major bronchi

5. Hila

6. Lymph nodes

7. Phrenic, upper vagus, and recurrent laryngeal nerves


What resides in the posterior compartment of the mediastinum?

1. Esophagus

2. Descending aorta

3. Azygous and hemiazygous veins

4. Thoracic duct

5. Lymph nodes

6. Vagus nerves (lower portion)

7. Sympathetic chains


Mediastinal masses can be organized in categories of  _____ or _____, and ____ or _____.

Asymptomatic or symptomatic, benign or malignant


How are asymptomatic mediastinal masses found?

Incidental finding on imaging


What are the local and systemic symptoms of mediastinal masses?

Local symptoms: Compression or invasion of adjacent structures

Systemic symptoms: Fever, anorexia, weight loss (often lymph node related). Endocrine syndromes (thymus related). Autoimmune symptoms (thymus related)


____ percent of asymptomatic masses are benign



____ percent of symptomatic masses are malignant



In terms of mediastinal mass location, what is most common in adults vs. children?

Adults - anterior

Children - posterior


Are adults or children more symptomatic when it comes to mediastinal masses?

Children are more symptomatic (66%)

Adults (33%)


When evaluating for mediastinal mass, what are symptoms associated with obstructions of contiguous organs?

Dysphagia (compression of esophagus)

Hoarseness (compression of recurrent laryngeal nerve)

SVC syndrome (facial/upper extremity swelling from compression of superior vena cava)

Cough, stridor, hemoptysis, shortness of breath (compression of lungs)

Horner syndrome (sympathetic chain compression resulting in miosis (a constricted pupil), ptosis (a weak, droopy eyelid), apparent anhidrosis (decreased sweating))


What are B symptoms that can be seen with mediastinal masses? (3)

- Fevers

- Weight Loss

- Drenching night sweats


For mediastinal mass evaluation, what should be checked in physical exams?

- blood pressure

- weight loss

- lymphadenopathy

- Exam of head, neck, upper extremities, and chest


What imaging is done when evaluating for mediastinal mass?

CXR (PA and Lateral)

- to localize

CT Chest

- anatomic location

- differentiate between cyst vs solid lesions

- identify fatty structures

- lympadenopathy vs. vascular structures


Which compartment is the mediastinal mass in?

Anterior compartment.


What's the differential diagnosis for an anterior compartment mediastinal mass? (7)

The 4 Terrible T's is to help you remember the most common differential diagnosis for anterior compartment mediastinal masses.

1. Thymic neoplasm

2. Teratoma (germ cell tumor)

3. (Terrible) Lymphoma (hogkin's disease or non-hodgkin's lymphoma)

4. Thyroid neoplasm

And less commonly:

5. Mesenchymal neoplasm

6. Diaphragmatic hernia (Morgagni)

7. Primary carcinoma


Which compartment is the mediastinal mass in?

Middle compartment.


20% of middle compartment mediastinal masses are due to ____



What is the differential diagnosis for middle compartment masses? (10)

1. Lymphadenopathy

2. Developmental cysts

3. Reactive and granulomatous inflammation

4. Metastasis (going to lymph nodes)

5. Lymphoma

6. Pericardial Cyst

7. Bronchogenic Cyst

8. Enteric Cyst

9. Vascular Enlargements

10. Diaphragmatic hernia (hiatal)


Which compartment is the mediastinal mass in?

Posterior compartment


What is the differential diagnosis for posterior compartment mediastinal masses? (9)

1. Peripheral nerve (neurinomas)

2. Neurogenic tumors

3. Sympathetic ganglia

4. Paraganglionic tissue

5. Meningocoele

6. Esophageal lesions

7. Carcinoma

8. Diverticuli

9. Diaphragmatic hernia (Bochdalek)


What kind of mass would a CBC with differential help in diagnosing?

Helpful for diagnosing lymphoma


What kind of mass would beta-HCG and alpha-fetoprotein help in diagnosing?

B-HCG and a-fetoprotein are markers associated with germ cell tumors (e.g. teratoma)


What kind of mass would anti-acetylcholine receptor antibodies lab test be helpful in diagnosing?

Thymoma (thymus tumor)


What are 3 needle aspiration techniques that can be used to biopsy a mediastinal mass?

- Transbronchial Needle Aspiration (down the trachea and through the bronchial wall)

- Percutaneous Needle Aspiration (coming from outside of the chest cavity)

- Endoscopic ultrasound guided Aspiration (through esophagus or trachea)


What are 2 surgical approaches for obtaining tissue for diagnostic evaluation of mediastinal masses?

- mediastinoscopy (under sternum)

- thoracoscopy (through chest wall)


What are 4 complications of mediastinal masses?

- Tracheal obstruction

- SVC syndrome (facial and upper extremity edema)

- Vascular invasion (hemorrhage)

- Esophageal rupture


Is the visceral or parietal pleura innervated (and can sense pain)?

Parietal pleura. Patients that have issues with the visceral pleura don't experience pain while patients who have issues with parietal pleura will feel pain.


The pleural space is a _____ space between the visceral and parietal pleura

Potential. IRL, the two surfaces are right up against each other but things can get into this space (e.g. air, fluid, masses, etc)


The ____ of a pneumothorax is important to note.



Pneumothoraces can be categorized into what 2 groups?

Spontaneous and traumatic


What are the kinds of spontaneous pneumotoraces?

Primary Pneumothoraces

Secondary Pneumothoraces


- Pneumocystis Pneumonia, Mycobacterium Tuberculosis, Necrotizing pneumonia

- Cystic Fibrosis

- Interstitial lung disease (e.g. lymphangioleiomyomatosis)

- Pneumoconoiosis

- Lung Cancer


What are the kinds of traumatic pneumothoraces that can occur?

Iatrogenic (Iatrogenesis refers to any effect on a person, resulting from any activity of one or more persons acting as healthcare professionals or promoting products or services as beneficial to health, that does not support a goal of the person affected)

- Complication of trans-thoracic needle biopsoy

- Complication of central line placement


- Intubation

- Mechanical ventilation


- Penetrating

- Non-penetrating


What is primary spontaneous pneumothorax?

Primary spontaneous pneumothrax is when there is no precipitating event (occurs at rest) and no known underlying lung disease.


What kind of patients are more prone to getting primary spontaneous pneumothorax? (5)

- Males

- Smokers

- Family history of Primary Spontaneous Pneumothorax

- History of primary spontaneous pneumothorax (recurrence in 25-54%)

- Peak age is in early 20s


What kind of clinical history do you find in people with pneumothorax? (6)

1. Acute onset chest pain

2. Dyspnea

3. Cough

4. Anxiety

5. Cyanosis

6. Respiratory distress


What kind of physical exam do you find for pneumothorax? (5)

1. Hyper resonant chest percussion

2. Decreased/absent breath sounds (on the side with the pneumothorax)

3. Decreased fremitus

4. Chest wall trauma

5. Decreased rib space


What does a pneumothorax look like on a CT scan?


What are 3 things that can mimic pneumothorax in CXR?

1. Bullae

2. Skin folds

3. Stomach herniation following traumatic rupture of the left hemidiaphragm


What's going on here?

Bullae on both sides. Patients with COPD can develop these large air sacs in their lungs.


How do you treat pneumothoraces?

1. Observation

2. Supplemental Oxygen (100%)

3. Simple aspiration (release air from pleural space)

4. Tube thoracostomy (chest tube)

5. Pleurodesis (where you reattach the parietal and visceral pleura)


How does supplemental oxygen at 100% O2 help with pneumothoraces?

When a patient has a pneumothorax, the majority of the air in the pleural space is nitrogen which has a hard time being absorbed into the body. If you give 100% oxygen into the lungs, it creates a gradient for oxygen to go into the pneumothorax and for nitrogen to come out. Oxygen has an easier time than nitrogen in being absorbed by the body so this technique can help diminish the pneumothorax.


What is tension pneumothorax?

A tension pneumothorax is a medical emergency where the intrapleural pressure exceeds the atmospheric pressure throughout expiration and often during inspiration. As it grows bigger, it has a positive pressure against the mediastinum which causes hemodynamic compromise by decreasing venous return and limiting cardiac output.


What are signs of a tension pneumothorax? (4)

1. Tachycardia

2. Hypotension

3. Cyanosis

4. Respiratory distress


What's going on here?

This is a left-sided tension pneumothorax.


How do you treat a tension pneumothorax?

If you suspect a tension pneumothorax, do not wait for a confirmatory chest radiograph. It is a medical emergency and should be addressed immediately.

Emergently insert an 18 gauge angiocath in the 2nd intercostal space along hte midclavicular line. You can confirm that there is air coming out of the angiocath if you attach an IV tube to it and put it in some saline--it will bubble if their is air coming out. Please a tube thoracostomy if pneumothorax is confirmed.


What are pleural effusions?

Pleural effusions are when fluid accumulates in the potential pleural space.


The pleural space has a normal production of 0.2-0.3 mL/kg of fluid and the lymphatic system drains this fluid. Fluid accumulation occurs when the rate of fluid production exceeds the rate of fluid drainage. This can be associated with both local pleural disorders and systemic conditions that affect the pleura.


What is clinical history and exam like for pleural effusion patients?

1. Dyspnea

2. Pleuritic chest pain (pain when taking deep breaths)

3. Dry cough

4. Symptoms associated with underlying disease

5. Decreased breath sounds, dullness to percussion, decreased tactile and vocal fremitus on examination. (on side that has the fluid)


What's going on here?

Pleural effusion on the left side. Notice the meniscus.


What's going on here?

There is a pleural effusion that's involving the entire right hemithorax.


What's going on here?

There is a pleural effusion.

Note that this CT is set to mediastinal module which enhances soft tissue so the lungs appear black.


What's going on here?

Pleural effusion finding on ultrasound


How are pleural effusions classified? (2 classes)

Transudative and Exudative.

Transudative effusions result from alteration in hydrostatic forces that affect fluid formation (non-protein rich).

Exudative effusions are due to alterations in permeability of pleura or rate of fluid removal (protein rich).


Transudative (hydrostatic issues), Exudative (oncotic issues)


How do you determine if a pleural effusion is a transudative or exudative process?


You aspirate the fluid from the pleural space. Aim for above the diaphragm (ultrasound).


When doing needle aspiration, why is it important to go above a rib, not below?

The neurovascular bundle is below the rib. Going above the rib is so you don't hit a neurovascualr bundle.


What's a good way to remember this? Just picture that the neurovascular bundle is hanging on the bottom of the rib bc of gravity. (it's not bc of gravity... but this might help you remember)


Which studies do you do on pleural fluid obtained from thoracentesis?

LDH (+serum)

Total protein (+serum)



Cell counts (WBC,RBC) and differential

Gram stain, routine culture

AFB/fungal stains and culture

Cytology (if concerned about malignancy)


What's Light's Criteria?

Light's Criteria is used to determine transudate vs. exudate

For Transudate, you have to have..

LDHpl/LDHserum less than or equal to 0.6 and

Proteinpl/Proteinserum less than or equal to 0.5

For exudate, you have to have

LDHpl/LDHserum greater than 0.6 or

Proteinpl/Proteinserum greater than 0.5 or

LDHpl that is greater than 2/3 of the upper limit of normal for serum


What's on the differential diagnosis for transudative pleural effusions? (12)

1. Congestive heart failure

2. Cirrhosis with ascites

3. Nephrotic syndrome

4. Peritoneal dialysis

5. Myxedema (thyroid)

6. Acute atelectasis

7. Congestive pericarditis

8. SVC syndrome

9. Fontan procedure

10. Sarcoidosis

11. Eurinothorax.

12. Pulmonary embolism


What's the differential diagnosis for exudative pleural effusions?

1. Infection (e.g. inflammation related to bacterial pneumonia, viral infections, fungal infections, etc.)

2. Cancer

3. Pulmonary embolism

4. Post-CABG

5. Post-MI syndrome

6. Connective tissue disease (RA, lupus, etc.)

7. GI disease (e.g. pancreatitis)

8. Asbestos

9. Sarcoidosis

(10. Uremia

11. Drug reaction

12. Chronic atelectasis/trapped lung

13. Radiation therapy

14. Hemothorax

15. Chylothorax)


What are 3 pleural based abnormalities?

1. Pleural thickening (most commonly seen in someone who had a previous pleural effusion. Thickening related to prior event)

2. Pleural plaques (seen in patients w/ asbestos exposure)

3. Pleural tumors


What can cause pleural thickening? (6)

- Inflammation following infection

- Hemorrhage

- Prior treatment for effusion/pneumothorax

- Occupational exposure (e.g. asbestos)

- Trauma

- Neoplasm


What's going on here?

Pleural thickening


What are the arrows pointing at?

Pleural plaques.

This happens with asbestos exposure about 20-30 years after initial exposure. The arrows are pointing at the thickened calcified areas lining the pleura.


What's going on here?

Pleural tumors.


The majority of pleural tumors are from malignant and metastatic tumors from other parts of the body that migrate and establish in the pleura (lung, breast, lymphoma, GI, GU).