IMCT 2014

SGD 11: Anterior and Superior Mediastinal Structures

1. Review the boundaries and contents of the superior mediastinum.

Bounded in front by the manubrium sterni and behind by the first four thoracic vertebrae.
Contents: thymus, large veins, large arteries, trachea, esophagus & thoracic duct,
sympathetic trunks.

2. Describe the following vessels:

Arch of the aorta
o Origin: continuation of the ascending aorta
o Commencement:
o Course: lies behind the manubrium sterni and arches upward, backward, and to the left
in front of the trachea. Passes downward to the left of the trachea, and at the level of the
sternal angle, becomes continuous with the descending aorta.
Brachiocephalic artery
o Origin: from convex surface of the aortic arch.
o Commencement:
o Course: Passes upward and to the right of the trachea and divides into the right
subclavian and right common carotid arteries behind the right sternoclavicular joint.
Right and left brachiocephalic vein
Origin: Root of the neck by union of the left subclavian and left internal jugular veins
Course:
o Right is accompanied by right phrenic vein; receives lymph from right lymph duct.
o Left is twice as long as right; runs obliquely down and behind the manubrium;
crosses roots of three major branches of aorta; receives lymph from thoracic
duct. Joins the right brachiocephalic vein to form superior vena cava
Superior vena cava
o Origin: Union of two brachiocephalic veins, contains all venous blood from the head and
neck, and both upper limbs.
o Commencement:
o Course: Passes downward to end in the right atrium of the heart. Vena azygos joins the
posterior aspect of the superior vena cava just before it enters the pericardium.
3. Describe the vagus nerve as to its course, component fibers, branches, and its spatial
relationship with other structures in the superior mediastinum.
Right vagus nerve
Descends in thorax, first lying posterolateral to the brachiocephalic artery, then lateral to
the trachea, and medial to the terminal part of the azygos vein.
Passes behind the root of the right lung, assists formation of pulmonary plexus.
Passes through esophageal opening of diaphragm behind the esophagus to reach
posterior surface of the stomach.
Gives off cardiac branches
Right recurrent laryngeal nerve arises from the right vagus in the neck and hooks around
the subclavian artery and ascends between trachea and esophagus.

Compiled by: AMSA-UST

Credits to the owner

IMCT 2014

SGD 11: Anterior and Superior Mediastinal Structures

Left vagus nerve

Descends between left common carotid and left subclavian arteries
Crosses left side of the aortic arch and itself crossed by phrenic nerve.
Vagus turns backward behind the root of left lung and assists in formation of pulmonary
plexus.
Left recurrent laryngeal nerve
o Originates from here as the nerve crosses arch of aorta; hooks around the
ligamentum arteriosum and ascends in the groove between trachea and
esophagus on left side.
o Supplies all muscles acting on left vocal cord (except cricothyroid muscle, a
tensor of cord, supplied by external laryngeal branch of the vagus)
4. Review the phrenic nerve
Arise from neck from the anterior rami of the 3rd, 4th, and 5th cervical nerves.
Efferent fibers (sole nerve supply to muscle of diaphragm)
Afferent fibers (carry sensation to CNS from
o peritoneum covering central region of the undersurface of the diaphragm,
o the pleura covering central region of upper surface of diaphragm,
o pericardium and mediastinal parietal pleura.
Right phrenic nerve
Descends in thorax along right side of the right brachiocephalic vein and superior vena
cava.
Passes in front of the root of the right lung and runs along the right side of the
pericardium (which separates nerve from the right atrium)
Descends on right side of inferior vena cava through the caval opening in the diaphragm
to supply central part of peritoneum on its underaspect.
Left phrenic nerve
Descends in thorax along left side of left subclavian artery.
Crosses left side of aortic arch and there crosses left side of left vagus nerve.
Passes in front of the root of the left lung and descends over left surface of the
pericardium, which separates nerve from left ventricle.
On reach diaphragm, terminal branches pierce the muscle and supply central part of
peritoneum on its underaspect.
5. Illustrate the interrelationships of the following structures: trachea, esophagus, arch of the
aorta and its branches, brachiocephalic vein, vagus nerve & left laryngeal nerve, phrenic nerve,
thoracic duct.
Trachea
Anteriorly: sternum, thymus, left brachiocephalic vein, origins of brachiocephalic and left
common carotid arteries, arch of the aorta.
Posteriorly: esophagus, left recurrent laryngeal nerve
Right side: azygos vein, right vagus nerve, pleura
Left side: arch of the aorta, left common carotid, left subclavian arteries, left vagus and
left phrenic nerves, pleura
Esophagus
Anteriorly: trachea and left recurrent laryngeal nerve
Posteriorly: Bodies of thoracic vertebrae; thoracic duct; azygos veins; right posterior
intercostal arteries; descending thoracic aorta
Right side: mediastinal pleura and terminal part of azygos vein
Left side: left subclavian artery, aortic arch, thoracic duct, mediastinal pleura
6. Discuss the thymus gland
Flattened, bilobed structure
Lies between sternum and pericardium in the anterior mediastinum.
In newborn infant, reaches largest size relative to size of the body, may extend up
through superior mediastinum in front of great vessels into the root of the neck.
Continues to grow until puberty, but undergoes involution.
Pink, lobulated appearance site for development of T(hymic) lymphocytes.
Blood supply: inferior thyroid and internal thoracic arteries.

Compiled by: AMSA-UST

Credits to the owner

IMCT 2014

Compiled by: AMSA-UST

Credits to the owner

SGD 11: Anterior and Superior Mediastinal Structures