Chest Radio 8 Widening of The Mediastinum

8 WIDENING OF THE MEDIASTINUM
Fig. 8.1
82
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CHAPTER 8 Widening of the Mediastinum 83
QUESTIONS
1. What is the most likely cause of the mediastinal widening in this patient (Fig 8.1, A and B)?
a. Lipomatosis.
b. Hematoma.
c. Adenopathy.
d. Mediastinitis.
e. Thymoma.
2. Which one of the following statements regarding aortic trauma is true?

a. The mediastinal width is at least 8 cm.
b. Mediastinal hematoma is specific for aortic injury.
c. Ascending aorta is the most common sight of aortic injury.
d. Computed tomography (CT) angiography is the definitive test for aortic injury.
e. Right flail chest excludes aortic injury.
3. Which of the following statements about mediastinal hematomas are true?

a. Often obscure the aortic arch and descending aorta.
b. May indicate aortic injury.
c. May be caused by vertebral fractures.
d. May occur when sternal fractures injure internal mammary vessels.
e. All of the above.

Chart 8.1 WIDENING OF THE MEDIASTINUM
I. Radiographic technique
A. Magnification (anteroposterior [AP] supine chest radiograph, low-volume
inspiration)
B. Lordotic position
II. Adenopathy
A. Neoplasms
1. Lymphoma
2. Primary lung cancer (small cell tumors)
3. Metastases
B. Inflammatory
1. Mycobacterium avium-intracellulare (in patients with acquired immunodefi
ciency syndrome [AIDS]314)
2. Tuberculosis261
3. Coccidioidomycosis
4. Anthrax125
5. Sarcoidosis
III. Hematoma
A. Aortic injury655
B. Venous and arterial tears
C. Sternal fractures
D. Vertebral fractures (thoracic and lower cervical spine)115
E. Postoperative bleeding
F. Malposition of vascular catheters (also the cause of hydromediastinum)
IV. Vascular structures (nontraumatic)
A. Tortuous atherosclerotic dilation of aorta
B. Aneurysm
C. Aortic dissection265,267
D. Coarctation of aorta658
E. Congenital, left superior vena cava (SVC) with absent right SVC622
84 PART 1 Chest Wall, Pleura, and Mediastinum
Chart 8.1 WIDENING OF THE MEDIASTINUM—cont’d
V. Mediastinitis
A. Perforated esophagus (Boerhaave syndrome, carcinomas)
B. Tracheobronchial rupture (traumatic)165
C. Iatrogenic (postoperative, endoscopic)
D. Pneumonias
E. Tuberculosis641
F. Coccidioidomycosis
G. Histoplasmosis141,492,633
H. Actinomycosis393
I. Fibrosing or sclerosing mediastinitis147,306,371,492
J. Extension of extrathoracic infections
1. Pharyngeal abscess
2. Abdominal abscess
3. Pancreatitis or pancreatic pseudocyst
VI. Lipomatosis251,439,566
A. Cushing syndrome
B. Corticosteroid therapy
C. Obesity
VII. Other
A. Chylomediastinum (thoracic duct obstruction or iatrogenic laceration)165
B. Mediastinal edema (allergic)165
C. Penetrating trauma (stab wound)
D. Achalasia
Discussion
Mediastinal widening (Chart 8.1) is a common observation on the posterior-anterior
(PA) chest radiograph. It is more difficult to identify confidently on a supine AP view
because of magnification and crowding of normal vascular structures by the splinting
effect on the patient’s chest. In addition, a lordotic projection distorts and magnifies
the superior mediastinum. This is a common problem in the patient who is unable
to make a deep inspiratory effort voluntarily, and it is a serious consideration in the
emergency department or intensive care unit in which the critically ill patient must be
evaluated with portable supine radiography.
Chest radiograph analysis must begin with the identification of as many normal
structures as possible, including the ascending aorta, aortic arch, descending aorta,
aortic pulmonary window, trachea, paratracheal stripes, carina, main stem bronchi,
and paraspinous stripes.84 Failure to visualize these landmarks requires an explanation
and may be an indication for additional procedures, including CT angiography and
magnetic resonance imaging (MRI).
Clinical considerations often determine the urgency for a definitive diagnosis. Medi-
astinal widening after major trauma is strongly suggestive of mediastinal hematoma
and requires urgent exclusion of aortic injury. Determining the cause of mediastinal
widening in patients without a history of trauma may also be challenging.
Determining the cause of the mediastinal widening is often more difficult than
recognizing the presence of an abnormality, especially in older patients with athero-
sclerotic vascular disease that leads to dilation and tortuosity of the aorta and great
vessels. Patients who have had cardiac or vascular surgery are easily recognized by the
radiographic identification of surgical clips and metal sutures, but this may further
confuse the evaluation of mediastinal widening. These patients may have both tortu-
ous vessels and postoperative abnormalities, including hematomas during the acute
convalescent period and, later, mediastinal scarring. A mass lesion that develops sub-
sequent to mediastinal or cardiac surgery may be obscured by postoperative changes.
B
Fig. 8.2 A, Widening of the mediastinum is suggested by the appearance of the upper mediasti-
num with increased opacity on both sides of the trachea, obscuring the aorta and left hilum with a
subcarinal mass. B, CT confirms that the mediastinal widening is the result of large soft-tissue masses
involving the anterior, middle, and posterior mediastinum. This is extensive adenopathy resulting from
B cell lymphoma.
ADENOPATHY
Mediastinal tumors are expected to produce discrete masses, but neoplasms that
involve multiple lymph node groups may cause diffuse mediastinal widening. This
type of tumor dissemination results from lymphomas and metastases from either pri-
mary lung cancer or distant primaries. It is particularly common with poorly differenti-
ated primary tumors, such as small cell lung cancer. Such extensive nodal involvement
may also be seen with metastases from retroperitoneal tumors and even from testicular
tumors, particularly seminomas.
Lymphoma frequently involves mediastinal lymph nodes and, when the involve-
ment is extensive, numerous large nodes may diffusely widen the mediastinum
(Fig 8.2, A and B). The tumor should regress following chemotherapy, but the nodes
may be replaced by extensive fibrosis, which may leave residual mediastinal widening.
This is most often recognized by the identification of paramediastinal reticular opaci-
ties that result from mediastinal fibrosis. In their early stages, radiation pneumonitis
and fibrosis may appear to become more prominent over a short period, requiring fur-
ther consideration of recurrent tumor. Increasing opacity from the radiation effect on
the mediastinum may be further evaluated with MRI, which has been reported to be
useful for identifying viable tumor in the midst of postradiation scarring.
Inflammatory adenopathy is not a common cause of mediastinal widening, but
granulomatous diseases cause involvement of the hilar and mediastinal nodes, and the
adenopathy may become extensive, as in the case of sarcoidosis (see Fig 8.1, A and B;
answer to question 1 is c).
HEMATOMA
Aortic injury is one of the most urgent diagnoses to be considered following major
trauma. The reported chest radiograph findings include the following: mediastinal
widening; obscuration of the aortic arch or descending aorta; widened right paratra-
cheal stripe; left apical pleural cap; deviation of a tracheal or nasogastric tube to the
right; and pleural effusion (Fig 8.3).102,655 These are all signs suggestive of mediastinal
hemorrhage, but they are not specific for aortic injury. CT angiography186 (Fig 8.4,
A-C) is required to confirm and classify an aortic injury. Transection of the ascending
aorta carries a high risk for hemopericardium. It is likely the most common cause of
death at the scene of a motor vehicle accident with only a small number of patients
surviving to have diagnosis and treatment via CT. The proximal descending aorta is
the most common sight of CT-detected aortic injury. Distal descending aortic injuries
are possible but much less frequent. Most patients who survive to reach the hospital
have partial transections. CT signs of aortic injury include extravasation of contrast
(Fig 8.5), pseudoaneurysms (Fig 8.6), intimal defects, aortic contour abnormalities, and
intraluminal thrombus. CT angiography is very sensitive and specific for the detection
of aortic injuries and has detected intimal tears in patients who have no associated
hematoma (answer to question 2 is d).
Mediastinal hematomas following acute trauma have also been well documented
to result from injuries to structures other than the aorta, including other great ves-
sels, internal mammary vessels, SVC, and fractures. Hematomas often result from
fractures of the sternum, posterior ribs, and thoracic and lower cervical vertebrae
(Fig 8.7, A and B; answer to question 3 is e). Although these findings may explain
the source of a mediastinal hematoma, they do not exclude the possibility of associ-
ated aortic injury and should therefore not be used as a reason to avoid or delay CT
angiography.
VASCULAR STRUCTURES
Dilation of the aorta and great vessels with tortuosity is most often the result of ath-
erosclerotic disease and is very frequent in older patients. Dilation of the ascending
aorta is observed in patients with severe hypertension and may also result from aortic
stenosis. The dilated tortuous aorta must be distinguished from aortic aneurysms, aor-
tic dissection, and even mass lesions (Fig 8.8, A-C). When the entire aorta is extremely
dilated and tortuous, the abnormality may be regarded as a long fusiform aneurysm.
Dissection of the aorta results from an intimal tear followed by intramural hema-
toma. Complete dissection occurs when there are multiple tears, permitting blood to
flow through the aortic wall and creating a false lumen. The patient may be asymptom-
atic, but typically presents with retrosternal chest pain, syncope, and signs of periph-
eral vascular arterial occlusion.
The most frequent radiographic findings in dissection of the aorta include mediasti-
nal widening and enlargement of the aortic arch and descending aorta (Fig 8.9, A and B).
Other findings may include enlargement of the ascending aorta, blurring of the aortic
2
A
B
Fig. 8.3 A, This motor vehicle accident victim developed a wide mediastinum and left subpulmonic
pleural effusion with deviation of a nasogastric tube to the right. B, Contrast-enhanced CT scan shows
a large left effusion and extraluminal contrast medium around the descending aorta, indicating severe
aortic injury.
C
Fig. 8.4 A, Widening of the mediastinum around the aortic arch with a shift of the trachea to the
left is very suggestive of a mediastinal hematoma from an aortic injury. B, CT angiography confirms a
mediastinal hematoma and an irregular filling defect at the arch of the aorta. C, Coronal reconstruction
confirms a pseudoaneurysm in the proximal descending aorta. This is the most common site for aortic
injuries, but such injuries may also occur in the ascending and lower descending portions of the aorta.
Fig. 8.5 Mediastinal hematoma and a large left pleural effusion with extravasation of contrast on CT
angiography are signs of aortic transection requiring urgent treatment.
Fig. 8.6 Pseudoaneurysm of the aorta is the result of a contained aortic hemorrhage from a partial
transection.
A B
Fig. 8.7 A, Wide mediastinum, loss of definition of the aortic arch, and apical cap indicate medias-
tinal hematoma, but this patient had a normal aortogram. B, Tomogram of the upper thoracic spine
better demonstrates the fracture dislocation that caused the mediastinal hematoma.
C
Fig. 8.8 A, Large tortuous aorta must be distinguished from an aneurysm and could obscure a mass
in the mediastinum or either hilum. B, Lateral view reveals dilated ascending aorta and tortuosity of the
descending aorta. Also note the increased opacity of the hila projected between the aortic opacities.
C, This contrast-enhanced CT scan was performed to exclude the diagnosis of aneurysm and confirmed
the thoracic aorta to be very tortuous with an upper abdominal aneurysm (not shown). The scan also
confirmed right hilar adenopathy caused by small cell carcinoma.
arch, soft-tissue opacity lateral to calcification in the aortic arch, deviation of the trachea
or nasogastric tube, a wide paraspinal stripe, and pericardial and pleural effusions. The
finding of widening of the mediastinum and aortic arch (Fig 8.10, A-C) should be fol-
lowed by CT or MRI. CT angiography or conventional aortography may be required for
patients who are hemodynamically unstable and are candidates for emergency surgery.
Either of these procedures provides precise anatomic detail and permits the applica-
tion of anatomic classification of the dissection. The Stanford classification175 is used to
A B
Fig. 8.9 A, Tortuous aorta accounts for the wide mediastinum. Observe the sharply deﬁned aortic
arch and descending aorta. B, This examination was done 13 months later. The patient reported acute
chest pain. The widening of the aorta has increased as a result of aortic dissection.
B
Fig. 8.10 A, Widening of the mediastinum from the level of the aortic arch to the diaphragm with a
left, subpulmonic pleural effusion should suggest a mediastinal hematoma. The patient had a history of
hypertension and presented with severe chest pain. B, CT section from just below the carina confirms
a mediastinal hematoma around the descending aorta with a lucent curved line through the aorta. The
lucent line is the intimal flap and confirms the diagnosis of aortic dissection. C, Coronal reconstruction
shows the extent of the mediastinal hematoma and confirms that the flap extends from the level of the
arch into the abdomen.
determine surgical versus medical management. Dissections that involve the ascending
aorta are classified as type A and require urgent surgical treatment, whereas type B dissec-
tions are limited to the descending aorta and are medically managed.
INFECTIONS
Mediastinal infection may take the form of diffuse mediastinitis or abscess, and these two
forms may even coexist. Acute infections may enter the mediastinum by direct extension
from a nasopharyngeal abscess, subphrenic abscess, pancreatic pseudocyst, pneumonia, or
empyema. Infection may also result from spontaneous esophageal perforation (Boerhaave
syndrome), rupture of an esophageal carcinoma, iatrogenic esophageal perforation from
endoscopy, or dilation of an esophageal stricture.189 Perforation of either the esophagus
or tracheobronchial tree also causes mediastinal emphysema, which often precedes the
mediastinitis and may be the initial cause of mediastinal widening. Mediastinitis has been
reported as an infrequent but serious complication of cardiovascular surgery.
Granulomatous infections, including tuberculosis,641 coccidioidomycosis, and his-
toplasmosis, may also produce diffuse mediastinitis. Mediastinal adenopathy is a com-
mon manifestation of primary tuberculosis, but diffuse involvement of the mediastinal
nodes by tuberculosis is rare, except in patients who are immunologically compromised.
Fibrosing mediastinitis (Fig 8.11, A and B) may be idiopathic, but is most often
caused by histoplasmosis.147,633,634 Rossi et al.492 have reported two types of fibros-
ing mediastinitis that they described as focal and diffuse. The focal type is the most
common and presents as a fibrous mass that often contains multiple calcifications.
The fibrous mass is most frequently seen in the subcarinal or paratracheal regions of
the mediastinum or pulmonary hila. The right side of the mediastinum is the most
common area of involvement, and calcification is seen in as many as 63% of cases.
Although the focal type appears more localized, it may still occlude vessels, bronchi,
or the esophagus.
The diffuse type infiltrates through all compartments of the mediastinum and is
less commonly calcified. The diffuse type is less likely to result from histoplasmosis
and may occur in patients with other fibrosing diseases, including retroperitoneal
fibrosis. Fibrosing mediastinitis may cause pulmonary venous and arterial obstruc-
tion, leading to cor pulmonale and death.634 Both fibrosing mediastinitis and tumors
may cause SVC syndrome,141 but it is often not possible to make this distinction by
radiograph. CT scans showing a smooth, tapered mediastinal widening with calcifica-
tions favor a diagnosis of mediastinal fibrosis, whereas a more lobulated, noncalcified
mass favors a diagnosis of tumor. Lung cancer is a most common tumor, causing SVC
syndrome; however, lymphoma, metastases, and mesothelioma may also occlude the
SVC. Biopsy may be required to distinguish fibrosing mediastinitis from tumor.
Anthrax is a very rare bacterial infection that has not received much attention
in the radiologic literature until the terrorist attacks of 2001. Earls et al.125 have
reported the chest radiograph and CT findings in two patients who survived inhala-
tional anthrax. The radiologic findings include diffuse mediastinal widening, hilar
adenopathy, pleural effusions, and air space opacities. CT reveals that the mediasti-
nal widening results from a combination of adenopathy and edema of mediastinal
fat. This study showed the adenopathy to be hyperattenuating and extensive, involv-
ing the paratracheal, aorticopulmonary window, subcarinal, hilar, and azygoesopha-
geal recess nodes. As the patients in this limited series recovered, the pulmonary air
space opacities and pleural effusions improved, but the adenopathy persisted for
more than 2 weeks after the patients showed considerable clinical improvement.
Their study125 emphasized the importance of distinguishing the early finding of
mediastinal widening from atherosclerotic tortuosity of the aorta. The acute onset of
mediastinal widening is also an important feature of anthrax when compared with
most other bacterial pneumonias.
B
Fig. 8.11 A, Fibrosing mediastinitis accounts for the widening of the middle portion of the medi-
astinum. Observe the tapered right paratracheal mass that partially obscures the right hilum. There is
also an opacity adjacent to the arch of the aorta. B, CT confirms a large right paratracheal mass with
multiple calcifications. The SVC is occluded and is therefore not seen. Large collateral veins have devel-
oped, including a large hemiazygos vein posterior to the aorta and a dilated, superior intercostal vein
lateral to the aortic arch.
LIPOMATOSIS
Mediastinal lipomatosis is a benign cause of diffuse mediastinal widening (Fig 8.12,
A and B).195,439,566 Some signs that help suggest this diagnosis include the following:
(1) a large mediastinum without indentation on the trachea; (2) smooth contours
of pleural lines; and (3) a prominent epicardial fat pad. Although fat appears similar
B
Fig. 8.12 A, Mediastinal lipomatosis is a common cause of a wide mediastinum and is often the
result of obesity. Compared with the attenuation of the aorta and the lucency of the lungs, the fat is in-
termediate in opacity and often does not obscure normal structures, such as the aorta. B, CT confirms
the diagnosis of mediastinal lipomatosis.
to soft tissue when compared with the opacity of the aerated lung on a chest radio-
graph, the diagnosis of lipomatosis should be easily confirmed with a CT scan.251 The
condition causes attenuation intermediate between that of the normal soft-tissue
structures of the mediastinum and the lower attenuation of the aerated lung. Medi-
astinal lipomatosis may result from Cushing syndrome, corticosteroid therapy, or
exogenous obesity.
Top 5 Diagnoses: Widening of the Mediastinum

1. Hematoma
2. Tortuous aorta
3. Metastases
4. Lymphoma
5. Granulomatous infections
Summary
Acute, posttraumatic mediastinal widening with loss of definition of the aortic arch or
descending aorta should be considered suspicious for aortic injury.
Atherosclerotic dilation and tortuosity of the aorta are very common in older adults.
A change in aortic size or definition is suggestive of dissection. This diagnosis may be
confirmed with the use of contrast-enhanced CT or MRI.
Tortuosity of the aorta and great vessels may obscure mediastinal masses.
Neoplasms that involve mediastinal nodes may diffusely widen the mediastinum.
Mediastinitis may result from bacterial and granulomatous infections, esophageal

perforation, and extension of extrathoracic abscesses.
Lipomatosis is a benign cause of mediastinal widening.
ANSWER GUIDE
Legend for introductory figure
Fig. 8.1 A, Mediastinal widening usually obscures the normal mediastinal contours. In
this case there is mild lobulation, which is suggestive of adenopathy. B, CT confirms ex-
tensive anterior and middle mediastinal adenopathy. This would most likely be the result
of metastases, or lymphoma, but biopsy revealed nonnecrotizing granulomas consistent
with sarcoidosis.
ANSWERS
1.
c 2.
d 3.
e

Chest Radio 8 Widening of The Mediastinum

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8 WIDENING OF THE MEDIASTINUM

2. Which one of the following statements regarding aortic trauma is true?

3. Which of the following statements about mediastinal hematomas are true?

Chart 8.1 WIDENING OF THE MEDIASTINUM

Chart 8.1 WIDENING OF THE MEDIASTINUM—cont’d

Top 5 Diagnoses: Widening of the Mediastinum

Mediastinitis may result from bacterial and granulomatous infections, esophageal

Lipomatosis is a benign cause of mediastinal widening.

Vous aimerez peut-être aussi

Chest Radio 8 Widening of The Mediastinum

Transféré par

Informations du document

Titre original

Copyright

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Partager ce document

Partager ou intégrer le document

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Chest Radio 8 Widening of The Mediastinum

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8 WIDENING OF THE MEDIASTINUM

2. Which one of the following statements regarding aortic trauma is true?

3. Which of the following statements about mediastinal hematomas are true?

Chart 8.1 WIDENING OF THE MEDIASTINUM

Chart 8.1 WIDENING OF THE MEDIASTINUM—cont’d

Top 5 Diagnoses: Widening of the Mediastinum

Mediastinitis may result from bacterial and granulomatous infections, esophageal

Lipomatosis is a benign cause of mediastinal widening.

Vous aimerez peut-être aussi

2. Which one of the following statements regarding aortic trauma is true?

3. Which of the following statements about mediastinal hematomas are true?

Chart 8.1 WIDENING OF THE MEDIASTINUM

Chart 8.1 WIDENING OF THE MEDIASTINUM—cont’d