Mediastinal masses

Mediastinal masses are classified according to their location in the mediastinum: anterior, middle and posterior mediastinum. It is possible to localise these with reasonable accuracy on plain films by assessing which silhouette has been lost. If, for example, part of the silhouette of the ascending thoracic aorta or heart border is blurred, then the mass must be anterior. If the lung hilum is seen projected through the mass and the hilum is of normal appearance, then the abnormality cannot be in the middle mediastinum. Posterior mediastinal masses are identified by the loss of the thoracic spine contour or the descending thoracic aorta outline. Other clues of a posteriorly sited mass are abnormalities of the adjacent ribs or bony involvement of the spine (see Fig. 1.30).

Lateral plain films will confirm the position in the mediastinum. Cross-sectional imaging (CT or MRI) are routinely used to give further anatomical detail of mediastinal masses (Table 1.2).

Fig. 1.30 Posterior mediastinal mass, a neurogenic tumour. It could be difficult to locate this mass in the posterior mediastinal on frontal chest X-ray - the clue to look for is the expansion of the neural foramina.

Table 1.2 Mediastinal masses

Anterior mediastinal masses - anatomical space anterior to trachea and major bronchi

■ Ascending aortic aneurysm

Middle mediastinum - space between anterior and posterior mediastinum

■ Aortic arch aneurysm

■ Bronchogenic cyst

Posterior mediastinal mass - anatomical space posterior to anterior aspect of thoracic spine

■ Hiatus hernia

■ Descending aortic aneurysm

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Fig. 1.32 CT thymoma. Cross-sectional imaging demonstrates the position of the mass in the anterior mediastinum.

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Fig. 1.34 Quiz case.

■ What anaesthetic precautions are necessary?

Fig. 1.34 Quiz case.

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