Widened mediastinum: Difference between revisions
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{{CMG}} | {{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S. | ||
==Overview== | ==Overview== | ||
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|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular''' | |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular''' | ||
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | | |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | | ||
*[[Aortic dissection]] | |||
*[[Partial anomalous pulmonary venous connection]] | |||
*[[Pericardial effusion]] | |||
*[[Superior vena cava obstruction]] | |||
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|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
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|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Dermatologic''' | | '''Dermatologic''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| [[Dermoid cyst]] | ||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
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| '''Ear Nose Throat''' | | '''Ear Nose Throat''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*Acute descending necrotizing mediastinitis | |||
*[[Goitre]] | |||
*[[Thyroid cancer]] | |||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Endocrine''' | | '''Endocrine''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*[[Goitre]], when more than 50% of the mass is located below the thoracic inlet, is termed intrathoracic goitre<ref name="pmid9818814">{{cite journal| author=Netterville JL, Coleman SC, Smith JC, Smith MM, Day TA, Burkey BB| title=Management of substernal goiter. | journal=Laryngoscope | year= 1998 | volume= 108 | issue= 11 Pt 1 | pages= 1611-7 | pmid=9818814 | doi= | pmc= | url= }} </ref> which appear as mediastinal mass. | |||
*[[Thyroid cancer]] | |||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Environmental''' | | '''Environmental''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| Intrathoracic [[goitre]] | ||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Gastroenterologic''' | | '''Gastroenterologic''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*[[Esophageal achalasia]] | |||
*[[Esophageal cancer]] | |||
*[[Esophageal rupture]] leading to [[pneumomediastinum]] secondary to excessive [[vomiting]]. | |||
*[[Hiatus hernia]] | |||
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| '''Hematologic''' | | '''Hematologic''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*[[Hilar lymphadenopathy]] | |||
*[[Lymphoma]] | |||
*[[Non-Hodgkin lymphoma]] | |||
*[[Thymoma]] | |||
*Mediastinal [[lymphangiomas]] | |||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Iatrogenic''' | | '''Iatrogenic''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| [[Mediastinitis]] | ||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Infectious Disease''' | | '''Infectious Disease''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*Acute descending necrotizing mediastinitis <ref> MKSAP 11: Medical knowledge self-assessment program. Philadelphia: American College of Physicians, 1998:966-7.</ref> <ref> Corsten MJ, Shamji FM, Odell PF, Frederico JA, Laframboise GG, Reid KR, et al. Optimal treatment of descending necrotising mediastinitis. Thorax 1997;52:702-8. </ref> <ref> Wheatley MJ, Stirling MC, Kirsch MM, Gago O, Orringer MB. Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990;49:780-4.</ref> <ref> Estrera AS, Landay MJ, Grisham JM, Sinn DP, Platt MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545-52. </ref> <ref> Alsoub H, Chacko KC. Descending necrotising mediastinitis. Postgrad Med J 1995;71:98-101.</ref> Dental infections are the cause in 60-70% of the cases<ref name="pmid10760723">{{cite journal| author=Sakamoto H, Aoki T, Kise Y, Watanabe D, Sasaki J| title=Descending necrotizing mediastinitis due to odontogenic infections. | journal=Oral Surg Oral Med Oral Pathol Oral Radiol Endod | year= 2000 | volume= 89 | issue= 4 | pages= 412-9 | pmid=10760723 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10760723 }} </ref>. Can also occur secondary to head and neck infections. [[Streptococcus|Hemolytic group streptococci]] and [[Bacteroides]] species are the common organisms. | |||
*[[Anthrax]]- This is a classic finding associated with inhalational [[anthrax]]. A widened mediastinum was found in 7 of the first 10 victims infected by anthrax (''[[Bacillus anthracis]]'') in 2001.<ref name="pmid11747719">{{cite journal |author=Jernigan JA, Stephens DS, Ashford DA, ''et al'' |title=Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States |journal=Emerging Infect. Dis. |volume=7 |issue=6 |pages=933–44 |year=2001 |pmid=11747719 |doi=}}</ref> | |||
*[[Mediastinitis]] | |||
*[[Tularemia]] | |||
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| '''Neurologic''' | | '''Neurologic''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| Mediastinal [[neurilemmoma]] may originate from right phrenic nerve<ref name="pmid10064956">{{cite journal| author=Hirose H, Ohmori K, Nakaoka Y, Kitamura K, Muramatsu T, Namiki Y et al.| title=[Mediastinal neurilemmoma originating in the right phrenic nerve: a case report]. | journal=Nihon Kokyuki Gakkai Zasshi | year= 1998 | volume= 36 | issue= 12 | pages= 1027-31 | pmid=10064956 | doi= | pmc= | url= }} </ref>, intrathoracic vagal nerve<ref name="pmid8152184">{{cite journal| author=Ito I, Komota K, Nakajima T, Ishibashi K, Kawazoe K| title=[A case of mediastinal neurilemmoma originating from the intrathoracic vagal nerve]. | journal=Kyobu Geka | year= 1994 | volume= 47 | issue= 4 | pages= 325-7 | pmid=8152184 | doi= | pmc= | url= }} </ref> | ||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Nutritional / Metabolic''' | | '''Nutritional / Metabolic''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| Intrathoracic [[goitre]] | ||
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| '''Oncologic''' | | '''Oncologic''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*[[Esophageal cancer]] | |||
*[[Lymphoma]] | |||
*[[Mediastinal germ cell tumor]] | |||
*[[Mediastinal tumor]] | |||
*[[Mediastinal mass]] | |||
*[[Neurilemmoma]] | |||
*[[Non-Hodgkin lymphoma]] | |||
*[[Teratoma]] | |||
*[[Thymoma]] | |||
*[[Thyroid cancer]] | |||
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| '''Overdose / Toxicity''' | | '''Overdose / Toxicity''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| Inhaled recreational drugs such as [[cocaine]] which induced bronschospasm, increased alveolar pressure followed by alveolar rupture leading to [[interstitial emphysema]] and [[pneumomediastinum]]<ref name="pmid1416301">{{cite journal| author=Panacek EA, Singer AJ, Sherman BW, Prescott A, Rutherford WF| title=Spontaneous pneumomediastinum: clinical and natural history. | journal=Ann Emerg Med | year= 1992 | volume= 21 | issue= 10 | pages= 1222-7 | pmid=1416301 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1416301 }} </ref>. | ||
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| '''Pulmonary''' | | '''Pulmonary''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*[[Bronchogenic cyst]] | |||
*[[Pneumomediastinum]] secondary to air leak from any part of the lung or airways into the mediastinum due to excessive coughing, sneezing. | |||
*[[Sarcoidosis]] | |||
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| '''Rheum / Immune / Allergy''' | | '''Rheum / Immune / Allergy''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*[[Churg-Strauss syndrome]] | |||
*[[Sarcoidosis]] | |||
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| '''Trauma''' | | '''Trauma''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*[[Pneumomediastinum]] | |||
*Hemorrhagic [[pericardial effusion]] | |||
*[[Chylopericardium]] refers to a communication between the pericardial sac and the thoracic duct, as a result of trauma | |||
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| '''Miscellaneous''' | | '''Miscellaneous''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| | ||
*[[Dermoid cyst]] is thick-walled and contains various tissue materials of skin, hair, occasionally teeth, and caseous (cheesy) substance. They are usually found in the front of the chest, but rarely are located within the pericardium. If not removed, it may get infected and rupture. | |||
*Supine AP [[chest x ray]] can yield a [[false positive]] "widened mediastinum". | |||
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Revision as of 03:27, 26 July 2011
Widened mediastinum | |
Widened mediastinum | |
DiseasesDB | 29459 |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.
Overview
A widened mediastinum is a mediastinum which measures greater than 8 cm in width on PA chest X-ray. A widened mediastinum can be indicative of life threatening conditions such as aortic dissection and esophageal rupture.
Complete Differential Diagnosis of the Causes of ...
(By organ system)
Cardiovascular | |
Chemical / poisoning | No underlying causes |
Dermatologic | Dermoid cyst |
Drug Side Effect | No underlying causes |
Ear Nose Throat |
|
Endocrine |
|
Environmental | Intrathoracic goitre |
Gastroenterologic |
|
Genetic | No underlying causes |
Hematologic | |
Iatrogenic | Mediastinitis |
Infectious Disease |
|
Musculoskeletal / Ortho | No underlying causes |
Neurologic | Mediastinal neurilemmoma may originate from right phrenic nerve[9], intrathoracic vagal nerve[10] |
Nutritional / Metabolic | Intrathoracic goitre |
Obstetric/Gynecologic | No underlying causes |
Oncologic | |
Opthalmologic | No underlying causes |
Overdose / Toxicity | Inhaled recreational drugs such as cocaine which induced bronschospasm, increased alveolar pressure followed by alveolar rupture leading to interstitial emphysema and pneumomediastinum[11]. |
Psychiatric | No underlying causes |
Pulmonary |
|
Renal / Electrolyte | No underlying causes |
Rheum / Immune / Allergy | |
Sexual | No underlying causes |
Trauma |
|
Urologic | No underlying causes |
Miscellaneous |
|
Complete Differential Diagnosis of Causes of a Widened Mediastinum
In alphabetical order
- Anthrax
- This is a classic finding associated with inhalational anthrax. A widened mediastinum was found in 7 of the first 10 victims infected by anthrax (Bacillus anthracis) in 2001.[8]
- Aortic dissection
- Bronchogenic cyst
- Churg-Strauss syndrome
- Dermoid cyst
- Esophageal achalasia
- Esophageal cancer
- Esophageal rupture
- Goitre
- Hiatus hernia
- Hilar lymphadenopathy
- Lymphoma
- Mediastinal germ cell tumor
- Mediastinal tumor
- Mediastinal mass
- Mediastinitis
- Neurilemmoma
- Non-Hodgkin lymphoma
- Partial anomalous pulmonary venous connection
- Pericardial effusion
- Pneumomediastinum
- Sarcoidosis
- Superior vena cava obstruction
- Supine AP chest x ray can yield a false positive "widened mediastinum".
- Among patients who have sustained blunt traum, AP chest radiographs are often obtained in the supine position to maintain spinal precautions. This supine position may result in fluid shifts that are in turn associated with a widening of the mediastinum. After the spine had been "cleared", some authors recommend repeating the chest X ray with the patient in the erect position which results in normalization of the mediastinal size in around 40% of patients.
- Teratoma
- Thymoma
- Thyroid cancer
- Tularemia
Diagnosis
Widening of the mediastinum on the chest X ray may represent a medical emergency and the following diagnoses should be excluded immediately:
In ruling out the presence of traumatic aortic injury in a patient, a widened mediastinum is reported as having a 53% sensitivity, 59% specificity and 83% negative predictive value.
Other less sensitive signs on the chest x ray of aortic injury include the following:
- Depression of the left main-stem bronchus
- Deviation of a naso-gastric tube to the right
- Apical pleural hemoatoma (cap)
- Disruption of the calcium ring in the aortic knob (broken-halo)
Chest X Ray
Shown below is the development of a new widened mediastinum in a patient with aortic dissection:
-
Chest x ray of a patient 3 months before an aortic dissection
-
Chest x ray of the same patient the day of admission for aortic dissection showing a new widened mediastinum
References
- ↑ Netterville JL, Coleman SC, Smith JC, Smith MM, Day TA, Burkey BB (1998). "Management of substernal goiter". Laryngoscope. 108 (11 Pt 1): 1611–7. PMID 9818814.
- ↑ MKSAP 11: Medical knowledge self-assessment program. Philadelphia: American College of Physicians, 1998:966-7.
- ↑ Corsten MJ, Shamji FM, Odell PF, Frederico JA, Laframboise GG, Reid KR, et al. Optimal treatment of descending necrotising mediastinitis. Thorax 1997;52:702-8.
- ↑ Wheatley MJ, Stirling MC, Kirsch MM, Gago O, Orringer MB. Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990;49:780-4.
- ↑ Estrera AS, Landay MJ, Grisham JM, Sinn DP, Platt MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545-52.
- ↑ Alsoub H, Chacko KC. Descending necrotising mediastinitis. Postgrad Med J 1995;71:98-101.
- ↑ Sakamoto H, Aoki T, Kise Y, Watanabe D, Sasaki J (2000). "Descending necrotizing mediastinitis due to odontogenic infections". Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 89 (4): 412–9. PMID 10760723.
- ↑ 8.0 8.1 Jernigan JA, Stephens DS, Ashford DA; et al. (2001). "Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States". Emerging Infect. Dis. 7 (6): 933–44. PMID 11747719.
- ↑ Hirose H, Ohmori K, Nakaoka Y, Kitamura K, Muramatsu T, Namiki Y; et al. (1998). "[Mediastinal neurilemmoma originating in the right phrenic nerve: a case report]". Nihon Kokyuki Gakkai Zasshi. 36 (12): 1027–31. PMID 10064956.
- ↑ Ito I, Komota K, Nakajima T, Ishibashi K, Kawazoe K (1994). "[A case of mediastinal neurilemmoma originating from the intrathoracic vagal nerve]". Kyobu Geka. 47 (4): 325–7. PMID 8152184.
- ↑ Panacek EA, Singer AJ, Sherman BW, Prescott A, Rutherford WF (1992). "Spontaneous pneumomediastinum: clinical and natural history". Ann Emerg Med. 21 (10): 1222–7. PMID 1416301.
- ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
- ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
- ↑ MKSAP 11: Medical knowledge self-assessment program. Philadelphia: American College of Physicians, 1998:966-7.
- ↑ Corsten MJ, Shamji FM, Odell PF, Frederico JA, Laframboise GG, Reid KR, et al. Optimal treatment of descending necrotising mediastinitis. Thorax 1997;52:702-8.
- ↑ Wheatley MJ, Stirling MC, Kirsch MM, Gago O, Orringer MB. Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990;49:780-4.
- ↑ Estrera AS, Landay MJ, Grisham JM, Sinn DP, Platt MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545-52.
- ↑ Alsoub H, Chacko KC. Descending necrotising mediastinitis. Postgrad Med J 1995;71:98-101.