This document discusses the anatomy and contents of the thorax, heart, and pericardium. It outlines the boundaries, compartments, and normal contents of the thorax. It then discusses common mediastinal masses and their typical locations. Finally, it reviews injuries that can occur to the thorax including pneumothorax, hemothorax, rib fractures, and cardiac tamponade.

1. Thorax, Heart, Pericardium
Dr. Prabhu Dayal Sinwar
Assistant Professor

2. Boundaries
Superior- Thoracic inlet
Inferior- Diaphragm
Anterior- Sternum
Posterior- Vertebral
bodies
Lateral- Pleura

3. Compartments
Anterior or Anterosuperior: Lies in front of
anterior pericardium and trachea
Middle or Visceral: Lies within pericardial
cavity including trachea
Posterior or paravertebral sulci: Lies posterior
to posterior pericardium and trachea

5. Normal Contents
 Anterosuperior: thymus, extrapericardial aorta
and branches, IVC, SVC, lymphatic tissue
 Middle: heart, intrapericardial great vessels,
pulmonary hila, pericardium, trachea
 Posterior: esophagus, vagus nerves, thoracic
duct, sympathetic chain, descending thoracic
aorta, azygous venous system

6. Location of common mediastinal
masses
Anterior Middle Posterior
1. Thymoma
Most common in anterior
mediastinum
1. Cysts Most common
in middle
mediastinum
• Pericardial (m/c)
• Bronchogenic
• Enterogenous
• Neuroenteric
1. Neurogenic tumor Most
common overall
2. Lymphoma 2. Vascular Masses 2. Meningocele
3. Germ cell Tumor 3. Lymphoma 3. Mesenchymal tumors
4. Thyroid and
parathyroid masses
4. Mesenchymal tumor 4. Pheochromocytoma
5. Bronchogenic cyst 5. Pheochromocytoma 5. Lymphoma
6. Aneurysm 6. Bochdalek hernia
7. Bronchogenic cyst
8. Enterogenous Cyst

7. Anterosuperior Masses
Thymus
• Thymoma
• Thymic carcinoma
• Thymic carcinoid
• Thymolipoma
Mediastinal Lymphoma
• Hodgkin’s Lymphoma
• Non-Hodgkin’s Lymphoma
• Poorly differentiated
lymphoblastic
• Diffuse lymphocytic
• Primary Mediastinal B-cell
Lymphoma
Germ Cell Tumor
• Teratoma
• Mature
• Immature
• Seminoma
• Nonseminomatous Germ Cell
• Embryonal cell carcinoma
• Endodermal sinus tumor
• Choriocarcinoma
• Malignant teratoma
• Mixed
Thyroid/Parathyroid
• Goiter
• Parathyroid adenoma

10.  A neoplasm of the Thymic epithelial cells .
 Results from dysregualtion of the proliferation
and maturation of T- lymphocytes .
 This process results in either Autoimmunity or
Immune defeciency .
 As a result , thymomas are associated with
autoimmune diseases in 70% of the patients
during diagnosis .
 Thymomas are ussually encapsulated and spread
by local extension .

11.  Mostly asymptomatic
 Local symptoms :
Dyspnea .
Dyspahgea .
Cough .
SVC obstruction .
 Thymomas tend to be highly vascular →
bleeding and necrosis .

12. Autoimmune
disorder
Haematological Neuromuscular
SLE Cytopenia Myesthenia gravis
RA Red cell aplesia Neuromuscular disorder
Polymyositis Hypogammaglobulenemi
a
Myotonic dystrophy
Sarcoidosis Erythrocytosis Myositis
CT scan is Investigation of choice
Definative diagnosis by histology

13. 1. Lymphocytic. 25%
2. Epithelial. 25%
3. Lymphoepithelial 50%

14.  Masaoka Staging system .
I : Macrospcopically encapsulate , no capsular
invasion .
II: Macroscopic invasion to surrounding tissue
or microscopic capsular invasion .
III : Macroscopic invasion into neighboring
organs.
IVa : Pleural or pericardial dissemination.
IVb : Lymphogenous or hematogenous
metastases

15. Treatment
of choice
•Total
thymectomy
Large
thymoma
>5cm with
invasion
•Thymectomy
with
chemotherapy
Myesthenia
gravis
•Thymectomy and
anticholinesterase
drug

16.  Pneumothorax
 Haemothorax
 Pulmonary contusion
 Parenchymal injury
 Trachea and bronchial injuries
 Pneumomediastinum

18. 18
 Blunt chest trauma
 Most common cause of serious chest injuries
 Motor vehicle collisions (MVCs), falls, direct
blows, and crushing injuries
 Many injuries are not immediately apparent
in physical exam
 Injuries linked to size of object applying force
and most important, to speed

19. 19
 Penetrating trauma
 Increasingly common in today’s society
 Immediate result can be severe bleeding or
impaired breathing
 Any chest wound can involve underlying organ
injury
 No matter how superficial it looks
 Injuries to the heart, lungs, and great vessels can
quickly lead to shock and cardiac arrest

20.  Most common thoracic injury
 Localised pain, tenderness, crepitus
 CXR to exclude other injuries
 Analgesia..avoid taping
 Underestimation of effect
 Upper ribs, clavicle or scapula fracture: suspect
vascular injury

21.  Air within the pleural cavity (i.e. between
visceral and parietal pleura)
 The air enters via a defect in the visceral pleura
(e.g. ruptured bulla) or the parietal pleura (e.g.
puncture following rib fracture)

22. Primary
spontaneous
Due to rupture
of apical
pleural blebs
Simple needle
aspiration
Open
Due to large
open defect in
the chest
Promptly close
the defect
Tension
Due to one
way valve air
leak
Immediate
decompression

24.  White line of visceral pleura parallel to chest
wall
 No lung markings lateral to the line
 There may be associated rib fractures
 Do not confuse the line with skin fold or with
scapula
 The most sensitive test if in doubt is a CXR
taken in expiration

25. •Pencil-thin white line
running parallel to chest
wall
•No lung markings lateral
to the line
Blade of right scapula

26.  Spontaneous
 Rupture of an apical bleb
 Traumatic
 With rib fractures
 Penetrating chest trauma
 Pre-existing lung abnormality
 Pulmonary fibrosis
 Asthma
 Vasculitis
 Pulmonary metastases close to edge of lung

27. I. Spontaneous
• Pneumothorax with no obvious cause
• (A). Primary spontaneous pneumothorax
– Occurs with no underlying lung disease
– Most (80%) have small subpleural blebs
– Typically happens in tall, thin, young adults
– >90% have had short-term smoking history
• Smoking cessation recommended
• (B). Secondary spontaneous pneumothorax
– Occurs with underlying lung disease
• Most common associated disease is COPD
• Also seen during exacerbations of asthma and CF
• Interstitial lung diseases with normal lung volumes
– Sarcoidosis

28. II. Traumatic pneumothorax
• (A). Penetrating chest trauma
– Common secondary to bullet or knife penetration
– Chest tube is usually adequate to treat.
– May require surgery if bleeding is severe
• (B). Blunt trauma
– Broken ribs puncture lung with air escape into pleura.
– Chest tube is all that is generally required
– Tracheal fracture and esophageal rupture
• These are two special causes of pneumothorax that require
surgical repair.
III. Iatrogenic
– Most common cause of traumatic pneumothorax
– Common iatrogenic causes are
• Needle aspiration lung biopsy
• Thoracentesis
• Central venous catheter placement

29.  Blunt or penetrating mechanism
 Bleeding into the pleural cavity
 May be associated with a pneumothorax
 Air or blood in the
pleural space
compromises lung
capacity

30.  Two or more adjacent ribs fractured in more
than one place
 Compromises the structural integrity of the
chest, causing paradoxical movement while
breathing
 Associated with underlying injury
 Pneumothorax
 Hemothorax
 Pulmonary contusion

32. Oxygen = Should be administered to all patients
– Supplemental O2 speeds absorption of air from
pleural space
Immediate decompression by larger bore needle in
second intercostal space (ICS), midclavicular line
Immediately followed by chest tube in fifth ICS,
anterior axillary line Connected to underwater seal
or Heimlich valve
Pleurodesis: consider with recurrent pneumothoraces

35.  Signs and symptoms
 Beck’s triad
 Muffled heart sound
 Distended neck veins
 Hypotension
 Diagnosis
 ECHO is diagnostic
 Treatment
 Needle pericardiocentasis
 TOC
 Surgical pericardiotomy