Topography of the veins of the posterior mediastinum. Tumor of the mediastinum. Cellular spaces of the chest cavity

There are several approaches to dividing our body into sections. Clear boundaries of organs and systems, as well as their totality, help doctors more accurately navigate the body, prescribing treatment, describing any malfunctions and pathologies. At the same time, doctors, regardless of their profile, use the same terms to refer to specific areas of the body. So the zone that is localized in the middle and in the upper part of the body can be called the sternum. However, experts medical profile it is called the mediastinum. Today we will talk about the mediastinum, mediastinal tumors, mediastinal nodes, what is its anatomy, where is it located.

Structure

To more accurately describe the location of pathologies and plan correction methods, the mediastinum is divided into upper and lower, as well as anterior, posterior and middle.

The anterior part of this area is limited on the front side by the sternum, and behind by the brachiocephalic vessels, as well as the pericardium and brachiocephalic trunk. Inside this space pass thoracic veins, in addition, it houses the thymus gland, in other words the thymus gland. It is in front of the mediastinum that the thoracic artery goes and The lymph nodes. The middle part of the area under consideration includes the heart, hollow, brachiocephalic, phrenic, and pulmonary veins. In addition, it includes the brachiocephalic trunk, aortic arch, trachea, main bronchi, pulmonary arteries. Concerning posterior mediastinum, then it is limited to the trachea, as well as the pericardium from the frontal area, and the spine from the posterior side. This part includes the esophagus and the descending aorta, in addition it includes the hemizygos and azygos vein, and the thoracic lymphatic duct. The posterior mediastinum also contains lymph nodes.

Upper zone The mediastinum consists of all the anatomical structures located above upper limit pericardium, represented by the upper aperture of the sternum, as well as a line extending from the angle of the chest and intervertebral disc Th4-Th5.

As for the lower mediastinum, it is limited by the upper edges of the diaphragm and pericardium.

Mediastinal tumors

Various tumor-like formations can develop in the mediastinum area. At the same time, neoplasms of this organ include not only true formations, but also those cysts and tumor-like ailments that have a different etiology, location, and other course of the disease. Any neoplasm of this type originates from tissues of different origins; they are united solely by their location. In this case, doctors consider:

Neoplasm Clinic

Tumor formations are usually found in young and middle-aged people. age group, regardless of gender. As practice shows, mediastinal diseases often do not indicate themselves; they can only be detected during preventive studies. At the same time, there are some symptoms that can indicate such disorders and which need to be paid attention to.

So, tumor formations inside the mediastinum often make themselves felt by mild painful sensations that can radiate towards the neck, shoulder area and between the shoulder blades. In the event that the formation grows inside the borderline sympathetic trunk, the patient’s pupils dilate, drooping of the eyelid and retraction may be observed eyeball.

Damage to the recurrent laryngeal nerve often makes itself felt by hoarseness in the voice. Classic symptoms tumor formations are painful sensations in the chest area, as well as a feeling of heaviness in the head. In addition, shortness of breath may occur, cyanosis, swelling of the face, and disturbances in the passage of food through the esophagus may occur.

If tumor diseases reach an advanced stage of development, the patient experiences a noticeable increase in body temperature, as well as severe weakness. In addition, arthralgia, irregular heart rhythms, and some swelling of the extremities are observed.

Lymph nodes of the mediastinum

As mentioned above, there are many lymph nodes located inside the mediastinum. The most common lesion of these organs is lymphadenopathy, which can develop against the background of metastases of carcinoma, lymphoma, as well as some non-tumor diseases, for example, sarcoidosis, tuberculosis, etc.

In addition to changes in the size of the lymph nodes, lymphadenopathy makes itself felt by fever, as well as excessive sweating. In addition, severe weight loss occurs, hepatomegaly and splenomegaly develop. The diseases provoke frequent infections of the upper respiratory tract in the form of tonsillitis, various types of sore throat and pharyngitis.

In some cases, lymph nodes can be affected in isolation, and sometimes tumors grow into other organs.

Elimination of tumor diseases and other problems with the mediastinum is carried out according to generally accepted standards of therapeutic influence.

The mediastinum is the part of the thoracic cavity bounded below by the diaphragm, in front by the sternum, behind by the thoracic spine and necks of the ribs, and on the sides by the pleural layers (right and left mediastinal pleura). Above the manubrium of the sternum, the mediastinum passes into the cellular spaces of the neck. The conventional upper border of the mediastinum is the horizontal plane passing along the upper edge of the manubrium of the sternum. A conventional line drawn from the place of attachment of the manubrium of the sternum to its body towards the IV thoracic vertebra divides the mediastinum into upper and lower. The frontal plane, drawn along the posterior wall of the trachea, divides the superior mediastinum into anterior and posterior sections. The cardiac bursa divides the inferior mediastinum into anterior, middle and inferior sections (Fig. 16.1).

In the anterior section of the upper mediastinum there are the proximal sections of the trachea, the thymus gland, the aortic arch and its branches, the upper section of the superior vena cava and its main tributaries. In the posterior section there is the upper part of the esophagus, sympathetic trunks, vagus nerves, and the thoracic lymphatic duct. In the anterior mediastinum between the pericardium and the sternum are the distal part thymus gland, fatty tissue

ka, lymph nodes. The middle mediastinum contains the pericardium, heart, intrapericardial sections of large vessels, bifurcation of the trachea and main bronchi, bifurcation lymph nodes. In the posterior mediastinum, limited in front by the bifurcation of the trachea and pericardium, and behind by the lower thoracic spine, there are the esophagus, the descending thoracic aorta, the thoracic lymphatic duct, sympathetic and parasympathetic (vagus) nerves, and lymph nodes.

Research methods

To diagnose mediastinal diseases (tumors, cysts, acute and chronic mediastinitis), the same instrumental methods, which are used to diagnose lesions of organs located in this space. They are described in the corresponding chapters.

16.1. Mediastinal injuries

There are open and closed damage mediastinum and organs located in it.

Clinical picture and diagnosis. Clinical manifestations depend on the nature of the injury and which organ of the mediastinum is damaged, on the intensity of internal or external bleeding. With a closed injury, hemorrhages almost always occur with the formation of a hematoma, which can lead to compression of vital organs (primarily thin-walled veins of the mediastinum). When the esophagus, trachea and main bronchi are ruptured, mediastinal emphysema and mediastinitis develop. Clinically, emphysema is manifested by intense pain behind the sternum, characteristic crepitus in the subcutaneous tissue of the anterior surface of the neck, face, and less commonly the chest wall.

The diagnosis is based on anamnesis (clarification of the mechanism of injury), the sequence of development of symptoms and objective examination data, identifying symptoms characteristic of the damaged organ. An X-ray examination shows a displacement of the mediastinum in one direction or another, an expansion of its shadow due to hemorrhage. Significant clearing of the mediastinal shadow is a radiological symptom of mediastinal emphysema.

Open injuries

usually combined with damage to the mediastinal organs (which is accompanied by corresponding symptoms), as well as bleeding, development of pneumonia

Rice. 16.1. Anatomy of the mediastinum (schematic MOMediastinum.

image). Treatment sent before

1 - upper anterior mediastinum; 2 - posterior medial TOTAL ON NORMZ LYZATION OF FUNCTIONS

nie; 3 - anterior mediastinum; 4 - middle mediastinum. VITAL ORGANS (SVRD-

ca and lungs). Antishock therapy is carried out, and if the frame function of the chest is impaired, artificial ventilation and various methods of fixation are used. Indications for surgical treatment are compression of vital organs with a sharp disruption of their functions, ruptures of the esophagus, trachea, main bronchi, large blood vessels with ongoing bleeding.

For open injuries, surgical treatment is indicated. The choice of surgical method depends on the nature of the damage to a particular organ, the degree of infection of the wound and the general condition of the patient.

16.2. Inflammatory diseases

16.2.1. Descending necrotizing acute mediastinitis

Acute purulent inflammation of the mediastinal tissue occurs in most cases in the form of necrotizing, rapidly progressing phlegmon.

Etiology and pathogenesis. This form of acute mediastinitis, arising from acute purulent foci located on the neck and head, is the most common. Average age Those affected are 32-36 years old, men get sick 6 times more often than women. The cause in more than 50% of cases is odontogenic mixed aerobic-anaerobic infection, less often the infection comes from retropharyngeal abscesses, iatrogenic injuries to the pharynx, lymphadenitis of the cervical lymph nodes and acute thyroiditis. The infection quickly descends through the fascial spaces of the neck (mainly along the visceral - retroesophageal) into the mediastinum and causes severe necrotizing inflammation of the tissues of the latter. The rapid spread of infection to the mediastinum occurs due to gravity and the pressure gradient resulting from the suction effect of respiratory movements.

Descending necrotizing mediastinitis differs from other forms of acute mediastinitis in the unusually rapid development of the inflammatory process and severe sepsis, which can be fatal within 24-48 hours. Despite aggressive surgical intervention and modern antibiotic therapy, mortality reaches 30%.

Perforation of the esophagus (damage by a foreign body or instrument during diagnostic and therapeutic procedures), failure of sutures after operations on the esophagus can also become sources of descending infection of the mediastinum. Mediastinitis that occurs under these circumstances should be distinguished from necrotizing descending mediastinitis, since it constitutes a separate clinical entity and requires a special treatment algorithm.

Clinical picture and diagnosis. Characteristic signs of descending necrotizing mediastinitis are high body temperature, chills, pain localized in the neck and oropharynx, and respiratory failure. Sometimes there is redness and swelling in the chin area or neck. The appearance of signs of inflammation outside the oral cavity serves as a signal to begin immediate surgical treatment. Crepitus in this area may be due to anaerobic infection or emphysema due to injury to the trachea or esophagus. Difficulty breathing is a sign of threatened laryngeal edema and airway obstruction.

X-ray examination reveals an increase in retro-

visceral (retroesophageal) space, the presence of fluid or edema in this area, anterior displacement of the trachea, mediastinal emphysema, smoothing of lordosis in the cervical spine. A CT scan should be performed immediately to confirm the diagnosis. Detection of tissue edema, accumulation of fluid in the mediastinum and in the pleural cavity, emphysema of the mediastinum and neck makes it possible to establish a diagnosis and clarify the boundaries of the spread of infection.

Treatment. The rapid spread of infection and the possibility of developing sepsis with a fatal outcome within 24-48 hours oblige to begin treatment as early as possible, even if there is doubt about the presumptive diagnosis. It is necessary to maintain normal breathing, apply massive antibiotic therapy, and early surgical intervention is indicated. In case of swelling of the larynx and vocal cords, airway patency is ensured by tracheal intubation or tracheotomy. For antibiotic therapy, broad-spectrum drugs that can effectively suppress the development of anaerobic and aerobic infections are selected empirically. After determining the sensitivity of the infection to antibiotics, appropriate drugs are prescribed. Treatment is recommended to begin with penicillin G (benzylpenicillin) - 12-20 million units intravenously or intramuscularly in combination with clindamycin (600-900 mg intravenously at a rate of no more than 30 mg per minute) or metronidazole. A good effect is observed with a combination of cephalosporins and carbopenems.

The most important component of treatment is surgery. The incision is made according to leading edge m. sternocleidomastoideus. It allows you to open all three fascial spaces of the neck. During the operation, non-viable tissues are excised and the cavities are drained. From this incision, the surgeon cannot gain access to the infected tissues of the mediastinum, so it is recommended in all cases to additionally perform a thoracotomy (transverse sternotomy) to open and drain the abscesses. In recent years, interventions using video technology have been used to drain the mediastinum. Along with surgical intervention, the entire arsenal of intensive care means is used. Mortality with intensive treatment is 20-30%

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The thoracic aorta represents the third section of the aorta. Its length is about 17 cm. Its projection on the spine corresponds to the distance between the IV and XII thoracic vertebrae. It then follows through the aortic window of the diaphragm into the retroperitoneal space. On the right it borders with the thoracic duct and azygos vein, on the left with the semi-gyzygos vein, the pericardium and left bronchus are adjacent to it in front, and the spine behind it.

9-10 pairs of intercostal arteries depart from the thoracic aorta, located parietally. The bronchial, esophageal, pericardial and mediastinal arteries depart from it to the internal organs. The azygos vein is a direct continuation of the right ascending lumbar vein; the boundary between them is the hole between the inner and middle legs of the diaphragm. The azygos vein is located to the right of the aorta, thoracic duct and vertebral bodies. On its way, it receives up to 9 lower intercostal veins on the right side, veins of the esophagus, posterior bronchial veins and mediastinal veins of the posterior mediastinum.

At the level of the IV-V thoracic vertebrae, the azygos vein bends around the right lung root from back to front and opens into the superior vena cava. The hemizygos vein is a continuation of the left ascending lumbar vein; the boundary between them is the slit-like opening between the inner and middle legs of the diaphragm. It is located behind the thoracic aorta and runs along the lateral surface of the vertebral bodies; takes on its way most intercostal veins. The upper part of the intercostal veins opens into the superior accessory hemizygos vein or directly into the azygos vein.

The thoracic duct extends from the aortic opening of the diaphragm to the superior thoracic outlet. Near the diaphragm, the thoracic duct is covered by the edge of the aorta, higher up - by the posterior wall of the esophagus, its length is 35-45 cm.

Usually the thoracic duct runs in front of the intercostal arteries. Having reached the level of the III-IV-V vertebra, it turns to the left behind the esophagus, aortic arch and left subclavian vein, ascends to VII cervical vertebra and flows into subclavian vein left.

On its way, the thoracic duct receives lymph from the posterior parts of the chest and the organs of the left half of the chest cavity.

The esophagus extends from the VI cervical to the XI thoracic vertebra. On average, its length is 25 cm. In relation to the midline, the esophagus makes two bends. The upper left bend of the esophagus forms at the level of the third thoracic vertebra, deviating to the left from midline. At the level of the IV thoracic vertebra, the esophagus occupies a strictly median position and at the level of the VII thoracic vertebra again changes direction to the left. At the base of the X thoracic vertebra, the esophagus passes through the diaphragm.

When the esophagus passes through the upper aperture into the thoracic cavity, the trachea lies in front of it, and at the level of the V thoracic vertebra, the left stem bronchus crosses in front.

In the lower thoracic region, the thoracic duct and spine are adjacent to the esophagus, in front is the heart, on the right is the azygos vein and on the left is the thoracic aorta.

Vagus nerves

The left vagus nerve enters the thoracic cavity between the common carotid and left subclavian arteries and crosses the aortic arch anteriorly. At the level of the lower edge of the aorta, the left recurrent nerve departs from the left vagus nerve, which bends around the aortic arch from behind and returns to the neck. Next, the vagus nerve is located along the posterior surface of the left stem bronchus and along the anterior surface of the esophagus.

The right vagus nerve enters the chest cavity between the subclavian artery and vein. At the intersection subclavian artery In front of it, the right recurrent nerve departs, which behind the right subclavian artery returns to the neck. Below, the vagus nerve passes behind the right stem bronchus and descends along the posterior surface of the esophagus.

The vagus nerve, together with the sympathetic trunks, forms the anterior and posterior pulmonary plexuses and innervates the pericardium. The sympathetic trunks are paired formations located on the side of the spine at the level of the costal heads.

The intrathoracic lymph nodes are divided into parietal and visceral. The parietal lymph nodes are divided into anterior (along the intrathoracic arteries) and posterior - the paravertebral space. There are anterior, posterior and peri-bronchial nodes of the mediastinum. The posterior mediastinal lymph nodes are located around the esophagus and aorta. The anterior ones form the upper, or prevascular, and the lower - diaphragmatic lymph nodes. Peribronchial lymph nodes are represented by a group of paratracheal, bifurcation and hilar nodes.

The physiology of the mediastinum as an anatomical complex has not been sufficiently studied, despite the well-known physiological characteristics each organ separately. During inhalation and exhalation, as well as during coughing and forced breathing, the shape and position of the mediastinum changes. These displacements do not cause any functional disorders from vital organs. During active breathing, the heart and aorta move slightly more than the azygos vein and thoracic duct.

Sclerotic changes in the mediastinal tissue disrupt blood flow in the venous system of the superior vena cava. The mediastinum shifts when intrapleural pressure is disturbed, especially when the latter decreases. The median position of the mediastinum depends on the negative pressure in the pleural cavities. In the mediastinum, there is normally negative intramediastinal pressure (A.I. Trukhalev, 1958). When you inhale, this pressure decreases, and when you exhale, it increases. These pressure fluctuations within the mediastinum create the conditions for blood to move through the veins to the right atrium.

Lability of the mediastinum and the presence of a large nerve reception are one of the reasons rapid violations hemodynamics and breathing in pathological conditions (pneumothorax, hemothorax, etc.). On the other hand, compensatory-adaptive mechanisms designed to adapt the body are quite well expressed in pathological conditions, when there is a significant displacement of the mediastinum, for example, after pneumonectomy, extensive resections of the lung, etc.

K.T. Ovnatanyan, V.M. Kravets

Which doctors should you contact if you have malignant neoplasms of the anterior mediastinum?

What are malignant neoplasms of the anterior mediastinum?

Malignant neoplasms of the anterior mediastinum in the structure of all oncological diseases make up 3-7%. Most often, malignant neoplasms of the anterior mediastinum are detected in persons 20-40 years old, i.e., in the most socially active part of the population.

Mediastinum is called the part of the thoracic cavity limited in front by the sternum, partially by the costal cartilages and retrosternal fascia, behind by the anterior surface of the thoracic spine, the necks of the ribs and prevertebral fascia, and on the sides by the layers of the mediastinal pleura. The mediastinum is limited below by the diaphragm, and above by the conditioned horizontal plane, drawn through the upper edge of the manubrium of the sternum.

The most convenient scheme for dividing the mediastinum, proposed in 1938 by Twining, is two horizontal (above and below the roots of the lungs) and two vertical planes (in front and behind the roots of the lungs). In the mediastinum, therefore, three sections (anterior, middle and posterior) and three floors (upper, middle and lower) can be distinguished.

In the anterior section of the superior mediastinum there are: the thymus gland, the upper section of the superior vena cava, the brachiocephalic veins, the aortic arch and its branches, the brachiocephalic trunk, the left common carotid artery, left subclavian artery.

In the posterior part of the upper mediastinum there are: the esophagus, the thoracic lymphatic duct, the trunks of the sympathetic nerves, the vagus nerves, the nerve plexuses of the organs and vessels of the thoracic cavity, fascia and cellular spaces.

In the anterior mediastinum there are: fiber, spurs of the intrathoracic fascia, the leaves of which contain the internal mammary vessels, retrosternal lymph nodes, and anterior mediastinal nodes.

In the middle section of the mediastinum there are: the pericardium with the heart enclosed in it and the intrapericardial sections of large vessels, the bifurcation of the trachea and the main bronchi, the pulmonary arteries and veins, the phrenic nerves with the accompanying phrenic-pericardial vessels, fascial-cellular formations, and lymph nodes.

In the posterior part of the mediastinum there are: the descending aorta, azygos and semi-gypsy veins, trunks of sympathetic nerves, vagus nerves, esophagus, thoracic lymphatic duct, lymph nodes, tissue with spurs of the intrathoracic fascia, surrounding organs mediastinum.

According to the departments and floors of the mediastinum, certain preferential localizations of most of its neoplasms can be noted. Thus, it has been noticed, for example, that intrathoracic goiter is often located in the upper floor of the mediastinum, especially in its anterior section. Thymomas are found, as a rule, in the middle anterior mediastinum, pericardial cysts and lipomas - in the lower anterior. The upper floor of the middle mediastinum is the most common location of teratodermoids. In the middle floor of the middle part of the mediastinum, bronchogenic cysts are most often found, while gastroenterogenic cysts are detected in the lower floor of the middle and posterior parts. The most common neoplasms of the posterior mediastinum along its entire length are neurogenic tumors.

Pathogenesis (what happens?) during malignant neoplasms of the anterior mediastinum

Malignant neoplasms of the mediastinum originate from heterogeneous tissues and are united by only one anatomical border. These include not only true tumors, but also cysts and tumor-like formations of different localization, origin and course. All mediastinal neoplasms according to their source of origin can be divided into the following groups:
1. Primary malignant neoplasms of the mediastinum.
2. Secondary malignant tumors of the mediastinum (metastases of malignant tumors of organs located outside the mediastinum to the lymph nodes of the mediastinum).
3. Malignant tumors of the mediastinal organs (esophagus, trachea, pericardium, thoracic lymphatic duct).
4. Malignant tumors from tissues limiting the mediastinum (pleura, sternum, diaphragm).

Symptoms of malignant neoplasms of the anterior mediastinum

Malignant neoplasms of the mediastinum are found mainly in young and middle age (20 - 40 years), equally often in both men and women. During the course of the disease with malignant neoplasms of the mediastinum, an asymptomatic period and a period of pronounced clinical manifestations can be distinguished. Duration asymptomatic period depends on the location and size of the malignant neoplasm, growth rate, relationship with organs and formations of the mediastinum. Very common mediastinal neoplasms long time They are asymptomatic and are accidentally discovered during a routine chest x-ray.

Clinical signs malignant neoplasms The mediastinum consists of:
- symptoms of compression or tumor growth into neighboring organs and tissues;
- common manifestations diseases;
- specific symptoms characteristic of various neoplasms;

The most common symptoms are pain resulting from compression or growth of the tumor into the nerve trunks or nerve plexuses, which is possible with both benign and malignant neoplasms of the mediastinum. The pain is usually mild, localized on the affected side, and often radiates to the shoulder, neck, and interscapular area. Pain with left-sided localization is often similar to pain caused by angina pectoris. If bone pain occurs, the presence of metastases should be assumed. Compression or germination of the borderline sympathetic trunk by a tumor causes the occurrence of a syndrome characterized by drooping of the upper eyelid, dilation of the pupil and retraction of the eyeball on the affected side, impaired sweating, changes in local temperature and dermographism. Damage to the recurrent laryngeal nerve is manifested by hoarseness of voice, the phrenic nerve - by a high standing dome of the diaphragm. Compression spinal cord leads to spinal cord dysfunction.

A manifestation of compression syndrome is compression of large venous trunks and, first of all, the superior vena cava (superior vena cava syndrome). It manifests itself as a violation of the outflow venous blood from the head and upper half of the body: patients experience noise and heaviness in the head, worsening in an inclined position, chest pain, shortness of breath, swelling and cyanosis of the face, upper half of the body, swelling of the veins of the neck and chest. Central venous pressure rises to 300-400 mmH2O. Art. When the trachea and large bronchi are compressed, coughing and shortness of breath occur. Compression of the esophagus can cause dysphagia, an obstruction in the passage of food.

On late stages development of neoplasms occurs: general weakness, increased body temperature, sweating, weight loss, which are characteristic of malignant tumors. Some patients experience manifestations of disorders associated with intoxication of the body by products secreted by growing tumors. These include arthralgic syndrome, reminiscent of rheumatoid polyarthritis; pain and swelling of the joints, swelling of the soft tissues of the extremities, increase in heart rate, disturbance heart rate.

Some mediastinal tumors have specific symptoms. So, itchy skin, night sweats characteristic of malignant lymphomas (lymphogranulomatosis, lymphoreticulosarcoma). A spontaneous decrease in blood sugar levels develops with mediastinal fibrosarcomas. Symptoms of thyrotoxicosis are characteristic of intrathoracic thyrotoxic goiter.

Thus, Clinical signs neoplasms, mediastinum are very diverse, however, they manifest themselves in the late stages of the disease and do not always allow an accurate etiological and topographic-anatomical diagnosis to be established. Data from radiological and instrumental methods are important for diagnosis, especially for recognizing the early stages of the disease.

Neurogenic tumors of the anterior mediastinum are the most common and account for about 30% of all primary mediastinal neoplasms. They arise from nerve sheaths (neurinomas, neurofibromas, neurogenic sarcomas), nerve cells(sympathogoniomas, ganglioneuromas, paragangliomas, chemodectomas). Most often, neurogenic tumors develop from elements of the border trunk and intercostal nerves, rarely from the vagus and phrenic nerves. The usual location of these tumors is the posterior mediastinum. Much less often, neurogenic tumors are located in the anterior and middle mediastinum.

Reticulosarcoma, diffuse and nodular lymphosarcoma(gigantofollicular lymphoma) is also called " malignant lymphomas". These neoplasms represent malignant tumors of lymphoreticular tissue, most often affect young and middle-aged people. The tumor initially develops in one or more lymph nodes, followed by spread to neighboring nodes. Generalization occurs early. In addition to the lymph nodes, the metastatic tumor process involves the liver, bone marrow, spleen, skin, lungs and other organs. The disease progresses more slowly in the medullary form of lymphosarcoma (gigantofollicular lymphoma).

Lymphogranulomatosis (Hodgkin's disease) usually has a more benign course than malignant lymphomas. In 15-30% of cases in stage I of the disease, primary local damage to the mediastinal lymph nodes can be observed. The disease is more common between the ages of 20-45 years. The clinical picture is characterized by an irregular wave-like course. Weakness, sweating, periodic rises in body temperature, pain in the chest. But characteristic of lymphogranulomatosis are skin itching, enlargement of the liver and spleen, changes in the blood and bone marrow are often absent at this stage. Primary lymphogranulomatosis of the mediastinum can be asymptomatic for a long time, while enlargement of the mediastinal lymph nodes for a long time may remain the only manifestation of the process.

At mediastinal lymphomas The lymph nodes of the anterior and anterior upper parts of the mediastinum and the roots of the lungs are most often affected.

Differential diagnosis is carried out with primary tuberculosis, sarcoidosis and secondary malignant tumors of the mediastinum. A test of radiation may be helpful in diagnosis, since malignant lymphomas are in most cases sensitive to radiation therapy (the “melting snow” symptom). The final diagnosis is established by morphological examination of the material obtained from a biopsy of the tumor.

Diagnosis of malignant neoplasms of the anterior mediastinum

The main method for diagnosing malignant neoplasms of the mediastinum is x-ray. The use of a comprehensive X-ray examination allows in most cases to determine the localization of the pathological formation - the mediastinum or neighboring organs and tissues (lungs, diaphragm, chest wall) and the extent of the process.

Mandatory X-ray methods for examining a patient with a mediastinal tumor include: - fluoroscopy, radiography and tomography of the chest, contrast examination of the esophagus.

Fluoroscopy makes it possible to identify a “pathological shadow”, get an idea of its location, shape, size, mobility, intensity, contours, and establish the absence or presence of pulsation of its walls. In some cases, one can judge the connection between the identified shadow and nearby organs (heart, aorta, diaphragm). Clarification of the localization of the neoplasm largely makes it possible to predetermine its nature.

To clarify the data obtained during fluoroscopy, radiography is performed. At the same time, the structure of the darkening, its contours, and the relationship of the neoplasm to neighboring organs and tissues are clarified. Contrasting the esophagus helps to assess its condition and determine the degree of displacement or growth of a mediastinal tumor.

They are widely used in the diagnosis of mediastinal tumors. endoscopic methods research. Bronchoscopy is used to exclude bronchogenic localization of a tumor or cyst, as well as to determine whether a malignant tumor has invaded the mediastinum of the trachea and large bronchi. During this study, it is possible to perform a transbronchial or transtracheal puncture biopsy of mediastinal formations localized in the area of the tracheal bifurcation. In some cases, mediastinoscopy and videothoracoscopy, in which the biopsy is performed under visual control, turns out to be very informative. Taking material for histological or cytological examination it is also possible with transthoracic puncture or aspiration biopsy performed under x-ray control.

If there are enlarged lymph nodes in the supraclavicular areas, they are biopsied, which makes it possible to determine their metastatic lesions or establish a systemic disease (sarcoidosis, lymphogranulomatosis, etc.). If mediastinal goiter is suspected, scanning the neck and chest area after administration of radioactive iodine is used. If compression syndrome is present, central venous pressure is measured.

Patients with mediastinal tumors undergo general and biochemical analysis blood, Wasserman reaction (to exclude the syphilitic nature of the formation), reaction with tuberculin antigen. If echinococcosis is suspected, determination of the latexagglutination reaction with echinococcal antigen is indicated. Changes morphological composition peripheral blood are found mainly when malignant tumors(anemia, leukocytosis, lymphopenia, increased ESR), inflammatory and systemic diseases. If systemic diseases are suspected (leukemia, lymphogranulomatosis, reticulosarcomatosis, etc.), as well as immature neurogenic tumors, a bone marrow puncture is performed with the study of a myelogram.

Treatment of malignant neoplasms of the anterior mediastinum

Treatment of malignant neoplasms of the mediastinum- operational. Removal of tumors and mediastinal cysts must be done as early as possible, as this is the prevention of their malignancy or the development of compression syndrome. The only exceptions may be small lipomas and coelomic cysts of the pericardium in the absence of clinical manifestations and a tendency to their increase. Treatment of malignant tumors of the mediastinum in each specific case requires an individual approach. Usually it is based on surgical intervention.

The use of radiation and chemotherapy is indicated for most malignant tumors of the mediastinum, but in each specific case their nature and content are determined by the biological and morphological features tumor process, its prevalence. Radiation and chemotherapy are used both in combination with surgical treatment and independently. As a rule, conservative methods form the basis of therapy for advanced stages of the tumor process, when radical surgery is impossible, as well as for mediastinal lymphomas. Surgical treatment for these tumors can only be justified if early stages diseases when the process locally affects a certain group of lymph nodes, which is not so common in practice. In recent years, the videothoracoscopy technique has been proposed and successfully used. This method allows not only to visualize and document mediastinal tumors, but also to remove them using thoracoscopic instruments, causing minimal surgical trauma to patients. The results obtained indicate the high effectiveness of this treatment method and the possibility of carrying out intervention even in patients with severe concomitant diseases and low functional reserves.

Mediastinal surgery, one of the youngest branches of surgery, has received significant development due to the development of issues of anesthesia, surgical techniques, diagnosis of various mediastinal processes and neoplasms. New diagnostic methods allow not only to accurately establish the localization of the pathological formation, but also make it possible to assess the structure and structure of the pathological focus, as well as obtain material for pathomorphological diagnosis. Recent years have been characterized by the expansion of indications for surgical treatment of mediastinal diseases, the development of new highly effective, low-traumatic treatment methods, the introduction of which has improved the results of surgical interventions.

Classification of mediastinal disease.

Mediastinal injuries:

1. Closed trauma and wounds of the mediastinum.

2. Damage to the thoracic lymphatic duct.

Specific and non-specific inflammatory processes in the mediastinum:

1. Tuberculous adenitis of the mediastinum.

2. Nonspecific mediastinitis:

A) anterior mediastinitis;

B) posterior mediastinitis.

According to the clinical course:

A) acute non-purulent mediastinitis;

B) acute purulent mediastinitis;

B) chronic mediastinitis.

Mediastinal cysts.

1. Congenital:

A) coelomic pericardial cysts;

B) cystic lymphangitis;

B) bronchogenic cysts;

D) teratomas

D) from the embryonic embryo of the foregut.

2. Purchased:

A) cysts after hematoma in the pericardium;

B) cysts formed as a result of the disintegration of a pericardial tumor;

D) mediastinal cysts arising from the border areas.

Mediastinal tumors:

1. Tumors arising from the organs of the mediastinum (esophagus, trachea, large bronchi, heart, thymus, etc.);

2. Tumors arising from the walls of the mediastinum (tumors of the chest wall, diaphragm, pleura);

3. Tumors arising from the tissues of the mediastinum and located between organs (extraorgan tumors). Tumors of the third group are true tumors of the mediastinum. They are divided according to histogenesis into tumors of nervous tissue, connective tissue, blood vessels, smooth muscle tissue, lymphoid tissue and mesenchyme.

A. Neurogenic tumors (15% of this location).

I. Tumors arising from nervous tissue:

A) sympathoneuroma;

B) ganglioneuroma;

B) pheochromocytoma;

D) chemodectoma.

II. Tumors arising from nerve sheaths.

A) neuroma;

B) neurofibroma;

B) neurogenic sarcoma.

D) schwannomas.

D) ganglioneuromas

E) neurilemmomas

B. Connective tissue tumors:

A) fibroma;

B) chondroma;

B) osteochondroma of the mediastinum;

D) lipoma and liposarcoma;

D) tumors arising from blood vessels (benign and malignant);

E) myxomas;

G) hibernomas;

E) tumors from muscle tissue.

B. Tumors of the thymus gland:

A) thymoma;

B) thymus cysts.

D. Tumors from reticular tissue:

A) lymphogranulomatosis;

B) lymphosarcoma and reticulosarcoma.

E. Tumors from ectopic tissues.

A) retrosternal goiter;

B) intrathoracic goiter;

B) adenoma about thyroid gland.

The mediastinum is a complex anatomical formation located in the middle of the thoracic cavity, enclosed between the parietal layers, spinal column, sternum and lower diaphragm, containing fiber and organs. The anatomical relationships of the organs in the mediastinum are quite complex, but knowledge of them is mandatory and necessary from the standpoint of the requirements for providing surgical care to this group of patients.

The mediastinum is divided into anterior and posterior. The conventional boundary between them is the frontal plane drawn through the roots of the lungs. In the anterior mediastinum there are: the thymus gland, part of the aortic arch with branches, the superior vena cava with its sources (brachiocephalic veins), the heart and pericardium, the thoracic part of the vagus nerves, the phrenic nerves, the trachea and the initial sections of the bronchi, nerve plexuses, lymph nodes. In the posterior mediastinum there are: the descending aorta, azygos and semi-gypsy veins, the esophagus, the thoracic part of the vagus nerves below the roots of the lungs, the thoracic lymphatic duct (thoracic region), the border sympathetic trunk with the splanchnic nerves, nerve plexuses, lymph nodes.

To establish a diagnosis of the disease, localization of the process, its relationship to neighboring organs, in patients with mediastinal pathology, it is first necessary to conduct a complete clinical examination. It should be noted that the disease in the initial stages is asymptomatic, and pathological formations are an accidental finding during fluoroscopy or fluorography.

The clinical picture depends on the location, size and morphology pathological process. Typically, patients complain of pain in the chest or heart area, interscapular area. Painful sensations are often preceded by a feeling of discomfort, expressed in a feeling of heaviness or foreign formation in the chest. Shortness of breath and difficulty breathing are often observed. When the superior vena cava is compressed, cyanosis of the skin of the face and upper half of the body and their swelling may be observed.

When examining the mediastinal organs, it is necessary to conduct thorough percussion and auscultation and determine the function of external respiration. Important during the examination are electro- and phonocardiographic studies, ECG data, and X-ray studies. Radiography and fluoroscopy are carried out in two projections (direct and lateral). When a pathological focus is identified, tomography is performed. The study, if necessary, is supplemented with pneumomediastinography. If the presence of a substernal goiter or an aberrant thyroid gland is suspected, a ultrasonography and scintigraphy with I-131 and Tc-99.

In recent years, when examining patients, instrumental research methods have been widely used: thoracoscopy and mediastinoscopy with biopsy. They allow a visual assessment of the mediastinal pleura, partly the mediastinal organs, and collection of material for morphological examination.

Currently, the main methods for diagnosing mediastinal diseases, along with radiography, are computed tomography and nuclear magnetic resonance.

Features of the course of individual diseases of the mediastinal organs:

Damage to the mediastinum.

Frequency - 0.5% of all penetrating chest wounds. Damage is divided into open and closed. Peculiarities clinical course are caused by bleeding with the formation of a hematoma and compression of organs, vessels and nerves.

Signs of mediastinal hematoma: slight shortness of breath, mild cyanosis, swelling of the neck veins. X-ray shows darkening of the mediastinum in the area of the hematoma. Often a hematoma develops against the background of subcutaneous emphysema.

When the vagus nerves are imbibited by blood, vagal syndrome develops: respiratory failure, bradycardia, deterioration of blood circulation, and confluent pneumonia.

Treatment: adequate pain relief, maintaining cardiac activity, antibacterial and symptomatic therapy. With progressive mediastinal emphysema, puncture of the pleura and subcutaneous tissue of the chest and neck with short and thick needles to remove air is indicated.

When the mediastinum is injured, the clinical picture is complemented by the development of hemothorax and hemothorax.

Active surgical tactics are indicated for progressive impairment of external respiratory function and ongoing bleeding.

Damage to the thoracic lymphatic duct can occur with:

1. closed chest injury;
2. knife and gunshot wounds;
3. during intrathoracic operations.

As a rule, they are accompanied by severe and dangerous complication chylothorax. If conservative therapy is unsuccessful, surgical treatment is required within 10-25 days: ligation of the thoracic lymphatic duct above and below the injury, in rare cases, parietal suturing of the duct wound, implantation into the azygos vein.

Inflammatory diseases.

Acute nonspecific mediastinitis- inflammation of the mediastinal tissue caused by a purulent nonspecific infection.

Acute mediastinitis can be caused by the following reasons.

Open mediastinal injuries.
1. Complications of operations on the mediastinal organs.
2. Contact spread of infection from adjacent organs and cavities.
3. Metastatic spread of infection (hematogenous, lymphogenous).
4. Perforation of the trachea and bronchi.
5. Perforation of the esophagus (traumatic and spontaneous rupture, instrumental damage, damage by foreign bodies, tumor disintegration).

The clinical picture of acute mediastinitis consists of three main symptom complexes, the varying severity of which leads to a variety of its clinical manifestations. The first symptom complex reflects the manifestations of severe acute purulent infection. The second is associated with the local manifestation of a purulent focus. The third symptom complex is characterized clinical picture damage or disease that preceded the development of mediastinitis or was its cause.

General manifestations of mediastinitis: fever, tachycardia (pulse - up to 140 beats per minute), chills, decreased blood pressure, thirst, dry mouth, shortness of breath up to 30 - 40 per minute, acrocyanosis, excitement, euphoria with transition to apathy.

With limited posterior mediastinal abscesses, the most common symptom is dysphagia. There may be a dry barking cough up to suffocation (involvement of the trachea), hoarseness of voice (involvement of the recurrent nerve), as well as Horner's syndrome - if the process spreads to the sympathetic nerve trunk. The patient's position is forced, semi-sitting. There may be swelling in the neck and upper chest. On palpation there may be crepitus due to subcutaneous emphysema, as a result of damage to the esophagus, bronchus or trachea.

Local signs: chest pain - the earliest and constant sign mediastinitis. The pain intensifies when swallowing and throwing the head back (Romanov's symptom). The localization of pain mainly reflects the localization of the abscess.

Local symptoms depend on the location of the process.

Anterior mediastinitis	Posterior mediastinitis
Chest pain	Chest pain radiating into the interscapular space
Increased pain when tapping the sternum	Increased pain with pressure on the spinous processes
Increased pain when tilting the head - Gehrke's symptom	Increased pain when swallowing
Pastiness in the sternum area	Pastosity in the area of the thoracic vertebrae
Symptoms of compression of the superior vena cava: headache, tinnitus, cyanosis of the face, swelling of the veins of the neck	Symptoms of compression of the paired and semi-gypsy veins: dilation of the intercostal veins, effusion in the pleura and pericardium
With CT and NMR - a darkened zone in the projection of the anterior mediastinum	With CT and NMR - a darkened zone in the projection of the posterior mediastinum
X-ray - shadow in the anterior mediastinum, presence of air	X-ray - shadow in the posterior mediastinum, presence of air

When treating mediastinitis, active surgical tactics are used, followed by intensive detoxification, antibacterial and immunostimulating therapy. Surgical treatment consists of providing optimal access, exposing the injured area, suturing the rupture, draining the mediastinum and pleural cavity (if necessary) and applying a gastrostomy tube. Mortality in acute purulent mediastinitis is 20-40%. When draining the mediastinum, it is best to use the method of N.N. Kanshin (1973): drainage of the mediastinum with tubular drainages, followed by fractional rinsing with antiseptic solutions and active aspiration.

Chronic mediastinitis divided into aseptic and microbial. Aseptic include idiopathic, posthemorrhagic, coniotic, rheumatic, dysmetabolic. Microbial diseases are divided into nonspecific and specific (syphilitic, tuberculous, mycotic).

What is common to chronic mediastinitis is the productive nature of inflammation with the development of sclerosis of the mediastinal tissue.

Idiopathic mediastinitis (fibrous mediastinitis, mediastinal fibrosis) is of greatest surgical importance. In a localized form, this type of mediastinitis resembles a tumor or mediastinal cyst. In the generalized form, mediastinal fibrosis is combined with retroperitoneal fibrosis, fibrous thyroiditis and orbital pseudotumor.

The clinical picture is determined by the degree of compression of the mediastinal organs. The following compartment syndromes are identified:

Superior vena cava syndrome
Pulmonary vein compression syndrome
Tracheobronchial syndrome
Esophageal syndrome
Pain syndrome
Nerve compression syndrome

Treatment of chronic mediastinitis is mainly conservative and symptomatic. If the cause of mediastinitis is determined, its elimination leads to a cure.

Mediastinal tumors. All clinical symptoms of various mediastinal masses are usually divided into three main groups:

1. Symptoms from the mediastinal organs, compressed by the tumor;

2. Vascular symptoms resulting from compression of blood vessels;

3. Neurogenic symptoms developing due to compression or sprouting of nerve trunks

Compression syndrome manifests itself as compression of the mediastinal organs. First of all, the brachiocephalic and superior vena cava veins are compressed - superior vena cava syndrome. With further growth, compression of the trachea and bronchi is noted. This is manifested by cough and shortness of breath. When the esophagus is compressed, swallowing and passage of food are impaired. When the tumor of the recurrent nerve is compressed, phonation disturbances, paralysis of the vocal cord on the corresponding side. When the phrenic nerve is compressed, the paralyzed half of the diaphragm stands high.

When the borderline sympathetic trunk is compressed, Horner's syndrome causes drooping of the upper eyelid, narrowing of the pupil, and retraction of the eyeball.

Neuroendocrine disorders manifest themselves in the form of joint damage, heart rhythm disturbances, and disturbances in the emotional-volitional sphere.

The symptoms of tumors are varied. The leading role in making a diagnosis, especially in the early stages before the appearance of clinical symptoms, belongs to computed tomography and x-ray methods.

Differential diagnosis of mediastinal tumors themselves.

		Location		Content		Malignancy	Density
Teratoma	The most common tumor of the mediastinum	Anterior mediastinum	Significant	Mucous membrane, fat, hair, organ rudiments	Slow		Elastic
Neurogenic	Second most common	Posterior mediastinum	Significant	Homogeneous	Slow			Fuzzy
Connective tissue	Third most common	Various, most often anterior mediastinum	Various	Homogeneous	Slow
Lipoma, hibernoma		Various	Various	Mixed structure	Slow			Fuzzy
Hemangioma, lymphangioma		Various						Fuzzy

Thymomas (tumors of the thymus) are not classified as mediastinal tumors themselves, although they are considered together with them due to the peculiarities of localization. They can behave both benign and malignant tumors, giving metastases. They develop either from epithelial or lymphoid tissue of the gland. Often accompanied by the development of myasthenia gravis. The malignant variant occurs 2 times more often, is usually very severe and quickly leads to the death of the patient.

Surgical treatment is indicated:

at established diagnosis and suspected mediastinal tumor or cyst;
for acute purulent mediastinitis, foreign bodies mediastinum, causing pain, hemoptysis or suppuration in the capsule.

The operation is contraindicated for:

established distant metastases to other organs or cervical and axillary lymph nodes;
compression of the superior vena cava with transition to the mediastinum;
persistent paralysis of the vocal cord in the presence of a malignant tumor, manifested by hoarseness;
dissemination of a malignant tumor with the occurrence of hemorrhagic pleurisy;
in general in serious condition a patient with symptoms of cachexia, hepatic-renal failure, pulmonary and heart failure.

It should be noted that in choosing the volume surgical intervention in cancer patients, one should take into account not only the growth pattern and extent of the tumor, but also general state patient, age, condition of vital organs.

Surgical treatment of malignant tumors of the mediastinum gives poor results. Hodgkin's disease and reticulosarcoma respond well to radiation treatment. For true mediastinal tumors (teratoblastomas, neuromas, connective tissue tumors), radiation treatment is ineffective. Chemotherapy methods for the treatment of malignant true tumors of the mediastinum are also ineffective.

Purulent mediastinitis requires emergency surgical intervention as the only way to save the patient, regardless of the severity of his condition.

To expose the anterior and posterior mediastinum and the organs located there, various surgical approaches are used: a) complete or partial longitudinal dissection of the sternum; b) transverse dissection of the sternum, in which both pleural cavities are opened; c) both the anterior and posterior mediastinum can be opened through the left and right pleural cavity; d) diaphragmotomy with and without opening abdominal cavity; e) opening the mediastinum through an incision in the neck; f) the posterior mediastinum can be penetrated extrapleurally from behind along the lateral surface of the spine with resection of the heads of several ribs; g) the mediastinum can be entered extrapleurally after resection of the costal cartilages at the sternum, and sometimes with partial resection of the sternum.

Rehabilitation. Work ability examination.

Clinical examination of patients

To determine the ability of patients to work, general clinical data are used with a mandatory approach to each person examined. During the initial examination, it is necessary to take into account clinical data, the nature of the pathological process - disease or tumor, age, complications from the treatment, and in the presence of a tumor - possible metastasis. It is common to be placed on disability before returning to professional work. At benign tumors after them radical treatment the prognosis is favorable. The prognosis for malignant tumors is poor. Tumors of mesenchymal origin are prone to relapses followed by malignancy.

Subsequently, the radicality of the treatment and complications after treatment are important. Such complications include lymphostasis of the extremities, trophic ulcers after radiation treatment, and disturbances in the ventilation function of the lungs.

Control questions

1. Classification of mediastinal diseases.
2. Clinical symptoms of mediastinal tumors.
3. Methods for diagnosing mediastinal tumors.
4. Indications and contraindications for surgical treatment mediastinal tumors and cysts.
5. Operative approaches to the anterior and posterior mediastinum.
6. Causes of purulent mediastinitis.
7. Clinic of purulent mediastinitis.
8. Methods for opening ulcers with mediastinitis.
9. Symptoms of esophageal rupture.

10. Principles of treatment of esophageal ruptures.

11. Causes of damage to the thoracic lymphatic duct.

12. Chylothorax clinic.

13. Causes of chronic mediastinitis.

14. Classification of mediastinal tumors.

Situational tasks

1. A 24-year-old patient was admitted with complaints of irritability, sweating, weakness, and palpitations. Ill for 2 years. Thyroid not enlarged. Basic exchange +30%. A physical examination of the patient did not reveal any pathology. An X-ray examination reveals a rounded formation 5x5 cm with clear boundaries in the anterior mediastinum at the level of the second rib on the right. lung tissue transparent.

Which additional research necessary to clarify the diagnosis? What is your tactic in treating a patient?

2. Patient, 32 years old. Three years ago I suddenly felt pain in my right hand. She was treated with physiotherapy - the pain decreased, but did not go away completely. Subsequently, I noticed a dense, lumpy formation on the right side of the neck in the supraclavicular region. At the same time, the pain in the right side of the face and neck intensified. At the same time I noticed a narrowing of the right palpebral fissure and a lack of sweating on the right side of the face.

Upon examination, a dense, lumpy, immobile tumor and an expansion of the superficial venous section of the upper half of the body in front were discovered in the right clavicular region. Slight atrophy and decreased muscle strength of the right shoulder girdle and upper limb. Dullness percussion sound above the apex of the right lung.

What kind of tumor can you think of? What additional research is needed? What's your tactic?

3. Patient, 21 years old. She complained of a feeling of pressure in her chest. X-ray to the right upper section The mediastinal shadow is adjacent to an additional shadow in front. The outer contour of this shadow is clear, the inner one merges with the shadow of the mediastinum.

What disease can you think of? What is your tactics in treating the patient?

4. Over the past 4 months, the patient has developed vague pain in the right hypochondrium, accompanied by increasing dysphagic changes. An X-ray examination on the right revealed a shadow in the right lung, which is located behind the heart, with clear contours about 10 cm in diameter. The esophagus at this level is compressed, but its mucous membrane is not changed. Above compression is observed long delay in the esophagus.

What is your presumptive diagnosis and tactics?

5. A 72-year-old patient immediately after fibrogastroscopy developed substernal pain and swelling in the neck area on the right.

What complication can you think of? What additional studies will you perform to clarify the diagnosis? What is your tactics and treatment?

6. Sick 60 years. A day ago in the hospital, a fish bone was removed at level C 7. After which swelling appeared in the neck area, temperature up to 38°, abundant salivation, palpation on the right began to detect an infiltrate of 5x2 cm, painful. X-ray signs of phlegmon of the neck and expansion of the mediastinal body from above.

What is your diagnosis and tactics?

1. To clarify the diagnosis of intrathoracic goiter, it is necessary to carry out the following additional methods examinations: pneumomediastinography - to clarify the topical location and size of tumors. Contrast study of the esophagus - to identify dislocation of mediastinal organs and displacement of tumors during swallowing. Tomographic examination - in order to identify narrowing or pushing aside of the vein by a neoplasm; scanning and radioisotope study of thyroid function with radioactive iodine. Clinical manifestations thyrotoxicosis determines the indications for surgical treatment. Removal of a retrosternal goiter in this location is less traumatic to be carried out using a cervical approach, following the recommendations of V.G. Nikolaev to cross the sternohyoid, sternothyroid, and sternocleidomastoid muscles. If there is a suspicion of fusion of the goiter with surrounding tissues, transthoracic access is possible.

2. You can think about a neurogenic tumor of the mediastinum. Along with a clinical and neurological examination, radiography in direct and lateral projections, tomography, pneumomediastinography, diagnostic pneumothorax, angiocardiopulmography is necessary. In order to identify disorders of the sympathetic nervous system, the Linara diagnostic test is used, based on the use of iodine and starch. The test is positive if, during sweating, starch and iodine react, taking on a brown color.

Treatment of a tumor that causes compression of nerve endings is surgical.

3. You can think about a neurogenic tumor of the posterior mediastinum. The main thing in diagnosing a tumor is to establish its exact location. Treatment consists of surgical removal tumors.

4. The patient has a tumor of the posterior mediastinum. The most likely neurogenic character. The diagnosis can be clarified by a multifaceted X-ray examination. At the same time, you can identify interest neighboring organs. Considering the localization of pain, the most probable cause- compression of the diaphragmatic and vagus nerve. Treatment is surgical, in the absence of contraindications.

5. One can think about iatrogenic rupture of the esophagus with the formation of cervical mediastinitis. After an X-ray examination and X-ray contrast examination of the esophagus, an urgent operation is indicated - opening and drainage of the rupture zone, followed by sanitation of the wound.

6. The patient has perforation of the esophagus with subsequent formation of phlegmon of the neck and purulent mediastinitis. Treatment is surgical opening and drainage of neck phlegmon, purulent mediastinotomy, followed by wound debridement.