Ministerul Sanatatii al Republicii Moldova

IP Universitatea de stat de Medicina si Farmacie

N. Testemiteanu

Disciplina “Pneumologie”
Sindromul Madiastinal
 Sindrom mediastinal defineste un grup de tulburari cu caracter
expansiv, infiltrativ si de compresie a structurilor mediastinale
cauzat de prezenta aerului, lichidului sau a tesutului patologic la
acest nivel.
 Etiologie

1. Tumori mediastinale primare si metastatice: cancer

bronhoalveolar, gastric, esofagian, uteroovarian, b. Hoadgkin si
limfoamele nonhodgkiene, timoame, tumori neurogene, tumori
embrionare, gusa intratoracica malignizanta.
2. Procese mediastinale compresive netumorale: gusa intratoracica,
chist hidatic mediastinal, anevrism aortic, dilatari ale camerelor
cordului, adenopatii inflamatorii (tuberculoase si netuberculoase).
3. Mediastinite acute si cronice.
Etiologie
 Tabloul clinic
Deseori este asimptomatic, semnele si simptomele apar prin compresie, obliterare
sau iritare a structurilor mediastinului.
•Dureri-mai mult permanente, retrosternale, profunde, difuze, poate fi de tip
nevralgic sau de tip “osos” (intensa, persistenta).
•Dispnee-paroxistica, permanenta, accentuata de effort, de tip bradipnee inspiratorie
cu tiraj si cornaj sau prin paralizia diafragmului.
•Tusea-seaca, iritativa, caracter “latrator”, timbru metalic, in paralizia nervului
recurent-de tonalitate joasa, fara inceput abrupt, eruptiv sau betonala.
•Disfagia poate fi insotita de regurgitare si sialoree.
•Manifestari de compresie medulara, tetraparalizii in tumori neurogene.
•Manifestari generale (impregnare canceromatoasa si bacilara)- febra, astenie,
scadere ponderala; myastenia gravis in timom; hipoglicemie in mezoteliom,
fibrosarcom, teratom; tetanie in tumori paratiroidiene.
 Examenul clinic obiectiv
•Inspectie: modificari de aspect a cutiei toracice, cianoza fetei, a gatului, umerilor,
bratelor, a partii superioare a toracelui (“cianoza in pelerina”), colaterale venoase
superficiale, edem (rece, dur, fara godeu), mioza, ptoza palpebrala si enoftalm (s.
Horner)
•Auscultatie: ral ronfalnt monofonic constant pe o arie restransa apare prin obstructia
bronhiei.
•La compresia arterelor mari- anizosfigmie, chilotorax la obstructia canalului limfatic
toracic.

Examenul paraclinic
•Hemoleucograma
•Radiografie toracica/radioscopie, CT, RMN.
•Laringoscopie, traheobronhoscopie.
•Arteriografie, cavografie,mediatinoscopie, biopsie prescalenica.
 Examenul radiologic
Se exprima prin opacitate si hipertransparenta.
Incidenta PA permite afirmarea caracterului mediastinal al unei opacitati.

Caracteristicile opacitatilor:
•Densitate hidrica
•Structura omogena
•Limite externe nete si continue
•Racordare cu mediastinul in panta lina
•Limitele interne invizibele, contopite cu mediastinul.
Semne radiologice asociate:
•Deplasare evidenta a unui organ mediastinal
•Semnul cervico-toracic
•Semnulconvergentei hilare
•Semnul de “acoperire hilara”
•Semnul toraco-abdominal (“aisbergului”)
•Semnul “atractiei esofagiene”
Figure 5a.  Right-sided retrosternal goiter. Posteroanterior chest radiograph demonstrates a
thyroid goiter (arrow) extending into the middle mediastinum, obliterating the right paratracheal
stripe, and causing deviation of the trachea to the left (black arrowhead). Above the level of the
clavicles, the margins of the mass are not sharp (white arrowhead), indicating that the mass has
an anterior mediastinal component. 
 Figure 3a.  Hilum overlay sign in a patient with lymphoma. (a) Posteroanterior chest radiograph clearly
depicts the hila (white arrow), which indicates that the mass is either anterior or posterior to the hila. In
addition, the descending aorta is clearly seen (black arrow), indicating that the mass is not within the posterior
mediastinum.
Whitten CR. Published Online: May 01, 2007
https://doi.org/10.1148/rg.273065136
 Figure 3b ) Chest CT scan demonstrates an anterior mediastinal mass. The anterior
junction line is obliterated, whereas the lung interfaces with the hilar vessels (arrow)
and aorta (arrowhead) are preserved.
Whitten CR. Published Online: May 01, 2007
https://doi.org/10.1148/rg.273065136
Figure 23a.  Neurogenic tumor. (a) Posteroanterior chest radiograph shows a small mass
(arrow) disrupting the left paraspinal line inferiorly.
Whitten CR. Published Online: May 01, 2007
https://doi.org/10.1148/rg.273065136
(b) Coronal T2-weighted magnetic resonance (MR) image helps confirm a left
paraspinal mass (arrow). Whitten CR. Published Online: May 01, 2007
https://doi.org/10.1148/rg.273065136
 Hipertransparente mediastinale
Exprima prezenta unui pneumomediastinului, herniei hiatale, anomalii esofagiene,
abces mediastinal (imagine mixta).
Pneumomediastin:
•Hipertransparente liniare, verticala de-a lungul meddiasstinului si contururilor
cardiace
•La profil hipertransparenta liniara care contureaza structurile mediastinului.
Hernie hiatala-hipertransarenta retrocardiaca, deplaseaza linia paraesofagiana
inferioara sau este sub forma une imagini hidroaerice, se associaza cu lipsa bulei
de aer a stomacului sub diafragmul stang.
Abcces mdiasstinal-aspect de tumooare localizata, de obicei postero-superior, se
insoteste cu deviere laterala de trahee.
Aomalii de esofag-megaesofag n (deplasarea liniei paraesofagiene cu aparitia unei
linii ingrosate, dense, delimitata de ambele parti de aer intraalveolar si cel
intraesofagian.
 This chest radiograph (posteroanterior and lateral view) is from a 3-year-old girl with a
history of prematurity, chronic lung disease, and asthma who presented with a viral
pneumonitis and persistent cough. On the posteroanterior view, a
pneumomediastinum (arrow) is noted. Also, extensive subcutaneous air is observed

https://emedicine.medscape.com/article/1003409-
overview
 On the lateral radiograph from the
patient in Media file 2, anterior
mediastinal air is observed. Left
lower lobe atelectasis is also
present

https://emedicine.medscape.com/article/1003409-
overview
 A plain chest
radiograph showing a
well-defined, rounded
lucency in the
retrocardiac region,
consistent with a
sliding hiatal hernia.

https://radiopaedia.org/cases/sliding-hiatus-
hernia-1
https://radiopaedia.org/cases/sliding-hiatus-
hernia-1
The superior mediastinal collection has reaccumulated since the prior CXR from 4 years prior. This measures up to 8.5
cm transversely, has an air fluid level superiorly and displaces the trachea to the right with mild lateral flattening. This
lies in the same location as the initial CXR though is larger. No free pneumomediastinum or gas tracking into the base
of neck. Heart size is normal. Lungs and pleural spaces are clear. No pneumothorax or pleural fluid collection

https://radiopaedia.org/cases/superior-mediastinal-abscess?lang=us
 Bibliografie
•V. Botnaru “Pneumologie” pag.141-142
•V. Botnaru “Semiologia radiologica a toracelui” pag. 109-119
•V. Botnaru “Medicina interna Breviar” pag.28-29
•Radiographics “A Diagnostic Approach to Mediastinal Abnormalities1”
https://pubs.rsna.org/doi/pdf/10.1148/rg.273065136
•Pneumomediastinum
https://emedicine.medscape.com/article/1003409-overview
•Mediastinal abscess https://radiopaedia.org/cases/mediastinal-absces
•Sliding hiatus hernia https://radiopaedia.org/cases/sliding-hiatus-hernia