History and Physical Examination
A large percentage of mediastinal tumors and cysts produce no symptoms and are found incidentally during a chest radiograph or other imaging study of the thorax performed for some other reason (see the image below). [2] Symptoms are present in approximately one third of adult patients with a mediastinal tumor or cyst but are more commonly observed in the pediatric population, in which nearly two thirds of individuals present with some symptoms. In adults, asymptomatic masses are more likely to be benign. [10]
Asymptomatic mass is found incidentally after chest radiography in adult patient.
Symptoms associated with the respiratory tract predominate in pediatric patients because airway compression is more likely. This occurs because of the significant malleability of the airway structures and the small size of the chest cavity in infants and children. Symptoms most commonly observed include persistent cough, dyspnea, and stridor. If the location and size of the mass produces partial or complete obstruction, obstructive pneumonia can also occur. Infectious symptomatology, and even signs of sepsis, can occur if a mediastinal cyst becomes infected.
Constitutional symptoms, such as weight loss, fever, malaise, and vague chest pain, commonly occur in association with malignant tumors in pediatric patients but also may be signs associated with secondary infection of a congenital cyst, such as a bronchogenic cyst.
Symptoms associated with compression of some portion of the respiratory tract can be produced by benign lesions in adults. This is much less likely to occur in adults than it is in children. Infectious symptoms or sepsis from infection of a mediastinal cyst can also occur in adults, though, again, this is very unlikely in persons in this age group.
Bronchogenic cysts are asymptomatic in as many as 20-30% of children. When they are symptomatic, children most commonly present with vague respiratory problems or dysphagia. They may have a history of recurrent respiratory problems or pneumonia. Symptoms in infants can range from none to significant upper airway distress (see the image below) manifested as severe stridor and wheezing. Likewise, physical examination findings can range from normal to significantly decreased breath sounds on the affected side.
Chest radiograph of infant in respiratory distress with large air-filled bronchogenic cyst in right chest. Arrow indicates inferior border of cyst.
A large percentage of adults with bronchogenic cysts are asymptomatic, though several authors report that more than 50% of those followed nonsurgically become symptomatic and usually manifest symptoms of airway or esophageal compression or infection. In those adults who present with symptoms, respiratory complaints or dysphagia predominate.
Neurenteric cysts can manifest in persons of any age group. When they are identified in symptomatic infants or children, clinical findings are usually those of airway compression. A triad consisting of the presence of a mediastinal mass, symptoms referable to the airway, and the presence of a vertebral anomaly has been observed in approximately 70% of pediatric patients with neurenteric cysts.
Communication of a neurenteric cyst with the spinal canal has been reported. Patients with this added abnormality may develop neurologic symptoms, including gait abnormalities, back pain, and motor or sensory deficits.
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Asymptomatic mass is found incidentally after chest radiography in adult patient.
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Chest radiograph of infant in respiratory distress with large air-filled bronchogenic cyst in right chest. Arrow indicates inferior border of cyst.
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Chest radiograph of child with large right-side bronchogenic cyst. This cyst is partially filled with fluid and is also causing some compression of right lung.
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CT scan of child (same patient as in Image above) with large right-side bronchogenic cyst with air-fluid level.
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Posteroanterior chest radiograph showing large bronchogenic cyst causing compression of right mainstem bronchus and right lung in child.
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Lateral chest radiograph (same patient as in Image above) of large right-side bronchogenic cyst in child.
