History and Physical Examination

A large percentage of mediastinal tumors and cysts produce no symptoms and are found incidentally during chest radiography or imaging studies of the thorax performed for other reasons.^[20] 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, nearly two thirds of which presents with some symptoms. In adults, asymptomatic masses are more likely to be benign.

Symptoms associated with the respiratory tract predominate in pediatric patients because airway compression is more likely. This occurs because of the significant amount of malleability of the airway structures and the small size of the chest cavity in infants and children. Symptoms observed most commonly include persistent cough, dyspnea, and stridor. If the location and size of the mass produce partial or complete obstruction, obstructive pneumonia can also occur. Infectious symptomatology, and even signs of sepsis, can also occur if a mediastinal cyst becomes infected.

Constitutional symptoms such as weight loss, fever, malaise, and vague chest pain occur commonly with malignant tumors in pediatric patients.

Symptoms associated with compression of some portion of the respiratory tract can also be produced by benign lesions in adults, but this is much less likely than in children. Intrathoracic extension of a cervical goiter is one noted largely benign abnormality that commonly manifests with upper respiratory symptoms. At least 70% of individuals with intrathoracic goiters have some symptoms of airway compression. Cough, wheezing, stridor, dyspnea, and dysphagia are among the common complaints.

Infectious symptoms or sepsis from infection of a mediastinal cyst can also occur in adults, although, again, this is very unlikely in this age group.

Malignant lesions are more likely to produce signs and symptoms of obstruction and/or compression than benign lesions because they invade or transfix normal mediastinal structures. Clinical findings associated with these malignant properties include cough, dyspnea, stridor, dysphagia, and more dramatic findings (eg, superior vena cava syndrome [SVCS]).

Invasion of the chest wall or pleura by a malignant neoplasm can produce persistent pleural effusions and significant local pain. Invasion of nearby nerves within the thorax can also produce local and referred pain and various other findings such as hoarseness from recurrent nerve paralysis, diaphragmatic paralysis from phrenic nerve paralysis, Horner syndrome from autonomic nerve invasion, and even motor paralysis from direct spinal cord involvement. Pain in the shoulder or upper extremity can occur from invasion of the ipsilateral brachial plexus. Systemic findings, such as weight loss, fever, and malaise, also occur.

Mediastinal tumors that produce bioactive substances are associated with symptoms produced by those substances, as discussed in Systemic pathophysiology above.

Workup

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Media Gallery

Lymphomas, endocrine, mesenchymal, and other rare tumors of the mediastinum. Posteroanterior chest radiograph of a 30-year-old man found to have Hodgkin disease of the mediastinum. Arrows indicate areas of prominent lymphadenopathy associated with his disease.
Lymphomas, endocrine, mesenchymal, and other rare tumors of the mediastinum. Lateral chest radiograph of a 30-year-old man found to have Hodgkin disease of the mediastinum (same patient as in previous image). Arrow indicates area of fullness in the anterior mediastinum, probably related to the presence of prominent lymphadenopathy.

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Author

Mary C Mancini, MD, PhD, MMM

Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel S Schwartz, MD, MBA, FACS Medical Director of Thoracic Oncology, St Catherine of Siena Medical Center, Catholic Health Services

Daniel S Schwartz, MD, MBA, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Richard Thurer, MD B and Donald Carlin Professor of Thoracic Surgical Oncology, University of Miami, Leonard M Miller School of Medicine

Richard Thurer, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Medical Association, American Thoracic Society, Florida Medical Association, Society of Surgical Oncology, Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Jane M Eggerstedt, MD, to the development and writing of this article.