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Ectopically located parathyroid adenoma is one of the major causes of persistent and recurrent hyperparathyroidism and hypercalcemia. Approximately 0.3–8% of parathyroid adenoma is found in an ectopic location. Ectopic parathyroid adenomas are uncommon causes of persistent hypercalcemia and can be present at uncommon locations, including the hypoglossal nerve, the posterior triangle of the neck, axilla, and pericardium 3. A high index of suspicion is warranted when we see persistently elevated levels of parathyroid hormones (PTHs) and calcium levels post parathyroidectomy. Here, we present a patient who persistently had elevated calcium and PTH levels after parathyroidectomy.

Primary hyperparathyroidism is a common endocrinology anomaly which involves head and neck region. The diagnosis and treatment of parathyroid adenoma however still remains a challenge. Giant parathyroid adenomas are rare and involve more surgical expertise. Retrospective study was carried in Departments of ENT and Endocrinology, SMS Medical College and Hospital, Jaipur. Records of patients operated between 2010 and 2019 were evaluated and analysed for size and site of parathyroid adenomas, biochemical parameters, intra-operative findings and postoperative course. Tumours with size > 3 cm were termed as giant parathyroid adenomas and this is a rarity in literature. Records of 79 patients were found to be complete. Out of these 9 had giant parathyroid adenomas: 4 left inferior, 2 right inferior, 1 ectopic location (superior mediastinum) and 1 each in left and right superior glands. The size, symptomatology and biochemical parameters are discussed in light of available literature. Giant parathyroid adenomas are a rare entity and their behaviour are same as of non giant parathyroid adenomas. In the view of literature published on pub Med, this is found to be largest case series on parathyroid Adenoma considering size more than 3 cm.

Thymic masses are one of the most common tumors in the anterior mediastinum. Nevertheless, because the thymus originates in the third and fourth pharyngeal pouches and descends into the anterior mediastinum, ectopic thymic tissue may be found anywhere from the angle of the mandible to the superior mediastinum. Ectopic cervical thymoma (ECT) is an extremely rare tumor that originates from ectopic thymic tissue trapped during the migration of the embryonic thymus and is often misdiagnosed as a thyroid tumor or other neck masses. Herein, we report an unusual case of ectopic cervical thymoma associated to myasthenia gravis (MG).

This is a rare case of a 55 year-old immunocompetent female who developed Methicillin sensitive Staphylococcus aureus sternoclavicular septic arthritis. The infection was not limited to the joint space but extended into adjacent bones and superior mediastinum. However the patient was successfully treated without surgical intervention and preservation of joint function was obtained with only intravenous antibiotic therapy.

Background Germ cell tumors prefer gonadal regions, but they can be expected in extragonadal sites such as the anterior mediastinum, which is the commonly involved region after gonads. Amongst germ cell tumors, teratomas are the rarer subtypes which develop in the anterior mediastinum. Case presentation The authors present two adult patients, a male and a female, both complaining of chronic chest pain and cough. Chest CT scans were performed revealing characteristic CT features of mature teratomas in the anterior mediastinum which were extending to the superior mediastinum in both patients. Conclusion Germ cell tumors are involving the mediastinum; however, amongst all germ cell tumors, teratoma is the least common type arising in the mediastinum, and a chest CT scan considered the imaging investigation of choice. Surgery is the best option and patients may have a very good prognosis.

Over the past decade there has been tremendous development in the clinical application of minimally invasive esophagectomy (MIE) for the treatment of squamous esophageal carcinoma. The major challenges in the performance of MIE include limitations in visualization and manipulation within the confined, rigid thoracic cavity; the need for adequate patient positioning and anesthetic techniques to accommodate the surgical exposure; and changes in the surgical steps for achieving radical nodal dissection, especially for the superior mediastinum. The surgical procedure for MIE is more and more standardized, and there is an increasing practice of MIE worldwide. Randomized trials and meta-analyses have confirmed the advantages of MIE over open esophagectomy, including a significantly lower rate of complications and shorter hospital stays. The recent application of robotics technologies for MIE has further enhanced the quality and safety of the surgical dissection, while intraoperative nerve monitoring has contributed to a lower rate of recurrent laryngeal nerve palsy. With the application of new technologies, we expect further improvement in surgical outcomes for MIE in the treatment of squamous esophageal cancer.

Mediastinal glomus tumors are rarely recognized, and only seven cases have been reported in the literature. Here, we describe a rare mediastinal glomus tumor and review the characteristics of this rare clinical case. The patient was a 50-year-old female who presented with coughing for 3 months. Her chest computed tomography scan demonstrated a localized tumor in the posterior superior mediastinum. Intraoperatively, we found a longitudinal rupture of the membranous trachea above the carina. We completely resected the tumor and repaired the tracheal rupture under a thoracoscopy using a pedicled muscle flap. The tissue was diagnosed as a mediastinal glomus tumor according to its histological and immunophenotypic characteristics.

Surgery of large mediastinal tumors is a great challenge for the surgeons due to wide number of organs that may be involved despite the narrow space. Any treatment plan should be thoroughly planned step-by-step since the diagnosis to assess the features of the tumor and its relationship with the surrounding organs. Radicality is main goal of the surgeons even if this includes the sacrifice of some structure and the reconstruction of others. Cooperation with the anesthesiologist and surgeons of other speciality is often necessary especially in case of infiltrating tumors. Evolution of the surgical technique end of the peri-operative management as well as the availability of new-generation prosthesis and the increasingly widespread of extracorporeal circulation (ECC) have turned this kind of surgery into a feasible, safe and effective procedure. The cornerstones of this surgery are a detailed preoperative assessment, the ability to prevent any potential complication and involve a multidisciplinary equipe.

Background. Primary hyperparathyroidism is caused by the excessive growth of parathormone secretion, its consequence being hypercalcemia. The parathyroid adenoma is responsible for over half of primary hyperparathyroidism cases. The mandibular tumor can be the initial sign in the case of primary hyperparathyroidism.Case presentation. We present the case of a 33 year old patient with history of a mandibular operated tumor, repetitive pathological fractures and hypercalcemia manifestations. The level of the parathormone at the first measurement indicated a very high value. The parathyroid scintigraphy with 99mTc-MIBI (methoxy-isobutyl-isonitrile) evidenced a high uptake of the tracerin the superior mediastinum, suggestive for an ectopic parathyroid adenoma. The histopathological examination after surgery leads to the diagnosis of parathyroid adenoma. The association between the primary hyperparathyroidism, the mandibular tumour, the clinical history and the nuclear imaging lead to the diagnosis of primary hyperparathyroidism – Jaw tumor syndrome.Conclusion. The hyperparathyroidism-Jaw tumor syndrome has a special clinical importance because of the severe and progressive symptomatology, and because of the risk of developing neoplasia of parathyroid glands, which have a reserved prognosis.

The thymus is the main organ in the (anterior) (pre-vascular) mediastinum, playing a central role in the maintenance of both cellular and humoral immunity. The function of the thymus has been long underlooked due to its involution starting during young adulthood and unawareness regarding its immunological function. A variety of primary tumors and inflammatory/reactive/disreactive processes occur in the mediastinum and may involve the anterior-superior compartment and the thymus. Maldevelopment processes also take place in the pre-vascular compartment mediastinum. Although infective diseases do not currently represent the main processes in western countries, they may represent a diagnostic challenge in developing countries. The purpose of this review is to provide a short overview of the main thymic cellular components, their tumors, pseudotumors, in order to provide insights into their clinical setting and the features which assist pathologists in their differential diagnosis (DD). Specific differential diagnostic points are provided, both for “solid” tumors as well as for haematological malignancies, together with a morphological overview of cases of concern that occur in the anterior mediastinum. The main immunohistochemical characteristics of neoplastic/non-neoplastic pathology and updated specific references are also provided.

Mediastinum is one of most the enigmatic areas of the human body and its pathology can be equally riveting. The mediastinum is broadly divided into four regions: Anterior mediastinum; Superior mediastinum; Middle or visceral mediastinum and Posterior or paravertebral mediastinum. All these compartments contain vascular, lymphatic, neural, capsular and solid organ structures, which may be affected by various disease processes and tumours. Mediastinal masses can be silent for a long time and present suddenly as a life-threatening situation, which can be confusing to the untrained mind. These include symptoms of sudden airway obstruction, bronchospasm, venous engorgement and sometimes, even sudden death. While a lot has been published regarding their anaesthetic and surgical management, there is paucity of literature on emergency or intensive care management. This narrative review proposes to highlight the varied acute presentations of mediastinal tumours and their critical care management. Keywords : Airway obstruction; Bronchospasm; Emergency; Mediastinum; Mass

Haemangiomas are most common non-malignant vascular tumours of infancy. Here, we describe an antenatally detected mass over the neck causing compressive respiratory compromise at birth requiring resuscitative measures at birth. The mass showed increased vascularity on Contrast Enhanced Computed Tomography (CECT) with extension upto superior mediastinum. Surgical excision was required following failure to medical measures with steroids and propranolol. Histopathology confirmed it to be a venous haemangioma. This case highlights that these benign lesions may reach large sizes and antenatal detection may help in planning effective delivery and resuscitative measures.

As a preliminary work the macroscopic and macroscopic study of thymus of pig was carried out. 2 male and 2 female pigs weighing 80±10 kgs were used. The thymus of these animals was procured in the slaughter house where it is sacrificed for edible purpose. It was a large bilobed structure situated in the superior mediastinum. Tissue from the thymus was processed and stained with H&E. Lobules were observed. Cortex and medulla could be differentiated. Two to three Hassall's corpuscles were observed and the distribution was uniform. Key Word: Thymus, Hassall's corpuscles, cortex, medulla.

Ectopic adrenocorticotropic hormone (ACTH) secretion is associated with a heterogeneous spectrum of neuroendocrine tumours (NETs) as well as non-NET tumours. Both ectopic ACTH secretion (EAS) and NETs are relatively uncommon. Large cell neuroendocrine carcinoma (LCNEC) is considered to be a poorly differentiated NET, and is very rarely associated with EAS. Only case reports of EAS associated with LCNEC have been documented. We present a case of disseminated LCNEC associated with EAS. The LCNEC was diagnosed on bone marrow trephine biopsy, and the likely but unproven primary was a NET arising from the superior mediastinum, which also caused superior vena cava (SVC) syndrome at presentation.

Thymoma is a rare case presenting in the paediatric age group. Only 30 cases have been reported so far. Our case is a 14 month old female, presented with respiratory distress. CT scan showed gross widening of superior mediastinum with a homogeneous opacity. Immunohistochemistry was suggestive of thymoma. She underwent excision of the thymic mass and is well at present.J Nepal Paediatr Soc 2015;35(1):76-78

Background Surgical stabilization of the sternoclavicular joint (SCJ) is infrequent, and cardiothoracic surgery assistance is often recommended. Patient safety and surgeon efficiency may be improved by greater understanding of the anatomic relationships near the SCJ. The purpose of this study is to determine the distances from the SCJ to critical structures in the superior mediastinum. Materials and methods Distances from the posterior SCJ to adjacent mediastinal structures were recorded using contrast computed tomography scans of 49 consecutive patients. Patient sex, height, body mass index, side, age, and thickness of the sternum and medial clavicle were also recorded. Results The mean distance to the nearest anatomic structure deep to the clavicular region of the SCJ was 6.6 mm and was 12.5 mm for the sternal region. The clavicle was an average thickness of 18 mm, and the sternum was an average thickness of 17 mm. The closest structure was the brachiocephalic vein. An artery was identified as the closest structure in 21.2% of patients. Distance differences between the right and left sides were noted, but sex had no bearing on distance to structures. Conclusion Multiple mediastinal structures are close to the SCJ. The most frequent structure at risk of injury deep to the SCJ is the brachiocephalic vein. Such knowledge may improve patient safety.

Lesions at the thoracic inlet are difficult to access via a thoracic or cervical approach. The use of the anterior cervico-thoracic trapdoor incision has been reported to give good exposure to the anterior superior mediastinum in adults. We report our experience of four cases where a trapdoor incision was used to gain excellent access and exposure to thoracic inlet pathology in children.

A fifty year old male, diagnosed to have an acute retropharyngeal space infection reported two days after his discharge from the hospital with breathing difficulty and rapidly progressive diffuse swelling of the neck. Immediate clinical evaluation failed to localize the exact cause but computed tomography revealed large anterior visceral compartment abscess with recurring retropharyngeal space infection. In this case the involvement of visceral compartment of the neck was a unique presentation. Retropharyngeal space infections are known for their spread to other spaces. However, involvement of visceral compartment is rare. Proximity to visceral vascular space and possibility of spread of infection to superior mediastinum makes visceral space infections a life threatening condition. Deep neck space infections should be observed for extensions beyond the primary site. The role of imaging is indispensable while monitoring these infections. Prompt initiation of definitive treatment can prevent

Background Schwannomas are benign, well-differentiated tumors that originate from Schwann cells. Involvement of the cervical sympathetic nerve is relatively rare. Computed tomography is indispensable for the diagnosis. The treatment is surgical. Histological examination confirms the diagnosis. Horner’s syndrome postoperatively is supportive of the diagnosis. The rarity of giant cervical sympathetic chain schwannoma made the case of our patient interesting to report. Furthermore, our patient’s immense tumor size is very rare, and we could not find any similar report in the literature. Cervical sympathetic chain schwannoma is frequently confused with schwannoma of the vagus nerve on clinical and radiological examination, and its diagnosis can therefore be challenging for clinicians, radiologists, and pathologists. Case presentation We report a rare case of cervical schwannoma in a 40-year-old Moroccan woman who presented with a large parapharyngeal mass. Computed tomography revealed a giant, heterogeneous, well-defined mass measuring 110 × 100 × 147 mm, occupying the right carotid triangle, and descending to the superior mediastinum. Surgical excision with a transcervical approach was done. Histological examination confirmed the diagnosis. The patient’s postoperative course was marked by Horner’s syndrome. Conclusions Cervical sympathetic chain schwannoma is a rare, benign tumor. It should be considered in the differential diagnosis in patients presenting with a lateral neck mass. Surgical exploration must be discussed for a tumor with a large volume.

Background. Critical care in Uganda is a neglected speciality and deemed costly with limited funding/prioritization. We studied admission X-ray and MEWS as mortality predictors of ICU patients requiring mechanical ventilation.Materials and Methods. We did a cross-sectional study in Mulago Hospital ICU and 87 patients for mechanical ventilation were recruited with mortality as the outcome of interest. Chest X-ray results were the main independent variable and MEWS was also gotten for all patients.Results. We recruited 87 patients; most were males (60.92%), aged between 16 and 45 years (59.77%), and most admissions for mechanical ventilation were from the Trauma Unit (30.77%). Forty-one (47.13%) of the 87 patients died and of these 34 (53.13%) had an abnormal CXR with an insignificant IRR = 1.75 (0.90–3.38) (p=0.062). Patients with MEWS ≥ 5 (pvalues = 0.018) and/or having an abnormal superior mediastinum (pvalues = 0.013) showed a positive association with mortality while having a MEWS≥5 had an incidence risk ratio = 3.29 (1.00–12.02) (p=0.018). MEWS was a good predictor of mortality (predictive value = 0.6739).Conclusion. Trauma (31%) caused most ICU admissions, having an abnormal admission chest X-rays positively associated with mortality and a high MEWS was also a good predictor of mortality.

Castleman's disease is a slowly progressive and rare lymphoproliferative disorder. Here, we report a 55-year-old woman with superior mediastinal Castleman's disease being misdiagnosed for a long term. We found a 4.3 cm mass localized in the superior mediastinum accompanied with severe clinical symptoms. The patient underwent an exploratory laparotomy, but the mass failed to be totally excised. Pathologic examination revealed a mediastinal mass of Castleman's disease. After radiotherapy of 30 Gy by 15 fractions, the patient no longer presented previous symptoms. At 3 months after radiotherapy of 60 Gy by 30 fractions, Computed tomography of the chest showed significantly smaller mass, indicating partial remission. Upon a 10-month follow-up, the patient was alive and free of symptoms.

Although very rare, mediastinal nodal angiomatosis is an entity radiologists should be aware of to be a differential diagnosis for a hypervascular mediastinal mass lesion. The CT- and MR-morphological features are non-specific and only histopathology can reveal the definitive diagnosis.

Neurogenic tumors are the most common type of mediastinal tumor and constitute the majority of neoplasms of the posterior mediastinum. Schwannomas originating from the intrathoracic vagus nerve are extremely rare. The present study describes the case of a 58-year-old man with a large vagal schwannoma in the left superior mediastinum. A large tumor with a round shape was identified in the left superior mediastinum. The tumor originated from and encased the vagus nerve. Using video-assisted thoracoscopic surgery, the tumor was completely excised with amputation of the vagus nerve encased within in the tumor. One year post-surgery, the patient was free of recurrence with no symptoms other than hoarseness.

Mediastinal thoracic duct cyst is a rare benign cystic disease. The lesion is generally in the post-erior or superior mediastinum, where the thoracic duct passes. We herein report an extremely rare case of surgically resected anterior mediastinal thoracic duct cyst. A thoracic duct cyst should be considered as an uncommon differential diagnosis of an anterior mediastinal lesion.

OBJETIVO: Avaliar três casos de linfangioma cervical por ressonância magnética e correlacionar com os achados da ultrassonografia. MATERIAIS E MÉTODOS: Três pacientes com idade gestacional entre 24 e 35 semanas, com suspeita de higromas císticos cervicais fetais na ultrassonografia obstétrica de rotina, foram submetidas a ressonância magnética e, posteriormente, a nova ultrassonografia para correlação dos achados. Em ambos os métodos de imagem foram avaliadas as dimensões, a localização, o conteúdo e a extensão das lesões. RESULTADOS: Tanto a ultrassonografia quanto a ressonância magnética avaliaram de modo semelhante a localização, o tamanho e o conteúdo dos tumores. As três lesões localizavam-se na região cervical posterior e lateral. Quanto ao conteúdo, duas eram predominantemente císticas com finos septos em seu interior e uma era heterogênea. A extensão e invasão das estruturas adjacentes foram mais bem caracterizadas na ressonância magnética do que na ultrassonografia, demonstrando de forma adequada o acometimento do pavilhão auditivo do feto em um caso e do mediastino superior em outro. CONCLUSÃO: A ressonância magnética fetal pode ser um complemento útil da ultrassonografia em fetos portadores de linfangiomas, avaliando de forma mais precisa a extensão e invasão de estruturas vizinhas, permitindo melhor planejamento cirúrgico pós-natal. OBJECTIVE: To evaluate three cases of cervical lymphangioma with magnetic resonance imaging and correlating with sonographic findings. MATERIALS AND METHODS: Three pregnant women between the 24th and 35th gestational weeks, with sonographic findings suggestive of fetal cystic hygroma, were submitted to magnetic resonance and subsequently to a new ultrasonography for correlation of imaging findings. Tumors size, location, content and extent were evaluated both at magnetic resonance imaging and ultrasonography. RESULTS: Findings regarding tumor location, size and content were similar for both methods. All the lesions were found in the posterior and lateral cervical space. As regards the tumors content, two of the lesions were predominantly cystic, with thin septations, and the other was heterogeneous. Lesions extent and adjacent structures invasion were better characterized by magnetic resonance imaging, with appropriate demonstration of invasion of the pinna in one case and invasion of the superior mediastinum in another. CONCLUSION: Fetal magnetic resonance imaging can be a useful adjuvant to obstetric ultrasonography in cases of lymphangioma because of its higher accuracy in the determination of these tumors extent and adjacent structures invasion, allowing a better postnatal surgical planning.

SUMMARY. Bronchogenic cysts are rare congenital cystic lesions mostly located in the middle and superior mediastinum. Esophageal bronchogenic cysts are extremely rare. We review here 23 cases reported in English in the literature to date of intramural esophageal bronchogenic cyst and their features, including our patient. Although they are extremely rare, intramural esophageal bronchogenic cysts should be kept in mind in the differential diagnosis of benign esophageal lesions. With accurate diagnosis and treatment the prognosis is excellent and serious complications may be prevented.

A 55-year-old man with tracheal adenocarcinoma presented with difficulty in breathing and cough with blood-tinged expectoration. As the patient refused surgery, he was treated with definitive radiotherapy to the neck and superior mediastinum to a total dose of 50 Gy (initially 40 Gy by AP/PA portals followed by 10 Gy with a three-field technique). He showed significant symptomatic relief to radiotherapy and defaulted from further treatment. He remained asymptomatic for 7 years, following which he developed sternal metastases and a local tumour recurrence. This case illustrates that long-term clinical remission can be achieved by radiotherapy alone in this rare histological subtype of tracheal carcinoma.

A method of exposing the posterior and superior mediastinum in video-assisted thoracoscopic surgery (VATS) will be introduced. In the study, all cases underwent two-port VATS as follows: two or three pieces of suture were stitched on the invagination between the visceral and parietal pleura of the posterior or superior mediastinum; the suture was drawn out of the operating port and fixed, so that the lung could be depressed and posterior or superior mediastinum could be exposed very well. This method was performed in 215 cases; there were no operative deaths and all cases recovered. This stitching method to expose the posterior or superior mediastinum can reduce the wound size and decrease the operation time. Additionally, it is simple, practicable and safe.

Summary Juvenile xanthogranuloma (JXG) is the most common form of non-Langerhans histiocytosis in the pediatric population. JXG most typically presents as a subcutaneous nodule. The natural course of the disease is usually spontaneous resolution without treatment. However, there have been case reports of juvenile xanthogranuloma involving the larynx and trachea that required treatment for symptoms of airway obstruction. We describe the first case of juvenile xanthogranuloma involving the superior mediastinum with impingement on the trachea causing airway obstruction.

Retropharyngeal masses are benign or malignant. Because of their location, even the most benign lesion may endanger life by compressing and obstructing the air and/or food passages. Lipomas of the retropharyngeal region are rare; slow-growing tumors that attain a large size before producing symptoms such as dysphagia and dyspnoea. Clinical diagnosis may be difficult. However, computed tomography or magnetic resonance imaging is the investigation of choice and helps in definitive diagnosis pre-operatively, although final histological confirmation is essential. We present the case of a giant lipoma of the retropharyngeal space extending from the nasopharynx to the superior mediastinum causing symptoms of obstructive sleep apnea. The tumor removed surgically and the patient passed an uneventful post-operative period.

Mediastinoscopy has been widely used by thoracic surgeons to evaluate the superior mediastinum since 1959. Large series of mediastinoscopy have been reported with very low morbidity and no mortality. Proper attention to surgical techniques and mediastinal anatomy are essential to maintain the safety of the procedure. Situs inversus totalis is exceedingly rare, but variations in mediastinal anatomy in this group of patients can render the procedure challenging for the thoracic surgeon. A case of mediastinoscopy in a situs inversus patient is presented with emphasis on anatomical variations of the mediastinum and technical pitfalls of the procedure in this rare group.

We report the case of a Hodgkin’s lymphoma presenting as chest pain due to the presence of multiple lymphoadenopathies of the superior mediastinum and a poly-lobated mass in the middle lobe of the right lung. Diagnostic approach and differential diagnosis are discussed.

嚢胞性変化を来したfunctional paragangliomaの一手術例を経験したので報告する.症例は70歳, 男性.他院にて高血圧及び胸部異常陰影を指摘され, 当院紹介.CT, MRIにて左肺尖椎体左側に嚢胞状の縦隔腫瘍を認め, 内分泌検査にて, 血中アドレナリン, ノルアドレナリンと尿中VMAの著明な上昇を認めた.開胸下に縦隔腫瘍摘出術を行い, 術後, 高血圧の改善とホルモン値の著明な改善を認めた.病理組織検査では, 腫瘍の出血に起因した著明な嚢状変性と退行性変化を認め, 海綿状血管腫を強く疑ったが, 免疫染色にて神経細胞及び神経内分泌細胞が同定され, functional paragangliomaの診断を得た.

This text describe through images, how a knife is retrieved from the superior mediastinum.

Digit-assisted thoracoscopic surgery (DATS) is a novel, minimally invasive approach for achieving a superior mediastinal mass, by allowing the surgeon's finger to pass into the superior mediastinum through a suprasternal route. In this study a DATS procedure for a bronchogenic cyst in the superior mediastinum was performed. The procedure worked well for dissecting the tissue around the mass, and thus reduced the effort required to perform the operation. In the current study DATS was found to be superior to the standard technique.

Robot-assisted excision of an ectopic parathyroid adenoma in the superior mediastinum was performed in a 57-year-old man. The mass was located by methoxyisobutylisonitrile scan and computed tomography. Identification of the ectopic parathyroid adenoma was facilitated by the 3-dimensional images of the da Vinci robotic system, and resection was achieved using EndoWrist instruments. Robot-assisted excision of parathyroid adenoma located in the relatively inaccessible superior mediastinum proved to be feasible.

Resection of the medial third of the clavicle is a safe and effective surgical approach for exposure of the uppermost portion of the superior anterior and posterior mediastinum for resection of parathyroid adenomata. Two patients underwent this transclavicular approach to resect parathyroid adenomata of the anterior and posterior superior mediastinum following initial negative cervical exploration. One patient had 3 previous operations performed elsewhere resulting in a permanent vocal-cord paralysis. Preoperative localization in both patients included, but was not limited to, Tc-99m sestamibi single-photon emission computed tomography (SPECT), and 1 patient had a positive emission tomography (PET) scan. One adenomata was deep to the left sternoclavicular junction and left sternothyroid muscle, and the other 7 cm caudad in the posterior mediastinum affixed to the thoracic esophagus and thoracic vertebra. There were no major intraoperative or postoperative complications following resection of the medial third of the clavicle; however, 1 patient had a temporary vocal-cord paralysis. Resection of the medial third of the clavicle provides excellent surgical access to parathyroid adenomata located in the uppermost superior anterior mediastinum and the posterior superior mediastinum. Tc-99m sestamibi SPECT and PET images are valuable in the location of such adenomata. In 1 of the patients, PET imaging confirmed the location.

Germ cell, mesenchymal, and thymic tumors of the mediastinum are an uncommon and heterogeneous group of neoplasms. Together they account for less than 25% of mediastinal tumors in childhood. The majority of these tumors are found in the anterior and superior mediastinum, but germ cell tumors and mesenchymal tumors may be located in all compartments. They share a broad range of histological subtypes and clinical behavior, tendency to be large in size, and a requirement for complete surgical excision as the major requirement for successful therapy.

OBJECTIVE: Our objective was to assess the technical feasibility, safety, and accuracy of sonographically guided fine-needle aspiration biopsy of superior mediastinal masses by the suprasternal route. CONCLUSION: Sonographically guided biopsy through the suprasternal route is safe and effective for lesions in the pretracheal, right paratracheal, and prevascular compartments of the superior mediastinum. This procedure is especially useful for lesions with an acoustic window too small for parasternal biopsy under sonographic guidance.

Thymic carcinoid is a rare tumor. The case of an 86-year-old male with a thymic carcinoid is presented. The patient was discovered to have an abnormal mass, as an incidental finding, at the thoracic inlet during a routine examination. He had slight dysphagia for 6 months. The tumor had displaced the trachea to the right, and compressed the esophagus. A CT scan demonstrated that the tumor was located in the superior mediastinum, and extended to the aortic arch. The preoperative diagnosis was a mediastinal goiter. The tumor was resected completely through a general collar incision, without a median sternotomy. The tumor measured 6.5×5.5×4.5cm in size, was grossly well-encapsulated and was diagnosed histologically as a carcinoid tumor. Mitoticfigures were not seen. The tumor cells had a few argyrophillic granules, and showed positive immunoreactivity for chromogranin A. Electronmicroscopy disclosed small granules with diameters of about 160nm. There were no clinical manifestations suggestive of a specific syndrome, such as a carcinoid syndrome. The patient recieved no postoperative radiation or chemotherapy, and is now quite well at 2 years after the operation.

Traditionally, surgical exposure to the larynx, pharynx and trachea has been achieved by lateral, horizontal, or apron incisions. Although these incisions provide excellent surgical exposure, they violate the vertically oriented blood supply to the cervical skin. A single vertical midline incision with limited lateral dissection can provide satisfactory access to the anterior neck without jeopardizing cervical skin perfusion or subsequent carotid artery exposure. We have found this incision useful after preoperative irradiation for total and partial laryngectomy, laryngopharynectomy, and tracheal resection. Superior and inferior extensions provide access to the superior mediastinum and facilitate pharyngostome fashioning and limited neck dissection. We have not observed skin necrosis. Cosmesis and patient acceptance have been excellent.