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Navigating the Thoracic Inlet¹

¹ From the Department of Radiology, Division of Radiologic Sciences, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1088. Recipient of a Magna Cum Laude award for a scientific exhibit at the 1997 RSNA scientific assembly. Received December 28, 1998; revision requested January 7, 1999 and received January 28; accepted January 28. Address reprint requests to C.C.

The thoracic inlet is often seen on the "edge of the film" at computed tomography (CT); consequently, lesions affecting this structure are easily overlooked. A vascular abnormality that may be overlooked is venous thrombosis. The CT appearance of jugular vein thrombosis varies with the age of the lesion: In the acute phase, there is often loss of soft-tissue planes surrounding an enlarged, peripherally enhancing thrombus. In the chronic phase, the jugular vein appears as a tubular, nonenhancing "mass" without loss of surrounding fat planes. Intrathoracic goiters typically manifest as well-defined, markedly enhanced inhomogeneous lesions that are continuous with the cervical thyroid gland. Thyroid adenomas are typically round or oval low-attenuating lesions that enhance after contrast material administration. Thyroid carcinomas may manifest as single or multiple, irregularly shaped low-attenuating areas with or without calcification. Primary tracheal malignancies may appear as smooth or irregular, sessile or pedunculated intraluminal filling defects. Tracheomalacia manifests as destruction of the tracheal walls with soft-tissue narrowing of the tracheal lumen, whereas esophageal abnormalities manifest as thickening of the esophageal wall, dilatation of the esophageal lumen, or both. Schwannomas manifest as well-circumscribed lesions with soft-tissue attenuation that enhance after contrast material administration. Neurofibromas tend to have lower attenuation than schwannomas. Lymphangiomas typically have a cystic appearance with near water attenuation. Familiarity with the normal anatomy of the thoracic inlet as well as the CT features of related abnormalities is critical for correct diagnosis and prompt treatment.

Index Terms: Arteriovenous malformations, 94.14 • Esophagus, neoplasms, 71.321 • Head and neck neoplasms, 20.36 Neck, infection, 27.21, 27.24 • Lung neoplasms, 61.3222, 64.3222 • Nerves, neoplasms, 27.364 • Thorax, neoplasms, 32.30, 474.30 • Thyroid, neoplasms, 273.368, 273.373 • Trachea, diseases, 275.1496, 275.373 • Veins, jugular, 907.751

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