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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.

View larger version (147K): [in a new window]   Figure 1.   Normal anatomy of the thoracic inlet. Axial contrast material-enhanced CT scan obtained at the level of the thyroid gland shows the anterior jugular vein (aj), anterior scalene muscle (as), biceps muscle (b), common carotid artery (cc), internal jugular vein (ij), long muscle of the neck (lc), levator muscle of the scapula (ls), middle scalene muscle (ms), greater pectoral muscle (p), sternocleidomastoid muscle (sc), trachea (t), and trapezius muscle (tp).

View larger version (121K): [in a new window]   Figure 2.   Aberrant right subclavian artery. Axial contrast-enhanced CT scan shows the artery (arrowhead) passing behind the esophagus.

View larger version (151K): [in a new window]   Figure 3.   Asymmetry of the jugular veins. On an axial contrast-enhanced CT scan, the right jugular vein (J) is larger than the left.

View larger version (147K): [in a new window]   Figures 4, 5.   Venous thrombosis. (4) Axial contrast-enhanced CT scan shows a filling defect (arrow), a finding that is consistent with thrombosis of the left internal jugular vein. (5) T1-weighted spin-echo MR image shows increased signal intensity in a thrombosed left subclavian vein (arrow).

View larger version (142K): [in a new window]   Figures 4, 5.   Venous thrombosis. (4) Axial contrast-enhanced CT scan shows a filling defect (arrow), a finding that is consistent with thrombosis of the left internal jugular vein. (5) T1-weighted spin-echo MR image shows increased signal intensity in a thrombosed left subclavian vein (arrow).

View larger version (145K): [in a new window]   Figures 6, 7.   (6) Multinodular goiter. Axial contrast-enhanced CT scan demonstrates multiple low-attenuating nodules in an enlarged gland. (7) Goiter. Axial contrast-enhanced CT scan demonstrates tracheal stenosis due to external compression.

View larger version (120K): [in a new window]   Figures 6, 7.   (6) Multinodular goiter. Axial contrast-enhanced CT scan demonstrates multiple low-attenuating nodules in an enlarged gland. (7) Goiter. Axial contrast-enhanced CT scan demonstrates tracheal stenosis due to external compression.

View larger version (150K): [in a new window]   Figure 8.   Thyroid carcinoma. Axial contrast-enhanced CT scan shows a solitary mass (M) within the thyroid gland, lymphadenopathy (N), and infiltration of adjacent tissues.

View larger version (125K): [in a new window]   Figures 9, 10.   (9) Hemiagenesis of the thyroid gland. Axial contrast-enhanced CT scan demonstrates absence of the left lobe, which is a typical finding in hemiagenesis. (10) Pyramidal lobe. Axial contrast-enhanced CT scan shows persistence of the distal portion of the thyroglossal duct. This condition is present in 50% of the population. P = pyramidal lobe.

View larger version (121K): [in a new window]   Figures 9, 10.   (9) Hemiagenesis of the thyroid gland. Axial contrast-enhanced CT scan demonstrates absence of the left lobe, which is a typical finding in hemiagenesis. (10) Pyramidal lobe. Axial contrast-enhanced CT scan shows persistence of the distal portion of the thyroglossal duct. This condition is present in 50% of the population. P = pyramidal lobe.

View larger version (143K): [in a new window]   Figure 11.   Lymph nodes of the thoracic inlet. Axial contrast-enhanced CT scan shows a slight mass effect on the right internal jugular vein by an enlarged lymph node (arrow).

View larger version (131K): [in a new window]   Figure 12.   Tracheal malignancy. Axial contrast-enhanced CT scan shows a soft-tissue mass on the left lateral wall of the trachea.

View larger version (153K): [in a new window]   Figure 13.   Tracheal stenosis. Axial contrast-enhanced CT scan demonstrates tracheal stenosis due to proliferation of granulation tissue, which is a complication of intubation.

View larger version (145K): [in a new window]   Figure 14.   Esophageal cancer. Axial contrast-enhanced CT scan depicts a soft-tissue mass displacing the lumen to the left.

View larger version (105K): [in a new window]   Figure 15.   Esophagitis. Axial contrast-enhanced CT scan demonstrates thickening and irregularity of the esophageal wall due to Cytomegalovirus esophagitis. Flecks of contrast material are also seen.

View larger version (86K): [in a new window]   Figure 16.   Superior sulcus tumor. Posteroanterior chest radiograph shows asymmetry in the lung apices. CT revealed a tumor at the left lung apex.

View larger version (172K): [in a new window]   Figure 17.   Pancoast tumor. Sagittal T1-weighted spin-echo MR image shows a Pancoast tumor at the lung apex (T) encasing the subclavian artery and vein (arrow).

View larger version (133K): [in a new window]   Figure 18a.   Pancoast tumor. (a) Axial contrast-enhanced preoperative CT scan shows invasion of the left first (arrow) and second ribs by a superior sulcus tumor. (b) Axial contrast-enhanced CT scan obtained after surgery and external radiation therapy shows surgical clips at the site of en bloc resection of the chest wall (arrow).

View larger version (148K): [in a new window]   Figure 18b.   Pancoast tumor. (a) Axial contrast-enhanced preoperative CT scan shows invasion of the left first (arrow) and second ribs by a superior sulcus tumor. (b) Axial contrast-enhanced CT scan obtained after surgery and external radiation therapy shows surgical clips at the site of en bloc resection of the chest wall (arrow).

View larger version (131K): [in a new window]   Figure 19a.   Tumor involvement of the brachial plexus. (a) Coronal T1-weighted spin-echo MR image of the brachial plexus shows slightly thickened upper, middle, and lower trunks (arrowhead) lying cephalad to the subclavian artery (A) and vein (V). (b) Coronal contrast-enhanced fat-suppressed MR image shows enhancement and thickening (arrows), findings that suggest extensive tumor involvement of the brachial plexus by a Pancoast tumor.

View larger version (130K): [in a new window]   Figure 19b.   Tumor involvement of the brachial plexus. (a) Coronal T1-weighted spin-echo MR image of the brachial plexus shows slightly thickened upper, middle, and lower trunks (arrowhead) lying cephalad to the subclavian artery (A) and vein (V). (b) Coronal contrast-enhanced fat-suppressed MR image shows enhancement and thickening (arrows), findings that suggest extensive tumor involvement of the brachial plexus by a Pancoast tumor.

View larger version (73K): [in a new window]   Figure 20a.   Posttraumatic meningocele in a patient who had sustained a traction injury to the left arm and presented with weakness of the arm. (a) Posteroanterior chest radiograph shows a convexity at the left lung apex (arrow). (b) Axial CT scan obtained after intrathecal instillation of metrizamide demonstrates a posttraumatic meningocele extending through the left neural foramen (arrow).

View larger version (79K): [in a new window]   Figure 20b.   Posttraumatic meningocele in a patient who had sustained a traction injury to the left arm and presented with weakness of the arm. (a) Posteroanterior chest radiograph shows a convexity at the left lung apex (arrow). (b) Axial CT scan obtained after intrathecal instillation of metrizamide demonstrates a posttraumatic meningocele extending through the left neural foramen (arrow).

View larger version (137K): [in a new window]   Figure 21.   Neurofibromas in a 38-year-old woman with neurofibromatosis. Axial contrast-enhanced CT scan demonstrates multiple nonenhancing masses (arrows), predominantly within the perivertebral space.

View larger version (119K): [in a new window]   Figure 22.   Metastatic disease to the axial skeleton. Axial contrast-enhanced CT scan (bone window) demonstrates metastases involving the ribs and spine.

View larger version (145K): [in a new window]   Figure 23.   Metastatic disease to the axial skeleton. Sagittal T1-weighted spin-echo MR image reveals a soft-tissue mass (M) resulting from metastatic involvement of the manubrium and sternum. At CT, this mass was seen as a lytic lesion.

View larger version (123K): [in a new window]   Figures 24, 25.   (24) Desmoid tumor. Axial contrast-enhanced CT scan depicts a soft-tissue mass in the right supraclavicular fossa (M). (25) Extraosseous sarcoma. Axial contrast-enhanced CT scan shows an inhomogeneous mass in the left trapezius muscle.

View larger version (123K): [in a new window]   Figures 24, 25.   (24) Desmoid tumor. Axial contrast-enhanced CT scan depicts a soft-tissue mass in the right supraclavicular fossa (M). (25) Extraosseous sarcoma. Axial contrast-enhanced CT scan shows an inhomogeneous mass in the left trapezius muscle.

View larger version (133K): [in a new window]   Figure 26.   Retropharyngeal space abscess in a 42-year-old man with Down syndrome, sore throat, and dyspnea. Axial contrast-enhanced CT scan shows a large fluid collection in the retropharyngeal space (A) with peripheral enhancement and an air-fluid level.

View larger version (111K): [in a new window]   Figure 27.   Fibromatosis colli of infancy in a 2-month-old male infant with a right-sided neck mass. Axial contrast-enhanced CT scan demonstrates an enlarged right sternocleidomastoid muscle with normal attenuation (S).

View larger version (126K): [in a new window]   Figure 28.   Lymphangioma in an adult patient. Axial contrast-enhanced CT scan demonstrates a smoothly marginated, low-attenuating neck mass representing a lymphangioma (cystic hygroma) (L). This lesion is more commonly detected in infancy.

View larger version (153K): [in a new window]   Figure 29a.   Cervical lipoma in a 55-year-old woman with a soft left-sided neck mass. (a) Sagittal T1-weighted MR image demonstrates a soft-tissue mass with increased signal intensity within the anterior cervical space extending from the mandible to the thoracic inlet (arrow). (b) Axial T1-weighted MR image also demonstrates the mass (arrow), which had the same imaging appearance as fat with all pulse sequences and was suppressed appropriately with fat suppression.

View larger version (170K): [in a new window]   Figure 29b.   Cervical lipoma in a 55-year-old woman with a soft left-sided neck mass. (a) Sagittal T1-weighted MR image demonstrates a soft-tissue mass with increased signal intensity within the anterior cervical space extending from the mandible to the thoracic inlet (arrow). (b) Axial T1-weighted MR image also demonstrates the mass (arrow), which had the same imaging appearance as fat with all pulse sequences and was suppressed appropriately with fat suppression.

View larger version (139K): [in a new window]   Figure 30a.   Madelung disease in a 27-year-old woman with marked fat deposition in the neck, shoulders, and upper trunk. (a) Sagittal T1-weighted MR image demonstrates marked accumulation of fat in the neck and upper thorax. (b) Axial T1-weighted MR image shows the extent of fat deposition in the cervicothoracic region.

View larger version (143K): [in a new window]   Figure 30b.   Madelung disease in a 27-year-old woman with marked fat deposition in the neck, shoulders, and upper trunk. (a) Sagittal T1-weighted MR image demonstrates marked accumulation of fat in the neck and upper thorax. (b) Axial T1-weighted MR image shows the extent of fat deposition in the cervicothoracic region.

View larger version (153K): [in a new window]   Figure 31.   Tracheal stenosis. Axial contrast-enhanced CT scan demonstrates tracheal stenosis due to compression by the thoracic skeleton in the absence of thoracic kyphosis.