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(Radiographics. 2002;22:S231-S246.)
© RSNA, 2002

AIRWAYS AND ESOPHAGUS

The Retrotracheal Space: Normal Anatomic and Pathologic Appearances1

Tomás Franquet, MD, Jeremy J. Erasmus, MD, Ana Giménez, MD, Santiago Rossi, MD and Rosa Prats, MD

1 From the Department of Radiology, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Avda Sant Antoni M. Claret 167, 08025 Barcelona, Spain (T.F., A.G., R.P.); the Department of Radiology, M. D. Anderson Cancer Center, Houston, Tex (J.J.E.); and the Department of Radiology, Fundación Dr Enrique Rossi, Buenos Aires, Argentina (S.R.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received February 22, 2002; revision requested April 2 and received May 29; accepted June 12. Address correspondence to T.F. (e-mail: 19429tfc@comb.es).


   Abstract
Top
 Abstract
Introduction
 Normal Anatomy
 Pathologic Conditions
 Conclusions
 References
 
A variety of diseases can arise from the normal contents of the retrotracheal space or from adjacent structures. Mediastinal diseases in the retrotracheal space typically manifest radiographically as a contour abnormality or an area of increased opacity, although computed tomography (CT) or magnetic resonance (MR) imaging is usually required for diagnosis. The most common aortic arch anomaly, a right subclavian artery that originates from an otherwise normal left-sided aortic arch, appears at posteroanterior chest radiography as an obliquely oriented soft-tissue area of increased opacity that extends superiorly to the right from the superior margin of the aortic arch. CT and MR imaging can reveal associated vascular or mediastinal abnormalities. Aortic aneurysms and pseudoaneurysms can manifest radiographically as fusiform or saccular masslike lesions that protrude into the retrotracheal space. Thoracic MR imaging and spiral CT angiography are the diagnostic procedures of choice for evaluating diverse pathologic conditions of the thoracic aorta. Esophageal diseases can manifest as an abnormality in the retrotracheal space, which may be the initial clue to the diagnosis. At CT, lymphatic malformations in the mediastinum manifest as lobular, multicystic tumors that surround and infiltrate adjacent mediastinal structures. Familiarity with the normal radiologic appearance of the retrotracheal space and with the clinical manifestations of diseases that affect the retrotracheal space and adjacent structures can facilitate detection, diagnosis, and management.

© RSNA, 2002

Index Terms: Aneurysm, aortic, 56.73 • Aorta, abnormalities, 562.1521, 562.1532 • Esophagus, abnormalities, 71.141, 71.142 • Esophagus, neoplasms, 71.3131, 71.321 • Mediastinitis, 67.272 • Mediastinum, abscess, 67.272 • Mediastinum, hemorrhage, 67.4128 • Mediastinum, neoplasms, 67.31, 67.3151, 67.319


   Introduction
Top
 Abstract
 Introduction
Normal Anatomy
 Pathologic Conditions
 Conclusions
 References
 
The retrotracheal space (also known as the Raider triangle or retrotracheal triangle) is a radiolucent area that extends from the thoracic inlet to the aortic arch and is visible on lateral chest radiographs (1). A wide spectrum of diseases can occur in this region; they may arise either from the normal contents of the retrotracheal space (esophagus, left recurrent laryngeal nerve, thoracic duct, lymph nodes, lung) or from adjacent structures. Mediastinal disease in the retrotracheal space typically manifests radiographically as a contour abnormality or an area of increased opacity (1,2). Although lung diseases may project over the retrotracheal space, they have been excluded from this discussion because they do not occur within the retrotracheal space. A comprehensive understanding of the normal radiologic appearance of the retrotracheal space and of the manifestations of diseases that affect the retrotracheal space can facilitate the detection and diagnosis of intrathoracic disease. In this article, we review the anatomy and normal radiologic appearance of the retrotracheal space and discuss and illustrate diseases that affect the retrotracheal space. These disease entities include congenital vascular malformations, acquired vascular lesions, esophageal abnormalities, tumors, and infections.


   Normal Anatomy
Top
 Abstract
 Introduction
 Normal Anatomy
Pathologic Conditions
 Conclusions
 References
 
The retrotracheal space is best visualized on lateral chest images as a radiolucent triangular area bounded anteriorly by the trachea, posteriorly by the spine, inferiorly by the aortic arch, and superiorly by the thoracic inlet. Both lungs contribute to the radiolucency of the space: The right lung extends posterior to the trachea and outlines the tracheal wall, whereas the left lung extends above the transverse aorta and outlines the aortic arch (1,2). The retrotracheal space is triangular and varies in size depending on the patient’s age and habitus (Fig 1). The size of the space is also affected by the degree of lung inflation. In patients with emphysema, the space is typically larger and its upper margin is extended and may appear trapezoidal. A vertically oriented line behind the tracheal air column, the posterior tracheal line, usually forms the anterior margin of the retrotracheal space (3,4). This line is produced by lung tissue in contact with the posterior wall of the trachea and is up to 2.5 mm in thickness. On occasion, a stripe up to 5.5 mm in thickness, the tracheoesophageal stripe, will form the anterior margin of the normal retrotracheal space (3,4). The tracheoesophageal stripe is composed of the posterior wall of the trachea and the anterior wall of the air-filled esophagus or, in some instances, the collapsed esophagus outlined by retroesophageal lung tissue (3,4).



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  		Figure 1a.  Normal radiologic anatomy of the retrotracheal space. (a) Lateral chest radiograph shows the lung tissue posterior to the trachea as a radiolucent triangular space (*). This space extends from the thoracic inlet superiorly to the aortic arch inferiorly and is bounded posteriorly by the spine. The anterior edge of the scapula (arrow) projects over the space and may sometimes be misidentified as the posterior border of the retrotracheal space (arrowheads). (b) Computed tomographic (CT) scan shows the normal retrotracheal space occupied by a dilated esophagus.

 


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  		Figure 1b.  Normal radiologic anatomy of the retrotracheal space. (a) Lateral chest radiograph shows the lung tissue posterior to the trachea as a radiolucent triangular space (*). This space extends from the thoracic inlet superiorly to the aortic arch inferiorly and is bounded posteriorly by the spine. The anterior edge of the scapula (arrow) projects over the space and may sometimes be misidentified as the posterior border of the retrotracheal space (arrowheads). (b) Computed tomographic (CT) scan shows the normal retrotracheal space occupied by a dilated esophagus.

 

   Pathologic Conditions
Top
 Abstract
 Introduction
 Normal Anatomy
 Pathologic Conditions
Conclusions
 References
 
A wide spectrum of abnormalities can occur in the retrotracheal space (Table). The most common lesions are vascular in origin and are due to developmental anomalies of the aortic arch (5).


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  		Lesions of the Retrotracheal Space

 
Congenital Vascular Lesions
Anomalous development of the aortic arch can result in a variety of anatomic variants that encircle the trachea or esophagus (2,5,6). The most frequently encountered vascular rings in the retrotracheal space are (a) a left-sided aortic arch with an aberrant right subclavian artery, (b) a right-sided aortic arch with an aberrant left subclavian artery, and (c) a complete double aortic arch (6–10). Vascular rings are often asymptomatic but can produce symptoms in infants (stridor, wheezing, dysphagia) that are due to compression of the trachea or esophagus (7). Aneurysmal dilatation of the vascular rings may also occur in adults (8,9).

Left-sided Aortic Arch with an Aberrant Right Subclavian Artery.— The most common aortic arch anomaly is an aberrant right subclavian artery that originates from an otherwise normal left-sided aortic arch. This anomaly occurs in approximately 1% of the population and is frequently encountered incidentally at upper gastrointestinal or chest radiographic examination (5,9). The aberrant right subclavian artery arises from the posterior portion of the aortic arch and crosses the mediastinum obliquely from left to right, posterior to the esophagus and trachea (Fig 2). Dilatation of the origin of the right subclavian artery (Kommerell diverticulum) is common in the elderly, occurring in up to 60% of all elderly patients, and can manifest as dysphagia (2,9). Findings at lateral chest radiography can be normal, but the anomalous artery often manifests as an area of increased opacity in the retrotracheal space associated with a focal indentation on the posterior wall of the trachea (2,6,9). Posteroanterior chest radiography reveals an obliquely oriented soft-tissue area of increased opacity that extends superiorly to the right from the superior margin of the aortic arch. CT and magnetic resonance (MR) imaging can be helpful by revealing associated vascular or mediastinal abnormalities (Fig 3) (7–10).



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  		Figure 2a.  Left-sided aortic arch with an aberrant right subclavian artery in an asymptomatic 53-year-old man. (a) Close-up view of a lateral chest radiograph shows an area of increased opacity in the retrotracheal space and displacement of the trachea anteriorly (arrows). (b) Contrast material-enhanced CT scan shows an aberrant right subclavian artery that arises as the last branch of a left-sided aortic arch posterior to the esophagus.

 


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  		Figure 2b.  Left-sided aortic arch with an aberrant right subclavian artery in an asymptomatic 53-year-old man. (a) Close-up view of a lateral chest radiograph shows an area of increased opacity in the retrotracheal space and displacement of the trachea anteriorly (arrows). (b) Contrast material-enhanced CT scan shows an aberrant right subclavian artery that arises as the last branch of a left-sided aortic arch posterior to the esophagus.

 


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  		Figure 3a.  Aberrant right subclavian artery in a 64-year-old man with esophageal carcinoma and dysphagia. (a) Close-up view of a lateral chest radiograph shows an area of increased opacity in the retrotracheal region (arrows). (b) Contrast-enhanced CT scan shows the retrotracheal space occupied by an aberrant right subclavian artery that courses posterior to an esophageal carcinoma.

 


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  		Figure 3b.  Aberrant right subclavian artery in a 64-year-old man with esophageal carcinoma and dysphagia. (a) Close-up view of a lateral chest radiograph shows an area of increased opacity in the retrotracheal region (arrows). (b) Contrast-enhanced CT scan shows the retrotracheal space occupied by an aberrant right subclavian artery that courses posterior to an esophageal carcinoma.

 
Right-sided Aortic Arch with an Aberrant Left Subclavian Artery.— The most common right-sided aortic arch anomaly is an aberrant left subclavian artery. This anomaly has a prevalence of approximately 0.05%, is usually diagnosed incidentally, and is usually not associated with congenital heart disease (11). Like a left-sided aortic arch with an aberrant right subclavian artery, this aberration may be associated with dysphagia and may be exacerbated if the origin of the aberrant subclavian artery from the aorta is dilated. Recognition at radiography of the absence of a left-sided aortic arch associated with a well-defined soft-tissue area of increased opacity in the right paratracheal region is useful in suggesting the diagnosis. Lateral radiography typically reveals a masslike area of increased opacity in the retrotracheal space that silhouettes the upper aspect of the aortic arch (Fig 4) (2,5,8). CT and MR imaging are useful in confirming the diagnosis and differentiating this abnormality from a right-sided aortic arch with mirror image branching (an anomaly associated with a high prevalence of congenital heart disease) and a double aortic arch (7). In addition, CT and MR imaging can demonstrate associated abnormalities or complications (Fig 5) (8,9,12).



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  		Figure 4a.  Right-sided aortic arch with an aberrant left subclavian artery in a 58-year-old man. (a) Posteroanterior chest radiograph shows a right-sided thoracic aorta. (b) Lateral esophagogram shows an aberrant left subclavian artery as a masslike area of increased opacity in the retrotracheal space. The artery displaces the trachea anteriorly and leaves its classic posterior impression on the esophagus. (c) Contrast-enhanced CT scan reveals the origin of the anomalous left subclavian artery.

 


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  		Figure 4b.  Right-sided aortic arch with an aberrant left subclavian artery in a 58-year-old man. (a) Posteroanterior chest radiograph shows a right-sided thoracic aorta. (b) Lateral esophagogram shows an aberrant left subclavian artery as a masslike area of increased opacity in the retrotracheal space. The artery displaces the trachea anteriorly and leaves its classic posterior impression on the esophagus. (c) Contrast-enhanced CT scan reveals the origin of the anomalous left subclavian artery.

 


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  		Figure 4c.  Right-sided aortic arch with an aberrant left subclavian artery in a 58-year-old man. (a) Posteroanterior chest radiograph shows a right-sided thoracic aorta. (b) Lateral esophagogram shows an aberrant left subclavian artery as a masslike area of increased opacity in the retrotracheal space. The artery displaces the trachea anteriorly and leaves its classic posterior impression on the esophagus. (c) Contrast-enhanced CT scan reveals the origin of the anomalous left subclavian artery.

 


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  		Figure 5a.  Right-sided aortic arch with an aneurysmal left subclavian artery in an asymptomatic 74-year-old man. (a) CT scan shows a partially calcified, aneurysmal retrotracheal left subclavian artery. An azygous lobe (arrowheads) is seen adjacent to a right-sided aortic arch. (b) Contrast-enhanced CT scan shows the aneurysm without associated mural thrombus.

 


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  		Figure 5b.  Right-sided aortic arch with an aneurysmal left subclavian artery in an asymptomatic 74-year-old man. (a) CT scan shows a partially calcified, aneurysmal retrotracheal left subclavian artery. An azygous lobe (arrowheads) is seen adjacent to a right-sided aortic arch. (b) Contrast-enhanced CT scan shows the aneurysm without associated mural thrombus.

 
Double Aortic Arch.— The double aortic arch is one of the most common symptomatic arch anomalies (10). Because of esophageal and tracheal compression, it usually manifests in infancy as respiratory distress or difficulty in feeding. The anomaly is rarely associated with congenital heart disease and can, in rare cases, remain undiagnosed into adulthood (13). The right arch is usually larger, higher, and more posterior than the left arch. The arches join posteriorly to form a single descending aorta that is typically left-sided. Chest radiography shows a right paratracheal masslike area of increased opacity with a focal tracheal impression that can simulate mediastinal adenopathy (5,13). Lateral chest radiography typically shows a large area of increased opacity in the retrotracheal space. Diagnostic imaging modalities include surface echocardiography in infants and children and MR imaging and CT in adults (Fig 6) (13).



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  		Figure 6a.  Double aortic arch that was incidentally discovered in an asymptomatic 58-year-old man. (a) Frontal chest radiograph reveals bilateral paratracheal masses that represent double aortic knobs. Focal wall calcification is present in the right aortic arch (arrowheads). (b) Coronal T1-weighted MR image shows right and left aortic arches. (c) On a sagittal T1-weighted MR image, the retrotracheal space is obscured by both aortic arches.

 


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  		Figure 6b.  Double aortic arch that was incidentally discovered in an asymptomatic 58-year-old man. (a) Frontal chest radiograph reveals bilateral paratracheal masses that represent double aortic knobs. Focal wall calcification is present in the right aortic arch (arrowheads). (b) Coronal T1-weighted MR image shows right and left aortic arches. (c) On a sagittal T1-weighted MR image, the retrotracheal space is obscured by both aortic arches.

 


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  		Figure 6c.  Double aortic arch that was incidentally discovered in an asymptomatic 58-year-old man. (a) Frontal chest radiograph reveals bilateral paratracheal masses that represent double aortic knobs. Focal wall calcification is present in the right aortic arch (arrowheads). (b) Coronal T1-weighted MR image shows right and left aortic arches. (c) On a sagittal T1-weighted MR image, the retrotracheal space is obscured by both aortic arches.

 
Acquired Vascular Diseases
Aneurysmal dilatation of the thoracic aorta, defined as enlargement of the aorta to more than twice its normal caliber, is common, occurring in up to 10% of elderly adults (14). Dilatation usually occurs as a result of degenerative changes in the aorta associated with aging or as a result of congenital abnormalities, connective tissue disorders, infections, prior surgery, trauma, or valvular disease (15,16). Aneurysmal dilatation can also be due to pseudoaneurysms of the aorta (false aneurysms that do not contain all components of the aortic wall), which are usually the result of chest trauma, infection, or surgery (14,17). A penetrating atherosclerotic ulcer of the aorta (ulceration of an atheromatous plaque that disrupts the internal elastic lamina and results in an intramural hematoma) is another cause of aortic pseudoaneurysm (18,19). A potential complication of thoracic aneurysms is rupture, the prevalence of which is as high as 70% (Fig 7). Because the risk of rupture increases fivefold if the aneurysm is over 6 cm in diameter, most aneurysms with diameters over 5–5.5 cm are surgically repaired (14,15). Aortic aneurysms and pseudoaneurysms can manifest radiographically as fusiform or saccular masslike lesions that protrude into the retrotracheal space. Thoracic MR imaging and spiral CT angiography are the diagnostic procedures of choice to evaluate diverse pathologic conditions of the thoracic aorta (14,16,20–22).



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  		Figure 7a.  Progressive enlargement of an aneurysm of the transverse aortic arch in an 82-year-old man. (a) Unenhanced CT scan shows a mass that was caused by a large aortic aneurysm and fills the retrotracheal space. The esophagus (arrowhead) is displaced to the right and posterior to the mass. (b) Contrast-enhanced CT scan shows a penetrating atherosclerotic ulcer and a contained rupture or mediastinal hematoma (arrow).

 


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  		Figure 7b.  Progressive enlargement of an aneurysm of the transverse aortic arch in an 82-year-old man. (a) Unenhanced CT scan shows a mass that was caused by a large aortic aneurysm and fills the retrotracheal space. The esophagus (arrowhead) is displaced to the right and posterior to the mass. (b) Contrast-enhanced CT scan shows a penetrating atherosclerotic ulcer and a contained rupture or mediastinal hematoma (arrow).

 
Esophageal Abnormalities
Diseases of the esophagus can manifest as an abnormality in the retrotracheal space, which may be the initial clue to the diagnosis.

Esophageal Atresia and Tracheoesophageal Fistula.— Esophageal atresia and tracheoesophageal fistula are congenital anomalies characterized by incomplete formation of the tubular esophagus with or without abnormal communication with the trachea (23). Esophageal atresia can manifest as an air-distended pouch or, owing to mucosal secretion, as a masslike lesion in the retrotracheal space that deforms the adjacent part of the trachea (Fig 8) (23).



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  		Figure 8a.  Esophageal atresia in a newborn. Frontal (a) and lateral (b) radiographs show an air-distended pouch in the retrotracheal space (arrows in a) that deforms the adjacent portion of the trachea. A radiopaque tube has been placed on the blind pouch of the proximal portion of the esophagus (arrow in b). (Case courtesy of Elida Vázquez, MD, Hospital Vall D’Hebrón, Barcelona, Spain.)

 


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  		Figure 8b.  Esophageal atresia in a newborn. Frontal (a) and lateral (b) radiographs show an air-distended pouch in the retrotracheal space (arrows in a) that deforms the adjacent portion of the trachea. A radiopaque tube has been placed on the blind pouch of the proximal portion of the esophagus (arrow in b). (Case courtesy of Elida Vázquez, MD, Hospital Vall D’Hebrón, Barcelona, Spain.)

 
Duplication Cyst.— Esophageal duplication cysts are congenital abnormalities that account for 0.5%–2.5% of all tumors and tumorlike lesions of the esophagus (24,25). Approximately 60% of duplication cysts are in the lower part of the esophagus (24). Many patients are asymptomatic, the abnormality sometimes being discovered incidentally at an advanced age. Bleeding or infection may cause mediastinal cyst enlargement and associated symptoms. Cysts may also be complicated if ectopic gastric mucosa is present in the lining of the cyst. Esophageal duplication cysts, either symptomatic or asymptomatic, are treated with complete surgical excision to prevent complications (26). Duplication cysts that arise in the upper portion of the esophagus can manifest as masses in the retrotracheal space (2). At CT, they typically manifest as spheric or tubular masses in proximity to the esophageal wall (Fig 9) (24). They are usually homogeneous and have water attenuation. However, they may have soft-tissue attenuation owing to intracystic hemorrhage or proteinaceous debris. At MR imaging, duplication cysts have variable signal intensity on T1-weighted images, depending on cyst contents, and markedly increased signal intensity on T2-weighted images (26).



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  		Figure 9a.  Esophageal duplication cyst in a 23-year-old woman in whom a mass was incidentally found at chest radiography. (a) Lateral chest radiograph reveals an area of increased opacity in the retrotracheal region and anterior displacement of the trachea. (b) CT scan shows a well-circumscribed mass with water attenuation adjacent to the esophagus. The appearance and location of the mass are typical for an esophageal duplication cyst.

 


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  		Figure 9b.  Esophageal duplication cyst in a 23-year-old woman in whom a mass was incidentally found at chest radiography. (a) Lateral chest radiograph reveals an area of increased opacity in the retrotracheal region and anterior displacement of the trachea. (b) CT scan shows a well-circumscribed mass with water attenuation adjacent to the esophagus. The appearance and location of the mass are typical for an esophageal duplication cyst.

 
Esophageal Dilatation and Diverticula.— Esophageal dilatation and diverticula may include focal dilatation in the Zenker (pharyngoesophageal) diverticulum (upper part of the esophagus), traction diverticula due to granulomatous disease (middle part of the esophagus), and epiphrenic diverticula (lower right part of the esophagus). The Zenker diverticulum usually extends dorsally into the postcricoid area and, if large, can be detected in the retrotracheal space as a large air-filled or fluid-filled masslike lesion (Fig 10) (27). Diffuse dilatation of the esophagus can occur as a result of motility disorders (achalasia, postvagotomy syndrome, Chagas disease, scleroderma, systemic lupus erythematosus, presbyesophagus, diabetic neuropathy, esophagitis) or distal obstruction (carcinoma, stricture, extrinsic compression) (28). Achalasia, a motor disorder that results in dilatation of the esophagus because of aperistalsis of the lower part of the esophagus and inadequate relaxation of the lower esophageal sphincter, frequently manifests as an abnormality in the retrotracheal space (29). Retained fluid, food debris, and an air-fluid level are common, as are anterior displacement and bowing of the trachea by the fluid- or food-filled esophagus. Aspiration pneumonia is an associated complication (Fig 11) (30).



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  		Figure 10a.  Zenker diverticulum in a 54-year-old man with dysphagia and cough. (a) Posteroanterior chest radiograph shows abnormal widening of the superior portion of the mediastinum. An air-fluid level is also seen (arrows). (b) CT scan shows a large retrotracheal diverticulum with an air-fluid level due to retained alimentary content.

 


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  		Figure 10b.  Zenker diverticulum in a 54-year-old man with dysphagia and cough. (a) Posteroanterior chest radiograph shows abnormal widening of the superior portion of the mediastinum. An air-fluid level is also seen (arrows). (b) CT scan shows a large retrotracheal diverticulum with an air-fluid level due to retained alimentary content.

 


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  		Figure 11a.  Achalasia in a 47-year-old woman with chest pain. (a) Close-up view of a posteroanterior chest radiograph shows abnormal widening of the superior part of the mediastinum. An air-fluid level is seen (arrowheads). A calcified paratracheal lymph node is also visible. (b) Lateral radiograph shows anterior displacement and bowing of the trachea caused by the fluid-filled esophagus. An air-fluid level within the retrotracheal space is also apparent (arrowheads), a finding that suggests the diagnosis of achalasia.

 


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  		Figure 11b.  Achalasia in a 47-year-old woman with chest pain. (a) Close-up view of a posteroanterior chest radiograph shows abnormal widening of the superior part of the mediastinum. An air-fluid level is seen (arrowheads). A calcified paratracheal lymph node is also visible. (b) Lateral radiograph shows anterior displacement and bowing of the trachea caused by the fluid-filled esophagus. An air-fluid level within the retrotracheal space is also apparent (arrowheads), a finding that suggests the diagnosis of achalasia.

 
Esophageal Tumors.— Esophageal tumors that affect the retrotracheal space include esophageal carcinoma and leiomyoma (25,31). On lateral chest radiographs, widening of the posterior tracheal-tracheoesophageal stripe and the presence of an esophageal air-fluid level are the two most common manifestations of esophageal carcinoma in the retrotracheal space (Fig 12) (3,4). Widening of the posterior tracheal-tracheoesophageal stripe may be secondary to (a) paratracheal and paraesophageal lymphatic engorgement due to obstruction or direct invasion by a tumor, or (b) retained secretions due to a tumor that occludes the esophagus at a lower level (3,4).



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  		Figure 12a.  Esophageal carcinoma in a 68-year-old man with dysphagia and stridor. (a) Lateral chest radiograph shows marked widening of the retrotracheal stripe. Posterior indentation and irregularity of the tracheal air column, produced by neoplastic infiltration of the tracheal wall, are also apparent (arrowheads). (b) CT scan shows marked inhomogeneous thickening of the esophageal wall. Infiltration of the posterior tracheal wall is also seen (arrowhead).

 


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  		Figure 12b.  Esophageal carcinoma in a 68-year-old man with dysphagia and stridor. (a) Lateral chest radiograph shows marked widening of the retrotracheal stripe. Posterior indentation and irregularity of the tracheal air column, produced by neoplastic infiltration of the tracheal wall, are also apparent (arrowheads). (b) CT scan shows marked inhomogeneous thickening of the esophageal wall. Infiltration of the posterior tracheal wall is also seen (arrowhead).

 
Leiomyomas, the most frequently occurring benign tumors of the esophagus, nevertheless represent less than 1% of all esophageal neoplasms (32). They are usually slow-growing tumors that range from 2 to 8 cm in size (31). Although leiomyomas typically occur in the lower part of the esophagus, those that arise in the upper portion can manifest as masses in the retrotracheal space.

Miscellaneous Mediastinal Masses
Mediastinal Lymphatic Malformations.— Lymphatic malformations (previously described as lymphangiomas) are rare benign lesions (32). Approximately 75% occur in the neck and 5% in the mediastinum (33). Most mediastinal lesions are due to tumor extension from the neck into the superior and anterior mediastinum, although such tumors can extend into the retrotracheal space. They usually occur in patients less than 2 years old, and they have a male predilection. In adults, lymphatic malformations in the mediastinum are usually due to recurrence of an incompletely resected childhood tumor. At CT, these lesions manifest as lobular, multicystic tumors that surround and infiltrate adjacent mediastinal structures. They can appear solid at CT because of intracystic protein or hemorrhage (34). MR imaging can be useful in confirming the cystic nature of these lesions; lymphatic malformations usually have markedly increased signal intensity on T2-weighted images (Fig 13) (34). Their appearance on T1-weighted images is more variable: Although most have low to intermediate signal intensity, they can occasionally have high signal intensity similar to that of fat (34).



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  		Figure 13a.  Lymphatic malformation of the superior mediastinum in an asymptomatic 46-year-old woman. (a) Axial T1-weighted MR image shows a large, lobulated lymphatic malformation with intermediate signal intensity. (b) T2-weighted MR image shows a characteristic hyperintense lesion that surrounds but does not displace the trachea and great vessels. The tumor extends toward the anterior soft tissues of the chest wall. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a biopsy specimen shows large, dilated lymphatic channels (*) with walls that contain connective tissue and lymphocytes (arrowheads).

 


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  		Figure 13b.  Lymphatic malformation of the superior mediastinum in an asymptomatic 46-year-old woman. (a) Axial T1-weighted MR image shows a large, lobulated lymphatic malformation with intermediate signal intensity. (b) T2-weighted MR image shows a characteristic hyperintense lesion that surrounds but does not displace the trachea and great vessels. The tumor extends toward the anterior soft tissues of the chest wall. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a biopsy specimen shows large, dilated lymphatic channels (*) with walls that contain connective tissue and lymphocytes (arrowheads).

 


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  		Figure 13c.  Lymphatic malformation of the superior mediastinum in an asymptomatic 46-year-old woman. (a) Axial T1-weighted MR image shows a large, lobulated lymphatic malformation with intermediate signal intensity. (b) T2-weighted MR image shows a characteristic hyperintense lesion that surrounds but does not displace the trachea and great vessels. The tumor extends toward the anterior soft tissues of the chest wall. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a biopsy specimen shows large, dilated lymphatic channels (*) with walls that contain connective tissue and lymphocytes (arrowheads).

 
Hemangiomas.— Hemangiomas are rare mediastinal tumors that usually occur in the anterior or posterior mediastinum (68% and 22% of cases, respectively) (35,36). Most are cavernous hemangiomas composed of large interconnecting vascular spaces with varying amounts of interposed stromal elements such as fat and fibrous tissue. Focal areas of organized thrombus can calcify as phleboliths. At radiography, hemangiomas manifest as smooth, well-marginated mediastinal masses. Phleboliths are present in less than 10% of cases (36). CT typically reveals a heterogeneous mass with intense central and rimlike peripheral enhancement after intravenous administration of contrast material. Hemangiomas typically have heterogeneous signal intensity on T1-weighted MR images. In lesions with significant stromal fat, linear areas of increased signal intensity on T1-weighted images can occasionally be identified. The central vascular lakes typically become markedly hyperintense on T2-weighted images, a potentially diagnostic feature (Fig 14) (35,36).



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  		Figure 14a.  Mediastinal hemangioma in a 67-year-old man. (a) CT scan shows a well-defined heterogeneous mass that lies behind the trachea and displaces the esophagus laterally. A small, rounded calcification (phlebolith) appears within the mass (arrow). (b) Contrast-enhanced CT scan demonstrates the mass with intense central and rimlike peripheral enhancement. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a surgical specimen shows multiple vascular spaces lined by a thin endothelial layer (arrow).

 


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  		Figure 14b.  Mediastinal hemangioma in a 67-year-old man. (a) CT scan shows a well-defined heterogeneous mass that lies behind the trachea and displaces the esophagus laterally. A small, rounded calcification (phlebolith) appears within the mass (arrow). (b) Contrast-enhanced CT scan demonstrates the mass with intense central and rimlike peripheral enhancement. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a surgical specimen shows multiple vascular spaces lined by a thin endothelial layer (arrow).

 


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  		Figure 14c.  Mediastinal hemangioma in a 67-year-old man. (a) CT scan shows a well-defined heterogeneous mass that lies behind the trachea and displaces the esophagus laterally. A small, rounded calcification (phlebolith) appears within the mass (arrow). (b) Contrast-enhanced CT scan demonstrates the mass with intense central and rimlike peripheral enhancement. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a surgical specimen shows multiple vascular spaces lined by a thin endothelial layer (arrow).

 
Thyroid Goiter.— Most thyroid masses in the mediastinum are caused by intrathoracic extension of thyroid goiters, a condition that occurs most often in women in their 60s and 70s and accounts for up to 10% of mediastinal masses resected at thoracotomy (36). True ectopic thyroid masses in the mediastinum are rare. A thyroid goiter typically extends into the thyropericardiac space anterior to the recurrent laryngeal nerve and brachiocephalic vessels, although posterior extension behind the esophagus and adjacent to the trachea in the retrotracheal space occurs in 20% of cases (36). Many patients with an intrathoracic goiter are asymptomatic, the anomaly being incidentally discovered at screening chest radiography. On radiographs, posterior intrathoracic thyroid goiters can manifest as sharp, smoothly marginated mediastinal masses that displace the trachea anteriorly and occupy the retrotracheal space (Fig 15). CT scans typically reveal a heterogeneous mass continuous with the cervical thyroid gland. Areas of hemorrhage, necrosis, and calcification are common (36).



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  		Figure 15a.  Intrathoracic goiter in a 62-year-old woman. (a) Lateral chest radiograph shows a large thyroid mass that fills the retrotracheal space and displaces the trachea anteriorly. (b) CT scan shows a well-defined, homogeneous soft-tissue mass that fills the retrotracheal space and displaces the trachea, esophagus, and supraaortic vessels anteriorly.

 


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  		Figure 15b.  Intrathoracic goiter in a 62-year-old woman. (a) Lateral chest radiograph shows a large thyroid mass that fills the retrotracheal space and displaces the trachea anteriorly. (b) CT scan shows a well-defined, homogeneous soft-tissue mass that fills the retrotracheal space and displaces the trachea, esophagus, and supraaortic vessels anteriorly.

 
Mediastinal Hemorrhage.— Mediastinal hemorrhage can result from iatrogenic procedures such as central venous catheter placement or from vascular injuries secondary to chest trauma (37,38). Traumatic aortic injury typically occurs in patients who sustain rapid deceleration injury or blunt injury to the chest. Traumatic transection of the aorta is usually immediately fatal, although 10%–25% of patients survive the initial injury (39,40). Transection typically occurs between the origin of the left subclavian artery and the attachment of the ligamentum arteriosum (ligament of Botallo), although the ascending and descending portions of the aorta at the level of the diaphragmatic hiatus are other sites of injury. Radiographic manifestations of traumatic aortic injury are nonspecific and include widening of the mediastinum, tracheal displacement, inferior displacement of the left primary bronchus, displacement of a nasogastric tube to the right of the T4 spinous process, and extrapleural blood tracking along the subclavian vasculature (apical pleural cap) (41). Mediastinal hemorrhage, an indirect sign of aortic injury, can extend posteriorly and manifest as a masslike area of increased opacity in the retrotracheal space. Spiral CT is the initial procedure of choice for evaluating a mediastinal abnormality after traumatic injury to the chest (40–42). Aortic transection can manifest as extravasation of contrast material, a pseudoaneurysm (Fig 16), abrupt change in aortic caliber, or an intimal flap with diffuse mediastinal hemorrhage (38).



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  		Figure 16a.  Aortic transection in a 36-year-old man who had sustained a rapid deceleration injury. (a) CT scan shows a mediastinal hematoma that obscures the mediastinal vessels, occupies the retrotracheal space, and displaces the trachea to the right. (b) Contrast-enhanced CT scan shows a pseudoaneurysm (*) medial to the proximal descending thoracic aorta. Bilateral pleural effusions are also seen.

 


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  		Figure 16b.  Aortic transection in a 36-year-old man who had sustained a rapid deceleration injury. (a) CT scan shows a mediastinal hematoma that obscures the mediastinal vessels, occupies the retrotracheal space, and displaces the trachea to the right. (b) Contrast-enhanced CT scan shows a pseudoaneurysm (*) medial to the proximal descending thoracic aorta. Bilateral pleural effusions are also seen.

 
Infectious Lesions
Infection can spread to the retrotracheal space from contiguous structures such as the thoracic spine and paravertebral spaces or from retropharyngeal and prevertebral spaces.

Cervical Abscess with Mediastinal Extension.— Infections in the retropharyngeal and prevertebral spaces can spread caudad to the retrotracheal space. In children, cervical abscesses usually result from tonsillar infection or traumatic perforation of the pharynx (Fig 17) (42–44), whereas in adults, they are often associated with mediastinal tuberculosis and pyogenic spondylitis (45,46).



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  		Figure 17.  Retropharyngeal infection with mediastinal abscess formation in an 18-year-old man with iatrogenic pharyngeal perforation. CT scan shows widening of the middle mediastinum with a large retrotracheal abscess that fills the retrotracheal space and displaces the trachea and esophagus anteriorly. An air-fluid level within the abscess cavity is also seen.

 
Acute Mediastinitis.— Rupture of the esophagus may be due to diagnostic and therapeutic endoscopic procedures as well as to blunt thoracic trauma and foreign body impaction (41,44). The cervical and upper thoracic portions of the esophagus are the most common sites of rupture. The majority of pharyngeal or esophageal foreign body impactions occur in children who accidentally or intentionally ingest coins, toys, or other foreign objects (43). In adults, the most common foreign bodies within the esophagus are animal or fish bones. Esophageal foreign bodies can manifest radiographically in the retrotracheal space as a focal area of increased opacity or as a retrotracheal abscess or mediastinitis due to esophageal perforation. Esophageal fistulization secondary to esophageal carcinoma may also be a cause of mediastinal abscess (Fig 18) (47,48).



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  		Figure 18.  Retrotracheal abscess due to fistulized esophageal carcinoma in a 56-year-old man. CT scan shows marked esophageal wall thickening. Air bubbles and a small amount of contrast material within the retrotracheal space due to formation of a fistula (arrow) are also seen.

 
Fulminant mediastinitis with abscess formation occurs in 1% of patients with esophageal perforation (44,49). The combination of high mortality and difficulty in establishing the clinical diagnosis increases the importance of the radiologist in detection of this complication. Radiologic features include mediastinal widening, pneumomediastinum, obliteration of fat planes, loculate fluid collections, and abscess formation. Loculate fluid collections and abscesses can manifest radiographically as large masslike lesions in the retrotracheal space. CT is optimal for establishing the diagnosis and is useful for assisting in percutaneous drainage of loculate fluid collections (44).


   Conclusions
Top
 Abstract
 Introduction
 Normal Anatomy
 Pathologic Conditions
 Conclusions
References
 
A wide spectrum of diseases can manifest as radiographic abnormalities in the retrotracheal space. Knowledge of the normal radiologic appearance of the retrotracheal space is required to appropriately interpret lateral radiographs. This knowledge, together with an understanding of the clinical manifestations of diseases in this region and of the diseases that commonly occur in the retrotracheal space, can facilitate detection, diagnosis, and management. However, the radiographic manifestations of diseases in the retrotracheal space are often nonspecific, and CT and MR imaging may be required for diagnosis.


   References
Top
 Abstract
 Introduction
 Normal Anatomy
 Pathologic Conditions
 Conclusions
 References
 

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