Mediastinal Masses - Direct Exam

Most common pathological lesions in mediastinum are masses. Tumor can originate from all of the structures located in  the mediastinum. Mediastinum is not examined on routine exam. Mediastinal abnormalities are detected first by chest x-ray or CT chest. Detection of abnormalities of mediastinum by physical exam is difficult. Masses have to be very large before they can be detected.

There are two types of physical findings one can elicit with mediastinum:

Physical Findings of Mass in Mediastinum

Focused Exam

  1. D'Spine Sign
    Normally bronchial breathing and bronchophony can be heard over cervical spine till C7. This is because trachea is close to spine at this level. Trachea divides at T3 level. If there is a large posterior mediastinal mass between trachea and vertebra, bronchial breathing and bronchophony can be heard further down thoracic vertebra below C7. A large subcarinal mass also can give you this finding as long as the tumor is in contact with trachea and vertebra. The mass conducts the sound generated in the trachea to chest wall.
  2. Reverse D'Spine Sign
    If there is a large anterior mediastinal mass between trachea and sternum, bronchial breathing and bronchophony can be heard over supracardiac vessel area.
  3. Dullness in Supracardiac Vessel Area
    Normally both lungs come close to midline in supracardiac vessel area thus you can elicit resonance to percussion. In patients with large anterior mediastinal mass the supracardiac vessel area will be dull to percussion.
  4. AP Displacement of Trachea
    A retro tracheal mass or dilatation of esophagus will push trachea forward. The trachea will be in flush with manubrium. With anterior mediastinal mass the trachea can be pushed backwards. In patients with obstructive lung disease the diaphragm descends due to hyperinflation and the trachea is pulled backwards. Variability of tracheal position makes it hard to decide when a posterior displacement is abnormal and is due to anterior mediastinal mass.
  5. Ballottement
    When the trachea is displaced forwards, try balloting. If the forward push is secondary to dilated esophagus the trachea will ballot. If it is due to a mass it will not ballot. I was able elicit ballottement in one patient with carcinoma esophagus with proximal dilatation. That patient almost choked to death by aspiration during that process. So be careful.
  6. Fixation of Trachea
    Trachea moves up and down with deglutition and deep breathing. If the trachea is encircled by tumor and tethered down this upward mobility will be restricted. Trachea also sinks towards dependent lung in lateral decubitus position. If the trachea is fixed in mediastinum the movement will not occur with lateral decubitus position.
  7. Tracheal Tug
    The arch of aorta encircles left main stem bronchus. When there is aneurysm of arch of aorta, tracheal tug could be elicited. Stand behind the patient and grab the trachea and hold it up after patient swallows water. In aortic arch aneurysm, the trachea will be pulled down (tugged) with each heart beat.