Thorax

MUDr. Veronika Nmcov, CSc.

Thorax

Borders, lines, borders of lungs and pleura, heart projection,

auscultation
Topography of the wall of thorax, intercostal spaces chest
drainage, surgical approaches sternotomy, thoracotomy
Diaphragm structures, nerve supplying, hernias
Presternal region sternal puncture
Regio pectoralis, breast lymph nodes
Clavipectoral triangle, subclavian puncture
Pleural cavity, parietal pleura, recesses, cupula pleurae,
scalenovertebral triangle, pneumothorax
Lungs segments, impressions,pulmonary hilum, lymph nodes
Superior mediastinum, crossection - schema, retrosternal
goitre, thymoma, superior vena cava syndrome - cavo-caval
anastomoses
Inferior mediastinum (anterior, middle, posterior),
transoesophageal ECHO, oesophageal varices porto-caval
anastomoses

Shapes of the thorax

Emphysema

Pectus excavatum

Muscles of the thorax

m.pectoralis
major

m.serratus
anterior

m.latissimus
dorsi

m.trapezius

m.latissimus
dorsi

Long thoracic nerve palsy

scapula alata
(winged scapula)

Mamma

Breast - lymph nodes

Apical axillary l.n.

Central axillary l.n.

Lateral axillary l.n.

Pectoral axillary l.n.

(Sorgius lymph node)

Supraclavicular l.n.

Parasternal l.n.

Bordes of the lungs and pleura

area thymica
II

IV

VI
VII
VIII

IX

area pericardiaca

Lower borders of the parietal pleura

are +1 rib

Pleura parietalis et
pleura visceralis

cupula
pleurae
(5cm above
the thoracis
inlet)

pneumothorax

pars costalis

pars mediastinalis

pars diaphragmatica
recessus
costodiaphragmaticus

parasternal anterior axillary paravertebral line

Section through
the intercostal
space in

1-f.thoracica spf.
2- fascia endothoracica
3-pleura parietalis
4-membrana intercostalis ext.
5-m.intercostalis int
6-m.intercostalis ext
7-m.intercostalis intimus
8-membrana intercostalis int
9-m.transversus thoracis

VANA

Chest drainage posterior axillary line above the level of the inferior
angle of scapule (Th7)

anterior axillary line

above
the rib
costodiaphragmatic
recess

!diaphragm, liver, spleen

! lungs
! long thoracic nerve, lateral thoracic vessels
! intercostal nerv and vessels

Thorax - anterior wall (posterior aspect)

vessels

Median sternotomy
approach to thymus,
pericardium,
heart and roots of great
vessels,
and anterior mediastinum

CT 14 days after sternotomy for bypass grafting

post surgery
wire migration
-sign of mediastinitis
3 weeks after sternotomy

wound dehiscention

 sternal puncture is a rapid and safe

method to ensure the diagnosis of poststernotomy mediastinitis

Thorax posterior wall

vessels and nerves
Ao
V.intercostalis suprema

V.azygos

Tr.sympaticus

Ductus thoracicus

Nn.splanchnici

Thorax inferior wall -diaphragm

4. intercostal space

5. intercostal space
Central tendon

lumbocostal triangle of
Bochdalek

Diaphragm inferior aspect

Sternal part

Central tendon

Inferior v.cava
+frenic nerve

Oesophagus
+vagus
nerves

Azygos vein
+ splanchnic
nerves
Lumbocostal
triangle
(Bochdaleki)

Costal part

Lumbar part
quadratus
lumborum

psoas
major

aorta +
thoracic duct

Hemiazygos vein
sympathetic + splanchnic
nerves
trunc

Mediastinum

oesophagus spatium retroviscerale

spatium paraviscerale
spatium previscerale

Superius
P
Inferius

A
M

aorta
diaphragma
abdominal cavity

angulus sterni
n. frenicus

Mediastinum superius
(thoracic inlet)

Layers: sternum
rest of the thymus
veins
nerves
arteries
trachea
oesophagus
lungs (laterally)

Superior mediastinum
Schema of the crossection

v.brachiocephalica dx

vasa thoracica int.

sternum
rest of the thymus n. frenicus
vrstva il
tr. brachiocephalicus
nerves
n.vagus dx
arteries
trachea
oesophagus
pleuras
tr. sympathicus

v.brachiocephalica sin
n. frenicus
a.carotis comm sin
n.vagus sin
a. subclavia sin
n.laryngeus
reccurens sin
ductus thoracicus

Th3
tr. sympathicus

pleura
visceralis
pleura
parietalis

Repetition

Th3

Superior vena cava syndrome

v.jugularis
externa

edema of the
face, neck and
upper chest,

distension of
axillary,
subclavian and
jugular veins

v.brachiocephalica dx
(compression)

v.cava superior

v.thoracica lat.

v.thoracoepigastrica

v.cava inferior

A 75-year-old man smoker, stage IV

nonsmall-cell carcinoma of the lung
-progressive cough, hoarseness, and
swelling of the face and arms.
- On examination: plethoric, with a ruddy
complexion, suffusion, pitting edema of the
face and upper torso, and prominent
spidery telangiectasia on his face and
chest (Panel A). The jugular veins were
nonpulsatile and distended.
- Contrast-enhanced CT: markedly
compressed superior vena cava (SVC)
- venogram: (Panel B) severe compression
of both the right and left subclavian veins
(RSV and LSV), a thrombus in the left
subclavian vein and multiple venous
collaterals (arrowheads).
-After stent placement, extending from
the left subclavian vein into the superior
vena cava, the patient felt better within a
day, and was back to baseline at 27 days
(Panel C), the venogram (Panel D)
-14 months after the procedure and
chemotherapy, remains free of symptoms
resulting from the obstruction of SVC.

Cavo-caval anastomoses
thoracoepigastric vein - superficial epigastric vein
superior epigastric vein inferior epigastric vein
lumbal veins azygos and hemiazygos veins

Subclavian Vein Cannulation

Retrosternal goitre
x-ray picture

Reccurent laryngeal
nerves

Young woman with dysphony

left reccurent laryngeal nerve palsy

Ortners syndrome is a rare cardiovocal syndrome and refers to reccurent

laryngeal nerve palsy from cardiovascular disease (mitral stenosis, pulmonary
hypertension)

pulmonary artery dilatation

Posterior
mediastinum

n.vagus sin
v. azygos
ductus thoracicus
truncus sympathicus
n.splanchnicus major

oesophagus

Mediastinum right veiw

n.vagus

n.frenicus

ductus thoracicus

n.splanchnicus major

n.splanchnicus minor

eparterial
bronchus

Mediastinum right view

Mediastinum left veiw

n.vagus

hyparterial bronchus

n.frenicus
+ vasa pericardiacofrenica

n.laryngeus
reccurens sin.

Mediastinum
transverse section (Th6)
truncus pulmonalis

aorta ascendens

n. frenicus sin
n. frenicus dx
v.cava superior
nn.vagi
bronchus
principalis sin

oesophagus
bronchus
principalis dx
v. azygos
ductus thoracicus
tr. sympathicus dx

Th6

aorta descendens
v. hemiazygos

tr. sympathicus sin

Mediastinum
transverse section (Th8)

n.frenicus sin

n.frenicus dx
vv. pulmonales
n.vagus sin

n.vagus dx
ductus thoracicus
v. azygos
tr. sympathicus dx

Th8

oesophagus
aorta descendens

Lungs and the heart anterior aspect

1-lobus sup. dx
2-fissura horizontalis
3-facies sternocostalis
4-facies diaphragmatica
5-sulcus interventricularis ant.
6-tr.brachiocephalicus
7-trachea
8-a.carotis communis sin
9-a.subclavia sin

Lungs posterior aspect

1-lobus inf.dx
2-lobus inf.sin
3-aorta
4-jcen
5-trachea

Medial wall of
the right lung

apex

sulcus a. subclaviae
sulcus v.cavae sup.
1.rib impression
sulcus v.azygos
a.pulmonalis dx

bronchus principalis dx

mesopneumonium

sulcus v.azygos
sulcus oesophageus
impressio cardiaca

vv.pulmonales

fissura horizontalis

fissura obliqua

lig. pulmonale

basis
pulmonis

Medial wall of
the right lung

Medial wall of
the left lung
fissura obliqua

apex
sulcus a. subclaviae
sulcus
v.brachiocephalicae sin
1.rib impression
sulcus aorticus

a.pulmonalis sin
bronchus principalis sin

vv.pulmonales sin

mesopneumonium
impressio cardiaca

impressio
oesophagea

lig. pulmonale

lingula pulmonis
basis pulmonis

Medial wall of
the left lung

Lymph of the lungs

truncus bronchomedistinalis
truncus tracheobronchialis

n.l.paratracheales dx

n.l. tracheobronchiales sup dx

n.l.paratracheales sin

n.l. tracheobronchiales sup sin

n.l. tracheobronchiales inf

n.l.pulmonales

perilobular

subpleural + peribronchial

n.l.bronchopulmonales
(v hilu)

Regional lymph node classification for lung

cancer staging adapted from the American
Thoracic Society mapping scheme

Superior Mediastinal Nodes (1-4)

1. Highest Mediastinal: above the left
brachiocephalic vein.
2. Upper Paratracheal: above the aortic arch,
but below the left brachiocephalic vein.
3. Pre-vascular or Pre-vertebral: these nodes
are not adjacent to the trachea like the nodes
in station 2. They are either anterior to the
vessels (3A) or behind the esophagus, which is
prevertebral (3P).
4. Lower Paratracheal (including Azygos
Nodes): below upper margin of aortic arch
down to level of main bronchus.

Aortic Nodes (5-6)

5. Subaortic (A-P window): nodes lateral to
ligamentum arteriosum. These nodes are not
located between the aorta and the pulmonary
trunk, but lateral to these vessels.
6. Para-aortic (ascending aorta or phrenic):
nodes lying anterior and lateral to the
ascending aorta and the aortic arch.

Inferior Mediastinal Nodes (7-9)

7. Subcarinal.
8. Paraesophageal (below carina).
9. Pulmonary Ligament: nodes lying within
the pulmonary ligaments.

Hilar, Interlobar, Lobar, Segmental and

Subsegmental Nodes (10-14)
10-14: these are located outside of the
mediastinum.
They are all N1-nodes.

Lymph nodes in the

superior mediastinum

4R, 3A

44-year-old HIV-positive man presents with progressive

dysphagia, epigastric pain, and post-prandial vomiting

Lymphoma of the esophagus

Oesophagus- endoskopy

G-E junction, 2 cm above cardia

ora serrata, Z-line)
squamocolumnar junction
vein

Transverse ridging of the normal esophagus

becoming evident during retching

squamous epithelium

columnar epithelium

Main porto-caval
anastomoses

vv. oesophageae-vv.gastricae
! esophageal varices-bleeding

vv.paraumbilicales - caput Medusae

v.rectalis superior-v.rectalis media

hemorrhoids-bleeding

Thorax x-ray picture

CT - adenocarcinoma, emphysema

CT thymoma in the anterior mediastinum

CT thymoma in
the anterior
mediastinum

CT aspirated tooth filling in the left lower bronchus

CT- ganglioneuroma in the posterior

mediastinum

CT- ganglioneuroma in the posterior

mediastinum

???

Breast implants

Sources

Grim, Zklady anatomie, 5.dl

Petrovick et al., Anatomie II
Elikov, Naka, Pehled anatomie
Schwarzenegger, Encyklopedie kulturistiky
http://anatomy.med.umich.edu/atlas
http://www.auntminnie.com
http://www.radiologyassistant.nl
http://jtcs.ctsnetjournals.org/cgi/content/full/125/3/611/FMTC03164002
http://www.breastcancer.org/treatment/surgery/lymph_node_removal/lymph_nodes.jsp
Mukesh Tripathi, MD, Mamta Tripathi, MBBS, Subclavian Vein Cannulation: An
Approach With Definite Landmarks
An anatomic landmark to simplify subclavian vein cannulation: the "deltoid tuberosity".
von Goedecke A, Keller C, Moriggl B, Wenzel V, Bale R, Deibl M, Moser P, Lirk P.
Department of Anesthesiology and Critical Care Medicine, Medical University of
Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. achim.von-goedecke@uibk.ac.at