THORAX

Stany Lobo PhD

stany.lobo@touro.edu

Surface Anatomy Of The Thoracic Wall:

 Clavicle is subcutaneous at the junction of thorax and neck.

 Sternum is subcutaneous.
 The jugular notch (suprasternal notch) lies at the level of the intervertebral disc between
T2 & T3 vertebrae (space between the spines of T1 & T2).
Manubrium sterni lies at the level of T3 & T4 vertebrae.
 Left side of the manubrium sterni is anterior to the arch of aorta.
 Right side of the manubrium sterni is anterior to the brachiocephalic veins and
Superior vena cava.
 It is common clinical practice to insert catheters into the SVC for feeding extremely ill
patients. SVC projects a finger breadth to the right of the margin of the bone. SVC
enters the right atrium opposite the right 3rd costal cartilage.
Sternal angle lies at the level of intervertebral disc between T4 -T5 (space between spines of T3
& T4)
 Sternal angle marks the level of 2nd pair of costal cartilages. Rib counting is from the 2nd
costal cartilage onwards opposite the sternal angle.
Body of the sternum lies opposite T5-T9 vertebrae
Xiphisternal joint lies at the inferior border of T9 vertebra.
Xiphoid process lies in the epigastric fossa, where the converging costal margins form the
infrasternal angle. This angle is used in Cardiopulmonary resuscitation (CPR) for locating
the proper hand position on the inferior part of the sternal body.
 Tip of ninth costal cartilage= L1
 Lowest part of costal margin= L3
 Root of spine of scapula= T3 spine
 Inferior angle of scapula= T7 spine
 Midclavicular line
 Anterior axillary line
 Midaxillary line
 Posterior axillary line
Dermatomes of the thoracic wall:
 Skin at the level of the clavicle and immediately below- C5
 Anterior chest wall immediately below C5 is supplied by T1.
 T4 dermatome includes the nipple.
 T7 dermatome includes xiphoid process.
  T10 includes the umbilicus.

MAMMARY GLAND
 It is a modified sweat gland.
 It is situated in the superficial fascia on the anterior thoracic wall.
 It is rudimentary in the male.
 A well-developed female adult breast is hemispherical in shape, I guess!
 The amount of fat surrounding the glandular tissue determines the size of the breasts.
 The glandular tissue becomes engorged during pregnancy and lactation. It atrophies in
old age.
 The glandular tissue lies within the lobule and the milk-secreting alveoli are arranged in
grape like clusters around the lactiferous duct.
Extent:
 Transversely- from the lateral border of the sternum to the midaxillary line (MAL).
 Vertically- from the 2nd to the 6th rib.

Nipple- It is an erectile, conical or cylindrical prominence of the skin in the center of the areola.
It has no fat, hair, or sweat glands. It usually lies at the level of the 4th intercostal space.
However, its position varies and consequently, the nipples are not a reliable guide to the 4th
intercostal spaces in adult females. Lactiferous ducts open on the tip of the nipple. Circular
smooth muscles surround the nipple.

Areola- It is a circular pigmented area of the skin surrounding the nipple. It contains numerous
sebaceous glands which appear as nodular elevations on the skin and are called Montgomery’s
tubercles. They provide a protective lubricant for the areola and nipple. The color of the
areola is rose pink and becomes darkly pigmented after pregnancy.

Axillary tail of Spence: It is a small prolongation from the upper outer portion of the mammary
gland extending towards the axilla. It may enlarge during menstrual cycle and give the false
impression of a “lump”.

Bed of the mammary gland: (deep relations). It rests on:

 the pectoral fascia
 Pectoralis major
 Serratus anterior
 Aponeurosis of the external oblique muscle
 Rectus abdominis insertion

Retromammary space:

It is the loose connective tissue space between the breast and pectoral fascia.
It contains fat and allows the breast some degree of movement.
It is relatively avascular, but has a free flow of lymphatics.
Suspensory ligaments of Cooper: These are fibrous condensations of the connective tissue
stroma extending from the skin to the pectoral fascia. They provide an internal support for the
gland.

Lobules of the gland:

The gland is divided into 18-20 radially arranged lobules. Emerging from each lobule, the
lactiferous duct converges towards the nipple like spokes of a bicycle wheel and opens on its
surface by separate opening. Deep to the areola, each duct has a dilated portion, the lactiferous
sinus.

Blood supply:

Arterial supply- 1. Lateral thoracic A (br. of axillary A)

2. Perforating branches (2nd, 3rd and 4th) of the Internal thoracic A (br.of
subclavian A)
3. Anterior intercostal AA (brs. of internal thoracic A)
4. 3rd, 4th & 5th posterior intercostal AA (brs. of the Thoracic Aorta)

Venous drainage- drain to the axillary, internal thoracic and intercostal veins

Nerve supply:
 3rd, 4th and 5th intercostal nerves anterior and lateral cutaneous branches -sensory
 Sympathetic fibers -through the intercostal nerves-to the blood vessels and smooth
muscles

Breast Quadrants:
The surface of the breast is divided into 4 quadrants.
This division enables us to-
 Understand the lymphatic drainage of the skin of the breast
 Upper outer quadrant is mostly involved in breast cancer

Lymphatic drainage-

I. Lymphatics of the skin of the breast except nipple and areola:

 From the upper lateral quadrant- go to the anterior axillary (pectoral) lymph
nodes. From there, to the apical group of axillary lymph nodes and subclavian
lymph trunk and finally end in the thoracic duct (left side) or right lymphatic duct
(right side)
 From the upper medial quadrant- drain to the parasternal (internal thoracic) group
of lymph nodes of the same side. Some lymphatics cross the midline to end in the
internal thoracic group of the opposite side. Some may go to the apical group of
axillary lymph nodes.
  From the lower medial quadrant- Some go to the internal thoracic group of the
same or opposite side. Others pass down towards the lymphatics of the abdominal
wall (communicate with subperitoneal plexus) or peritoneal cavity.
 From the lower lateral quadrant- some drain to the lymphatics of the abdominal
wall and others pass upwards to the axillary group

2. Lymphatics of the lobules of the breast including the skin of the nipple and areola:
Lymph vessels form two plexuses-
 Subareolar plexus of sappey
 Deep pectoral or submammary plexus
The lymphatics from these plexuses drain to the pectoral (anterior) or apical group of
axillary lymph nodes.

Clinical correlations:

Mammary gland glides freely on pectoralis major. If the cancer cells invade the retromammary
space and attach to pectoral fascia, the mammary gland elevates when the pectoralis major
contracts. This movement is a clinical sign of advanced cancer of the breast. The patient is
asked to place her hands on her hips and press. Check this out!

Metastasis of the carcinoma of the breast- cancer cells spread along the lymphatics to the
distant structures like liver, lungs, bones and ovary. Hence, understanding of the lymphatic
drainage is of practical importance in predicting the metastasis.
Axillary lymph nodes are the most common site of the metastasis of the breast cancer.
Enlarged axillary lymph nodes in a woman suggest the possibility of the carcinoma of the
breast. However, the absence of the enlargement is no guarantee that the metastasis has not
occurred.

Metastasis of the carcinoma to the vertebrae, skull and brain can occur through the venous
route (azygous system of veins).
The posterior intercostal veins carry cancer cells directly to the bodies of the vertebrae.
Retraction or puckering of the skin occurs in cancer of the breast. It is due to the involvement
(fibrosis and shortening) of the ligaments of Cooper.
Retraction of the nipple may occur in cancer induced fibrosis of the lactiferous ducts

Peau d’orange sign: Orange peel appearance of the skin of the breast due to edema and pitting
of the skin. Edema is due to obstruction of the cutaneous lymphatics by the cancer cells.
Cyst or Galactocoele- swelling due to obstruction of the lactiferous duct.
Mastectomy: Excision of a breast.
Mammography: Radiographic examination of breasts
Polymastia, polythelia, and Amastia: Amastia is absence of breast.
Gynecomastia: enlargement of the breasts in males. Drug induced, or genetic (eg., Klinefelter
syndrome).
 THORACIC WALL

Thorax (chest) is the part of the body between the neck and abdomen.
It is flat in front and behind but rounded at the sides.

Wall of the Thoracic cage:

The wall of the thorax is called thoracic cage. It is formed by-
 Vertebral column behind
 Ribs and intercostal spaces on the sides
 Sternum and costal cartilages in front.

It protects the lungs and heart and gives attachments for the muscles.
It helps in breathing by increasing or decreasing the size of the thoracic cavity. The muscles on
the wall of the thorax bring this movement.

Above, it is continuous with the neck at the superior thoracic aperture or anatomical inlet of the
thorax and below, it is separated from the abdomen by the diaphragm at the inferior thoracic
aperture or anatomical outlet of the thorax.

Boundaries of the inlet:

 1st thoracic vertebra posteriorly
 1st pair of ribs and their costal cartilages on the sides
 Superior border of the manubrium
The inlet is kidney shaped and slopes anteroinferiorly because of the obliquity of the 1st pair of
ribs. Major structures passing are-
Trachea, Esophagus, nerves and blood vessels that supply and drain the head, neck and the upper
limbs. The apex of the lung rises only to the level of the neck of the 1st rib.
A sheet of fascia, called Sibson's Fascia, extends from the transverse process of the 7th cervical
vertebra to the inner border of the 1st rib and covers and protects the apex of the lung.

Clinical correlation: Though anatomically it is known as “inlet”, clinically, a host of

pathological conditions (neurovascular conditions) associated with this aperture are referred as
“Thoracic outlet syndrome”. For ex: Costoclavicular syndrome- compression of subclavian
A b/w the clavicle & 1st rib
Cervical rib syndrome- compression of C8 & T1 nerve roots of the
brachial plexus
by development of a Cervical rib above the 1st rib.

Boundaries of the outlet:

 12th thoracic vertebra posteriorly
 11th & 12th pair of ribs
 cartilages of ribs 7 through 10
 Xiphisternal joint anteriorly
It is closed by the diaphragm.
The cavity of the thorax has a median septum called mediastinum. On both sides of the
mediastinum are the lungs covered by pleura.

Bones of the thoracic cage:

The thoracic skeleton includes-

12 pairs of ribs and costal cartilages
12 thoracic vertebrae and intervertebral discs
The sternum

STERNUM
Sternum lies in the midline in the front of the chest wall.
It is a flat bone.
It forms the anterior boundary of the mediastinum.

Parts of the sternum:

It has 3 parts- 1. Manubrium, 2. Body, 3. Xiphoid process

Manubrium- Is the upper part. It is the thickest and widest part of the sternum
Its upper end has suprasternal notch (at the level of the lower border of the body of 2nd thoracic
vertebra).
It lies at the level of 3rd and 4th thoracic vertebrae.
It forms the anterior boundary of the superior mediastinum
Its posterior surface is related to the arch of the aorta and its three branches.
It articulates on each side with clavicles, 1st and 2nd costal cartilages (of the ribs).
The 1st sternocostal joint is a primary cartilaginous joint
Below, it articulates with the body of the sternum- at the manubriosternal joint which projects in
front as the “sternal angle”.
Sternal angle or angle of Louis: This angle is at the level where the second rib articulates with
the sternum.

Palpation of the sternal angle locates:

1. the cartilage of the second rib (2nd costal cartilages)

2. the division between the superior and inferior mediastina
3. the beginning and end of the arch of the aorta
4. the bifurcation of the trachea
5. the inter vertebral disc between the 4th and 5th thoracic vertebra

Note: The 1st rib is not palpable because it is deep and partly hidden by the clavicle. Therefore,
rib counting in physical examinations starts with the 2nd rib adjacent to the sternal angle.

Body-
Thin, longer and narrower than manubrium. It lies below the manubrium.
It lies in front of the 5th – 9th thoracic vertebrae.
It forms the anterior boundary of the Inferior mediastinum
Above, it articulates with the manubrium at the manubriosternal joint (secondary cartilaginous
joint).
Below, it articulates with the xiphoid process at the xiphisternal joint (secondary cartilaginous
joint).
On each side, it articulates with the 2nd to the 7th costal cartilages (synovial joints)

Xiphoid process-
Lowest and smallest part
It lies in front of the 10th thoracic vertebra.
Its lower end may be pointed or bifid
Linea Alba is attached to its tip.
Ribs or costal cartilages are not attached to it.
Muscles attached to the sternum – Pectoralis major, sternocostalis, sternohyoid, sternothyroid,
sternocleidomastoid, Internal oblique, diaphragm.

RIBS
There are 12 pairs of ribs. They form the skeleton of the thoracic cage.
Ribs are long, curved, flat, elastic bones.
They extend from the vertebrae behind, to the sternum in front.
Each rib articulates with two vertebrae- with the numerically corresponding vertebra and
the vertebra above.

Classification of ribs:

Classified into 3 types:

 True ribs: 1st to 7th ribs. They directly articulate with sternum through their own costal
cartilages.
 False ribs: 8th, 9th, 10th ribs. They indirectly join the sternum through 7th costal
cartilage.
 Floating ribs: 11th and 12th ribs. They are not connected to the sternum. Their anterior
ends are free.

Typical and Atypical ribs:

3-9 ribs are typical because they have same features
1st, 2nd, 10th, 11th, and 12th ribs are atypical because they have features that are not common to
other ribs.

Typical Rib
Ribs 3-9 are typical.
Parts- Each typical rib has- head, neck, tubercle, shaft (body).

Head- Lies at the posterior end of the rib. It is broad.

It has two facets and a crest between the facets.
Lower facet is larger and articulates with the numerically corresponding vertebra.
Upper facet articulates with the vertebra above.
The crest articulates with the intervertebral disc.
Ligaments of the head- radiate ligament and intra articular ligament.
Neck- Narrow. Connects the head with the shaft. Internal intercostal membrane is attached to it.
Tubercle- Lies at the junction of the neck with the shaft.
It has a smooth medial articular part which articulates with the transverse process of
corresponding vertebra.
Lateral non-articular part gives attachment to costo-transverse ligament.
Shaft- Thin, flat, and curved. There is an angle of the rib where it bends lateral to the tubercle.

The concave internal surface has a costal groove along its lower border. Intercostal vein, artery
and nerve run along the groove in the order from above downwards (VAN). The lips give
attachment to intercostal muscles.
Muscles attached to the ribs: Intercostal muscles (external, internal & innermost intercostal
muscles), Serratus anterior, serratus posterior superior & inferior, external oblique muscle
Atypical Ribs
1st, 2nd, 10th, 11th, &12th ribs

1st Rib: Broadest & shortest. More curved. Has single facet on its head for 1st thoracic
vertebra.
There is a scalene tubercle on the inner border of its upper surface for attachment to Scalenus
anterior muscle. Groove in front and behind the tubercle is related to subclavian vein & artery
respectively. The area behind the groove for the subclavian artery receives the attachment of the
scalenus medius.
The inner border gives attachment to Sibson’s fascia (suprapleural membrane).
Outer border gives attachment to the 1st digitations of the serratus anterior muscle.

The neck of the 1st rib is related to the following structures from lateral to medial:
 1st thoracic spinal nerve (T1)
 Superior intercostal artery
 1st posterior intercostal vein
 Sympathetic chain

2nd Rib: Thinner and less curved (no angle). It has no twist and hence both ends touch
ground when placed. It has two facets on its head for articulation with T1 &T2 vertebrae.
Scalenus posterior and serratus anterior are attached to it
10th -12th Ribs- have only one facet on their heads. 12th rib gives attachment to diaphragm and
quadratus lumborum muscles and lumbocostal arches

Thoracic Vertebrae:
They are 12 in number. Each vertebra articulates with 4 ribs.
They have costal facet on the sides of the body for articulation with the head of the ribs. Costal
facet on the transverse processes articulates with the tubercle of the rib.
They can be identified by –
 Circular vertebral foramen
  Presence of costal facets on the sides of the bodies & in transverse processes
 Absence of “foramen transversarium”( characteristically seen in cervical vertebrae)
 Absence of mammilary and accessory processes (that are characteristic features of
lumbar vertebrae)

Typical thoracic vertebrae- 2nd – 8th are typical. They have costal facets on the body &
transverse process.
Atypical thoracic vertebrae- 1st, 9th 10th, 11th, & 12th
 1st thoracic vertebra has circular upper costal facets on the sides of the body articulating
with the whole of the facet on the head of the 1st rib & inferior demifacet for the 2nd rib.
 9th thoracic vertebra has only superior demifacet. Inferior demifacets are absent.
 10th, 11th & 12th have one circular facet on each side of the body. Costal facets in the
transverse processes are absent in the 11th and 12th vertebrae.

Parts of thoracic vertebra- Body, pedicles, transverse processes, laminae, spine

 Body is heart shaped. Anterior and posterior longitudinal ligaments are attached to it.
Vertebral foramen is small and circular. The left half of the anterior surfaces of the bodies
of the 5th -12th vertebrae is related to the descending aorta.
 Two demifacets or costal facets are located on the bodies of T2 through T8 vertebrae.
The superior demifacet articulates with the head of its own rib (rib of the same number).
 The anterior surfaces of the transverse processes have costal facet for articulation with
the tubercle of the ribs.
 Spine is directed downwards and backwards. Trapezius, latissimus dorsi, rhomboids
muscles, and the supraspinous and interspinous ligaments are attached to the spine.

Muscles of the Thoracic Wall:

Pectoralis Major, Pectoralis Minor, Subclavius, Serratus Anterior, Scalenus Anterior, Scalenus
medius and Scalenus posterior, external oblique are the muscles that attach to the outer surfaces
of the ribs and cover the thoracic wall. They assist in respiration by elevating the ribs. They are
called accessory respiratory muscles.
Serratus posterior superior and Serratus posterior inferior: are two inspiratory muscles. They
extend from vertebrae to the ribs.

Intercostal space
It is the space between two adjacent ribs.
There are 11 pairs of intercostal spaces.
They appear as horizontally running depressions between adjacent ribs and their cartilages.
These spaces are occupied by intercostal muscles, vessels, and nerves.
The space has intercostal muscles arranged in 3 layers.
 External intercostal muscle
 Internal intercostal muscle
 Innermost intercostal muscles.
Arrangement of the Nerves and vessels:
They run in the neurovascular plane between the internal and innermost intercostal muscles
Within each intercostal space there are two neurovascular bundles.
 The larger of the two travels along the groove on the inner surface of the inferior border
of the rib, with the vein most superior, then the artery, and finally the nerve most inferior
(VAN).
 The smaller, collateral branches of all three travel along the superior border of the rib
below. The orientation is just the opposite, with the nerve most superior, then the artery,
then the vein. (You could just remember that the vein is always closest to the rib and the
nerve farthest away.)

Typical intercostal spaces:

 3rd to 6th spaces are called typical intercostal spaces.
 They are located between the typical ribs.
 The intercostal nerves in these spaces restrict their supply to the thoracic wall only.

Atypical intercostal spaces:

 1st, 2nd, 7th-11th spaces
 1st and 2nd intercostal nerves supply upper limb.
 7th – 11th intercostal nerves supply anterior abdominal wall.
 Hence, the above intercostal spaces are atypical spaces.

Intercostal nerves
 Thoracic wall has 12 pairs of thoracic spinal nerves.
 Each thoracic spinal nerve emerges from the intervertebral foramen and divides into a
dorsal and ventral ramus.
 The ventral rami of T1-T11 nerves form the intercostal nerves that run along the
intercostal spaces
 Thus there are 11 pairs of intercostal nerves.
 The ventral ramus of the 12th thoracic spinal nerve runs below the 12th rib and is called
subcostal nerve. It is not called intercostal nerve because there is no 12th intercostal
space.
 The dorsal rami of thoracic spinal nerves pass posteriorly to supply the bones, joints,
muscles, and skin of the back in the thoracic region.

Typical and Atypical intercostal nerves:

 The nerves in the 3rd to 6th intercostal spaces are called typical intercostal nerves.
They have typical course in their own intercostal spaces and limit their supply to the
thoracic wall only.
 1st intercostal nerve is slender as the major part of it joins the brachial plexus to supply
the upper limb and it does not give a lateral cutaneous branch. Hence, it is atypical
  2nd intercostal nerve gives rise to a lateral cutaneous branch called the
intercostobrachial nerve which joins the medial cutaneous nerve of the arm to supply
the upper and medial aspect of the arm. Hence, it is atypical.
 The lower 5 intercostal nerves (7th-11th) run partly in the thoracic wall and partly in
the anterior abdominal wall. Hence they are atypical.

Typical intercostal nerve:

 3rd to 6th intercostal nerves are typical intercostal nerves.

 Each nerve emerges from the intervertebral foramen and reaches the posterior end of the
intercostal space. Here it lies between parietal pleura and internal (posterior) intercostal
membrane & joined by the intercostal vein and artery. Near the angle of the rib, it passes
forward in the costal groove in the neurovascular plane between the internal and
innermost intercostal muscles. In the costal groove, the vein, artery and the nerve lie in
that order from above downwards in the intercostal space (VAN).
 Near the angle of the rib it gives a collateral branch which supplies the intercostal
muscles.
 At the anterior end of the intercostal space, the nerve runs between the internal intercostal
and sternocostalis muscles and then runs in front of the internal thoracic artery. Here it
turns forwards and pierce the internal intercostal muscle, anterior (external) intercostal
membrane and ends as the anterior cutaneous branch.
Branches of the intercostal nerve:
 Communicating branches (rami communicantes) to the sympathetic trunk
 Collateral branch- this branch runs in the intercostal space along the upper border of the
rib below.
 Lateral cutaneous branch- divides into anterior and posterior branches and supply skin
 Anterior cutaneous branch- is the terminal end of the nerve. Supplies skin on the front of
the chest
 Muscular branches- supply the intercostal muscles and the serratus posterior muscles.

Dermatomes: Each thoracic spinal nerve through its sensory branches supplies a well-defined,
strip-like area of skin extending from the posterior median line to the anterior median line.
Closely related dermatomes overlap considerably. Hence, lesion of a single spinal nerve may not
produce noticeable sensory deficit.

Herpes Zoster infection: It produces dermatomally distributed skin lesion- shingles- a very
painful condition. It is a viral disease of the spinal ganglion that produces a sharp burning pain
in the dermatome supplied by the involved nerve. The affected area of skin becomes red and
vesicular eruptions appear.

Intercostal nerve block: To produce local anesthesia of an intercostal space, the anesthetic
agent is injected near the paravertebral line- corresponding to the tip of the transverse process
of the vertebra.

Thoracocentesis: Hypodermic needle is inserted through an intercostal space into the pleural
cavity to obtain a sample of pleural fluid, or to remove blood or pus.
To avoid damage to the intercostal nerve and vessels, the needle should be inserted superior
to the rib, high enough to avoid the collateral branch. The needle passes through the
intercostal muscles and the parietal pleura to reach the pleural cavity.

Arterial supply of the Thoracic wall:

 Subclavian artery – Through internal thoracic and superior intercostal arteries

 Axillary artery – through superior thoracic and lateral thoracic arteries.
 Thoracic aorta – through posterior intercostal and subcostal arteries

Intercostal arteries:

Each intercostal space has:

 Two anterior intercostal arteries
 One posterior intercostal artery

Anterior intercostal arteries:

 Two in each space except the last two spaces.

 10th and 11th intercostal spaces do not have anterior intercostal arteries.
 Anterior intercostal arteries of the upper 6 spaces are branches from the internal
thoracic artery
 Anterior intercostal arteries of the 7th, 8th & 9th spaces arise from the musculophrenic
artery

Posterior intercostal arteries:

 There are 11 posterior intercostal arteries, one for each space.

 The first and second posterior intercostal arteries are the branches of superior
intercostal artery, which is a branch of the costocervical trunk of the subclavian artery.
 The remaining 9 posterior intercostal arteries for 3rd to 11th spaces arise from the
descending thoracic aorta

Right posterior intercostal arteries are longer than the left.

This is because the thoracic aorta lies left of the median plane
Right posterior intercostal arteries arise from the posterior aspect of the aorta and course to the
right side behind:
 Esophagus
 Azygos vein
 Thoracic duct
 Sympathetic trunk
The left posterior intercostal arteries arise from the back of the thoracic aorta and course to the
left side behind:
 Hemiazygos veins
  Sympathetic trunk

Branches of the posterior intercostal artery

 dorsal branch which supplies the muscles and the skin of the back
 collateral branch
 muscular branches
 lateral cutaneous branch
Clinical: In coarctation of aorta, collateral anastomosis is established between branches of
thoracic aorta and internal thoracic artery

Venous Drainage of the Thoracic wall

INTERCOSTAL VEINS:
They accompany the intercostal arteries and nerves.
They correspond to their arteries.
They lie deepest (most superior) in the costal grooves.

There are two anterior intercostal veins in each space and one posterior intercostal vein.
Anterior intercostal veins of upper six spaces open into the "internal thoracic vein"
Anterior intercostal veins of 7th, 8th and 9th spaces open into the "musculophrenic vein"
10th & 11th spaces do not have anterior intercostal veins

Posterior intercostal veins:

There are 11 posterior intercostal veins.
They are different on right and left sides

Right posterior intercostal veins:

The first right posterior intercostal vein: It ascends in front of neck of the 1st rib.
It arches forwards superior to the apex of the lung and supraplueral membrane and opens into the
right brachiocephalic vein.

The 2nd, 3rd & the 4th posterior intercostal veins join together to form right superior intercostal
vein. It opens into the arch of azygos vein.
5th to 11th posterior intercostal veins open into the vertical part of the azygos vein

Left posterior intercostal veins:

The first left posterior intercostal vein - The same course as the right one and opens into the
left brachiocephalic vein.

The 2nd, 3rd and 4th posterior intercostal veins join to form the left superior intercostal vein.
It crosses superficial to arch of aorta and opens into left brachiocephalic vein.
The 5th, 6th, and 7th independently open into the superior hemiazygos vein
8th to 11th posterior intercostal veins open independently into the inferior hemiazygos vein.
 Intercostal muscles
They lie in the intercostal spaces between ribs.
They prevent separation of ribs.
They prevent bulging in or caving out of intercostal spaces.
Three intercostal muscles in each space-External intercostal, Internal intercostal and Innermost
intercostal- arranged in layers from outside inwards. They elevate the ribs

External Intercostal Muscles: 11 pairs.

 Extend from the tubercles of the ribs posteriorly to the costochondral junctions anteriorly.
 Anteriorly they are replaced by the anterior (external) intercostal membranes.
 Origin- from the inferior border of the rib above
 Insertion- to the superior border of the rib below. The fibres run downwards and
forwards.
 Action- Elevate the ribs – muscles of inspiration.

Internal Intercostal Muscles: 11 pairs.

 Lie deep to the external intercostal muscles.
 Extend from the sides of the sternum to the angle of the ribs posteriorly
 Medial to the angles they are replaced by the posterior (internal) intercostal membranes.
 Origin- from the floor of the costal groove
 Insertion- to the superior border of the rib below. Fibers run downwards and backwards
 Action- Muscles of inspiration.

Innermost Intercostal Muscles:

 Not continuous, present in 3 places and has 3 parts. Intercostal nerves and vessels lie
between these two muscles.
Intercostalis intimi:
 The fibers run in the same direction as that of internal intercostal muscles.
 Origin & Insertion-They pass between the internal surfaces adjacent ribs.
 Action- helps in inspiration

Subcostal muscles: Present in the posterior parts of the lower spaces only.
Extend from the internal surface of the angle of one rib to the internal surface of the rib
below crossing one or two intercostal spaces. Run in the same direction as internal
intercostal muscles.
Action- depress the ribs.

Sternocostalis: consists of 4 or 5 slips. Present in the anterior parts of the spaces.

Origin- from the posterior surface of the xiphoid process & inferior part of the body of the
sternum. The fibres run upwards and laterally
Insertion- to the costal cartilages of the 2nd- 6th ribs
Action- help in expiration movement. (depression of costal cartilages)
Note: Innermost intercostals, subcostals, and the sternocostal muscles together are called
“Transversus thoracis”.

JOINTS OF THE THORACIC WALL

1. Costovertebral Joints:
The rib articulate with the vertebra at two joints-
a) Joints of Heads of ribs:
Articulation between the heads of the ribs and the bodies of the thoracic vertebrae.
1st, 10th, 11th and 12th ribs articulate with their corresponding vertebrae only.
Other ribs each will articulate with the corresponding vertebra and the vertebra above it and
between the two vertebrae, with the intervertebral disc.
Type- Synovial- plane variety.
Ligaments- 1. Fibrous capsule
2. Radiate ligament
3. Intra-articular ligament
b) Costotransverse Joints :
Tubercle of the rib articulates with the costal facet on the transverse process of the
corresponding vertebra.
It is absent in the 11th and 12th ribs.
Type- synovial-plane variety
Ligaments-1. Fibrous capsule
2. Superior costotransverse ligament
3. Inferior costotransverse ligament
4. Lateral costotransverse ligament
2. Costochondral joints-
Primary cartilaginous joints permitting no movements

3. Interchondral joints-
Synovial type of joints between the costal cartilages of the 7th- 9th ribs

4. Sternocostal or chondrosternal joints-

1st sternocostal joint – Primary cartilaginous joint
2nd – 7th sternocostal joints are synovial joints

5. Manubriosternal joint-
Secondary cartilaginous joint
Slight sliding movement between the manubrium & body of sternum

6. Intervertebral joints- between:

1. Bodies of the vertebrae (secondary cartilaginous type)
2. Vertebral arches (plane synovial type).
 Movements –flexion & extension of the vertebral column & rotatory movement (best seen in
thoracic region).
Normal curvatures of the vertebral column- primary and secondary curvatures
Primary curvatures are thoracic and sacral (pelvic)- concave anteriorly
Secondary curvatures are cervical and lumbar- both concave posteriorly
Abnormal curvatures of the vertebral column:
Excessive Kyphosis: Hump back or hunch back
Excessive Lordosis: Sway back
Scoliosis: Crooked back

Movements of the Thoracic wall – Mechanism of Respiration:

Respiration consists of two parts - Inspiration and expiration.
The average rate of respiration is 18 per minute.
Movements of the thoracic wall and Diaphragm during inspiration produce increase in the
intrathoracic volume and diameters of the thorax.
Intrathoracic pressure changes- result in air being alternately drawn into the lungs (inspiration) or
expelled (expiration).
Air enters or leaves the lungs through the nose, mouth, pharynx, larynx & trachea.
 Inspiration is an active process (contraction of intercostal muscles & diaphragm). The
intrathoracic volume increases & intrathoracic pressure decreases.
 Expiration is a passive process (relaxation of intercostal muscles & diaphragm, elastic
recoil of the elastic tissue in the lungs). The intrathoracic volume decreases &
intrathoracic pressure increases.

During inspiration all three diameters of the thoracic wall increase causing increase in the
volume of the thorax.
The three diameters are- 1. Antero-posterior, 2. Transverse 3. Vertical

1. Antero-posterior diameter- (Pump-handle) increased by the elevation of the ribs by intercostal

muscles. The elevation of the ribs cause the sternum to move forwards and upwards.
A small movement in the posterior end of the rib (at the costovertebral joint) causes a larger
movement at the anterior end of the rib which lifts the sternum upwards and forward.
During expiration, the sternum is brought back to its position. This is called “Pump-handle”
movement.

2. Transverse diameter- (Bucket-handle). The middle of the shafts of the ribs is at a lower level
than their ends. The middle part of the rib elevates by outward twist- like lifting the handle of a
bucket. This increases the transverse diameter of the thoracic wall. This is called “Bucket-
handle” movement.

3. Vertical diameter-The contraction of the diaphragm results in the lowering of its central
tendon and this brings about increase in the vertical diameter.
Expiration – opposite of inspiration. It is passive (relaxation of intercostals & diaphragm, elastic
recoil of the lung)
 INTERNAL THORACIC ARTERY

It is a branch of the first part of the subclavian artery in the neck.

It arises 2cm above the sternal end of the clavicle
It runs downwards and medially behind:
 Sternal end of the clavicle
 Brachiocephalic vein
 First costal cartilage
 Phrenic nerve
It runs vertically behind the upper six costal cartilages about 1cm from the margin of the
sternum
It runs between the sternocostalis and internal intercostal muscles
It is accompanied by two venae comitantes upto the level of 3rd costal cartilage where they
unite to form one internal thoracic vein.
The artery is also accompanied by internal thoracic chain lymph nodes
Termination: It divides into its two terminal branches at the level of the sixth intercostal
space into:
 1) superior epigastric A
 2) musculophrenic A
Branches:
1. Pericardiacophrenic- accompanies Phrenic nerve to diaphragm. Supplies pericardium &
pleura
2. Mediastinal
3. Anterior intercostal arteries for the upper six spaces
4. Perforating arteries accompany the anterior intercostal nerves. In female, 2nd, 3rd and
4th perforating arteries are large and supply the breast.
5. Superior epigastric artery
6. Musculophrenic artery

Clinical: Internal thoracic artery is often used for grafting in the coronary bypass. As compared
to saphenous vein coronary bypass grafts, internal thoracic artery grafts have shown a better
survival rate.

DIAPHRAGM

It is a broad muscular partition between the thorax and abdomen.

It is the main muscle of respiration. It is dome shaped.
It has a central tendon and peripheral muscular part.
It has 3 major openings – for 1. Esophagus 2. Aorta 3. Inferior vena cava.

Origin- Sternal part- from the xiphoid process

Costal part- from the lower six ribs and their costal cartilages
 Vertebral part- has right crus which arises from upper 3 lumbar vertebrae
left crus that arises from the upper 2 lumbar vertebrae
Median, Medial and lateral Arcuate ligaments (lumbocostal arches): Median arcuate
ligament connects the medial sides of the right and left crus anterior to the aortic opening.
Medial arcuate ligament connects the lateral side of each crus to the transverse process of L1
vertebra. Lateral arcuate ligament passes over the anterior surface of the quadratus lumborum
and connects the transverse process of L1 vertebra to the 12th rib. A developmental deficiency in
the lateral arcuate ligament leads to diaphragmatic hernia

Insertion- into the Central tendon in the middle of the diaphragm.

Nerve supply of Diaphragm-

 Phrenic Nerve (C3, 4, 5- root value)- Motor to the entire muscle & sensory to the central
part
 lower 5 intercostal nerves & subcostal nerves- Sensory to the peripheral part

Action- on contraction, it pulls down the central tendon & increases the vertical diameter.
It is the Main muscle of inspiration.

Other functions of the diaphragm are:

Muscle of abdominal straining- increases the intra abdominal pressure during defecation,
micturition etc.
Weight lifting- by raising intra-abdominal pressure and supporting the vertebrae
Thoraco-abdominal pump- Descent of diaphragm decreases the intrathoracic pressure and
increases the intra-abdominal pressure. This forces blood in the inferior vena cava into the right
atrium.

Openings in the Diaphragm:

Three large openings—the aortic, the esophageal, and the vena caval—and a series of smaller
ones.
The aortic hiatus is the lowest and most posterior of the large apertures.
It lies at the level of the T12-twelfth thoracic vertebra.
The hiatus is situated slightly to the left of the middle line.
Structures passing through it are:
 Aorta
 Azygos vein
 Thoracic duct
The esophageal hiatus is situated in the muscular part of the diaphragm.
It is elliptical in shape
It lies at the level of T10- tenth thoracic vertebra.
It is placed above, in front, and a little to the left of the aortic hiatus.
It transmits:
 Esophagus
 Vagus nerves-Anterior and Posterior vagal trunks
 some small esophageal arteries- from the left gastric A
  tributaries of left gastric vein

The vena caval foramen is the highest of the three.

It is situated about the level of T8
It is quadrilateral in form, and is placed at the junction of the right and middle leaflets of the
central tendon, so that its margins are tendinous. IVC is adherent to the margins of the opening.
It transmits:
 Inferior vena cava
 Branches of the right phrenic nerve

Smaller apertures in the diaphragm:

 Left phrenic nerve

 For the greater and lesser splanchnic nerves
 Hemiazygos vein
 Sympathetic trunk enters the abdominal cavity behind the diaphragm under the medial
lumbocostal arches.
 Between the sternal and costal parts- transmits the superior epigastric artery & some
lymphatics.

Clinical correlations:
 Section of phrenic nerve- Complete paralysis and atrophy of the corresponding half of
the diaphragm (paralysis of hemidiaphragm), except in persons who have an accessory
phrenic nerve. It can be recognized radiographically by its permanent elevation and
paradoxical movement (ascends superiorly during inspiration).
 Hiccups: are involuntary spasmodic contractions of diaphragm due to irritation of nerve
supply.
 Referred pain from diaphragm: radiates in two directions-
o From the central part (irritation of the diaphragmatic pleura or peritoneum) is
referred to the shoulder region, the area supplied by the C3-C5 nerves (segment of
spinal cord contributing to phrenic nerves).
o From the peripheral parts of the diaphragm: is more localized, being referred to
the skin over the costal margins of the anterolateral abdominal wall (lower
intercostal nerves).
 Congenital diaphragmatic hernia: Posterolateral defect is the most common anomaly
of the diaphragm. It occurs on the left side in about 70% of cases due to failure of the
pleuroperitoneal canal to close completely during embryonic development. This defect in
the diaphragm is called foramen of Bochdalek and the hernia is called Bochdalek hernia.
 Rupture of diaphragm and herniation of viscera: May occur due to severe
trauma. Most ruptures occur on the left side. Stomach, Intestine, mesentery or
spleen may herniate

PLEURAL CAVITY AND LUNGS

The thoracic wall encloses the thoracic cavity.

The thoracic cavity is divided into 3 divisions or compartments.
 Two lateral compartments- the pulmonary cavities- that contain the lungs
and pleurae
 A central compartment- the mediastinum- that contains all other thoracic
structures- the Heart, great vessels, trachea, esophagus, thymus, and other
structures (lymph nodes).

 The two pulmonary cavities are completely separate from each other.
 The mediastinum extends from the superior thoracic aperture to the
diaphragm.

Pleura

 It is a thin, closed, serous sac

 It has two layers. The outer and the inner layer
 The outer layer lines the inner surface of the body wall and therefore called parietal
layer.
 The inner layer covers the outer surface of the lung and therefore it is called visceral
layer.
 Pleura is indeed a single layer that is folded inwards by the lung from its medial side.
 This folding results in the formation of two layers.
 Visceral pleura and Parietal pleura

 It is like a half air-filled balloon into which we push our fist. The part of the balloon
which covers our fist (representing the lung) is called visceral pleura and the rest of the
outer part is called parietal pleura.
 The point of invagination of the wrist represents the root of the lung where the two
layers are continuous with each other.
 The cavity between the two layers of the pleura is called pleural cavity.
 The pleural cavity is filled with a thin film of fluid called pleural fluid. The pleural fluid
permits the two layers to move on each other with very little friction.

Visceral pleura:

 It is also called pulmonary pleura

 It closely covers the lung and is attached to all its surfaces.
 It dips into the fissures of the lung.
 It forms the outer layer of the lung and gives the lung a smooth slippery
surface.
 The visceral pleura is continuous with the parietal pleura at the hilum (root) of
the lung where structures enter or leave the lung.
 It is absent at the hilum and at the attachment of the pulmonary ligament.
 It is developed from the splanchnic mesoderm.
  It is supplied by the autonomic nerves
 It is insensitive to pain.
Parietal pleura:

 It is the outer layer of the pleura.

 It lines the pulmonary cavities. It is attached to the inner surfaces of the
thoracic walls.
 It is developed from the somatic mesoderm
 It is supplied by the somatic nerves (intercostal and phrenic)
 It is supplied by the somatic vessels
 It is separated from the inner surface of the thoracic wall by the
endothoracic fascia

Parts of the parietal pleura:

It is divided into 4 parts-
(All the four parts are continuations of one single parietal layer that receives different
names in different places of the thoracic cavity).

1. Costal pleura- lines inner surface of thoracic wall (ribs and intercostal spaces).
Related to the sternum, ribs, costal cartilages & intercostal muscles.
Endothoracic fascia (Loose areolar tissue) lies between the thoracic wall and the
costal pleura.
The line along which the costal pleura is continuous with the mediastinal pleura is
called
"Costomediastinal line of reflection"
Nerve supply: intercostal nerves

2. Mediastinal pleura- It covers the sides of the mediastinum and forms its lateral wall.
It is related to structures in the mediastinum.
It extends from the costomediastinal reflection to the costovertebral reflection.
At the root of the lung it encloses the structures like a sleeve.
Below the root of the lung it forms a double layer of pleura called "pulmonary ligament".
Nerve supply: Phrenic nerve

3. Diaphragmatic pleura- It covers the superior surface of the diaphragm.

It is continuous with the costal pleura at the “costodiaphragmatic line of pleural
reflection”.
Nerve supply: Peripheral part is supplied by the intercostal nerves and the central part is
supplied by
the phrenic nerve

4. Cervical pleura-Covers the apex of the lung and extends into the root of the neck through
the inlet of the thorax.
It is related to the first rib and clavicle.
It extends 1 inch above the medial ⅓ of the clavicle. But posteriorly it does not rise
above the level
 of the neck of the 1st rib.
It is covered by suprapleural membrane (Sibson’s fascia).
Nerve supply: intercostal nerves

Supraplueral membrane: (Sibson's fascia):

It extends from the transverse process of the 7th cervical vertebra to the inner border of the
first rib. It protects the apex of the lung. All the structures related to the apex of the lung
must lie superficial to the suprapleueral membrane.
Pulmonary ligament:

Parietal pleura covers the root of the lung like a loose sleeve and not like a circular tube.
Therefore it extends inferiorly beyond the root as a double layer.
This fold of pleura is called the "pulmonary ligament"
This contains loose areolar tissue with a few lymphatics.
It provides "dead space" for the pulmonary veins, which can occupy this space when
they happen to bring more blood during strenuous exercise.
It lies between the side of the esophagus and the medial side of the corresponding lung below
its hilum.
Blood supply and lymphatic drainage of pleura:
Parietal pleura is supplied by the intercostal, internal thoracic and musculophrenic
arteries.
Veins drain into internal thoracic veins anteriorly and into azygos, superior & inferior
hemiazygos veins posteriorly.

Lymphatics drain into intercostal and internal thoracic nodes anteriorly, into posterior
mediastinal lymph nodes posteriorly, into diaphragmatic nodes inferiorly.

Pulmonary pleura is supplied by bronchial vessels like the lung

Lymph vessels of this pleura drain into bronchopulmonary lymph nodes.
Nerve supply of the pulmonary pleura is from the pulmonary plexus (autonomic)

Pleural Recesses:
These are spaces in the pleural cavity which are not filled by the lung during normal
quiet breathing.
These are filled by the pleural fluid.
The parietal pleura extends beyond the lung margins in these areas, creating a reserve space
to which lung expands during deep inspiration.
There are 2 pleural recesses-
1. Costo-mediastinal recess
2. Costo-diaphragmatic recess
 Costomediastinal recess: lies between the costal and mediastinal pleurae
 o It lies behind the sternum and costal cartilages along the
costomediastinal reflection
 This recess is particularly well defined in relation to the cardiac notch of
the left lung
 Costodiaphragmatic recess lies between the costal and diaphragmatic
pleura along the costodiaphragmatic line of reflexion.

The lung is at the level of 8th rib in the midaxillary line whereas pleurae extend to the
level of 10th rib.
The space between the 8th and 10th rib in the midaxillary line is the extra space called
costodiaphragmatic recess. Pleural effusion fills up this space first.

Surface marking of the pleura

Cervical pleura is marked by a curved line from the junction of medial third with the
middle third of the clavicle to the sternoclavicular joint.
The convexity of the line should be one inch above the clavicle.

Costomediastinal line of pleural reflection:

a. Upper part - (Common to right and left sides)

From the sternoclavicular joint to the midline at the sternal angle
A vertical line from the midpoint of the sternal angle to the level of fourth costal cartilage

b. Lower part - From here it is different on two sides.

Right side: It continues vertically along the midline to the level of the xiphisternal joint.
Left side: It arches laterally and descends along the sternal margin up to the 6th costal
cartilage.

Costodiaphragmatic line of pleural reflection:

This reflection is same on both sides except that the right pleura crosses the right
costoxiphoid angle while left pleura does not cross
The reflection is marked by selecting the following points and joining them:
6h costal cartilage (sternal end)
8th rib in the midclavicular line
10th rib in the midaxillary line
2 cm lateral to the spine of 12th thoracic vertebra
Posteriorly, it crosses the 12th rib and descends below it medially.
Therefore it crosses the costovertebral angles below the medial end of 12th rib (behind
the upper poles of the kidneys)
It is important to note that pleura descend below the costal margin at three places:
Right costoxiphoid angle
Right costovertebral angle
Left costovertebral angle
The inferior border of the visceral pleura or lung falls short of the parietal pleura by 2 rib
distance.

Costovertebral reflection of pleura (posterior border):

A vertical line is drawn connecting two points
 2 cm lateral to the 7th cervical spine
 2 cm lateral to the 12th thoracic spine
The costal pleura become mediastinal pleura along this line.

Clinical applications:

 Pleurisy: The inflammation of pleura

 Pneumothorax: presence of air in pleural cavity. It can lead to pulmonary collapse.
 Pleural effusion: collection of fluid in the pleural cavity (empyema, hydro-, hemo- &
chylothorax)
 Empyema: presence of pus in the pleural cavity
 Hydrothorax: Accumulation of serous fluid in one or both pleural cavities.
 Hemothorax: presence of blood in pleural cavity
 Chylothorax: collection of lymph fluid in pleural cavity
 Paracentesis thoracis: Aspiration of fluid from pleural cavity (8th or 9th intercostal
space in midaxillary line)
 Posterior approach at 11th rib for renal surgery may cause pneumothorax.
Lungs
 Lungs are the vital organs of respiration. They are two, right & left.
 They oxygenate the blood.
 Healthy lungs in living people are light, soft, and spongy.
 They are elastic. They float on water.
 Right lung is heavier than the left.
 Lungs are present in the pulmonary cavities.
 The lungs are separated from each other by the mediastinum (containing heart,
viscera and great vessels). In fact, mediastinum is the median septum between the
right and left pleurae.
 The lungs are conical in shape.
 Each lung is covered by the pulmonary pleura except at the hilum.
 The roots of the lungs connect them to the heart & trachea.

Root of the lung- Present on the medial surface of the lung. It is formed by the structures
entering or leaving the lung at its hilum - bronchus, pulmonary vessels, bronchial vessels,
lymphatics and nerves.
Hilum of the lung is the area on the medial surface of each lung where the structures
forming the root of the lung are present.
External features of the lungs:

Each lung has:

 an Apex
 a Base
 Medial surface
 Costal surface

It has 3 borders:
 Anterior
 Posterior
 Inferior

Apex of the lung:

 It extends into the neck above the level of sternal end of the clavicle
 Cervical pleura and Suprapleural membrane cover it
 The subclavian artery grooves it
 The other relations are same as the cervical pleura

Clinical Anatomy:

A tumor of the apex of the lung may compress the structures around the apex.

Following are its symptoms:

1. Enlargement of veins of upper limb and neck (because of the compression
of brachiocephalic veins)
2. Diminished pulse at the wrist (because of the compression of the
subclavian artery)
3. Paralysis of the corresponding side of the diaphragm (Due to the
involvement of phrenic nerve)
4. Hoarseness of voice (Due to compression of the recurrent laryngeal
nerve)
This syndrome is also called "Thoracic outlet syndrome"

Base of the lung:

 It is concave and related to the diaphragm.

 Right dome of diaphragm separates the base of right lung from the right lobe of
liver
 Left dome of diaphragm separates the base of the left lung from the left lobe of
liver, fundus of stomach and spleen

Medial surface relations differ in two lungs:

Mediastinal surface of right lung:

It is related to the following:

 Right atrium and its auricle
 Lower part of the right brachiocephalic vein
 Superior vena cava
 Arch of the Azygos vein
 Esophagus
 Inferior vena cava
 Trachea
 Right vagus nerve
 Right phrenic nerve

Hilum of the right lung is present on the mediastinal surface and it contains the following
structures:

 Eparterial bronchus (Upper lobar bronchus)

 Pulmonary artery
 Right principal bronchus
 Inferior pulmonary vein
 Superior pulmonary vein
 Bronchial vessels
 Lymphatics

Pulmonary ligament: It lies inferior to the hilum of the lung

Mediastinal surface of the left lung:

It is related to the following structures:

 Left ventricle, left auricle

 Arch of aorta
 Descending thoracic aorta
 Left subclavian artery
 Thoracic duct
 Esophagus
 Left brachiocephalic vein
 Left vagus nerve
 Left phrenic nerve
 Left recurrent laryngeal nerve

Hilum of the left lung lies on the mediastinal surface and contains the following:

 Pulmonary artery
 Left principal bronchus
  Inferior pulmonary vein
 Superior pulmonary vein
 bronchial vessels
 Lymphatics

Pulmonary ligament: It lies inferior to the hilum of left lung

Lobes and Fissures of the lungs:

Lungs are divided into lobes by the fissures.

Right lung- has 3 lobes and 2 fissures.
 The 3 lobes are - 1.superior lobe 2. Middle lobe 3. inferior lobe
 The 2 fissures are -1. Oblique fissure 2. Horizontal fissure

Left lung- has 2 lobes and 1 fissure.

 The two lobes are- 1.superior lobe 2. inferior lobe
 The one fissure is- Oblique fissure

Cardiac notch and Lingula:

The anterior border of the right lung is straight, whereas this border of the left lung has a
deep cardiac notch, due to the deviation of the apex of the heart to the left side. Below the
notch is a tongue-like process of the superior lobe called lingula.

Azygous lobe: It is an “accessory lobe” which appears in the right lung in about 1%
individuals. In these cases, the azygous vein arches over the apex of the lung and not over the
hilum, isolating the medial part of the apex of the lung.

Oblique fissure:

It is deep and therefore it cuts the whole lung except at the hilum
It acts as a plane of separation so that upper part of the lung can expand forward and
laterally when the ribs are elevated.

It is surface marked by two ways:

First method: Three points are taken.

1. The first point: 2 to 2.5cm lateral to the 3rd thoracic spine

2. The second point: 5th rib in the midaxillary line
3. The third point: 6th costal cartilage about 3 inches from the midline
A line joining these three points represents the oblique fissure on both sides.

Second method: When the arm is raised above the head, the medial border of the scapula
roughly corresponds to the oblique fissure.
Horizontal fissure:
It is present only in the right lung
A line drawn horizontally at the level of the 4th costal cartilage from the anterior border to
the oblique fissure in the mid-axillary line represents the horizontal fissure.
Horizontal fissure separates the superior lobe from the middle lobe of the right lung
Note: oblique fissure on the left lung separates the superior from the inferior lobe. On the
right lung, it separates the superior and middle lobes from the inferior lobe.
Surface Marking of Lungs
Apex:
A convex arch of one inch height above the medial third of the clavicle

Anterior border:

Anterior border of the right lung: (corresponds to costomediastinal line of pleural

reflection)

Following points are joined serially from above downwards:

1. Sternoclavicular joint
2. Median plane at the sternal angle
3. Median plane at the xiphisternal joint

Anterior border of the left lung: (Corresponds to the costomediastinal pleural reflection
only up to 4th costal cartilage)

Below this level it presents a cardiac notch.

Anterior border of the lung can be drawn by selecting the following points:
1. Left sternoclavicular joint
2. Median plane at the sternal angle
3. Median plane at the level of left 4th costal cartilage
4. A point over left 5th costal cartilage about 3.5 cm from the margin of the sternum
5. A point over the left 6th costal cartilage about 4 cm from the median plane.

The 3rd, 4th and 5th points are joined by a curved line that represents the cardiac notch.

Note: in the region of cardiac notch, the pericardium is covered only by a double layer of
pleura. This area is called the "area of superficial cardiac dullness", as it is dull on
percussion. (Resonance offered by lung is absent)

Inferior border of both the lungs:

It lies two ribs higher than the pleural reflection.

The following points are selected to mark it on the surface:
 6th costal cartilage
 6th rib in the midclavicular line
 8th rib in the midaxillary line
 2cm lateral to the 10th thoracic spine
A line connecting the above points represents the inferior border of the lung

Posterior border of both the lungs:

This border corresponds to the costovertebral pleural reflection except for the point that the
lower end terminates at the level of spine of T10 vertebra.
Two points
 a point 2 cm lateral to 7th cervical spine
 a point 2 cm lateral to the spine of 10th thoracic vertebra

These two lines are joined by a vertical line which represents the posterior border of the
corresponding lung.

ROOT OF THE LUNG

It connects the medial surface of the lung to the mediastinum.

It is the only area where lung is connected to the mediastinal structures.
It lies at the level of the bodies of the 5th, 6th, and 7th thoracic vertebrae

It contains:
 A tube carrying air (bronchus)
 An artery carrying deoxygenated blood (pulmonary artery)
 Two veins carrying oxygenated blood from the lung (two pulmonary veins)
 Lymph vessels from the lung and lymph nodes (bronchopulmonary)
 Plexus of autonomic nerves which are going to supply the lung (anterior &
posterior pulmonary plexuses)
 Blood vessels of parenchyma of the lung (bronchial artery and bronchial vein)
 Connective tissue
All these structures are covered by a tubular sheath of mediastinal pleura

Note: there are-

 One bronchial artery on the right side
 Two bronchial arteries on the left side
 Usually two bronchial veins on each side

RELATIONS OF THE ROOT

Root of the right lung:

Anterior:
 Superior vena cava & part of the right atrium
 Right phrenic nerve
  Right pericardiacophrenic vessels
 Anterior pulmonary plexus

Posterior:
 Right vagus nerve
 Posterior pulmonary plexus

Superior:
 Arch of Azygos vein

Inferior:
 Pulmonary ligament

Root of the left lung:

Anterior:
 Left phrenic nerve
 Left pericardiacophrenic vessels
 Anterior pulmonary plexus

Posterior:
 Left vagus nerve
 Posterior pulmonary plexus
 Descending thoracic aorta

Superior:
Arch of Aorta
Inferior:
Pulmonary ligament

Differences between the Right lung and Left lung

Right Lung Left Lung

1. Short, wide 1. Long, narrow
2. 3 lobes, 2 fissures 2. 2 lobes, 1 fissure
3. Weight- more, 625 gm. 3. weight- less, 550 gm.
4. Base more concave (because of 4. Base shallow
Diaphragm)
5. No cardiac notch (no lingula) 5. Cardiac notch present with lingula
6. Hilum has eparterial bronchus 6. Hyparterial bronchus
7. Cardiac impression shallow 7. Cardiac impression deep
8. Supplied by one bronchial artery 8. Supplied by two bronchial arteries
Arterial supply of the lungs:

 Bronchial arteries supply the bronchial tree and pulmonary tissue

 There is one bronchial artery on the right side and this artery arises from the
right 3rd posterior intercostal artery
 There are two bronchial arteries on the left side. They rise from the descending
thoracic aorta.

 Respiratory part of the lung is also supplied by the pulmonary arteries through
pulmonary capillary plexus.
 There is anastomosis between the bronchial and pulmonary arteries. This anastomosis
becomes enlarged when one of the vessels is obstructed (for example, in pulmonary
embolism)

Venous drainage of the lungs:

 Veins of the lung are divided into superficial and deep bronchial veins. Superficial
bronchial veins drain outside of the lung like pulmonary pleura, extrapulmonary
bronchi and open into arch of vena azygos on the right side and left superior
intercostal vein or superior hemiazygos vein on the left side.
 Deep bronchial veins drain intra-pulmonary bronchi and bronchioles and open usually
into pulmonary veins.

Lymphatic drainage of lungs:

 There are superficial and deep sets of lymph vessels in each lung.
 They open into the bronchopulmonary nodes which are present in the hilum.

Nerve supply of the lungs:

 Lung is supplied by autonomic nerves which include sympathetic and
parasympathetic nerves.
 They form anterior and posterior pulmonary plexuses in front and behind the hilum.

Sympathetic nerves: They are derived from the spinal segments of T2 to T5.
 They are inhibitory to the smooth muscle of the bronchial tree. Therefore they bring
about bronchodilatation. They are inhibitory to the glands of the bronchial tree.

Parasympathetic nerves: They are derived from the vagus nerve

 They are motor to the smooth muscle of the bronchus.
 They are secretomotor to the glands of the bronchial tree
 They also carry sensory fibres from the lung which help in cough reflex.

Clinical correlation:
Emphysema: A lung disease in which the air sacs are enlarged and damaged, impairing
breathing
Azygous lobe: It is an accessory lobe that appears in the right lung in 1% of people. Azygous
vein arches over the apex of the lung and cuts off a part of the medial part of the apex as an
azygous lobe.
Pneumonectomy, Lobectomy, segmentectomy: surgical removal of whole, a lobe or a B-P
segment
Lung cancer: two nerves may be involved- phrenic nerve damage resulting in corresponding
hemidiaphragm & the recurrent laryngeal nerve involvement (in apical lung cancer) leading
to hoarseness of the voice owing to the paralysis of the vocal fold.
Pulmonary embolism: obstruction of the pulmonary artery by blood clot or air that travels
from a leg vein to the right side of the heart to a lung leading to a partial or complete
obstruction of blood flow to the lung. Thus, although it is ventilated by air, that part of the
lung is not perfused with blood leading to respiratory distress. A large embolus may lead to
death in a few minutes in elderly. In physically active persons, due to establishment of
collateral circulation with bronchial arteries may avert the danger.
Cor pulmonale: is the condition where the right ventricle is enlarged either due to disease of
the lung or of the pulmonary blood vessels.
Lung cancer may metastasize to brain, bone, suprarenal glands through systemic circulation.
Often, the supraclavicular lymph nodes are enlarged in lung cancer and hence are called
sentinel lymph nodes for lung or stomach ailments.
Auscultation of the inferoposterior part of the inferior lobe is done by placing the
stethoscope to the posterior thoracic wall at the level of the 10th thoracic vertebra.

DIFFERENCES BETWEEN RIGHT AND LEFT BRONCHUS

Right bronchus Left bronchus

Short (one inch) Long (two inches)

Straight Oblique
Wide Narrow

Clinical correlation: Swallowed foreign objects tend to enter the right bronchus

Bronchopulmonary segments of the lungs:

These are well defined segments of the lung supplied by-
 A segmental (tertiary) bronchus
 Branch of pulmonary artery
 Bronchial vessels
 Lymphatics
The pulmonary vein is intersegmental.

 Bronchopulmonary units are not bronchovascular units as pulmonary veins do

not correspond to the segments
  The lung tissue of one bronchopulmonary segment is pyramidal in shape. The base is
towards the periphery and the apex is directed towards the hilum.
 They are independent respiratory units.
 There are 10 segments in each lung. They are-

Right Lung Left Lung

Superior lobe Superior lobe
1. Apical 1. Apical
2. Anterior 2. Anterior
3. Posterior 3. Posterior
4. Superior lingular
5. Inferior lingular

Middle lobe
4. Lateral
5. Medial

Inferior lobe Inferior lobe

6. Superior 6. Superior
7. Anterior basal 7. Anterior basal
8. Posterior basal 8. Posterior basal
9. Lateral basal 9. Lateral basal
10. Medial basal 10. Medial basal

 The apical and posterior segments of the left superior lobe are some times combined
together as apicoposterior segment. Similarly, the anterior basal and medial basal
combined as anteromedial basal
Clinical Importance of the Bronchopulmonary segments:

1. Knowledge of their position helps in draining pus from the infected area by adopting
different postures.

2. Infection is limited to the B-P segment. The fibrous septum between the segments
prevents spread of infection from one segment to the other.

3. The superior segment of the lower lobe and posterior segment of the superior (upper)
lobe are common sites for lung abscess (ex., in pneumonia).
4. Tuberculosis may spread from one segment to the other
5. Cancer spreads across the segments

4. Segmental resection - removal of a segment without damaging neighbor segment.

 MEDIASTINUM, PERICARDIUM
AND HEART

Mediastinum
 It is a median fibrous septum between the two pulmonary cavities.
 It is thick and movable partition between the two pleurae.
 It extends from the thoracic inlet superiorly to the diaphragm inferiorly.
 It is bounded by the sternum anteriorly and the thoracic vertebral column posteriorly
 On either side it is bounded by the mediastinal pleura which covers the medial surface
of the lung

Extent:
 Superiorly - from the Thoracic inlet at the root of the neck.
 Inferiorly - to the Diaphragm
 Anteriorly – Sternum
 Posteriorly – Thoracic vertebrae (T1-T12) of the vertebral column.
 On each side- Mediastinal pleura

Contents of the mediastinum are- Heart, large blood vessels, trachea, esophagus, vagus
nerve, sympathetic trunk, lymph nodes & thoracic duct.

Divisions of the mediastinum:

It is divided into– Superior mediastinum & Inferior mediastinum
 by a line drawn from the sternal angle(angle of Louis) to the lower border of the
T4 vertebra.
Superior mediastinum lies above the imaginary line. Inferior mediastinum lies below the line.

Superior Mediastinum
 Lies above the imaginary line

Boundaries:
Superior: Inlet of thorax which is bounded anteriorly by the upper border of manubrium
sternum,
on either side by the inner border of the first rib and posteriorly by the upper border of the
body of the first thoracic vertebra

Anterior: Posterior surface of the manubrium sterni

Posterior: Upper four thoracic vertebrae and intervening intervertebral disc
Inferiorly: it is separated from the inferior mediastinum by the Louis plane.
Lateral: bounded by the right and left mediastinal pleurae

Contents:
Two muscles anteriorly:
 1.Sternohyoid
 2. Sternothyroid
Two tubes:
 Trachea
 Esophagus

Four arteries:
 Arch of aorta
 Brachiocephalic trunk
 Left common carotid artery
 Left subclavian artery

Four veins:
 Right brachiocephalic vein
 Left brachiocephalic vein
 Upper half of superior vena cava
 Left superior intercostal vein

Four nerves:
 1)Vagus (bilateral)
 2) Phrenic (bilateral)
 3) Cardiac nerves (bilateral)
 4) Left recurrent laryngeal nerve

Four other structures:

 Thoracic duct
 Remains of thymus
 Lymph nodes
 Connective tissue.
Inferior mediastinum
It is subdivided into 3 parts – anterior, middle & posterior mediastinum

Anterior mediastinum: lies in front of the Pericardium of the heart

Boundaries:
Anterior: Body of the sternum
Posterior: Pericardium
Superior: Imaginary plane connecting the sternal angle with the lower border of the T4
vertebra
Inferior: superior surface of the diaphragm
Lateral: mediastinal pleura

Contents: 1) Superior and inferior sternopericardial ligaments

 2) Lymph nodes and lymphatics

Middle mediastinum: Largest part

Boundaries:
Anterior: anterior mediastinum
Posterior: Posterior mediastinum
Lateral: Mediastinal pleura.
Between the mediastinal pleura and fibrous pericardium, phrenic nerve and the
pericardiacophrenic vessels of the corresponding side are present.
Contents:
Heart with its pericardium
Two nerves: 1. Phrenic nerve 2. Deep cardiac plexus placed at the bifurcation of trachea
Two other structures: 1. tracheobronchial lymph nodes 2. Connective tissue
Three tubes: 1. bifurcation of trachea 2. Right bronchus 3. Left bronchus
Four arteries: 1. Ascending aorta
2. Pulmonary trunk
3. Right pulmonary artery
4. Left pulmonary artery
Four veins:
 Lower half of superior vena cava
 terminal part of azygos vein
 right pulmonary veins
 left pulmonary veins

Posterior mediastinum- Lies behind the pericardium of the heart.

Its boundaries are:
Anterior: Pericardium, bifurcation of trachea
Posterior: lower eight thoracic vertebrae and intervening intervertebral discs
Lateral: Mediastinal pleura of right and left sides.

Contents:
 One tube: Esophagus
 One artery: Descending thoracic aorta and its branches
 One duct: Thoracic duct
 One group of lymph nodes: Posterior mediastinal lymph nodes along the
thoracic aorta
 Two nerves: 1. vagus 2. splanchnic nerves
 Three veins: 1. Azygos vein 2. Superior hemiazygos vein 3. Inferior
hemiazygos vein

Clinical correlation

 Infection of the neck can spread to the superior and inferior mediastina
 In Hodgkin's disease mediastinal lymph nodes are enlarged
Compression of mediastinal structures by tumors can give rise to specific symptoms
known as "Mediastinal syndrome".

The following are the symptoms of the mediastinal syndrome:

 Dilatation of the veins of upper half of the body because of the
compression of superior vena cava
 Dyspnoea (difficulty in breathing) caused by the compression of trachea
 Dysphagia (difficulty in swallowing) caused by the pressure over
esophagus
 Hoarseness of voice because of involvement of left recurrent laryngeal
nerve
 Paralysis of the corresponding half of the diaphragm because of involvement
of phrenic nerve
 Pain over the thoracic dermatomes because of involvement of intercostal
nerves

PERICARDIUM AND HEART

Pericardium
 It is the double-walled fibroserous sac covering the heart and the roots of great
vessels.
 It is attached to the diaphragm below.
 It is situated in the middle mediastinum behind the body of sternum and 2nd to 6th
costal cartilages

It has two layers-

 Outer Fibrous pericardium
 Inner Serous pericardium. Serous pericardium is again divided into two
layers:
o Outer parietal layer
o Inner visceral layer

Heart lies inside the fibrous pericardium but outside the serous pericardium.

 It is as though heart is placed inside the fibrous pericardium and pushed from
above and behind towards the serous pericardium. Thereby, serous pericardium is
folded inwards to form two layers. The outer layer lines the inner surface of the
fibrous pericardium. It is called "parietal layer of the serous pericardium". The
inner layer covers the heart and is called "visceral layer of serous pericardium".

Pericardial cavity- is the space between the parietal & visceral layers of the serous
pericardium. It has thin fluid called pericardial fluid.
Fibrous pericardium:

 It is cone shaped.
 Its apex is directed above and fuses with the external coats of the roots of
ascending aorta and pulmonary trunk.

 Its base fuses with the upper surface of diaphragm. This fusion takes place
because both the fibrous pericardium and the diaphragm are developed from the same
source - the "septum transversum".

 Anteriorly it is connected to the upper and lower ends of the body of sternum by
superior and inferior sternopericardial ligaments.

 Posteriorly: it forms the anterior boundary of the posterior mediastinum and is

related to the following structures:
 Right and left bronchi
 Esophagus with esophageal plexus of nerves
 Descending thoracic aorta
 Thoracic duct
 Azygos and hemiazygos veins

Laterally: it is separated from the mediastinal pleura by the phrenic nerve and
pericardiacophrenic
vessels

Structures piercing the fibrous pericardium:

 AscendignAorta
 Superior vena cava
 Inferior vena cava
 Right and left pulmonary arteries
 Four pulmonary veins

Serous pericardium:

 It is a closed serous sac

 It lies inside the fibrous pericardium
 It is divided into two layers. The outer parietal and the inner visceral layers

 Pericardial cavity is a potential space between the parietal and visceral layers. It
contains a thin layer of fluid to act as a slippery surface. It helps reduce the
friction.
  The visceral layer covers the outer surface of the heart and forms the
epicardium of the heart.
 Along the cardiac grooves the visceral layer is separated from the heart by the
coronary blood vessels.

Parietal layer lines the inner surface of the fibrous pericardium.

The visceral and parietal layers are continuous with each other at the roots of the great
vessels - ascending aorta, pulmonary trunk, two venae cava and four pulmonary veins.
Along this continuity, pericardial cavity presents two sinuses:
 transverse sinus
 oblique sinus

Transverse sinus:
 It is a transverse gap between the arterial and venous ends of the heart tube.
 Therefore, ascending aorta and pulmonary trunk form its anterior boundary (both
derived from the common source, truncus arteriosus).
 Posteriorly, it is bounded by the superior vena cava and left atrium (venous end of
the heart tube)

Clinical anatomy:
Transverse sinus may be used to pass a ligature during cardiac surgery.

Oblique sinus:
It is a blind sac open at one end.
It lies behind the left atrium
It lies between the parietal and visceral layers of pericardium
It lies within the "J" shaped reflection of serous pericardium to the pulmonary veins and
inferior vena cava
It opens below and left into the remaining pericardial cavity.

Boundaries:
Anterior: left atrium
Posterior: Posterior part of pericardium & posterior mediastinum, vertebral column
Right side: Right superior and inferior pulmonary veins and inferior vena cava
Left side: Left superior and inferior pulmonary veins
Superiorly: upper margin of left atrium

Note: upper margin of left atrium lies between the roof of oblique sinus and the floor of
transverse sinus

Arterial supply of the Pericardium

Fibrous and parietal layer of serous pericardium are supplied by the branches of-
1) Internal thoracic artery
2) Descending thoracic aorta
 Visceral layer is supplied by coronary arteries

Venous drainage:
Fibrous and parietal layers are drained into internal thoracic veins and azygous veins
Visceral layer drains into coronary sinus
Nerve supply:
Fibrous and parietal layers are supplied by phrenic nerves
Visceral layer is supplied by the autonomic nerves through coronary plexus
Development:
Fibrous pericardium is developed from the septum transversum
Parietal layer of serous pericardium is developed from the somatopleuric mesoderm
Visceral layer is developed from the splanchnopleuric layer of mesoderm

Clinical correlation:

 Parietal layer is sensitive to pain

 Pain of pericarditis originates in the parietal layer
 Pain of the heart originates in cardiac muscle or vessels of the heart

Pericardial effusion: Collection of abnormal amount of fluid in the pericardial cavity.

It can be drained by three routs:
 Puncturing 5th or 6th intercostal space just lateral to apex of the heart
 Subcostal route: A needle may be inserted through left costoxiphoid angle and with
proper angulation and direction, fluid can be drained
 Parasternal route: A needle may be passed through the left fourth or fifth intercostal
space very close to the lateral margin of sternum to avoid injury to internal thoracic
artery and left pleura and lung.
pericardial tamponade

Heart:

 Heart is a hollow muscular organ. It is conical in shape.

 It is the major part of the circulatory system.
 It is situated in the middle mediastinum.
 It pumps deoxygenated blood to the lungs and oxygenated blood to all parts of the
body
 2/3 of the heart is to the left of the median plane and 1/3 of the heart is to the right of
the median plane.
 It is covered by the pericardium.
 It is about the size of a clenched fist. Its weight is about 250-300 grams.
 It has 4 chambers or cavities.
 The right side of the heart serves pulmonary circuit. The left side serves systemic
circuit.
BASIC PLAN OF THE HEART:

 Heart has four chambers. Two atria and two ventricles

 Right atrium and right ventricle are on the right side while left atrium and left
ventricle are on the left.
 Right atrium lies anterior and to the right of left atrium
 Right ventricle lies anterior and to the right of the left ventricle
 Interatrial septum separates the right and left atria
 Interventricular septum separates the right and left ventricles
 Venous blood from the upper half of the body reaches the right atrium through the
superior vena cava
 Venous blood from the lower half of the body reaches the right atrium through the
inferior vena cava.
 Right atrium receives deoxygenated blood from the wall of the heart by the coronary
sinus.
 Therefore right atrium is the receiving station of the deoxygenated blood

 This blood is pumped into the right ventricle through the right atrioventricular orifice
during atrial systole
 The right ventricle pumps blood to the lungs through pulmonary trunk and pulmonary
arteries during ventricular systole
 Lung oxygenates the blood and drains it into left atrium through four pulmonary
veins.
 Left atrium pumps this oxygenated blood to the left ventricle through left
atrioventricular orifice during atrial systole.
 Left ventricle pumps the blood through aorta to be distributed all over the body
during ventricular systole.
 Systolic blood pressure is generated by the contraction of the left ventricle
 During ventricular diastole, elastic recoil of large arteries generates diastolic
blood pressure.
 External features of the heart

 The heart has an apex, base, anterior surface, inferior (diaphragmatic) surface and left
surface.
 It has inferior, right and left borders

Apex:
 It is directed downwards, forwards and to the left.
 It is formed by the left ventricle.
 It is covered by the left lung and left pleura.
th
 It lies 9 cm away from the median plane in the left 5 intercostal space
 It lies below and medial to the left nipple.
 Apex beat is the forward thrust felt in the left 5th intercostal space during ventricular
systole (contraction).

Base of the heart:

 It is directed upwards and posteriorly
 It is mainly formed by the left atrium. Only a small part of the right atrium
contributes to it.
 Four pulmonary veins open into the left atrium in the base.
 Oblique sinus of the pericardium lies behind the base of the heart

Posteriorly base of the heart is related to the following structures of posterior

mediastinum:
 Esophagus
 Descending thoracic aorta
 Thoracic duct
 Azygos and hemiazygos veins

Clinical Anatomy:
 Distended left atrium in mitral stenosis (narrowing of the mitral valve) might cause
difficulty of swallowing because of its relation to the esophagus.

Clinical base of the heart:

 Line connecting the auscultatory areas of pulmonary sound in the left second
intercostal space and the aortic sound in the right second space is the clinical base of
the heart

Anterior surface of the heart:

 It is also called the sternocostal surface.

Parts of the heart forming this surface are the following:
 Anterior surface of the right atrium and its auricle
  Part of the left auricle
 Anterior surface of the right ventricle (2/3 of ventricular area)
 Anterior surface of the left ventricle (1/3 of ventricular area)
There are two grooves on this surface:
 Anterior part of the right atrioventricular groove (coronary sulcus) lies between
the right atrium and the right ventricle and it contains right coronary artery.
 Anterior interventricular groove lies between the right ventricle and left ventricle.
It contains:
 Anterior interventricular branch of left coronary artery
 Great cardiac vein
Inferior surface (Diaphragmatic surface):

Parts of the heart forming this surface:

Left ventricle forms the left 2/3 of the surface
Right ventricle forms the right 1/3 of the surface
Posterior interventricular groove lies between the right ventricle and left ventricle.
This groove contains:
 Posterior interventricular branch of the right coronary artery
 Middle cardiac vein

Crux of the heart: It is the junction of the posterior interventricular groove with the
posterior part of the atrioventricular groove.

Relations: Fibrous pericardium is adherent to the diaphragm. Diaphragm separates the

pericardium from the fundus of the stomach and the liver.

Left surface:
 It is formed by the left ventricle and at the upper end by the left auricle.
Relations:
 Pericardium and outside it, left phrenic nerve, and left peicardiaco-phrenic vessels

Borders:

Lower border
 It is also called inferior border
 It separates the sternocostal surface form the diaphragmatic surface
 Right marginal artery which is a branch of right coronary artery and right marginal
vein which is a tributary of small cardiac vein lie along this border

Right border:
 It is formed by the right atrium.
 It separates the base from the sternocostal surface.
 A shallow groove called sulcus terminalis lies along this border.

Left border:
It separates the sternocostal surface from the left surface of the heart.
It extends from the left auricle to the apex of the heart. Greater part of it is formed by the left
ventricle.
Relations:
Left marginal artery- This may be accompanied by the left marginal vein which opens into
the great cardiac vein.
Right Atrium
External features:
 It is the venous chamber of the heart situated on its right side
 Its upper end presents right auricle which covers the root of the ascending aorta and
partly overlaps the infundibulum.
 Anterior part of the right atrioventricular groove separates it from the right ventricle
and it contains the right coronary artery.
 Sulcus terminalis lies along the right border of the heart

INTERIOR OF THE RIGHT ATIRUM

 Interior of the right atrium is divided into two parts- anterior rough part and posterior
smooth part by the crista terminalis.
 Crista terminalis is a smooth, curved muscular ridge which extends from the
opening of superior vena cava superiorly to the opening of inferior vena cava
inferiorly. It corresponds to the sulcus terminalis on the external surface.
 Anterior part is rough because of musculi pectinati. These are parallel muscles
which extend from the crista terminalis to the atrioventricular opening. This part is
developed from the primitive atrium.

 Posterior part is smooth and is developed from the absorbed part of the right
horn of sinus venosus.
 It is called "sinus venarum". All veins open into sinus venarum except some times
anterior cardiac veins

Veins opening into the right atrium:

 Superior vena cava
 Inferior vena cava
 Coronary sinus
 Venae cordis minimae
 Anterior cardiac veins
Opening of superior vena cava lies in the posterosuperior part of the sinus venarum. It does
not possess a valve. SA node (sinu atrial node) is located just below its opening.
Opening of inferior vena cava lies in the posteroinferior part of the sinus venarum. It is
guarded by a rudimentary valve.
Coronary sinus opens between the opening of inferior vena cava and right atrioventicular
orifice. It is guarded by a semilunar valve.
Foramina venarum minimarum are the small foramina present in the interatrial septum.
Venae cordis minimae (minute veins from the heart) open into the right atrium through these
foramina
Anterior cardiac veins may open into the right atrium proper (anterior to crista terminalis)
through separate openings.
The septal wall of the right atrium: It has
 fossa ovalis ( a depression superior and left to the opening of inferior vena
cava )
 limbus fossa ovalis (prominent margin of the fossa ovalis)
Foss ovalis represents the septum primum of embryonic heart
Limbus fossa ovalis represents the free margin of the septum secundum of embryonic heart

Triangle of Koch:
It is a triangular area bounded by the opening of coronary sinus, base of the septal cusp of the
tricuspid valve inferiorly and by tendon of todaro anterosuperiorly.
A.V. node (Atrio-ventricular node) is situated in this triangle.

Clinical Anatomy: Right auricle contains the irregular network of musculi pectinati. This
might contribute to the formation of blood clots here. If they slip into the circulation, it might
result in fatal pulmonary embolism.
SA node is the ‘pace maker’ of the heart.

Right ventricle:
This is the chamber which pumps deoxygenated blood into the lungs
It forms the sternocostal surface, inferior border and diaphragmatic surface.
Anterior surface: It is separated from the right atrium by the atrioventricular groove
which contains right coronary artery.
It separated from the left ventricle by the anterior interventricular groove which contains
the anterior interventricular branch of the left coronary artery and the great cardiac
vein.

On the diaphragmatic surface, it is separated from the left ventricle by the posterior
interventricular groove which contains three structures:
 Terminal part of the anterior interventricuar artery
 Posterior interventricular artery and its anastomosis with anterior interventricular artery
 Middle cardiac vein.

INTERIOR OF THE RIGHT VENTRICLE

The wall of the right ventricle is thinner than the wall of the left ventricle (⅓ of that of the
left ventricle). In cross section, wall of the right ventricle appears semilunar (cresentric).

It is divided into two parts

 Inflowing part
 Outflowing part
 INFLOWING PART:
It is the ventricle proper. It is designed to receive blood from the right atrium through right
atrioventricular orifice. It has rough muscular ridges called “trabeculae carneae"
It develops from the primitive ventricle of the tubular heart.
Trabeculae carneae are made up of ridges, bridges and papillary muscles.
The ridges are just linear elevations of myocardium
The bridges are attached at their ends and the middle part is free.
Good example of a bridge is the "septomarginal trabecula" (moderator band) which
connects the
interventricular septum with the base of the anterior papillary muscle in the anterior wall
of the right ventricle. It transmits the right branch of atrioventricular bundle (AV bundle).

The papillary muscles are the conical muscular projections which are attached at one end
and free at the other end. Usually they are three in number. The anterior and the posterior &
septal
Chordae tendinae:
These are endothelial covered collagenous threads. They connect the apex of the papillary
muscle with the free margin and the ventricular surface of the cusp. The cusps are
prevented from collapsing back into the atrium by these attachments during ventricular
systole.

Right atrioventricular orifice: It usually admits three fingers.

Cusps of the tricuspid valve:

They are three in number- Anterior, Posterior, Septal cusps.
Each cusp is formed as a duplication of endocardium.
The atrial surface of the cusp is smooth while the ventricular surface is rough. The free
margin and the ventricular surface of the cusps receive the attachment of chordae tendinae.

OUTFLOWING TRACT:
This part of the right ventricle is smooth.
It is separated from the inflow tract by a smooth muscular ridge called "supraventricular
crest"
The upper end of this part gives rise to the pulmonary trunk which is guarded by a
"pulmonary valve". Pulmonary valve has three cusps.
Outflow tract is called "conus arteriosus" or infundibulum

Left Atrium:

 It lies behind and to the left of the right atrium.

 It receives oxygenated blood from the lung through pulmonary veins.
 Four pulmonary veins, two from each lung open into the left atrium.
 It forms the base of the heart.
 It forms the anterior wall of the oblique sinus of the pericardium
 It has a conical muscular projection called "left auricle" which skirts the left margin
of the pulmonary trunk
 Anterior and to the right of the left atrium, the right atrium is situated.
 It is connected to the left ventricle through Mitral (bicuspid) orifice.

Interior of the left atrium:

 Musculi pectinati are found only in the region of left auricle.

 The remaining part of the interior is smooth.
 The smooth part is developed from the absorbed pulmonary veins.
 Only small anterior part including left auricle is developed from the left half of the
primitive atrium
 The septal wall of the left atrium separates it from the right atrium.
 Foramina venarum minimarum are found in the septal wall.
 The cavity of the left atrium receives the openings of 4 pulmonary veins.
o It opens into the left ventricle by the left atrioventricular opening which is
guarded by the left atrioventricular (bicuspid or mitral) valve

Clinical anatomy:
 Thrombi (blood clots) may be formed in the left auricle. If they are dislodged into
circulation, then it might result in cerebral or renal embolism.

Left Ventricle:

 It is the thickest chamber of the heart.

 It receives the oxygenated blood from the left atrium through the bicuspid orifice
 It pumps the blood into ascending aorta.
 The contraction of the left ventricle generates the systolic blood pressure.
 Its wall is three times thicker than that of right ventricle.
 It forms the sternocostal surface, left surface, diaphragmatic surface and the
apex of the heart.

Interior of the left ventricle:

It is separated from the right ventricle by interventricular septum
It is divided into two parts
 Inflow tract
 Outflow tract
Inflow tract:
 It is the left ventricle proper and is developed from the left part of the primitive
ventricle.
 Left atrioventricular orifice admits the tips of two fingers.
 It connects the left atrium with the left ventricle. It is guarded by two cusps.
Therefore it is called as "Bicuspid orifice" or "mitral valve"
Cusps of the mitral valve are two in number
 Anterior
 Posterior
The cusps of the bicuspid orifice are short but strong
 Anterior cusp separates the aortic vestibule from the bicuspid orifice

 There are two papillary muscles. 1) anterior 2) posterior

 Anterior papillary muscle is attached to the sternocostal surface
 Posterior papillary muscle is attached to the diaphragmatic surface
 Chordae tendinae of both the muscles are attached to both the cusps of the mitral
valve

Outflow tract:
 It is smooth and is known as "aortic vestibule"
 It is mostly fibrous
 The top of the vestibule has the aortic valve with three cusps.
 Ascending aorta begins here.
 Aortic valve opens during left ventricular systole and closes during the ventricular
diastole.
 Bicuspid valve opens during ventricular diastole and closes during ventricular systole

Interatrial septum:
 Between the atria
 Obliquely placed
 It has fossa ovalis and limbus fossa ovalis
 It has openings of foramina venarum minimarum
 It may have a developmental defect –patent foramen ovale

Interventricular septum:
It is the partition between the two ventricles
It has two parts
 Lower thicker muscular part
 Upper thin membranous part
The membranous part has two divisions- interventricular and atrioventricular
divisions
Patent interventricular foramen is a developmental defect due to failure of fusion of the
two parts
Blood supply: Anterior ⅔ of interventricular septum is supplied by anterior
interventricular artery whereas posterior ⅓ is supplied by the posterior interventricular artery

First heart sound: (Lub) This is generated by the closure of the tricuspid and mitral valves
Second heart sound: (Dub) This is generated by the closure of the aortic and pulmonary
valves.

Semilunar valves:
  Aortic and pulmonary valves are called semilunar valves. They are similar to each
other.
 They are semilunar in shape. Each valve has three cusps. The cusp forms a small
pocket which is directed superiorly away from the ventricular cavity.
 Opposite the cusps the vessels are slightly dilated to form aortic and pulmonary
sinuses.

Surface Markings of the heart:

Employing two points and joining them marks the upper border. The two points are as
follows:
1) a point at the lower border of the 2nd left costal cartilage about 1/2 inch from the sternal
margin
2) a point at the upper border of the 3rd right costal cartilage about 1/2 inch from the
sternal margin

The lower border- The two points are as follows

1. A point at the lower border of the 6th right costal cartilage 2cm from the
sternal margin
2. A point at the apex of the heart in the left 5th intercostal space 9 cm from the
midline.
The right border is marked by joining the right ends of the upper and lower
borders with the maximum convexity at the level of 4th space (about 3.8cm from the
median plane)
A convex line connecting the left ends of the upper and lower borders marks the left
border.
Precordium is the area of the chest wall covering the heart

Surface marking of the cardiac valves:

 Pulmonary valve - behind the left 3rd sternocostal junction (3rd cartilage)
 Aortic valve - behind the left half of the sternum at the level of 3rd space
 Mitral valve behind the middle of the sternum at the level of 4th costal cartilage
 Tricuspid valve behind the right half of the sternum at the level of 4th space

Auscultatory areas of the valves:

All the valves are packed behind the level of sternum. Therefore if a stethoscope is placed
over the sternum sounds of different valves are not clear.
To hear the closure of valve clearly stethoscope is placed on that part of the chest wall
where the blood is thrust to the thoracic wall from the valve.
The auscultatory areas of different valves are as follows:
 Pulmonary area: Second left intercostal space near the sternum
 Aortic area: Second right cartilage or interspace near the sternum
 Mitral area: Cardiac apex
  Tricuspid area: Lower end of the sternum near left 5th intercostal space

The conducting system of the heart:

Specialized myocardial cells constitute the conducting system.
They are specialised for the generation and conduction of cardiac impulse.

The conducting system has the following parts:

 Sinuatrial node (S.A.node)
 Atrioventricualr node (A.V.node)
 Atrioventricular bundle (A.V.bundle or bundle of His)
 Right branch of A.V.bundle
 Left branch of A.V.Bundle
 The Purkinje fibers

SA Node:
 This is situated at the upper end of the sulcus terminalis where the superior vena
cava opens into the right atrium
 It is known as the "pace maker" of the heart
 It is mainly supplied by the right coronary artery
 Impulses travel through atrial wall to reach A.V.node

AV Node:
 It is situated in the triangle of Koch in the right atrium just above the opening of
coronary sinus.
 It is smaller than the S.A.node.
 A branch of posterior interventricular artery usually supplies it

AV Bundle:
 It is the only muscular connection between the atrium and the ventricle; otherwise the
fibrous skeleton of the heart separates the atria from the ventricle.
 It runs along the postero-inferior border of the membranous part of the
interventricular septum
 At the upper part of the muscular part of the interventricular septum it divides into
right and left branches
 Blood supply: Branches of right coronary artery supply this

Right branch of AV Bundle:

 It passes along the right side of the interventricular septum
 Part of it passes through the septomarginal trabecula and reaches the anterior wall.
 It divides into terminal purkinje fibers
 Blood supply: Branches of right coronary artery supply this

Left branch of AV Bundle:

 It descends on the left side of the interventricular septum
 It supplies the left ventricle after dividing into terminal Purkinje fibers
 Blood supply: Greater part of it is supplied by the anterior intrventricular branch of left
coronary.

Blood supply of the heart:

Arterial supply:

The heart is supplied by two coronary arteries

 Right coronary artery
 Left coronary artery
Note: Blood flows in coronary arteries during diastole of the heart

Right coronary artery:

 It arises from the anterior aortic sinus of the ascending aorta

 It runs downwards between the right auricle and the pulmonary trunk
 It runs in the anterior atrioventricular groove (coronary sulcus) between the right
atrium and right ventricle
 It winds round the inferior border of the heart, passes upwards in the posterior part of
the atrioventricular groove to reach the crux of the heart
 For the purpose of description, the artery is divided into two segments.
 First segment extends from its origin to the inferior border of the heart
 Second segment extends along the junction of the base and the diaphragmatic surface
of the heart in the posterior atrioventricular groove

Branches:
 Right Marginal artery
 posterior interventricular artery (it gives a branch to A.V.node which loops
back and supplies it)
 small atrial and ventricular (atrial branch gives Nodal branch to the SA node)
 Rt. conus artery
Posterior interventricular artery supplies posterior ⅓ of the interventricular septum

Left coronary artery:

It arises from the left posterior aortic sinus of the ascending aorta
It is wider branch and supplies larger volume of the myocardium
The trunk passes behind the pulmonary trunk and then appears between the pulmonary trunk
and left auricle. Here it divides into two branches.
 Anterior interventricular artery (Left Anterior Descending or LAD)
 Circumflex artery
Anterior interventricular artery (LAD) descends along the anterior interventricular groove
accompanied by great cardiac vein.
  It winds round the inferior border and continues on the diaphragmatic surface.
 It anastomoses with the posterior interventricular branch of right coronary artery
along the posterior interventricular sulcus. Anterior ⅔ of the interventricular septum
is supplied by the anterior interventricular artery.
Circumflex artery:
 It winds round the left border of the heart and runs in the posterior atrioventricular
groove (coronary sulcus).
 Near the crux of the heart it anastomoses with the right coronary artery
.
Posterior interventricular artery sometimes arises from the circumflex artery.
If posterior ventricular artery is a branch of left coronary artery, then it is called left
dominance arterial supply to the heart
If posterior interventricular artery is a branch of right coronary artery then it is called "right
dominance"
If posterior interventricular artery arises from both right and left coronary then it is called
"balanced arterial supply"

Clinical correlations:
 LAD is most prone to thrombosis. ‘widow maker’
 The order of frequency is: LAD> RCA> Left circumflex artery
 Circumflex artery is prone for injury during mitral valve replacement operations and
during removal of left auricle because of its strategic location
 Coronary vascular disease is more common in left dominance. Balanced arterial
supply is the safest.
 Angina pectoris: pain radiating along ulnar border of left upper limb in partial
obstruction of a branch of coronary artery. Pain sensation to the arm is carried
through T1 segment of the spinal cord.

Venous drainage of the heart:

About 60% of venous blood of the heart drains into the right atrium through coronary sinus
The remaining 40% of blood drains into different chambers of heart through venae cordis
minimae and anterior cardiac veins

Coronary sinus:
 It is a wide venous channel of about 2 to 3 cm in length.
 It is situated in the coronary sulcus.
 It begins in the left part of the atrioventricular groove as continuation of the great
cardiac vein.
 Termination: Coronary sinus opens into the right atrium

Tributaries of the coronary sinus:

 Great cardiac vein
 Middle cardiac vein
 Small cardiac vein
 Posterior vein of the left ventricle
  Oblique vein of the left atrium
Note: Since anterior cardiac and venae cordis minimae directly open into the atria, they are
not tributaries of the coronary sinus.

Nerve supply of the Heart:

Heart is supplied by the Autonomic nerves.
It is derived from the CARDIAC PLEXUSES.

 Superficial cardiac plexus

 Deep cardiac plexus
Both sympathetic and parasympathetic contribute to the formation of cardiac plexus
Sympathetic nerves supply coronary arteries. They dilate the coronary arteries & increase
the heart rate and cardiac output. They also carry pain sensation from the heart
They are derived from lateral horns of T1 to T5 segments of spinal cord which are
distributed through cervical sympathetic cardiac branches of the cervical sympathetic ganglia
Parasympathetic fibres
 Reach the cardiac plexus through vagi nerves
 Postganglionic neurons are situated in the cardiac plexus
 They are inhibitory to the nodal cells. They decrease the heart rate. They also carry
sensory fibers

Superficial cardiac plexus:

 It is situated below the arch of aorta
 It is formed by the superior cervical cardiac branch of the left superior cervical
sympathetic ganglia (sympathetic) and Inferior cervical cardiac branch of left vagus
nerve (parasympathetic)
 It gives branches to deep cardiac plexus and right coronary artery

Deep cardiac plexus:

 It is situated in front of the bifurcation of trachea
 It is formed by all the cardiac branches of cervical and upper thoracic ganglia of the
sympathetic chain and the cardiac branches of vagus except those which supply the
superficial cardiac plexus. Branches from it supply the atria and ventricles.
 Right half supplies the right coronary artery and left half supplies the left coronary
artery.

Muscles of the Heart:

 Heart is a muscular organ. The muscle of the heart is called cardiac muscle. It is
striated muscle but not under voluntary control.
 Each muscle has one nucleus. Intercalated disc separates one muscle cell from the
other.
 The fibres are arranged in two layers- superficial and deep, on the wall of the heart.
Fibrous Skeleton of the Heart:
 Four fibrous rings form the skeleton of the heart. They are present around the openings. The
rings are interconnected by fibrous tissue to form the skeleton of the heart. They serve to
completely divide the atria from the ventricles except at the point where the AV bundle runs.

MEDIASTINAL STRUCTURES

Ascending Aorta
 Origin: in the aortic vestibule of the left ventricle.
 Termination: continues as arch of aorta at the sternal angle or at the lower
border of T4 vertebra.
 The beginning is guarded by aortic valve which has three cusps.
 At the level of each cusp there is a dilatation called aortic sinus.
 There are three aortic sinuses. One anterior and two posterior aortic sinuses
 Right coronary artery arises from the anterior aortic sinus.
 Left coronary artery arises from the left posterior aortic sinus
 Right posterior aortic sinus is often called "non-coronary sinus" as it does not
give coronary artery
 It is 5cm in length.
 It is a content of the middle mediastinum.
 It lies inside the pericardium
 It forms the anterior wall of the transverse sinus of the pericardium
Arch of Aorta
 It begins and ends at the same level - at the sternal angle at the level of lower
border of 4th thoracic vertebra.
 Origin: It is the continuation of ascending aorta
 Termination: It continues as descending thoracic aorta
 Situation: It lies in the superior mediastinum

Branches:
Four
 Brachiocephalic trunk
 Left common carotid
 Left subclavian
 Thyroidea Ima artery (occasionally)

Clinical correlation:

o Coarctation of aorta:
  It is the narrowing of arch of aorta mostly due to the extension of fibrosing
ligamentum arteriosum. In postductal coarctation, an extensive collateral
circulation is established between the branches of subclavian artery (internal
thoracic artery) and a) descending thoracic aorta (posterior intercostal arteries), b)
via the epigastric arteries to the external iliac arteries. In this condition there is a
difference in the blood pressure of upper and lower limbs. There is also left
ventricular hypertrophy
 The enlarged vessels are pulsatile and notch the ribs which are evident in x-rays.
 If it is preductal coarctation of the aorta, the ductus arteriorsus may be fibrosed
or patent. If the ductus arteriosus remains patent (PDA), there is pulmonary
hypertension with right ventricular hypertrophy

 A retroesophageal right subclavian artery may compress the esophagus

causing dysphagia
 An aneurism of the arch of aorta may exert pressure on the trachea,
esophagus& left recurrent laryngeal nerve causing dyspnoea, dysphagia and
hoarseness of voice

 "Aortic knuckle" the shadow of arch of aorta seen in x-ray

Descending thoracic Aorta

 It is situated in the posterior mediastinum

 It begins as the continuation of the arch of aorta at the level of lower border of
4th thoracic vertebra
 It continues as abdominal aorta at the level of 12th thoracic vertebra
 It descends on the left side of the vertebral column with a slight inclination to the
right.

Branches:
1. Posterior intercostal arteries (9 pairs) for 3rd to 11th intercostal spaces
2. Subcostal arteries (Right and Left)
3. Superior phrenic arteries (to the diaphragm)
4. Oesophageal branches
5. Pericardial branches
6. Left bronchial arteries (2)
7. Mediastinal branches

Brachiocephalic veins
 There are two brachiocephalic veins – the right and the left brachiocephalic vein
 Beginning: formed posterior to the sternoclavicular joints by the union of the
internal jugular and subclavian veins.
  Termination: At the lower border of 1st right costal cartilage, they join to form the
SVC.
 The left brachiocephalic vein is twice as long as the right because it passes from left
to the right side.
 The left brachiocephalic vein crosses to the right in front of the left internal thoracic
artery & 3 major branches of the arch of aorta, 2 major nerves (Lt. phrenic and Lt.
Vagus) and superior to the arch of aorta.
Tributaries:
 Lt. brachiocephalic vein receives Lt. vertebral, Lt. internal thoracic, inferior
thyroid, Lt. Superior intercostal, 1st Lt. posterior intercostal veins

 Rt. Brachiocephalic vein receives Rt. Vertebral, Rt. Internal thoracic, and 1st
Rt. Posterior intercostal veins
Superior vena cava
It drains the venous blood from the upper part of the body into the right atrium
It has no valves
Beginning:
 By the union of right and left brachiocephalic veins behind the lower border
of the 1st right costal cartilage
It pierces the fibrous pericardium behind the 2nd costal cartilage.
Just before piercing the fibrous pericardium it receives azygos vein
It opens into the right atrium behind the 3rd right costal cartilage

Tributaries:
 Azygos vein arches over the root of the right lung and opens into the
superior vena cava

Clinical Anatomy:
 Superior vena cava syndrome: gradual compression of the superior vena cava
which can be life threatening. Causes: Bronchogenic carcinoma, lymphoma, and in
recent years, thrombosis from central venous instrumentation (dialysis catheter,
pacemaker leads, guidewire)
 If superior vena cava is obstructed above the level of azygos vein then blood
returns to the right atrium through collateral veins reaching the azygos vein. In
this case, superficial veins of chest wall alone are dilated.
 If superior vena cava is obstructed below the level of azygos vein, then blood has
to return to the right atrium through inferior vena cava, Therefore in this situation,
superficial veins of both chest and abdomen are dilated.

Trachea
 It is the tube which carries air to the lungs. It is about 6 inches long
 Its wall is partly made up of cartilages therefore it is not completely collapsible
  It lies both in the lower part of the neck and in superior mediastinum
 It begins as continuation of the larynx at the lower border of the cricoid
cartilage at the level of 6th cervical vertebra
 It terminates at the level of T5 (or lower border of T4) by dividing into right and
left principal bronchi.
 Right bronchus is wide & is in line with the trachea while the left bronchus is at
an angle & is narrow.
 It lies in the median plane except its terminal part which deviates slightly to the
right side
 In the living the bifurcation extends to a lower level (6th thoracic vertebral level)
 It has 16 to 20 "C" shaped tracheal rings. They cover the sides and the anterior
wall of the tube.
 Posterior wall of the tube contains transversely arranged smooth muscle called
"trachealis"
 Absence of cartilaginous rings posteriorly helps the oesophagus to expand during
swallowing.

Blood supply: Inferior thyroid artery

Venous drainage: into the left brachiocephalic vein
Lymphatic drainage: Drained into the pretracheal and paratracheal lymph nodes
Nerve supply:
Parasympathetic nerves come from recurrent laryngeal nerve which is a branch of vagus
nerve
Sympathetic nerves come from middle cervical sympathetic ganglia which reach trachea
along the inferior thyroid artery.
Clinical correlation:
Carina is a cartilaginous projection of the last tracheal ring. Normally it lies in the sagittal
plane. It can be observed as a keel-like ridge between the orifices of the main bronchi during
bronchoscopic examination. If the tracheobronchial lymph nodes in the angle between the
main bronchi are enlarged (ex: in bronchogenic carcinoma), the carina is distorted. Hence
morphological changes in carina are important diagnostic signs. Mucous membrane covering
carina is very sensitive and is associated with cough reflex.

Esophagus
 It is a muscular tube which carries food bolus to the stomach.
 It begins as continuation of the pharynx at the level of lower border of cricoid
cartilage that corresponds to the level of C6 vertebra
 It is 10 inches long
 It runs downwards in the superior and posterior mediastinum and pierces the
diaphragm at the level of T10 vertebra.
 Termination: It ends by opening into the stomach in the abdomen at the level of
T11 vertebra

Constrictions:
It has four constrictions:
 The 1st constriction lies about 6 inches from the incisor teeth (at its beginning)
 The 2nd constriction lies about 9 inches from the incisor teeth (crossed by arch
of aorta)
 The 3rd constriction lies about 11 inches from the incisor teeth (crossed by left
bronchus)
 The 4th constriction lies about 16 inches from incisor teeth (as it passes through
the diaphragm)

 These constrictions and their distance from the incisor teeth are very important
clinically while passing tube into stomach.

Blood supply:
 Inferior thyroid artery supplies the cervical part.
 Oesophageal branches of thoracic aorta supply the thoracic part
 Oesophageal branches of the left gastric artery supplies the abdominal part
Venous drainage:
 Upper part of oesophagus drains into the brachiocephalic vein
 Middle part drains into azygos veins
 Lower end of the oesophagus drains into the left gastric vein.

Clinical correlation:
 Left gastric vein is a tributary of the portal vein. It anastomoses with the
tributaries of the azygos veins in the wall of the lower end of the oesophagus. In
portal hypertension, due to the back pressure, this anastomosis enlarges causing
oesophageal varices. These may burst into the lumen of the oesophagus resulting
in haemetemesis (vomiting of the blood)

 In left atrial enlargement oesophagus is compressed

 In mediastinal syndrome, oesophagus is compressed
 GERD Gastroesophageal Reflux Disease (GERDis defined as chronic
symptoms or mucosal damage produced by the abnormal reflux of gastric
contents into the esophagus.This can be due to incompetence of the lower
esophageal sphincter (LES), transient LES relaxation, impaired expulsion of
gastric reflux from the esophagus, or association with a hiatal hernia.

 Achalasia, also known as esophageal achalasia, esophageal aperistalsis, is an

esophageal motility disorder. In this disorder, the smooth muscle layer of the
esophagus has impaired peristalsis (muscular ability to move food down the
esophagus), and the Lower esophageal sphincter (LES) fails to relax properly in
response to swallowing.
  Blockage of the esophagus: swallowed foreign objects are most likely to lodge at
any one of the constrictions. Stricture may develop following ingestion of caustic
liquid.

Thoracic duct
 It is the largest lymphatic vessel in the body
 It is 18 inches long
It has beaded appearance because of valves present in it.
It receives lymph from:
 the lower half of the body below the level of diaphragm
 the left half of the body above the level of the diaphragm
 It begins in the abdomen at the upper end of the cisterna chyli at the lower border of
T12 on the right side
 It passes through the aortic opening at the level of T12 vertebra
 In the aortic opening it lies between the aorta and azygos vein.
 It ascends in the posterior mediastinum on the right side till the level of T5 vertebra
 It crosses from right to left side at the level of T5 vertebra
 Then it ascends in the superior mediastinum on the left side of the oesophagus.
 It ends in the neck by opening into the junction of left internal jugular vein with
the left subclavian vein

Tributaries:
 Intercostal nodes
 Posterior mediastinal lymph nodes
 Left subclavian lymph trunk
 Left jugular lymph trunk from the left neck

Clinical correlations:
 Laceration of the thoracic duct in the posterior mediastinum (during an accident
or lung surgery) results in lymph escaping into the thoracic cavity or pleural
cavity producing chylothorax.

Azygos vein

 Azygos means unpaired

 It is a venous channel of the right side of posterior wall of thorax
 It is an important channel connecting the superior and inferior vena cava
Beginning:
 It usually begins in the abdomen as Lumbar azygos vein (Which is
connected to the back of the inferior vena cava)
 If lumbar azygos vein is not present, then it is formed by the union of:
o Right subcostal vein and right ascending lumbar vein
Course:
 It passes through the aortic opening at the level of T12
 It ascends in the posterior mediastinum till T4 vertebra.
Termination:
 It arches forwards over the root of the right lung to open into the superior vena
cava (before SVC pierces fibrous pericardium)

Tributaries:
 Right superior intercostal vein
 5th to 11th right posterior intercostal veins
 Superior hemiazygos vein
 Inferior hemiazygos vein
 Oesophageal, mediastinal and some pericardial veins
 Right subcostal and right ascending lumbar
 Right bronchial vein (usually, the last tributary)

Clinical correlations:
 Azygous lobe: in the right lung (cuts through the apex)
 Collateral circulation in the event of SVC or IVC obstruction

Superior hemiazygos vein

(Accessory hemiazygos vein)

 It is a venous channel of the upper part of the left side of posterior wall of thorax
 It drains the left 5th, 6th, 7th posterior intercostal veins.
 Left bronchial veins open into it
It crosses from left to right side at the level of T8 vertebra behind the following
structures:
 Thoracic aorta
 Thoracic duct
It terminates by opening into the azygos vein

Inferior hemiazygos vein

(Hemiazygos vein)

 It may originate from the back of the left renal vein

 It may begin by the union of left ascending lumbar vein and left subcostal vein
 It pierces the left crus of the diaphragm
 It ascends on the left side of the vertebral column behind the aorta
 At the level of T9 vertebra it crosses from left to right side behind:
o Thoracic aorta
o Thoracic duct
 It ends by opening into the azygos vein
 Tributaries: 8th, 9th, 10th and 11th posterior intercostal veins.
 Thoracic sympathetic trunk
 It is situated on either side of the vertebral column
 It is a ganglionated trunk.
 Superiorly it is continuous with the cervical trunk and inferiorly it is continuous
with the lumbar trunk
 Though we expect 12 thoracic sympathetic ganglia, one for each thoracic nerve,
usually only 10 to 11 ganglia are seen because of fusion of ganglia
 The first thoracic ganglion lies in front of the neck of the first rib.
 Then the sympathetic chain lies in front of the heads of the ribs from 2nd rib to
10th
 It lies in front of bodies of T11 and T12 vertebrae
 It passes behind the medial arcuate ligament of diaphragm and become
continuous with the lumbar sympathetic trunk

Branches:
 Its branches are divided into lateral and medial branches
 Lateral branches: join the corresponding spinal nerves through grey rami
communicantes and are distributed along the spinal nerves.
 They receive white rami communicantes from the spinal nerve which are
preganglionic fibers from the thoracic segments of the spinal cord

 Medial branches: Medial branches of the upper five ganglia supply heart, great
vessels, lung and oesophagus through plexuses.
 Pulmonary branches to pulmonary plexus
 Cardiac branches to the deep cardiac plexus
 Aortic branches to the aortic plexus
 Oesophageal branches to the oesophageal plexus

 Medial branches from the lower seven ganglia form three splanchnic nerves which
supply the visceral organs of the abdomen. They carry preganglionic fibers to synapse
in prevertebral ganglia in the abdomen
 Greater splanchnic nerve: formed by the branches of T5 to T9 ganglia
 Lesser splanchnic nerve: formed by the branches of T10 & T11 ganglia
 Least splanchnic nerve: formed by the branches of T12
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