ANATOMY OF THE WALL OF

TRUNK, THORACIC CAVITY AND

RESPIRATORY

Compiled by Nur Kanonge Mitonga

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Table of Contents
1. The vertebral column: gross anatomy, syndesmology and X-ray anatomy ............................................ 3
2. Functional anatomy of the atlantooccipital and atlantoaxial joints. ..................................................... 14
3. The bones and joints of the thorax, the movements of respiration ..................................................... 16
4. The diaphragm ....................................................................................................................................... 23
5. The muscles and layers of the thoracic wall. The intercostal space. ..................................................... 26
6. The muscles of the posterior abdominal wall and the deep muscles of the back. ............................... 35
7. The surface projections of thoracic organs. Topography of the thoracic cavity, the divisions of the
mediastinum.................................................................................................................................................. 42
8. The anatomy, blood supply and lymphatic drainage of the female breast........................................... 47
9. The definition and structures of the superior mediastinum. Topography and 
developmental stages
of the thymus. ............................................................................................................................................... 51
10. Upper airways: functional anatomy of the nasal cavity and paranasal sinuses(without structures of
the skull) ........................................................................................................................................................ 55
11. The cartilages, ligaments and cavity of the larynx. The anatomy of the hyoid bone. Laryngoscopic
image.60
12. The muscles, blood supply and innervation of the larynx. The histology of the larynx. ................... 65
13. The anatomy of the trachea. Organization of the bronchial system. The histological arrangement of
the trachea, the bronchi and bronchioli. ...................................................................................................... 70
14. Development of the respiratory system: ........................................................................................... 79
15. The gross anatomy and histology of the lung, the bronchopulmonary segments and pleura. The
innervation of the pleura. ............................................................................................................................. 82
16. The blood supply, innervation and lymphatic drainage of the lung: ................................................. 93
17. The anatomy of the pulmonary circulation, topography and branches of the pulmonary trunk. .... 94
18. The tributaries of the superior vena cava. The azygos-hemiazygos system. The lymphatic drainage
of the thoracic cavity: .................................................................................................................................... 96
19. The topography of the vagus nerve in the thoracic cavity and the anatomy and function of the
phrenic nerve .............................................................................................................................................. 102
20. Organization of the thoracic part of the sympathetic chain ............................................................ 110
21. General embryology I: fertilization, implantation, cleavage, gastrulation, development of the
neuroectoderm. Differentiation of intraembryonic mesoderm. ................................................................ 111
22. General embryology II: development of the amnion, yolk sacs, extraembryonic mesoderm.
Formation of the placenta........................................................................................................................... 118

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1. The vertebral column: gross anatomy, syndesmology and X-ray anatomy

• The vertebral column is also known as the spinal column or spine

• It consists of a sequence of vertebrae (total 33), each of which is separated and
united by an intervertebral disc.
• It extends from the inferior aspect of the occipital bone of the skull to the tip of the
coccyx.
• The vertebrae and intervertebral discs form the vertebral column.
• Function:
o Supports the weight of the Upper body
o Maintains posture and facilitates movement
o Houses and Protects the spinal cord

Intervertebral disc
• Fibrocartilaginous structure
• Acts as cushion to prevent shock and stress
between two vertebrae except between the
first two cervical vertebrae and between the
sacrum and coccyx
• Prevents friction

Regions of the Vertebral Column

• Cervical region(C)- 7 vertebrae of the

neck
• Thoracic Vertebrae(T)- 12 vertebrae
of the thorax
• 3 Lumbar vertebrae (L)- 5 vertebrae of
the loin
• 4 sacrum (S)- is formed from 5 fused
vertebrae
• 5 coccyx (Co)- is formed from 4-5
fused rudimentary vertebrae

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 Gross anatomy of the vertebral column

Curvatures
• Anterior curvatures:
o Cervical region: Cervical lordosis Function of curvatures
o Lumbar region: Lumbar lordosis • Increase flexibility
• Posterior Curvatures: • Distribute body weight more
o Thoracic region: Thoracic kyphosis evenly among vertebrae
o Sacral region: Sacral kyphosis

*Scoliosis: deviation to either side of the median sagittal plane

General organisation of vertebra

Part Function
Body ・ has costal facets or processes of the thoracic vertebrae anterior to the
pedicles, which articulate with the heads of the corresponding and
subjacent (just below) ribs

Vertebral (neural) arch ・ consists of paired pedicles laterally and paired laminae posteriorly
・ forms the vertebral foramen with the vertebral body
Facets

Superior / inferior ・ 2 superior and 2 inferior projections from the junction of the laminae and
articular facet pedicles
・ articulate with other articular processes of the arch above or below,
forming plane synovial joints

Facet for head of rib ・ an articular surface on the head of a rib that articulates with a
corresponding facet or two demifacets on the bodies of vertebrae

Processes

Spinous process ・ projects posteriorly from the junction of two laminae of the vertebral arch
・ bifid in the cervical region, spine-like in the thoracic region and oblong in
the lumbar region

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Transverse processes ・ project laterally on each side from the junction of the pedicle and the
lamina
→ articulate with the tubercles of ribs 1 to 10 in the thoracic region
・ have transverse foramina in the cervical region
Mamillary processes ・ tubercles on the superior articular processes of the lumbar vertebrae
Accessory processes ・ project backward from the base of the transverse process and lateral and
inferior to the mamillary process of a lumbar vertebra

Foramina

Vertebral foramina ・ formed by the vertebral bodies and vertebral arches (pedicles and
laminae)
・ collectively form the vertebral canal and transmit the spinal cord with its
meningeal coverings, nerve roots, and associated vessels

Intervertebral foramina ・ located between the inferior and superior surfaces of the pedicles of
adjacent vertebrae
・ transmit the spinal nerves and accompanying vessels as they exit the
vertebral canal

Transverse foramina ・ present in transverse processes of the cervical vertebrae

・ transmit the vertebral a. (except for C7), vertebral v., and autonomic nn.

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Structure
1. Hyaline cartilage
2. Nucleus pulposus
・ remnant of the embryonic notochord
・ consists of reticular and collagenous fibres embedded in mucoid material
・ may herniate or protrude through the annulus fibrosus
・ acts as a shock-absorber
3. Annulus fibrosus
・ consists of concentric layers of fibrous tissue and fibrocartilage
・ binds the vertebral column together, retains the nucleus
pulposus, and permits a limited amount of movement
・ acts as a shock absorber
4. Superior articular facet
5. Inferior articular facet

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Features of the vertebrae

≪Cervical vertebrae≫
・ Small body
・ Vertebral foramen: wide, triangular
・Transverse foramina present (only in cervical!!)
▪ contain vertebral a. & v.
・ Bifid spinous process

● 1st Cervical vertebrae

Known as Atlas
Supports skull
Has no vertebral body nor spinous process
Superiorly: articulates with occipital condyles on the
occipital bone of the skull
Inferiorly: Articulates with second cervical vertebra

● 2nd Cervical vertebrae

Known as Axis
1st and 2nd Cervical vertebrae
Has odontoid process(dens) on its superior surface

● 7th Cervical vertebrae

Known as vertebra prominens due to large spinous process(palpable) which protrudes
from under the skin and is visible to naked eye
Spinous process not bifid

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≪Thoracic vertebrae≫
● Body
Heart shaped and round
Aortic impression: descending aorta, T4-T9
Superior and Inferior costal facets: articulation
with head of the rib
▪ T1-T9: have two pairs of facets
▪ T10-12: have only one pair of facets
● Vertebral foramen: round or diamond-shaped
● Spinous process: long and point caudally
● Transverse process
Articulates with the costal tubercle of the rib
Not present on T11 and T12
● Articular processes
Projects in frontal plane
Superior articular facets point dorsally
Inferior articular facets point ventrally
The exception is the vertebra T12 which has caudal facets in sagittal plane

≪Lumbar vertebrae≫
● Kidney shape-shaped body
✓ Largest vertebral body
● Vertebral foramen: triangular, small
● Quadrangular spinous process
● Articular surfaces of zygapophyseal joints: Sagittal plane
✓ Cranial facets point medially
✓ Caudal facets point laterally
➢ Costal process: embryological remnant of the lumbar rib
o Mammillary process: the embryological remnant of
the transverse process

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Summary

Sacrum
・ A large, triangular, wedge-shaped bone composed of five fused sacral vertebrae
・ has 4 pairs of foramina for the exit of the ventral and dorsal primary rami of the first four sacral nerves
・ forms the posterior part of the pelvis and provides strength and stability to the pelvis
・ characterised by the following structures:

Promontory
・ prominent anterior edge of the first sacral vertebra (S1) Ala
・ superior and lateral part of the sacrum, which is formed by the fused transverse processes and fused costal
processes of the first sacral vertebra
Median sacral crest
・ formed by the fused spinous processes
Sacral hiatus
・ formed by the failure of the laminae of vertebra S5 to fuse
Sacral cornu or horn
・ formed by the pedicles of the 5th sacral vertebra
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Coccyx
・ a wedge-shaped bone formed by the union of the four coccygeal vertebrae ・ provides attachment for the
coccygeus and levator ani muscles

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 Openings of the vertebral column

≪Canal for vertebral arteries [C1-C6]≫

・ Contents: vertebral vessels
・ Formed by:
− Foramina transversaria

≪Vertebral canal≫
・ Contents: spinal cord [C1 – L2]
・ Formed by:
− Proximal opening

・ towards the foramen magnum

− Parts (segments)
・ Vertebral foramina
・ Sacral canal
− Side wards exits
・ Intervertebral foramina
> Contents: spinal nerves
> Sup. vertebral notch + Inf. vertebral notch [C2-L5]
> Ant. sacral foramina +Post. sacral foramina [Sacrum]
− Distal opening

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Syndesmoses of vertebral column
− Ligaments between the vertebrae

>between occipital bone and 7th cervical

vertebra
・ Nuchal Lig.

> between the vertebral bodies:

・ Ant. longitudinal Lig.
・ Post. longitudinal Lig.

> between the vertebral arches:

・ Ligamenta flava (yellow)

> between the transverse processes:

・ Intertransverse Lig.

> between the spinous processes:

・ Interspinous Lig.
・ Supraspinous Lig.

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X-ray anatomy

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2. Functional anatomy of the atlantooccipital and atlantoaxial joints.

❖ Atlas (C1) :
o Supports the skull (head) and rotates
on the facets of the axis (C2). o
Widest of cervical vertebras. o Has
no body and no spine.
o Anterior and posterior arches +
paired transverse processes.
o Articulates with the occipital
condyles of the skull
(atlantooccipital joint).

❖ Axis (C2) :
o Has the smallest transverse process. o
Characterized by the dens. (Teeth like
structure). o Articulate with anterior arch
of the atlas.
o Supported by: cruciate, apical and alar
ligaments and the tectorial membrane.
o o Articulates superiorly with the atlas
(atlantoaxial joint) which is responsible for
rotation of the head.

➢ Atlantooccipital joint: (craniovertebral joint).

a) Type: ellipsoid (synovial joint) / condylar.
b) Articular facets: occipital condyles of skull
and superior articular surface of atlas (C1).
c) Ligaments:
1. Anterior atlanto-occipital
membrane.
2. Posterior atlanto-occipital
membrane.
➔ They help prevent excessive movement of the joint.
d) Movements:
1. Sideway bending / sideway tilting. (frontal plane, sagittal axis).
2. Anterflexion-retroflexion. (sagittal plane, transverse axis).
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➢ Atlantoaxial joint: (divided into two parts).
● Median atlantoaxial joint:
a) Type: pivot (synovial joint).
b) Articular facets:
▪ Anterior part: facet for dens of the
atlas and anterior articular facet of
the dens.
▪ Posterior part: posterior articular
facet of the dens and transverse
ligament of atlas.
c) Ligaments:
1. Alar ligaments.
2. Apical ligament of dens.
3. Tectorial membrane.
4. Cruciate ligament of atlas:
- Transverse ligament.
- Longitudinal ligament.

● Lateral atlantoaxial joint:

a) Type: plane (synovial joint).
b) Articular facets: inferior articular facet of atlas and superior articular facet of axis.
c) Ligaments: (no ligaments).

✓ Movements: We only have one significant movement which is rotation.

(Transverse plane, vertical axis).

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3. The bones and joints of the thorax, the movements of respiration

● What is the thorax?

The part of the human body between the neck and the diaphragm, containing the heart
and lungs
● The thorax consists of 2 bones: The sternum and the Ribs
1. Sternum:
o flat bone
o Parts:
a) Manubrium
b) body of sternum
c) xiphoid process
d) sternal angle (Louis
angle)
o Location: in the center
of the chest

2. Ribs:
o curved flat bone - 12 pairs
o True ribs (1-7): articulate directly
with the sternum o False ribs (8-10):
do not articulate directly with the
sternum
o Floating ribs (11-12): articulate with
vertebral body only, have small
costal cartilage
o Parts of a rib:
a) head of the rib - has
articular facet + crest of
the head of the rib
b) neck of the rib
c) body of a rib – has tubercle of rib (1-10), costal groove, angle of rib.
d) costal cartilage: hyaline cartilage (may ossify). From 1-10
o Curvatures of the rib:
a) Edge curvature - first rib only
b) Flat surface curvature- 2-12 ribs
c) Longitudinal twist - 2-12 ribs
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● Joints of the thorax:
1) costovertebral joint:
A. Joint of head of the rib (1-12):
o Type: pivot (synovial joint)
o Articular facets: articular facet
of the head of the rib &
transverse costal facet
o Ligaments:
1. Intraarticular ligament of
head of rib
2. Radiate ligament of head of
rib
B. Costotransverse joint (1-10):
o Type: pivot (synovial joint)
o Articular facets: articular facet of tubercle of rib & transverse costal facet
o Ligaments: costotransverse ligaments

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 2) Sternocostal joints:
o Type: 1. 1st sternocostal joint: synarthrosis (not synovial)
2. 2nd to 7th sternocostal joints: diarthrosis (synovial)
o Articular facets: cartilages of ribs & costal notches on sternum
o Ligaments: 1. radiate sternocostal ligament -> sternal membrane
2. inter-articular sternocostal ligaments.

3) interchondral joints:
o Type: synovial joint
(diarthrosis)
o Articular facets: between 6-
10 costal cartilages
o Movements: small sliding
movements

4) manubriosternal symphysis:
o Type: symphysis
o Articular facets: body of
sternum & manubrium of
sternum
* This joint is the level of the “sternal angle.”

5) xiphisternal joint: (angle of Louis)

o Type: synchondrosis
o Articular facets: body of sternum & xiphoid process
Ligaments: Xiphisternal ligament

* This joint is the level of the “diaphragm."

**These joints often fuse and become synostosis in older individuals.

6) sternoclavicular jojnt

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 ➢ The Development of the Thorax
Ribs
・ bony portion of each rib is derived from sclerotome cells that remain in the paraxial mesoderm and that grow out
from the costal processes of thoracic vertebrae
・ costal cartilages are formed by sclerotome cells that migrate across the lateral somitic frontier into the adjacent
lateral plate mesoderm

Sternum
・ develops independently in the parietal layer of lateral plate mesoderm in the ventral body wall
・ 2 sternal bands are formed in the parietal (somatic) layer of lateral plate mesoderm on either side of the midline,
and these later fuse to form cartilaginous models of the manubrium, sternebrae and xiphoid process

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The movements of Respiration

Inspiration
— Movements:
・The rib cage is elevated.
・The sternum moves to the superior-anterior direction.
・The diaphragm moves to downward.

— Participating muscles:
・Ext. intercostal muscle
・Serratus post. sup. muscle
・Levator costarum

Expiration
— Movements:
・The rib cage is depressed.
・The sternum moves to the inferior-posterior direction.
・The diaphragm moves upward.

— Participating muscles:
・Int. intercostal muscle
・Innermost intercostal muscle
・Subcostalis
・Transverses thoracis
・Serratus post. inf. Muscle

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 Summary of Muscles of inspiration
➢ Contraction of diaphragm → abdominal pressure↑
➢ Elevation of ribs → intrathoracic pressure↓
Muscle Origin Insertion Innervation Function
① Diaphragm Sternal part: xiphoid the fibres phrenic n. muscle fibres draw the
process Costal part: converge from central tendon
lower 6 ribs Lumbar these sites of downward
part: first 3 lumbar origin and are
vertebrae, first lumbar inserted into
vertebra, last rib the central
tendon of the
muscle

② External lower border of a rib upper border of intercostal may elevate and
intercostal a rib nn. depress the ribs

③ Levator transverse processes outer surface intercostal elevate the ribs and
costarum of the last cervical and of the rib below nn. slightly rotates the
the next eleven vertebrae
(medially from
thoracic vertebrae
the angle)

④ Serratus last 2 thoracic and first inferior segmental draws the ribs
posterior 2 lumbar spines / borders of last thoracic nn. downward
superior supraspinal lig. 4 ribs

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Summary of Muscles of expiration

➢ Relaxation of diaphragm → abdominal pressure↓

➢ Depression of ribs → intrathoracic pressure↑

Muscle Origin Insertion Innervation Function

① Internal inferior rib superior rib may elevate
intercostal and depress
the ribs
② Innermost
intercostal

③ Subcostals inner surface of a rib inner surface of may depress

2nd or 3rd rib intercostal nn. the ribs
below

④ Transverse inner surface of the sternum inner surface of depress the

thoracis and from the 3rd-6th the 2nd-6th ribs
sternocostal junctions and costal cartilages
costal cartilages

⑤ Serratus last 2 thoracic and first 2 inf. borders of segmental draws the ribs
posterior lumbar spines and the last 4 ribs thoracic nn. downwards
inferior supraspinal lig.

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4. The diaphragm

・Dome-shape muscle (dome-shaped musculofibrous septum).

・separates the thoracic cavity (heart, lungs & ribs) from the abdominal cavity.
・performs an important function in respiration:
**As the diaphragm contracts, the volume of the thoracic cavity increases and air is drawn
into the lungs **

● Origin:
o costal part: lower margin of costal arch. Inner surface of 7-
12 ribs
o lumbar part: right and left crura.
o Medial parts: L1-L3 vertebral bodies, 2nd + 3rd
intervertebral disks, anterior longitudinal ligament
o Lateral parts: medial and lateral arcuate ligaments
● Insertion: central tendon
● Actions:
o principal muscle of respiration
o o Helps in compressing the abdominal viscera.
● Nerve supply:

o The diaphragm is primarily innervated by the phrenic nerve which is formed from the
cervical nerves C3, C4, and C5. (A useful mnemonic to remember this is, "C-3, 4, 5
keep the diaphragm alive.")
o central portion of the diaphragm : sends sensory afferents via the phrenic nerve
peripheral portions of the diaphragm : send sensory afferents via the intercostal
nerves

● Blood supply:
o Superior + inferior phrenic arteries from lower
thoracic aorta and upper part of abdominal aorta

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 o Musculophrenic artery internal o
Pericardiacphrenic artery thoracic artery

● Apertures through the diaphragm:

1. vena caval hiatus
2. Esophageal hiatus
3. Aortic hiatus
4. Lumbar part
5. Sternal part (sternocostal triangle)

● Sternocostal triangle:
Small zones lying between the costal and sternal attachments of the
thoracic diaphragm, potential site for hernia o Contents:
1. superior epigastric arteries + veins
2. internal thoracic arteries + veins
● Lumbocostal triangle:
o It is a space between the costal and lumbar parts of the diaphragm o The base
of this triangular space is formed by muscle attachments originating from the
12th rib and muscle fibers attached to the lateral arcuate ligament.
o The apex if this triangle is oriented towards the tendinous center of the
diaphragm
o Parietal pleura and renal capsule are in contact in this space, so possible
infection can be transmitted through this space
o The existence of this foramen might cause a congenital diaphragmatic hernia
● Diaphragm herniations:
1. retrosternal hernia: through sternocostal trigone
2. Dorsal hernia: through lumbocostal trigone
3. Paraoesophageal hernia: through esophageal hiatus

crus (singular), crura (plural)

One of the diaphragm’s origins.
The crura are tendinous in structure, and blend with the anterior longitudinal ligament of the
vertebral column.
・right crus (L1-3)
・left crus (L1-2)

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 ❖ Medial arcuate ligament (medial lumbocostal arch)
・L1
・passes over psoas muscle

❖ Lateral arcuate ligament (lateral lumbocostal arch)

・L1 → rib12
・passes over quadratus lumborum

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5. The muscles and layers of the thoracic wall. The intercostal space.

layers of the thoracic wall:

1. Skin
2. Subcutaneous tissue - the thoracoepigastric veins run In this layer
3. Pectoral fascia - encloses the pectoralis major
4. Clavipectoral fascia located under the pectoralis major spreads between the clavicle,
coracoid process, costal cartilages and pectoralis minor encloses the pectoralis minor
and subclavius
5. Thoracic fascia the superficial fascia of all ribs and Intercostal spaces
6. Intercostal space
7. Parietal fascia of thorax / endothoracic fascia- lines the inner surface of the thoracic
cavity
7. 1.Suprapleural membrane / fascia of Sibson - a thicker fascia at the pleural
cupula

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8. Parietal
pleura

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The muscles of the thoracic cavity

1. External Intercostals
● There are 11 pairs of external intercostal muscles.
● They run inferoanteriorly from the rib above to the rib below,
● continuous with the external oblique of the abdomen

Attachments: Originate at the lower border of the rib, inserting into the superior
border of the rib below.
Actions: Elevates the ribs, increasing the thoracic volume.
Innervation: Intercostal nerves (T1-T11)

2. Internal Intercostals

● flat muscles lie deep to the external intercostals.

● Run inferoposteriorly from the rib above to the one below

They are continuous with the internal oblique muscle of the abdominal wall.

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 ● Attachments: Originates from the lateral edge of the costal groove and inserts into the
superior surface of the rib below.
● Actions: The interosseous part reduces the thoracic volume by depressing the ribcage,
and the interchondral part elevates the ribs.

● Innervation: Intercostal nerves (T1-T11).

3. Innermost Intercostals
● These muscles are the deepest of the intercostal muscles
● They are separated from the internal intercostals by the intercostal neurovascular
bundle
● found in the most lateral portion of the intercostal spaces.
● Attachments: Originates from the medial edge of the costal groove and inserts into
the superior surface of the rib below.
● Actions: The interosseous part reduces the thoracic volume by depressing the
ribcage, and the interchondral part elevates the ribs.
● Innervation: Intercostal nerves (T1-T11)

4. Transversus Thoracis
● continuous with transversus abdominis inferiorly.
● Attachments: From the posterior surface of the inferior sternum to the internal
surface of costal cartilages 2-6.
● Actions: Weakly depress the ribs.
● Innervation: Intercostal nerves (T1-T11).

5. Subcostalis
● found in the inferior portion of the thoracic wall.
● comprise of thin slips of muscle
● run from the internal surface of one rib, to second and third ribs below. The
direction of the fibres parallels that of the innermost intercostal.
● Attachments: These originate from the inferior surface of the lower ribs, near the
angle of the rib. They then attach to the superior border of the rib 2 or 3 below.
● Actions: Share the action of the internal intercostals
● Innervation: Intercostal nerves

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Intercostal spaces
1. located between adjacent ribs.
2. They contain three layers of intercostal muscles. From superficial to deep these are the
external intercostal muscles, internal intercostal muscles and the innermost intercostal
muscles.
3. The intercostal neurovascular bundle runs between the internal and innermost
intercostal muscles.
4. It passes just below the lower margin of the rib in the costal groove.

Content
1. External intercostal muscles
2. Internal Intercostal muscles
3. Intercostal neurovascular bundle
3.1. Anterior and posterior Intercostal vein
3.2 Anterior and posterior Intercostal artery
3.3. Intercostal nerve
4. Collateral Neurovascular bundle
4.1. Collateral branch of posterior Intercostal artery
4.2 Collateral branch of Intercostal nerve which runs In the Inferior and posterior
part of the intercostal space
5. Innermost Intercostal muscles
Topography of the Intercostal Space
・ the space between 2 ribs
・ there are 11 intercostal spaces, each numbered for the superior to it
・ filled by the external, internal and innermost intercostal muscles, their fasciae, the
endothoracic fascia and the parietal pleura
・ protects the intercostal nerves and vessels in the form of intercostal canal
→ the canal is formed by internal and innermost intercostal muscles and
costal groove
→ contains vessels and nerves, in superior to inferior direction:
Vein
Artery
Nerve

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Summary: Superficial muscles of the trunk: Thoracohumeral muscles

Muscle Origin Insertion Innervation Function

Pectoralis anterior surface of the lateral lip of the medial & adduction / medial
major sternal half of the clavicle intertubercular sulcus lateral rotation of the arm
/ anterior surface of the on the humerus pectoral nn.
sternum / from the
cartilages of the true ribs
(except the 1st and 7th) /
aponeurosis of the
external abdominal
oblique muscle

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Pectoralis outer surface of the coracoid process of medial protractor and
minor 3rd-5th ribs the scapula pectoral n. rotator of the
scapula / elevates
the ribs during
forced inspiration

Subclavius 1st rib and its cartilage inferior surface of the subclavian Depresses /
middle 3rd of the n. from the stabilises the
clavicle brachial plx. clavicle

Serratus outer surfaces and
anterior superior borders of the
first 8 and 9 ribs and from
the fasciae covering the
external intercostals
muscles
ventral surface of the long thoracic suspends and
medial border of the n. fixes the scapula /
scapula / anterior rotates the inferior
surface of the angle laterally
jsuperior angle /
anterior surface of the
inferior angle of the
scapula

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 Summary: Spinohumeral muscles

Muscle Origin Insertion Innervation Function

Superficial muscles

Trapezius ext. occipital lateral 1/3 of spinal part of rotates / elevates =

protuberance / nuchal lig. clavicle / accessory n. / depresses the
/ spinous processes / acromion / spine scapula
supraspinal lig. of the 7th cervical
of the scapula
cervical and all thoracic (C3-C4) nn.
vertebrae

Latissimus lower 6 thoracic, lumbar, intertubercular thoracodorsal extends / adducts /

dorsi and sacral vertebrae by
means of the
thoracolumbar fascia /
post. part of the iliac
crest / lower 3-4 ribs
groove of the n. medially rotates the
humerus humerus / assists
in forced expiration

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 Summary of deep muscles of trunk

Deep muscles

Levator post. tubercles of medial border of dorsal scapular elevates scapula

scapulae transverse processes scapula superior (C5) n. / and tilts its glenoid
of C1-C4 vertebrae to root of spine cervical (C3, cavity inferiorly by
C4) nn. rotating scapula

Rhomboid nuchal lig. / spinous smooth

minor processes of C7 and triangular area at
T1 vertebrae medial end of
retract scapula and
scapular spine
rotate it to depress
dorsal scapular
glenoid cavity / fix
n. (C4, C5)
Rhomboid spinous processes of medial border of scapula to thoracic
major scapula from wall
T2-T5 vertebrae
level of spine to
inferior angle

34
 6. The muscles of the posterior abdominal wall and the deep muscles of the back.

Muscles of abdominal wall

Lateral posterior
Anterior
-External obliqe m. -quadratus lumborum m.
-rectus abdominis m.
-internal obliqe m. -iliacus m.
-pyramidalis m. -transversus abdominis m. -psoas major m.
-psoas minor m.

The muscles of the posterior abdominal wall

35
 M. erector spinae:
1. M. iliocostalis
Deep muscles of the back 2. M. longissimus
1. located underneath the erector spinae. 3. M. spinalis
2. short muscles
3. associated with the transverse and spinous processes of the vertebral column

1. Semispinalis
● The semispinalis is the most superficial of the deep intrinsic muscles.
● can be divided by its superior attachments into:
● Thoracic ● Cervicis ● Capitis.
● Attachments: Originates from the transverse processes of C4-T10. The fibres
ascend 4-6 vertebral segments, attaching to the spinous processes of C2-T4, and
to the occipital bone of the skull.
● Innervation: Posterior rami of the spinal nerves.
● Actions: Extends and contralaterally rotates the head and vertebral column

2. Multifidus
● located underneath the semispinalis muscle. It is best developed in the lumbar area.
● Attachments: Has a broad origin – arises from the sacrum, posterior iliac spine,
common tendinous origin of the erector spinae, mammillary processes of lumbar

36
 vertebrae, transverse processes of T1-T3 and articular processes of C4-C7. The fibres
ascend 2-4 vertebral segments, attaching the spinous processes of the vertebrae.
● Innervation: Posterior rami of the spinal nerves.
● Actions: Stabilizes the vertebral column.

3. Rotatores
The rotatores are most prominant in the thoracic region

● Attachments: Originates from the vertebral transverse processes. The fibres ascend,
and attach to the lamina and spinous processes of the immediately superior
vertebrae.
● Innervation: Posterior rami of the spinal nerves.
● Actions: Stabilizes the vertebral column, and has a proprioceptive function.

4. Minor Deep Intrinsic Muscles:

● Interspinales: Spans between adjacent spinous processes. Acts to stabilize the
vertebral column.
● Intertransversarii – Spans between adjacent transverse processes. Acts to stabilize
the vertebral column.
● Levatores costarum – Originates from the transverse processes of C7-T11, and
attaches to the rib immediately below. Acts to elevate the ribs.

37
 Summary: deep muscles of the back

Muscle Origin Insertion Innervation Function

① (a) Splenius nuchal ligament / below superior dorsal rami of rotates and extends the
capitis spinous process nuchal line / middle cervical nn. head
mastoid process
C3-T3 (C1-6)

(b) Splenius spinous process transverse dorsal rami of the rotates and extends the
cervicis T3-T6 process C1-3 lower cervical nn. head

(C8-L1)

Erector spinae

② (a) thick broad inferior borders of extends and laterally

Iliocostalis aponeurosis attached the angles of the flexes vertebral column /
last 6th-12th ribs assists in rotation /
lumborum to median sacral crest depresses ribs
/ iliac crest /
thoracolumbar fascia
dorsal rami of the
(b) Iliocostalis upper borders of the angles of the segmental spinal extends and laterally
thoracis angles of 7th-12th ribs 1st–6th ribs nn. flexes vertebral column

(c) Iliocostalis angles of the 3rd-6th transverse extends and laterally

cervicis ribs process of C4-C6 flexes vertebral column
vertebrae

⑥ Multifidus back of sacrum / spinous process of upper acting alone:

articular process of (2-4) vertebrae flexor and rotator
lumbar vertebrae / acting together:
transverse process of dorsal rami of extensor of
thoracic vertebrae / the segmental vertebral column
articular process of spinal nn.
C4-C7 vertebrae

38
⑦ Rotatores brevis transverse process base of spine/ margin of extensors and
& longus (thoracic region) / lamina of next vertebrae rotators
articular procecss
(lumbar and cervical
regions)

⑧ Interspinalis short, paired 6 pairs in cervical region / extend the

muscular bundles T1 and T10-T12 vertebral column
connecting adjacent vertebrae are connected
vertebral spines / 4 pairs in lumbar region

⑨ small muscles 2 pairs at each segment bend the vertebral

Intertransversarii between the in cervical region / 1 on column laterally
transverse processes each side between T9- when acting on
of the adjacent T12 / 1 pair on each side one side and
vertebrae between adjacent vert. in extend when acting
lumbar region together

Summary: Broad muscles of the abdomen

Muscle Origin Insertion Innervation Function

Transversus lateral third of the its own broad increases the
abdominis inguinal ligament / inner aponeurosis and intraabdominal
linea alba pressure
lip of the iliac crest /
thoracolumbar fascia /
inner surfaces of the last
6 costal cartilages lower
intercostals
Internal oblique* lateral half of the inguinal inf. borders of the
nerves
ligament / ant. part of the last 4 costal increases the
middle lip of the iliac cartilages / its own intraabdominal
crest broad aponeurosis pressure / flexes
of the vertebral
Rectus pubic crest / ligaments of cartilages of the column
abdominis the pubic symphysis 5-7th ribs

39
 External oblique outer surface of the ant. half of the lower increases the
lower 8 ribs outer lip of the iliac intercostals intraabdominal
crest / its own nerves pressure / flexes
broad aponeurosis of the vertebral
column

Summary: Muscles of the Posterior Abdominal wall

Muscle Origin Insertion Innervation Function

Quadratus transverse lower border of last subcostal n depresses rib
lumborum processes of L3–L5; rib; transverse (L1–L3) 12; flexes trunk
iliolumbar ligament; processes of L1–L3 laterally
iliac crest

Psoas major transverse lesser trochanter L2–L3 flexes thigh and

processes / trunk
intervertebral disks
and bodies of
T12–L5
Iliacus superior 2/3 of iliac lesser trochanter of femoral n. flexes thigh and
fossa / ala of femur and shaft (L2– L4) stabilizes hip
sacrum / anterior joint; acts with
inferior to it, and to
sacroiliac ligaments psoas major
psoas major tendon

40
Summary of layers of abdominal wall

Abdominal wall Scrotum

Skin Skin

Superficial fascia Dartos fascia

External oblique muscle External spermatic fascia

Internal oblique muscle Cremasteric fascia

Transversus abdominis muscle Cremaster muscle

Transversalis fascia Internal spermatic fascia

Peritoneum Tunica vaginalis

41
7. The surface projections of thoracic organs. Topography of the thoracic cavity, the
divisions of the mediastinum.

The Surface projections of thoracic organs

42
Topography of thoracic cavity
・ Filled laterally by the lungs - each lying in its pleural cavity
・ Space between the pleural cavities = mediastinum
・Heart (lying in its pericardial sac)
・Great vessels
・Oesophagus
・Trachea
・Thymus
・Thoracic duct and other major lymph trunks
・Lymph nodes
・Phrenic and vagus nerves

The divisions of the mediastinum

The mediastinum is an area found in the midline of the thorax that is surrounded by the
left and right pleural sacs.
It is divided into the superior and inferior mediastinum, of which the latter is larger.
The inferior mediastinum is further divided into the
anterior, middle and posterior mediastinum

Superior Mediastinum

➢ The superior mediastinum begins at the level of the first rib and descends to the
horizontal plane of the thoracic vertebra T4.

Anterior Inferior Mediastinum

➢ The anterior inferior mediastinum starts from the thoracic vertebra T4 and continues to
the diaphragm at the level of the thoracic vertebra T9. It extends posteriorly from the
body of the sternum and transversus thoracis muscle to the fibrous pericardium.

Middle Inferior Mediastinum

43
 ➢ The middle inferior mediastinum begins in the same area as the anterior inferior
mediastinum and finishes also in the same area between the T9 and T10vertebrae. It
extends posteriorly between the width of the fibrous pericardium.

Posterior Inferior Mediastinum

➢ The posterior inferior mediastinum again originates in the same place as the other two
subdivisions but extends the deepest, to the vertebra T12. Sagittally, it runs from the
posterior aspect of the fibrous pericardium to the vertebralcolumn.

Superior Mediastinum
➢ The superior mediastinum contains three visceral organs including the esophagus, the
trachea and remnants of the thymus.
➢ The nerves that run through this area are three and there are also two different
nervous plexuses. The phrenic nerve, the vagus nerve and the left recurrent laryngeal
nerve are the singular nerves, while the cardiac plexus branches and the pulmonary
plexus branches make up the peripheral neurological plexuses.

Arterial and venous constituents are comprised of:

● the superior vena cava

● the brachiocephalic veins

● the thoracic duct

● the aortic arch, which includes the brachiocephalic artery, the common carotid artery
and the left subclavian artery.

Anterior Inferior Mediastinum

The anterior inferior mediastinum has no major contents save remnants of the thymus and
some lymph nodes.

44
Middle Inferior Mediastinum

The middle inferior mediastinum contains a single nerve which is the phrenic nerve,
the heart and the pericardium. The vessels present include:

● the ascending aorta

● the pulmonary trunk

● the superior vena cava

● the pericardiacoophrenic artery

Posterior Inferior Mediastinum

The posterior inferior mediastinum has possibly the most anatomical structures. It
encompasses:

● the esophagus

● the thoracic aorta and its branches which include the posterior intercostal arteries, the
bronchial arteries and the esophageal arteries
● the azygos venous system

● the hemiazygos veins

● the accessory hemiazygos veins

● the thoracic duct

● the cisterna chyli

● the vagus nerve

● the esophageal plexus.

● several branches of the sympathetic trunk, like the greater splanchnic nerve, the lesser
splanchnic nerve and the least splanchnic nerve.

45
46
8. The anatomy, blood supply and lymphatic drainage of the female breast.

The anatomy of female breasts

❖ The breasts are paired structures located on the anterior thoracic wall, in the pectoral region.
❖ In females, the breasts contain the mammary glands – an accessory gland of the female
reproductive system.
❖ The mammary glands are the key structures involved in lactation.The breast is located on the
anterior thoracic wall.
❖ It extends horizontally from the lateral border of the sternum to the mid-axillary line.
Vertically, it spans between the 2nd and 6th intercostal cartilages. It lies superficially to the
pectoralis major and serratus anterior muscles.

The breast can be considered to be composed of two regions:

● Circular body – largest and most prominent part of the breast.

● Axillary tail – smaller part, runs along the inferior lateral edge of the pectoralis major
towards the axillary fossa.
At the centre of the breast is the nipple, composed mostly of smooth muscle fibres. Surrounding
the nipple is a pigmented area of skin termed the areolae.
There are numerous sebaceous glands within the areolae – these enlarge during pregnancy,
secreting an oily substance that acts as a protective lubricant for the nipple.

Mammary Glands

❖ The mammary glands are modified sweat glands. They consist of a series of ducts and
secretory lobules (15-20).
❖ Each lobule consists of many alveoli drained by a single lactiferous duct. These ducts
converge at the nipple like spokes of a wheel.

Connective Tissue Stroma

The connective tissue stroma is a supporting structure which surrounds the mammary glands. It
has a fibrous and a fatty component.

The fibrous stroma condenses to form suspensory ligaments (of Cooper). These ligaments have
two main functions:
● Attach and secure the breast to the dermis and underlying pectoral fascia.

● Separate the secretory lobules of the breast.

47
Pectoral Fascia
The base of the breast lies on the pectoral fascia – a flat sheet of connective tissue associated
with the pectoralis major muscle. It acts as an attachment point for the suspensory ligaments.
There is a layer of loose connective tissue between the breast and pectoral fascia – known as the
retromammary space. This is a potential space, often used in reconstructive plastic surgery.

Blood supply

Arterial supply to the medial aspect of the breast is via the internal thoracic artery, a branch of
the subclavian artery.
The lateral part of the breast receives blood from four vessels:

● Lateral thoracic and thoracoacromial branches – originate from the axillary artery.
● Lateral mammary branches – originate from the posterior intercostal arteries (derived from
the aorta). They supply the lateral aspect of the breast in the 2 nd 3rd and 4thintercostal
spaces.
● Mammary branch – originates from the anterior intercostal artery.
The veins of the breast correspond with the arteries, draining into the axillary and internal
thoracic veins.

48
Lymphatic drainage

The lymphatic drainage of the breast is of great clinical importance due to its role in the
metastasis of breast cancer cells.
There are three groups of lymph nodes that receive lymph from breast tissue – the axillary
nodes (75%), parasternal nodes (20%) and posterior intercostal nodes (5%).

The skin of the breast also receives lymphatic drainage:

● Skin – drains to the axillary, inferior deep cervical and infraclavicular nodes.
● Nipple and areola – drains to the subareolar lymphatic plexus.
Nerve Supply

The breast is innervated by the anterior and lateral cutaneous branches of the 4th to 6th
intercostal nerves. These nerves contain both sensory and autonomic nerve fibres (the
autonomic fibres regulate smooth muscle and blood vessel tone).
It should be noted that the nerves do not control the secretion of milk. This is regulated by the
hormone prolactin, which is secreted from the anterior pituitary gland.

I
II. III.
- Nodi laterales
- Nodi centrales - Nodi apicales
- Nodi subscapulares - Nodi - Nodi
interpectorales parasternales
- Nodi pectorales

- Nodi paramammarii

49
50
9. The definition and structures of the superior mediastinum. Topography and 
developmental stages
of the thymus.

● The mediastinum is the central compartment of the thoracic cavity.

● Anatomically, the mediastinum is divided into two parts by an imaginary line that runs
from the sternal angle (the angle formed by the junction of the sternal body and
manubrium) to the T4 vertebrae:

● Superior mediastinum – extends upwards, terminating at the superior thoracic

aperture.
● Inferior mediastinum – extends downwards, terminating at the diaphragm. It is
further subdivided into the anterior mediastinum, middle mediastinum and posterior
mediastinum.

bordered:

● Superior – Thoracic inlet.

● Inferior – Continuous with
the inferior mediastinum
at the level of the sternal
angle.
● Anterior – Manubrium of the sternum.
● Posterior – Vertebral bodies of T1-4.
● Lateral – Pleurae of the lungs.

Contents:
Arch of Aorta
The three major branches of the aortic arch arise within the superior mediastinum:
● Brachiocephalic artery – supplying the right side of the head & neck and the right
upper limb.
● Left Common carotid artery – to the left side of the head & neck. ● Left Subclavian
artery – to the left upper limb.
Superior Vena Cava
The following tributaries of the superior vena cava are located within the superior
mediastinum:
● Brachiocephalic veins – draining blood from the upper body.

51
 ● Left superior intercostal vein – collects blood from the left 2nd and 3rd intercostal
vein. It drains into the left brachiocephalic vein.
● Supreme intercostal vein – drains the vein from first intercostal space directly into
the brachiocephalic veins.
● Azygos vein – receiving blood from the right posterior intercostal veins. The left
intercostal veins drain first into the hemiazygos and accessory hemiazygos veins
before joining the azygos vein around T7-T9.

Vagus Nerve
In the superior mediastinum, the vagus nerve has two distinctive paths:
● Right vagus nerve – runs parallel to the trachea and passes posteriorly to the superior
vena cava and the right primary bronchus.
● Left vagus nerve – enters the superior mediastinum between the left common carotid
and the left subclavian arteries. It descends anteriorly to the aortic arch, before
travelling posterior to the left bronchus.
Phrenic Nerve
From the anterior surface of the anterior scalene muscle, the phrenic nerves (roots C3- C5)
enter the superior mediastinum lateral to the great vessels. They then descend anteriorly into
the middle mediastinum, passing anteriorly to the hilum of the lungs.
Other Nerves
● Cardiac nerves – originate from the superior, middle and inferior cardiac ganglion and
form the superficial and deep cardiac plexuses in the superior mediastinum. The
superior plexus sits between the aortic arch and right pulmonary vein. The deep plexus
lies on the surface of the trachea at the point of bifurcation.
● Sympathetic trunk – runs bilaterally to the vertebral bodies along the entire length of
the vertebral column.
Trachea
The trachea bifurcates into the primary bronchi posterior to the ascending aorta at the level of
the sternal angle.

Thoracic duct
In the superior mediastinum, the thoracic duct passes to the left of the oesophagus on its path
to the junction of the left internal jugular and subclavian veins.

Muscles
The sternohyoid and sternothyroid muscles originate from the posterior surface of the
manubrium. They are part of the infrahyoid muscle group of the neck. The inferior aspect of the
longus colli muscle also originates within the superior mediastinum.

52
Thymus
● The thymus gland is the most anterior structure within the superior mediastinum.
● It sits flush against the posterior surface of the sternum and extends into the anterior
mediastinum and can often reach into the neck.
● The thymus is a lymphoeplthellal organ located in the ventral part of the superior
mediastinum just behind the sternum.
● It contains T-lymphocytes undergoing maturation. The T-lymphocytes are selected in the
thymus to recognise self from non-self, meaning they are programmed to recognise and
attack foreign antigens that may be a potential threat to the organism.
● The thymus is the largest and most active during the neonatal period.
● During the teenage years it begins to atrophy and involute. After the age of around fifty,
the thymus is almost completely replaced by an adipose tissue. However, residual
thymus tissue may persist throughout the rest of life.
Development —
● The thymus appears in the form of two flask-shaped endoterm diverticula, which arise,
one on either side, from the third branchial pouch and extend lateralward and backward
into the surrounding mesoderm in front of the ventral aortæ.
● they meet and become joined to one another by connective tissue, but there is never
any fusion of the thymus tissue proper.
● The pharyngeal opening of each diverticulum is soon obliterated, but the neck of the
flask persists for some time as a cellular cord. By further proliferation of the cells lining
the flask, buds of cells are formed, which become surrounded and isolated by the
invading mesoderm. In the latter, numerous lymphoid cells make their appearance, and
are agregated to form lymphoid follicles. These lymphoid cells are probably derivatives
of the entodermal cells which lined the original diverticula and their subdivisions.
● Additional portions of thymus tissue are sometimes developed from the fourth
branchial pouches. Thymus continues to grow until the time of puberty and then begins
to atrophy.

Structure:

● Right lobe {lobus dexter)

● Left lobe {lobus sinister)
● Lobules [iobuii)
● Cortical septa (septa corticaiia) - bands of mediastinal fibrous tissue in the cortex
● Cortex - composed mainly of T-lymphocytes
● Medulla - contains epithelial reticular tissue, fewer T-lymphocytes and corpuscles of
Hassal Functions:
● Programming of T cells progenitors
● central tolerance - distinction between self and non-self anbgens

53
● most of the T-lymphocytes are eliminated by apoptosis (programmed cell death) during
the process of positive and negative selection
● selected T-lymphocytes migrate to the secondary lymphatic organs
● endocrine function: Influences T-lymphocyte proliferation and maturation, regulates
their functions and influences the migration of macrophages

54
10. Upper airways: functional anatomy of the nasal cavity and paranasal
sinuses(without structures of the skull)

Nasal cavity

● The nasal cavity is open through the nostrils to the external environment.
● Dorsally, it communicates with the nasopharynx through the posterior nasal apertures.
● The anterior apertures of the nasal cavities are the nares.
● The posterior apertures are the choanae, which open into the nasopharynx.
● It Is divided sagittally by the nasal septum, which is composed of cartilage ventrally and
bone dorsally.
● The floor of the nasal cavity is formed by the palate.
● The three conchae (inferior, medial and superior) protrude from the lateral wall and
divide the cavity into four groove-like air passages, the inferior, middle, superior and
common meatuses, which communicate with the paranasal sinuses and the
nasolacrimal duct.
● The roof is formed by the base of the anterior cranial fossa and is involved in olfaction.
● The nasal cavity serves to heat and humidity inspired air, and mechanically blocks
particles from entering.

55
Bony nasal cavities:
1. Ethmoid bone
2. Inferior nasal concha
3. Nasal bone
4. Maxilla
5. Palatine bone
6. Sphenoid bone
7. Frontal bone
8. Lacrimal bone
9. Vomer

Nasal Conchae
❖ Projecting out of the lateral walls of the nasal cavity are curved shelves of bone. They are
called conchae (or turbinates). The are three conchae – inferior, middle and superior.
❖ They project into the nasal cavity, creating four pathways for the air to flow. These
pathways are called meatuses:
● Inferior meatus: Lies between the inferior concha and floor of the nasal cavity.

56
 ● Middle meatus: Lies between the inferior and middle concha.
● Superior meatus: Lies between the middle and superior concha.
● Spheno-ethmoidal recess: Lies superiorly and posteriorly to the superior concha.
The function of the conchae is to increase the surface area of the nasal cavity – this
increases the amount of inspired air that can come into contact with the cavity
walls. They also disrupt the fast, laminar flow of the air, making it slow and turbulent.
The air spends longer in the nasal cavity, so that it can be humidified.

Paranasal sinuses

❖ The paranasal sinuses are air-filled extensions of the respiratory part of the nasal cavity.
❖ There are four paired sinuses, named according to the bone in which they are located;
maxillary, frontal, sphenoid and ethmoid.
❖ The function of the sinuses is not clear. It is thought that they may
contribute to the humidifying of the inspired air. They also reduce the
weight of the skull.
❖ Sinuses are formed in childhood by the nasal cavity eroding into surrounding
bone. As they are outgrowths of the nasal cavity, they all drain back into it –
openings to the paranasal sinuses are found on the roof and lateral walls of the
nasal cavity. The inner surface is lined by a respiratory mucosa.

57
Types
Frontal Sinuses:
❖ The most superior in location, found under the forehead.
❖ Opens through the infundibulum into the middle meatus.
❖ variable in size, but always triangular-shaped.
❖ Drain into the nasal cavity via the frontonasal duct, which opens out at the hiatus semilunaris
on the lateral wall.

Sphenoid Sinuses:
❖ Lie relatively superiorly, at the level of the spheno-ethmodial recess. (opens through its
anterior wall into the spheno-ethmoidal recess)
❖ Found more posteriorly, and are related superiorly and laterally to the cranial cavity.
❖ Drain out onto the roof of the nasal cavity.
❖ The relationships of this sinus are of clinical importance – the pituitary gland can be surgically
accessed via passing through the nasal roof, into the sphenoid sinus and through the sphenoid
bone.

Ethmoidal Sinuses:
There are three ethmoidal sinuses; anterior, middle and posteior. They empty into the nasal cavity at
different places:
● Anterior – Hiatus semilunaris
● Middle – Ethmoid bulla
● Posterior – Superior meatus

Maxillary Sinuses:
❖ The largest of the sinuses.
❖ Opens through the hiatus semilunaris into the middle meatus.
❖ Located laterally and slightly inferiorly to the nasal cavities.
❖ Drains into the nasal cavity at the hiatus semilunaris, underneath the frontal sinus opening. This
is a potential pathway for spread of infection – fluid draining from the frontal sinus can enter
the maxillary sinus.

Vasculature:
The nose has a very rich vascular supply – this allows it to effectively change humidity and
temperature of inspired air. The nose receives blood from both the internal and external
carotid arteries:
Internal carotid branches:
● Anterior ethmoidal artery
● Posterior ethmoidal artery
The ethmoidal arteries are branch of the opthalmic artery. They descend into the nasal cavity
through the cribriform plate

58
 External carotid branches:
● Sphenopalatine artery
● Greater palatine artery
● Superior labial artery
● Lateral nasal arteries

In addition to the rich blood supply, these arteries form anastamoses with each other.
This is particularly prevalent in the anterior portion of the nose .
The veins of the nose tend to follow the arteries. They drain into the pterygoid plexus, facial vein or
cavernous sinus.
In some individuals, a few nasal veins join with the sagittal sinus (a dural venous sinus). This
represents a potential pathway by which infection can spread from the nose into the cranial cavity.

59
11. The cartilages, ligaments and cavity of the larynx. The anatomy of the hyoid bone.
Laryngoscopic image.
❖ The larynx (voice box) is an organ located in the anterior neck. It is a component of the respiratory
tract, and has several important functions, including phonation (voice), the cough reflex, and
protection of the lower respiratory tract.
❖ The structure of the larynx is primarily cartilaginous, and is held together by a series of ligaments
and membranes. Internally, the laryngeal muscles move components of the larynx for phonation
and breathing.
❖ The larynx is located in the anterior compartment of the neck, suspended from the hyoid bone,
and spanning between C3 and C6. It is continuous inferiorly with the trachea, and opens
superiorly into the laryngeal part of the pharynx.
❖ It is covered anteriorly by the infrahyoid muscles, and laterally by the lobes of the thyroid gland.
The larynx is also closely related to the major blood
vessels of neck, which pass either side as they
ascend up to the head. the internal cavity of the
larynx can divided to 3 :

1. Supraglottis From the inferior surface of the

epiglottis to the vestibular folds (false vocal
cords).
2. Glottis – Contains vocal cords and 1cm below
them. The opening between the vocal cords is
known as rima glottidis, the size of which is
altered by the muscles of phonation.
3. Subglottis – From inferior border of the glottis
to the inferior border of the cricoid cartilage.

60
Cartilage of the larynx

61
Ligaments and cavity of the larynx

62
Anatomy of hyoid bone

63
The anatomy of the hyoid bone.

Superior view

Laryngoscopic image.

64
12. The muscles, blood supply and innervation of the larynx. The histology of the
larynx.

Muscles of the larynx

65
Blood supply and innervation of the larynx

66
Histology of the larynx
❖ Layers of larynx
Mucous membrane
o Epithelium
▪ Stratified squamous non-keratinized
▪ Pseudostratified ciliated columnar epithelium
*In epiglottis:
- Pharyngeal surface: stratified squamous non-keratized with high papillae
- Laryngeal surface w/o papillae
o Lamina propria
▪ Loose CT
Submucosa
o Loose CT with salivary gland(seromucous gland)
❖ Striated muscle, CT glands
Changes the size of the opening between thevocal cords
❖ Cartilages(covered with perichondrium)
Hyaline Cartilage
o Stained by HE
▪ Thyroid cartilage
▪ Cricoid cartilage
▪ Arytenoid cartilage (except vocal process)
Elastic cartilages
o Stained by orcein
• Vocal process of arytenoids
• Epiglottic cartilage
• Corniculate cartilage
• Cuneiform cartilage

67
Anatomical characteristics
• Vocal chords
o Skeletal muscle(vocalis m)
o Vocal ligament
o Stratified squamous non-keratinized epithelium
• Vestibular fold(false vocal cords)
o Loose CT contain glands, lymphoid aggregations
o Stratified squamous non-keratinizwd epithelium
• Fibroelastic membrane
o Quadroangular membrane
o Triangular membrane
o Conus elasticus

68
69
13. The anatomy of the trachea. Organization of the bronchial system. The
histological arrangement of the trachea, the bronchi and bronchioli.

Anatomy of the trachea

❖ The trachea (windpipe) is ~10- 13 cm in length , ~1.5-2 cm in diameter

❖ Connected to the larynx at the level of the vertebra C6
❖ Passes through the superior mediastinum and bifurcates into the two main bronchi at the level of the
vertebra T4
❖ Composed of 15-20 hyaline, C-shaped dorsally opened cartilages, which are interconnected by a
fibromuscular membrane
❖ Anatomically, the trachea is divided into two parts: the cervical part and the thoracic part

70
71
72
 Organization of the bronchial system

❖ The bronchi arise from the tracheal bifurcation at the level of the sternal angle and successively divide to
form the bronchial tree
❖ The main bronchi run in the mediastinum and divide into the lobar bronchi in the hilum of the lung
❖ Peripheral parts of the bronchial tree are located within the lung tissue itself
❖ Cartilaginous rings are incomplete, dorsally opened C-shaped rings in the primary bronchi
❖ They become irregular and infrequent towards the periphery of the bronchial tree

Right main (primary) bronchus (R) Left main (primary) bronchus (L)

Shorter (~ 2.5 cm) Longer (~ 5 cm)

Wider Narrower

Steeper More horizontal than the right main

bronchus.
More vertical than the left main bronchus. Slightly S-shaped
•Runs under the arch of the azygos vein. Runs inferior to the aortic arch.

Divides into three lobar bronchi divides into two lobar bronchi.

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The histological arrangement of the trachea, bronchi and bronchiole

The trachea
-The trachea is lined with a layer of pseudostratified ciliated columnar epithelium.
-The epithelium contains goblet cells, which are glandular, modified simple columnar epithelial cells that
produce mucins, the main component of mucus.
-Mucus helps to moisten and protect the airways.

Mucosa and sub-mucosa of Trachea

➢ The respiratory mucosa is made up of the epithelium and supporting lamina propria). The
epithelium is tall columnar pseudostratified with cilia and goblet cells.
➢ The supporting lamina propria underneath the epithelium contains elastin, that plays a role in
the elastic recoil of the trachea during inspiration and expiration, together with blood vessels
that warm the air.
➢ The sub-mucosa contains glands which are mixed sero-mucous glands. The watery secretions
from the serous glands humidify the inspired air.
➢ The mucous, together with mucous from the goblet cells traps particles from the air which are
transported upwards towards the pharynx by the cilia on the epithelium. This helps to keep the
lungs free of particles and bacteria.

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Summary of histology of trachea
1. Tunica mucosa
➢ Epithelium mucosae: Ciliated pseudostratified columnar epithelium, goblet cells,
endocrince cells
➢ Lamina propria: loose CT, lymphocytes,
plasma cells
2. Tunica Submucosa
➢ Loose CT
➢ Tracheal glands sero-mucous glands
3. Tunica fibro-musculo-cartilaginea
➢ Anterolateral wall: cartilaginous part
✓ Hyaline cartilage rings and annular
ligaments
➢ Posterior wall: membranous part
✓ Trachealis muscle, CT
4. Tunica adventitia
➢ Connective fibers, blood vessels, nerves

**There are lots of sero-mucous glands in the submucosa

layer.

The layer of cartilage is not seen here, but instead there is a layer of fibro-elastic connective tissue which runs
between the rings of cartilage.**

Bronchi

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 [Picture of tertiary bronchus)

➢ There is also lots of elastin present in the submucosa, as in the trachea.

➢ The epithelium is now tall columnar, not pseudostratified (difficult to see at this magnification) and
has very few goblet cells.

Bronchioles

➢ The tertiary bronchii branch into bronchioles, which have a diameter of 1mm or less, and the
wall structure changes.

➢ The epithelium is made up of ciliated columnar cells in larger bronchioles, or non-ciliated in

smaller bronchioles .There are no goblet cells, but there are cells called Clara cells.
➢ These cells are secretory - they secrete one of the components of surfactant.

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This is a picture of a bronchiole. There is no cartilage and no glands.

Summary of histology of bronchus and bronchiole

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14. Development of the respiratory system:

Formation of the lung buds:

➢ When the embryo is approximately 4 weeks old, the respiratory diverticulum (lung bud)
appears as an outgrowth from the ventral wall of the foregut.
➢ An increase in retinoic acid causes upregulation of the transcription factor TBX4 that will
induce formation of the bud, growth and differentiation of the lungs.
➢ The epithelium of the internal lining of the larynx, trachea, bronchi and lungs is entirely of
endodermal origin.
➢ The cartilagenous, muscular and connective tissue of trachea and lungs are derived from
splanchnic mesoderm.

1. The lung bud is in open communication with the foregut.

2. The diverticulum expands caudally and two tracheoesophageal ridges separate it from the
foregut.

3. Tracheoesophageal ridges fuse - tracheoesophageal septum.

4. The foregut is divided into a:

▪ dorsal portion – esophagus

▪ ventral portion – trachea and lung buds

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 Larynx:
➢ The internal lining of the larynx originates from endoderm, but the cartilages and muscles
originate from mesenchyme of the fourth and sixth pharyngeal arches.
➢ As a result of rapid proliferation of this mesenchyme, the laryngeal orifice changes in
appearance from a sagital slit to a T-shaped opening.
➢ When the mesenchyme of the two arches transforms into the thyroid, cricoid and arytenoid
cartilages the adult shape of the laryngeal orifice can be recognized.
➢ The laryngeal epithelium proliferates rapidly, resulting in a temporary occlusion of the lumen.
Subsequently, vacuolization and recanalization produces a pair of lateral recesses, the
laryngeal ventricles that are bounded by folds of tissue that differentiate into the false and
true vocal cords.
➢ Since musculature of the larynx is derived from mesenchyme of the fourth and sixth
pharyngeal arches, all laryngeal muscles are innervated by branches of vagus nerve (the
superior laryngeal nerve innervates derivatives of the fourth paryngeal arch and the
recurrente nerve innervates derivatives of the sixth laryngeal arch).
Trachea, bronchi and lungs:
➢ During its separation from the foregut, the lung bud forms the trachea and two bronchial
buds.
➢ At the beginning of the fifth week, each of these buds enlarges and form right and left main
bronchi.
➢ The right main bronchi gives rise to three secondary bronchi and the left main bronchi forms
two secondary bronchi.
➢ During further development, secondary bronchi divide repeatedly, forming ten tertiary
(segmental) bronchi in the right lung and eight in the left, creating the bronchopulmonary
segments of the adult lung.
➢ With subsequent growth, the lung expands into the pericardioperitoneal canals.
Pleuroperitoneal and pleuropericardial folds separate the pericardioperitoneal canals from the
peritoneal and pericardial cavities, respectively.
➢ The lung bud forms the trachea and two lateral outpockets - bronchial buds that will form the
right and left main bronchi.
➢ In the lungs the mesoderm which covers the outside of the lung will give rise to visceral
pleura; the somatic mesoderm layer which covers the body wall from the inside will become
the parietal pleura.
➢ The pleural cavity is the space between the parietal and visceral pleura.

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 Maturation of the lungs:

Periods time Features

Pseudoglandular 5 – 16 Branching has continued to form terminal bronchioles. No respiratory

period week bronchioles or alveoli are present.

Each terminal bronchiole divides into 2 or more respiratory bronchioles,

16 – 26
Canalicular period which in turn divide into 3-6 alveolar ducts. The cuboidal cells lining the
week
respiratory bronchioles.

Terminal sac Up to Cuboidal cells become very thin and flat and intimately associated with
period birth blood and lymph capillaries. Terminal sacs (primitive alveoli) form.

Up to Mature alveoli have well-developed epithelial endothelial (capillary)

Alveolar period
10 years contacts.

Fetal Breathing movements begin before birth and:

▪ cause aspiration of amniotic fluid

▪ stimulate lung development and conditioning of respiratory muscles

➢ At birth Lung fluid is reabsorb but not the surfactant coat. The surfactant prevents the
collapse of the alveoli durind expiration.
➢ Growth of the lungs after birth is due to an increase in the number of respiratory
bronchioles and alveoli and not an increase in size

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15. The gross anatomy and histology of the lung, the bronchopulmonary segments and
pleura. The innervation of the pleura.

Gross anatomy and histology of the lung

❖ The lung is a paired organ covered with the pleura and located in the pleural cavity
❖ Pulmonary tissue consists of the bronchial tree, connective tissue (pulmonary
interstitium), vessels, nerves and lymphatic nodes
❖ The lungs are divided into lobes each with its own lobar bronchus
❖ The lobes are further divided into segments, defined as the area ventilated by a
segmental bronchus and perfused by a branch of the pulmonary artery
❖ The right lung has 3 lobes and 10 segments, the left lung has 2 lobes and usually 8 segments

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Summary histology of lungs

83
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The bronchopulmonary segment

87
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 Pleura and innervation of the pleura

❖ The pleura: is a smooth glossy membrane lining the thoracic cavity

❖ It consists of a layer of loose subserous tissue covered by the mesothelium
❖ It is divided into the visceral pleura which is firmly attached to the surface of t he lungs and
extends into the interlobar fissures and the parietal pleura which covers the inner surface of the
thoracic cavity
❖ The pleural cavity is located between these two layers it contains a small amount of pleural
fluid which permits smooth movements of the lungs and pleura during breathing and ensures
negative pressure in the thoracic cavity keeping the lungs under tension.

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16. The blood supply, innervation and lymphatic drainage of the lung:

Blood supply

Innervation and lymphatic drainage

93
 17. The anatomy of the pulmonary circulation, topography and branches of the
pulmonary trunk.

❖ The pulmonary circulation is the portion of the circulatory system which carries
deoxygenated blood away from the right ventricle of the heart, to the lungs, and returns
oxygenated blood to the left atrium and ventricle of the heart.
❖ The term pulmonary circulation is readily paired and contrasted with the systemic
circulation.
❖ The vessels of the pulmonary circulation are the pulmonary arteries and the pulmonary
veins.
❖ Deoxygenated blood leaves the heart, goes to the lungs, and then re-enters the heart;
Deoxygenated blood leaves through the right ventricle through the pulmonary artery. From the
right atrium, the blood is pumped through the right atrioventricular valve, into the right ventricle.
Blood is then pumped from the right ventricle through the pulmonary valve and into the main
pulmonary artery.
❖ Pulmonary circuit carries the blood that needs to be oxygenated into the lungs where the
exchange of oxygen and carbon dioxide that the body has produced occurs before the blood
returns back to the heart.
❖ Red blood cells are responsible for oxygen binding and transportation using their hemoglobin
proteins which contain iron.
❖ Once this has happened, the heart then pumps the blood around the systemic circuit of the body
and delivers the oxygenated red blood cells to the tissues before collecting the deoxygenated
blood and sending it back to the heart with unused nutrients and waste products.
❖ Pulmonary arteries: originate from the arterial trunk, and in the developed heart, the
pulmonary trunk (main pulmonary artery) begins at the base of the right ventricle.
❖ The pulmonary trunk is a short and stout (wide) structure that is about 5 cm in length and 3 cm in
diameter, which branches into 2 pulmonary arteries; the left and right pulmonary arteries, which
act to deliver deoxygenated blood to its respective lung.

❖ On the other hand, pulmonary veins are large blood vessels that receive oxygenated blood from
the lungs to delivery to the rest of the body. There are 4 total pulmonary veins—with 2
pulmonary veins coming from each lung, left and right—that empty into the left atrium of the
heart.

❖ Two pulmonary veins emerge from the hilus of each lung, and each pulmonary vein receives
blood from 3-4 bronchial veins apiece before draining into the left atrium.
❖ The pulmonary veins are fixed to the pericardium travel alongside the pulmonary arteries .
The right superior pulmonary vein passes in front of and a tad below the pulmonary artery at
the root of the lung, and the inferior pulmonary vein is situated at the lowest part of the lung
hilum.

94
❖ In reference to the heart, the right pulmonary veins pass behind the right atrium and superior
vena cava return, and the left pulmonary veins pass in front of the descending thoracic aorta.
Finally, the bronchus is located behind the pulmonary artery.
❖ Once deoxygenated blood is pumped from the right atrium through the tricuspid valve into the
right ventricle, contraction of the right ventricle will push blood through the pulmonic valve into
the pulmonary artery that will carry deoxygenated blood to the lungs.
❖ Within the lungs, the blood passes through capillaries adjacent to alveoli and becomes
oxygenated through respiration (breathing). Branches of the pulmonary artery travel closely
alongside the bronchial tree on their way to the alveoli. However, the bronchial tree itself is
supplied by the bronchial artery, which arises from the aorta and carries systemic blood.
❖ Each alveolus is surrounded by a nest of blood capillaries that are supplied by small branches of
the pulmonary artery.
❖ In summary, the pulmonary circuit begins with the pulmonary trunk, which is a large vessel that
ascends diagonally from the right ventricle and branches into the right and left pulmonary
arteries.
❖ As the circuit approaches the lung, the right pulmonary artery branches into two arteries, and
both branches enter the lung at a medial indentation called the hilum of the lung.
❖ The upper branch is the superior lobar artery, which feeds into the superior lobe of the lung.
❖ The lower branch divides again within the lung to form the middle lobar and inferior lobar
arteries that supply the lower 2 lobes of the lung, since there are 3 lobes of the right lung.
❖ The left pulmonary artery is more variable in number and gives off several superior lobar
arteries that feed into the superior lobe before entering the hilum of the lung to branch off into
inferior lobar arteries that feed the left lower lung lobe.

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18. The tributaries of the superior vena cava. The azygos-hemiazygos system. The
lymphatic drainage of the thoracic cavity:

Tributaries of the superior vena cava

❖ The superior vena cava is a short vein of a large diameter, 2-3 cm without valves
❖ Arises from the confluence of the right and left brachiocephalic veins at the level of the
cartilage of the first right rib
❖ Descends vertically through the superior mediastinum to empty into the right atrium at the
level of the third sternocostal joint
❖ Carries deoxygenated blood from the upper half of the body(head, neck, upper limbs, thorax
and upper part of the back)
Tributaries
❖ azygos vein
❖ small veins draining the pericardium and other mediastinal structures

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 The azygos-hemiazygos system

❖ The azygos venous system is located on either side of the vertebral column and drains the
viscera within the mediastinum, as well as the back and thoracoabdominal walls.
❖ This system consists of the azygos vein and its two main tributaries: the hemiazygos vein and
the accessory hemiazygos vein.
❖ The azygos vein usually originates from the posterior aspect of the inferior vena cava, at the
level of the renal veins.
❖ It ascends within the posterior mediastinum to the level of T4 before it arches above the
right pulmonary hilum. It drains into the superior vena cava just before it pierces the
pericardium.
❖ The azygos vein has two tributaries, which are referred to as the hemiazygos vein and
the accessory hemiazygos vein.

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❖ The hemiazygos vein is often connected to the left renal vein. It is formed by the
oesophageal and mediastinal tributaries, the common trunk of the left ascending lumbar
vein and left subcostal vein, and by the lower three posterior intercostal veins.
❖ It ascends anterior to the vertebral column before crossing the column posterior to the
aorta, oesophagus and thoracic duct at the level of T8.
❖ The accessory hemiazygos vein is formed by veins from the fourth to eighth intercostal
spaces and sometimes by the left bronchial veins. It descends to the left of the vertebral
column before crossing T7, where it joins with the azygos vein. Sometimes it joins the
hemiazygos vein and, in this case, their common trunk drains into the azygos vein.

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The Lymphatic drainage of the thoracic cavity

Sternal or parasternal (internal thoracic) nodes:

● Are placed along the internal thoracic artery.

● Receive lymph from the medial portion of the breast, intercostal spaces, diaphragm, and
supraumbilical region of the abdominal wall.
● Drain into the junction of the internal jugular and subclavian veins.

Intercostal nodes:

● Lie near the heads of the ribs.

● Receive lymph from the intercostal spaces and the pleura.
● Drain into the cisterna chyli or the thoracic duct.

Phrenic nodes:

● Lie on the thoracic surface of the diaphragm.

● Receive lymph from the pericardium, diaphragm, and liver.
● Drain into the sternal and posterior mediastinal nodes.

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 19. The topography of the vagus nerve in the thoracic cavity and the anatomy and
function of the phrenic nerve

The Topography of the vagus nerve in the thoracic cavity

❖ The vagus nerve is the 10th cranial nerve (CN X).

❖ The vagus nerve has the longest course of all the cranial nerves, extending from the head to
the abdomen. Its name is derived from the Latin ‘vagary’ – meaning wandering. It is sometimes
referred to as the wandering nerve.
❖ Originates in the retro-olivary groove of the medulla oblongata and leaves the cranial cavity via
the jugular foramen
❖ Forms the lateral mixed system with the glossopharyngeal and accessory nerves
❖ Contains motor, sensory and special sensory(taste) fibres and is the only cranial nerve to reach
the abdominal cavity
❖ Gives numerous branches which provide parasympathetic and viscerosensory innervation to
the organs of the neck, thorax and abdomen, down to the Cannon-Bohm point at the left end
of the transverse colon

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In the Head
The vagus nerve originates from the medulla of the brainstem. It exits the cranium via the jugular
foramen, with the glossopharyngeal and accessory nerves (CN IX and XI respectively).
Within the cranium, the auricular branch arises. This supplies sensation to the posterior part of
the external auditory and canal external ear.

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In the Neck

Fig 1.0 – Overview of the major branches of the vagus nerve

In the neck, the vagus nerve passes into the carotid sheath, travelling inferiorly with the internal
jugular vein and common carotid artery. At the base of the neck, the right and left nerves have
differing pathways:

● The right vagus nerve passes anterior to the subclavian artery and posterior to the
sternoclavicular joint, entering the thorax.
● The left vagus nerve passes inferiorly between the left common carotid and left subclavian
arteries, posterior to the sternoclavicular joint, entering the thorax. Several branches arise
in the neck:

● Pharyngeal branches – Provides motor innervation to the majority of the muscles of the
pharynx and soft palate.
● Superior laryngeal nerve – Splits into internal and external branches. The external laryngeal
nerve innervates the cricothyroid muscle of the larynx. The internal laryngeal provides
sensory innervation to the laryngopharynx and superior part of the larynx.
● Recurrent laryngeal nerve (right side only) – Hooks underneath the right subclavian artery,
then ascends towards to the larynx. It innervates the majority of the intrinsic muscles of the
larynx.

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In the Thorax

Fig 1.1 – The origin of the recurrent laryngeal nerves

In the thorax, the right vagus nerve forms the posterior vagal trunk, and the left forms the
anterior vagal trunk. Branches from the vagal trunks contribute to the formation of the
oesophageal plexus, which innervates the smooth muscle of the oesophagus. Two other branches
arise in the thorax:

● Left recurrent laryngeal nerve – it hooks under the arch of the aorta, ascending to innervate
the majority of the intrinsic muscles of the larynx.
● Cardiac branches – these innervate regulate heart rate and provide visceral sensation to the
organ.
The vagal trunks enter the abdomen via the oesophageal hiatus, an opening in the diaphragm.

In the Abdomen
In the abdomen, the vagal trunks terminate by dividing into branches that supply the
oesophagus, stomach and the small and large bowel (up to the splenic flexure).

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 The Anatomy and function of the phrenic nerve

❖ The phrenic nerve is a nerve that originates in the neck (Anterior rami of C3, C4 and C5) and
passes down between the lung and heart to reach the diaphragm. It is important for breathing,
as it passes motor information to the diaphragm and receives sensory information from it.
❖ There are two phrenic nerves, a left and a right one.
❖ The phrenic nerve originates mainly from the 4th cervical nerve, but also receives contributions
from the 5th and 3rd cervical nerves (C3-C5) in humans.[1] Thus, the phrenic nerve receives
innervation from parts of both the cervical plexus and the brachial plexus of nerves.
❖ The phrenic nerves contain motor, sensory, and sympathetic nerve fibers. These nerves provide
the only motor supply to the diaphragm as well as sensation to the central tendon. In the
thorax, each phrenic nerve supplies the mediastinal pleura and pericardium.

❖ The nerve begins at the lateral border of the anterior scalene muscle. It then continues inferiorly
over the anterior surface of anterior scalene, deep to the prevertebral layer of deep cervical
fascia. From here, the course of the phrenic nerve differs between the left and right:

Right Phrenic Nerve:

● Passes anteriorly to second part of the subclavian artery, and posteriorly to the subclavian
vein.

● Enters the thorax via the superior thoracic aperture.

● Descends anteriorly to the right lung root, down the right side of the pericardium.

● Reaches the diaphragm and pieces the muscle to supply the underlying surface.

Left Phrenic Nerve:

● Passes anteriorly to the first part of the subclavian artery, and posteriorly to the subclavian
vein.

● Enters the thorax via the superior thoracic aperture.

● Crosses the aortic arch and vagus nerve, and descends anteriorly to the left lung root, down
the left side of the pericardium.

● Reaches the diaphragm and pieces the muscle to supply the underlying surface.

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 Fig 1.0 – The origin of the phrenic nerve from the anterior rami of C3,4 and 5.

Motor Functions

The phrenic nerve provides motor innervation to the diaphragm; the main muscle of respiration.
As the phrenic nerve is a bilateral structure, each nerve supplies the ipsilateral side of the
diaphragm (i.e. the hemi-diaphragm on the same side as itself).
● diaphragmatic paralysis : The phrenic nerve provides motor innervation to the diaphragm.
If the nerve becomes damaged, paralysis of the diaphragm will result. There are numerous
causes of phrenic nerve lesions:
● Mechanical trauma: ligation\ damage to the nerve during surgery
● Compression: due to tumor in chest cavity
● Myopathies: such as myasthenia gravis
● Neuropathies :diabetic neuropathy

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Sensory Functions

Sensory fibres from the phrenic nerve supply the central part of the diaphragm, including the
surrounding pleura and peritoneum. The nerve also supplies sensation to the mediastinal pleura
and the pericardium.

Fig 1.1 – The phrenic nerve provides sensory innervation to the diaphragm, mediastinal pleura
and pericardium

109
 20. Organization of the thoracic part of the sympathetic chain

❖ The sympathetic nervous system consists of both central and peripheral parts
❖ The central part consists of the intermediolateral nuclei in the grey mater of the spinal cord segments C8-L3
❖ The paired sympathetic trunks make up the peripheral part
❖ They lie lateral to the vertebral bodies and extend all the way from the base of the skull to the coccyx
❖ The penetrate the diaphragm as they pass from the thorax to the abdomen, and then lie in the retroperitoneal
space
❖ The sympathetic trunks consist of a series of ganglia, interconnected by interganglionic branches
❖ The sympathetic nervous system increases energy expenditure and catabolism, It increases heart rate and
myocardial contractility, dilates bronchi, increases blood pressure and indirectly increases blood glucose and lipid
levels

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 21. General embryology I: fertilization, implantation, cleavage, gastrulation, development
of the neuroectoderm. Differentiation of intraembryonic mesoderm.

General embryology
❖ Embryology is a scientific filed concerned with the creation and development of the embryo and foetus, all the way
from a fertilised oocyte to birth.
❖ Embryology also deals with anomalies that occur during development that give rise to congenita defects.
❖ The 3 germ layers arise during the third week of the development in the form of the trilaminar germ disc, which
comprises the endoderm, mesoderm and ectoderm.
❖ The pharyngeal arches originate from mesenchyme as pairs of arc-shaped prominences in the region of head and
neck of the embryo during the fourth and fifth week of development.

Fertilization

111
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Implantation

113
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Cleavage

Gastrulation

115
Development of the neuroectoderm

116
Differentiation of the intraembryonic mesoderm

117
22. General embryology II: development of the amnion, yolk sacs, extraembryonic
mesoderm. Formation of the placenta.

The Development of the amnion and yolk sac

118
The extraembryonic mesoderm

119
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The Formation of the placenta

122
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