Thorax anatomy

Lecture 13
Mediastinum (part 3)
• Trachea
• Esophagus & esophageal constrictions
• Vagus nerves
• Recurrent laryngeal nerves
• Phrenic nerves
• Azygos system of veins
Sajjad Abdulaziz
A 3rd-staged medical student at Al-Nahrain • Thoracic duct & lymphatic trunks
University

Trachea
🔵 The trachea is a cartilaginous tube that connects the larynx to the
bronchi of the lungs, allowing the passage of air . The trachea :
- begins at the level of C6 vertebra .
- descends anterior to the esophagus and enters the superior
mediastinum, inclining a little to the right of the median plane .
- bifurcates at the level of the sternal angle (posterior to the bifurcation
of pulmonary trunk) into the right and left main bronchi .

🔵 The bifurcation of trachea is called the carina .

🔵 Between the tracheal bifurcation & bifurcation of pulmonary trunk are
the following structures :
- tracheobronchial lymph nodes .
- cardiac nervous plexus .

Esophagus
🔵 The esophagus is a fibromuscular tube that
extends from the pharynx to the stomach .

the esophageal hiatus

🔵 The esophagus :
- begins at the level of C6 vertebra .
- descends posterior to the trachea .
- enters the superior mediastinum (the esophagus is the most posterior
structure in the superior mediastinum) .
- inclines initially to the left but is pushed back to the median plane by
arch of the aorta . Inferior to the arch, the esophagus again inclines
to the left .
- compressed anteriorly by the root of the left lung .
- enters in the posterior mediastinum .
- is surrounded in the posterior mediastinum by the esophageal
nervous plexus (which is composed of right & left vagus nerves &
sympathetic nerves) .
- descends posterior to the oblique pericardial sines and left atrium .
- passes through the esophageal hiatus in the diaphragm (at the level of
the T10 vertebra) and enter the abdominal cavity .

Esophageal constrictions
🔵 The esophagus has slight normal
constrictions :
1) Where it begins, in the form of
cricopharyngeus muscle .
2) Where it is crossed by the arch of the
aorta .
3) Where it is crossed by the left main
bronchus .
4) Where it pierces the diaphragm .

* their distances from the incisor teeth

is important for the gastroscopist .

🔴 Left atrial enlargement will indent the esophagus, a change best seen
in the lateral view with the esophagus outlined by barium .

Vagus nerves
🔵 The vagus nerves :
- exit the cranium and descend through the neck .
- enter the thorax posterior to the SC joints and brachiocephalic veins .

🔵 The right vagus nerve :

- enters the thorax anterior to the right subclavian artery .
- runs posteroinferiorly through the superior mediastinum on the right
side of the trachea .
- passes posterior to the root of the right lung .
- divides into many branches, which contribute to the right pulmonary
plexus, cardiac plexus &
esophageal plexus .

🔵 The left vagus nerve :

- enters the thorax between the left common carotid artery and left
subclavian artery .
- runs posteroinferiorly through the superior mediastinum on the left
side of the arch of aorta .
- passes posterior to the root of the left lung .
- divides into many branches,
which contribute to the left
pulmonary plexus, cardiac
plexus & esophageal plexus .

Recurrent laryngeal nerves

🔵 The right recurrent laryngeal nerve :
- is a branch arise from the right vagus nerve anterior to the right
subclavian artery .
- hooks around the right subclavian artery .
- ascends between the trachea and esophagus to supply the larynx .

🔵 The left recurrent laryngeal nerve :

- is a branch arise from the left vagus nerve on the left side of the arch
of aorta .
- passes inferior to the arch of the aorta, immediately lateral (distal) to
the ligamentum arteriosum .
- ascends between the trachea and esophagus to supply the larynx .

Phrenic nerves
🔵 The phrenic nerves :
- originate from the anterior rami of C3-C5 spinal nerves in the neck .
- enter the thorax posterior to the SC joints, lateral to the vagus nerves
and between the subclavian arteries and the origin of the
brachiocephalic veins .

🔵 The right phrenic nerve :

- descends along the right side of the
right brachiocephalic vein & SVC .
- passes anterior to the root of the
right lung .
- descends (with the right
pericardiacophrenic vessels) along
the fibrous pericardium on right to
the right atrium and IVC .

🔵 The left phrenic nerve :

- descends along the left side of the
arch of aorta .
- is separated from the left vagus
nerve by the left superior
intercostal vein .
- passes anterior to the root of the
left lung .
- descends (with the left
pericardiacophrenic vessels) along
the fibrous pericardium left to the
left atrium and ventricle .

🔵 The phrenic nerves carry :

- motor fibers to the diaphragm .
- sensory fibers to the diaphragm, pericardium & mediastinal pleurae .

Azygos system of veins

🔵 Consists of veins on each side of the vertebral column .
🔵 Drains the back, thoraco-abdominal walls and mediastinal viscera .

🔵 The azygos vein :

- forms a collateral pathway between the SVC and IVC .
- ascends in the posterior mediastinum, right to the bodies of T5-T12
vertebrae .
- arches over root of the right lung to joins the SVC .

🔵 Tributaries of the azygos vein are :

- right superior intercostal vein .
- right 5th-11th
posterior intercostal veins .
- right subcostal vein .
- right bronchial vein .
- hemiazygos vein .
- accessory hemiazygos vein .
- mediastinal veins .
- esophageal veins .

🔵 The hemiazygos vein :

- arises on the left side by the junction of the left subcostal and
ascending lumbar veins .
- ascends on the left side of the vertebral column as far as the T9
vertebra .
- crosses over the body of T9 vertebra to the right side (posterior to
thoracic aorta, thoracic
duct and esophagus) .
- ends in the azygos vein .
🔵 Tributaries of the
hemiazygos vein are :
- left 9th-11th posterior
intercostal veins .
- mediastinal veins .
- esophageal veins .

🔵 The accessory hemiazygos vein :

- begins at the medial end of the 4th or 5th intercostal space .
- descends on the left side of the vertebral column from T5 to T8
vertebrae
- crosses over the body of T8 vertebra to the right side (posterior to
thoracic aorta, thoracic
duct and esophagus) .
- ends in the azygos vein .
🔵 Tributaries of the
accessory hemiazygos
vein are :
- left 5th-8th posterior
intercostal veins .
- left bronchial veins .
- mediastinal veins .
- esophageal veins .

🔵 The left superior intercostal vein :

- drains the left 2nd-4th posterior intercostal veins
- may communicate with the
accessory hemi-azygos vein .
- passes between the left vagus &
left phrenic nerves .
- ends in the left brachiocephalic
vein .

Thoracic duct & lymphatic trunks

🔵 The thoracic duct (is the largest lymphatic channel in the body) :
- originates from the cisterna chyli (which collects the lymph from
the lower half of body) in the abdomen .
- ascends through the aortic hiatus in the diaphragm .
- ascends in the posterior mediastinum and related :
• on its left side : to the thoracic aorta .
• on its right side : to the azygos vein .
• anteriorly : to the esophagus .
• posteriorly : to the bodies of T4-T12 vertebrae .
- at the level of the sternal angle, the thoracic duct crosses to the left .
- ascends in the superior mediastinum on the left side of esophagus .
- enters the root of the neck, where it receives :
• the left jugular lymphatic trunk .
• the left subclavian lymphatic trunk .
• the left bronchomediastinal lymphatic trunk .

- usually empties into the venous system near the union of the left
internal jugular and subclavian veins (the left venous angle) .

🔵 The right jugular lymphatic trunk, right subclavian

lymphatic trunk and right bronchomediastinal lymphatic trunk
unite at the root of the neck to form the right lymphatic duct, which
empties into the venous system near the union of the right internal
jugular and subclavian veins (the right venous angle) .

🔵 The thoracic duct carries most lymph of the body (all lymph except
that from the right superior quadrant of the body) .

🔵 The right lymphatic duct carries the lymph from the right superior
quadrant of the body .

Q/ what are the structures and events that occur at the level
of sternal angle ?

A/ - 2nd Costal Cartilage .

- beginning & ending of Arch of Aorta .
- Tracheal bifurcation .
- Pulmonary trunk bifurcation .
- Ligamentum arteriosum .
- Looping of Left recurrent Laryngeal nerve around arch of aorta .
- Arch of Azygous vein .
- cardiac Nervous plexus .
- Tracheobroncheal lymph nodes .
- crossing of Thoracic duct from right to left .

Mnemonic : CAT PLANT

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