77

/ T h o r a x

Angle of Louis / Sternal angle

SN-1
manubrium and body of
a bony angulation formed at the junction of
eroduction I t
is
Intr

sternum

: It is situated five
centimeters below the suprasternal notch.
Situ ation

mediastinum. It passes through angle

superior and inferior
Events:

which separates the

AA Dlane intervertebral dise between fourth and fifth thoracic vertebra.
to the
of Louis
cardiac plexus.
Formation of
B. the base of heart.
C. Upper limit of
ends and arch of aorta begins.
Ascending aorta
D. ends and descending aorta begins.
E. Arch of the aorta arteries.
trunk divides into two pulmonary
F. Pulmonary bronchi.
divides into two principle
G. Trachea vena cava.
vein into
opens superior
H. Azygos to left.
Thoracic duct
crosses from right
I.
for counting the ribs.
It is an important land mark
4. Applied

Superior

>Posterior
Sternal angle Anterior

Interior
T4

Fig. 2.1:Angle of Louis

/ Sternal angle.
 horaz f n t e r c o s t a lm u s e l e

tabls shous origin, inssrtio

sho
and ations tf
Supra pleural
membrane (Sibson's fascia) 2.1
:
The

marantal muvls
SN2 the dome shaped musCulo
Tactal membrane which roofs thoraciC
avity
Tsblo
M u s c l e
Origin
nsertion Attias
Fscts is
Lower border of the upper rib Outer
Formation It has
A. External lip of the upper
occasionally by scalenus minimus muscle botder of the rib belrw
A Musculat partIts formedfrom cndothoracic fascia.
intercostal
Elevaes
It 1s formed
B Fascial part
Floor of the costal groove of
inner ip of the 12
Transverse process of severith cervical vertebra
B. Internal
the upper rib upper
border of the rib below it
i n t e r c o s t a

C.Transverse thoracis

Supr apieural Temtrane Inner suríace of the rib near Inner surface of the 2
Depresses
a . S u b c o s t a l i s

the angle or 3 rib below. 2" to 6

ribs

Intercostalis
Inner surface of the upper rib Inner surface of the rib
below
intimi

c. Sternocostalis
. Lower 1/3 of the posterior Costal cartilages of the
Firs Surface of the body of the to 6 ribs.
sternum.
II. Posterior surface of the
xiphoid process.
III.Posterior surface of the
costal cartilages of the
atera lower 3 or 4 true ribs near

the sternum.

rero

Fig.2.2: The suprapleural membrane.

Superficial
Costal pleura Deep 4
Attachments Rib
A Anteriorly Inner border of first rib. Intenoi
B Posteriorly Tip of the transverse process of seventh cervical vertebra Intercostal vein-
C. Medially Continuous with the
pretracheal fascia. Intercostal artery-
Intercostal nerve-
- Internal intercostal muscle

Functions : Protects the apex of the lung and cervical pleura during respiratory movements.
Intercostalis intimi -

Collateral branches
of intercostal

Applied anatomy Herniation of cervical pleura is a result of rupture of supra pleural v e s s e l s a n d nerve

membrane. Extemal intercostal muscle

LAQ-1 Describe intercostal space under following heads border of costal groove- -Floor of costal groove
Upper
1. Introduction 2. Intercostal muscles 3. Blood supply
4. Nerve supply & 5. Applied anatomy.

through an
intercostal space
1. Introduction:It is the space between the section
two consecutive typical ribs on the same side. Fig. 2.3:
Longitudinal
 Thorax
81
80
Thorax Upper six intercostal veins drain into
subclavian vein.
internal thoracic vein which drains into
are arranged in two oro.
I. Lower six intercostal veins drain into
3. Blood supply: in each intercostal
space musculophrenic vein.
AArterial supply The arteries
:
present in all spaces except th b. Posterior intercostal veins
intercostal arteries hey are anterior intercosta
tal art
Anterior there are two
intercostal spaces.
In cach space
ad the
and the other other follows the i
follows S. One Table
2.2 The table showing venous drainage of intercostal space.
lower margin of
the upper rib upper margin
follows the On
Veins right side they drain into On left side they drain into
of the lower rib. anterior intercostal arteries are
are the bran
branches of the
the
In the upper six spaces, intercostal vein Right brachiocephalic or Left brachiocephalic vein
internal thoracic arteries. derived from musculophrenic arteries. Vertebral vein
three spaces these areis
Inthe succeeding artery
There a posterior intercostal artery n dr& 4 intercostal Join to form right 4 superior Join to form left superior
b. Posterior intercostal each
intercostal arteries are the branches intercostal vein which drains
space. First
and second posterior vein
intercostal vein which drains into
|
branch of coSto_cervical runs,
a branch of
subciaw into the azygos vein
intercostal artery which is a theleft brachiocephalic vein
artery the posterior intercostal arteries are the brancho intercostal vein Azygos vein Accessory hemiazygos vein
In the lower nine spaces of 5th to 8
descending thoracic aorta. vein Hemiazygos vein
B. Venous dramage: Each intercostal space is drained by anterior and erior
9 to 11 and subcostal Azygos
intercostal vein.
a. Anterior intercostal veins: There are two anterior intercostal veins in each of t the
4. Nerve Supply Ihe supplied by intercostal nerves. They are
intercostal muscles are

upper nine spaces. rami of T11: The anterior primary ramus of the 12
spinal nerves T, to
Left superior intercostal vein anterior primary
hence
thoracic nerve forms the subcostal nerve. T4, Ts
and Ts supply only thoracic wall
Right brachiocephalic vein-
intercostal nerves.
HLeft brachiocephalic vein they are called typical
Supenor vena cava
Applied anatomy the front of
2 eauses severe pain and is referred to
AZygos vein A. Irritation of the intercostal nerve

Right superior intercostal vein
Right posterior intercostal vein-
Accessory hemiazygos vein
Supenor
3 the chest the abdomen. This is known as a root pain or girdle pain.
or
of the
the needle is inserted to the lower part
4 B. During tapping of the pleural effusion, intercostal nerve
4 intercostal space at the upper border of
the rib to avoid injury to the
Arch of aorta and vessels.
5 line because the level of
6 C. Paracentesis thoracis' is usually done in the mid-axillary
in the mid-axillary line.
pleural fluid is highest lower part of the intercostal space
to avoid the
D. Paracentesis thoracis' is done in the
8 the neurovascular bundle.
Hemiazygos vein injury to
the angles of the ribs
should never be done medial to
E. The tapping of pleural fluid obliquely from
below
intercostal space
9-
because the
intercostal arteries
posterior
cross

10 of the
upwards. tends to track along
the course
Rught. from the vertebral column
11 -11 F. The pus exit points.
bundle and may point out any one of the three
neurovascular
2
Left subcostal vein
Rightsubcostal vein
Left suprarenal vein
Right ascending lumbar vein - Left ascending lumbar vein
SNS Azygos vein
Left renal vein
Right renal vein The word "azygos" means unpaired.
1.
Meaning a link between
Inferior vena cava wall and upper
lumbar region. It iS

ntroduetion : It drains the thoracic

interior vena cava.
Superior and mediastinum.
abdominal wall and posterior
Situation It is situated in the posterior
union of
Formation: It is formed by the
Fig. 2.4:Venous drainage of posterior intercostal space. 4.
A. The lumbar azygos vein,
 Talorceilal arerve
Thorax T h o r a x
83
Right
subeostai vein
lumbar
and
vein. SN-5
Typical intercostal nerve(g-6
asvendins
called typical
CRight
the right of crus diaphrao
t r o d u
dduction Anterior primary
nerves. They
rami of 3 to 6 thoracic
confined only to thoracic wall.
are
spinal nerves are

vurse the thorax paSsing througn

by
along with theoh
Or by Dae. 1.
assing
intercosta

it enters
the
or
the diaphragm
aortic opening aorta aorta
through abdominal IS on the left side and thoracic Anterior c u t a n e o u s nenve
The
thoracic duct. Tight
side Pectoralis major muscle
ots to the fourth thoracic vertebra, where it arches torward over the root
rod
of Anterior
nght lung. Anterior
Intercostal membrane

Relations
A. Anteriorly: Ocsophagus. Media
aterai Internal thoracic

B. Posteriorly areiy
I. Lower eight thoracic vertebrae and Posterior

I. Right posterior intercostal arteries. Sternocostalis

C. To the right :
I. Right lung and pieura, - Intercostal intimus
II. Greater splanchnic nerve. Lateral cutaneousS

D. To the left:
nerve
I. Thoracic duct and aorta in the lower part, Pieurda

II. Oesophagus, trachea and right vagus in the upper part. Internal intercostal

7. Tributaries m u s c l e

Intercostal nerve

A. Right superior intercostal vein, formed by union of the 2 and 3 posterior intercostal
vein (occasionally 4 posterior intercostal vein). M u s c u l a r b r a n c h n i

B. 4 to 11 right posterior intercostal veins. Posterior

intercostal membrane

C. Hemiazygos vein (at the level of vertebra T7 or Tg)

D. Accessory hemiazygos vein (at the level of vertebra Ts External intercostal
or
Tg)
muscle.
E. Right bronchial vein, the termination of the veins.
near
azygos vein.
and pericardial
Several oesophageal, mediastinal vein
G. The common trunk of is azygos formed by the union of the right ascending
lumbar vein and the right subcostal vein. Fig. 2.5:Course
of typical inter-costal nerve
8. Applied anatomy : In obstruction of the superior or the inferior intercostal nerve:
cava, the azygos between posterior
vein acts
as an important channel to establish collateral
vena Course of typical intervertebral foramen and passes ies
circulation. from the respective nerve
A. It emerges of the space, the
intercostal m e m b r a n e
and the pleura. In major part
intercostal muscle.
between intercostalis intimi and the internal the pleura and
crossees
it runs medially on
Typical spinal nerve B. At the anterior edge of intercostalis intimus,

in front of internal mammary

artery. membrane.
Each the anterior intercostal
typical spinal nerve is formed by dorsal and ventral roots. Each C. It turns forward and pierces
ventral and dorsal ramus. spinal nerve divides into Each intercostal nerv gives into anterior
Branches line and divides
Dorsal ramus goes branch which appears at mid-axillary
posteriorly and divides into medial and lateral branch. A. Lateral cutaneous
1. The medial and lateral branches branches and in front of
and neck.
give muscular branches which supply muscles of the back and posterior
which comes anteriorly and
crosses the sternum
intercostal nerve
B. Anterior It p1erces
sternocostalis muscle.
2. vessel and the
Lateral branch of the dorsal in the the internal thoracic
An the
ramus lower half and medial branch of the dorsal Internal intercostal muscle,
upper half is cutaneous. L for L, L = lateral and lower
ramus a.
membrane,
b. Anterior intercostal
Ventral rami in cervical, lumbar skin.
and sacral region unites muscle to supply the
together to form
plexus. C. Pectoralis major
 ell L o u p .

ganit-Stst
ulbmenay ki (4-T)>Melasknum
84 Thorax
Thorax
85
Mediastinal surfaces of the right and left
lung
Describe parietal pleura under
SN-6

LAQ-2
1. Subdivisions of the pleura & 2. Applied anatomy.
Right side (venous)
a t r i u m and auricle.
1. Subdivisions of the pleura: Depending upon the structure it lines, it is called costal A. Right
or the right ventricle.
B. A small part
cervical and mediastina.
diaphragmatic, Superior vena cava.
A. Costal pleura : I t ines the inner surtace of the sternum, costal cartilage. C.
intercostal spaces and sides of vertebral bodies but the costal layer is separated ribs, p. Lower part oI the right brachiocephalic vein.
endothoracic fasci1a.
by E. Azygos vein.

F. Oesophagus.
Tracing vena cava.
a. It can be traced from back o f the sternum - mediastinal pleura - sternoclavicular
G. Inferior
joint middle of the sternal angle vertically upto the 4 costal cartilage. H. Trachea.

I. On the right side: It reflects vertically behind the xiphisternal joint right I. Right vagus nerve.
costoxiphoid angle - 7 costal cartilage costodiaphragmatic line of pleura. J. Right phrenic nerve.
II. On the left side It descends close to sternum and deviates laterally from
-Right vagus nerve
the sternum to 4" costal cartilage -

costodiaphragmatic line. Right subclavian artery-

-Right common carotid artery
b. Behind I t continues with mediastinal pleura by the Side of vertebral column
along a line known as the costo vertebral reflection.
Trachea
C. Above :
It continues as cervical pleura along the inner border of first rib. Brachio-cephalic trunk-
d. Below: t continues as the diaphragmatic pleura.
B. Diaphragmatic pleura It covers the thoracic surface of the corresponding part of
diaphragm and laterally it continues as the costal pleura. It continues medially as
Superior vena cavaa
( -AZygos vein

mediastinal pleura. SUP

C.
Cervical pleura :It extends from the inner border of first rib to the apex of the lung.
t continues medially with mediastinal pleura. The summit of the cervical pleura is
Right phrenic nerve-
-Oesophagus Anterior POsterior

3 to 4 cms above first costal

cartilage. It does not extend above upper border of neck
of first rib. Impression of -

- Inferior vena cava Inferior

D. Mediastinal pleura : It forms the lateral boundary of the mediastinum and is divided right atrium

into three parts,

a. Above the root of the lung
b.
: It extends from the sternum to vertebral column.
At the root of
the lung: The mediastinal pleura passes laterally in the form of a
tube enclosing the structures of the root of
lung and continues with 2.6: Mediastinal surface of right lung.
pleura. puimonary Fig.
Below the root Left side (arterial)
of the lung: The mediastinal pleura forms a bilaminar fold
known as pulmonary
ligament which extends from A. Left ventricle and left auricle.
I. ventricle.
Oesophagus to corresponding lung below its hilum. At the hilum, the two B. Infundibulum and adjoining part of the right
layers are continuous with pulmonary
pleura. C. Pulmonary trunk.
II. Contents of
pulmonary ligament : No important structures pass
. Loose areolar tissue, except D Arch of aorta.

i. Lymphatics and Descending thoracic aorta.

E.
1. Sometimes accessory bronchial F. Left subclavian artery.
artery.
Applied Anatomy: G. Thoracic duct.
A. Pleuritis : Inflammation of pleurae is known as
pleurisy H. Oesophagus.
or wet pleurisy.
or
pleuritis. It may be
dry Left brachiocephalic vein.
B. Paracentesis It is the
tapping of the fluid from the
pleural cavity. It is J. Left vagus nerve.
posterior to mid axillary line. performed
Pneumothorax Presence of the air in the K. Left phrenic nerve.
pleural cavity 1s Called
pneumothorax. nerve.
L. Left recurrent laryngeal
 Oesophagus
Thorax T h o r a x

87
Superior vena cava

Left subclavian artery

Thorack ducd-
Trachea -Azygos vein
Eparterial bronchus-
Pulmonary vein -
Bronchial vessels
Arch o BOrta Vagus nerve Right pulmonary artery-
Hyparterial bronchus
Lymph nodes
Pulmonary ligament-
upenor

Posterior
Anteriot
Impression of left ventricle
nteriot
Fig. 2.9:Root of the right lung.
Descending thoracic Left phrenic nerve
aorta

SN-8 Azygos lobe (A not; zygos paired)

Types Accessory or supernumerary lobes of lungs are called as azygos lobe. They are ot
three types
Fig. 2.7: Mediastinal surface of left lung. A. Upper azygos lobe.
B. Lower azygos lobe.
C. Lobe of azygos vein.

SN-7 Draw and label structure of the roots

and left lung.
of the right
The formal two types have little practical importance. And these are described in
reference to hilum of the lung.
The lobe of the azygos vein is present in 1% of population. It affects the upper lobe
of the right lung, where the apex of the lung splits into medial and lateral parts of the
fissure, the bottom of which contains the arch of the azygos vein suspended by a

pleural septum, the meso-azygos. The medial part of the split apex forms the lobe of
the azyg0S vein.

Bronchial vessels Left pulmonary artery It develops

2 Development: It is because of the upward development of apical bronchus.
Superior pulmonary vein medial to the arch of azygos vein instead lateral to it.
Left principal bronchus
Left
superior puimonary vein- Lymph nodes
3. Applied anatomy
small dense shadow close to the right sternal
A. The plane x-ray of the chest shows a
Left inferior
Descending thoracic aorta. pulmonary vein
angle.
Pulmonary ligament Super B. lt is one of the differential diagnosis of enlarged lymph node in the chest.
Oesophagus
Posterior nternor
Blood supply of lung
Fig. 2.8: Root of the left
SN9
lung. 1.Arterial supply
A. The nutrition of the lungs is by bronchial arteries.
a. These are small arteries varying in origin, size and number.
 88 Thorax horax
PAD
189
b. On the right side there is one bronchialartery which 1s a branch of third Do Relations

Pulmonary arteries ne dorsolateral to bronchus.

intercostal artery or from the upper left bronchial artery.
D.

bronchial arteries which arise ry veins do not accompany the bronchial or

On the left side there are_two from b. m of the lung, the pulmonary pulmonary arteries. Near
veins lie ventro medial to
ng the hilt
the bronchus.
thoracic aorta.
B. De-oxygenated blood to the lungs 1s brought bythe
pylmanary arteries. sie drainage There are two sets of
lymphatics both of which
returned to the heart by pulmonary veins. ympha drain into
C. Oxygenated blood is bronchopulmonary nodes
broncno ial Iymphatics drain into peripheral lung
tissue lying beneath the
2. Venous drainage A. The vessels pass round the borders of lung and pulmonaryy
A. Bronchial veins drain the lungs. They are usually two in number on each side margins of fissure to reach the
The
right bronchial veins drain into the azygos vein. The lett bronchial vein either dIrain hilum.
lymphatics drain into bronchial tree, the pulmonary vessels and the connective
vein.
into left superior intercostal vein or azygos
B. The greater part of the blood from the lung 1s drained by the pulmonary veins. ssue septa. They run towards the hilum where they drain into bronchopulmonary
nodes.

Super
LAQ-3 Draw and describe bronchopulmonary segment under 1Or
Apical
1. Definition 2. Gross anatomy
Posterior < Anterior
4. Applied anatomy.
3. Lymphatic drainage & Upper
lobe
unit Teri
TO Anterior
I. Definition It is the independent respiratory, surgical segment or
of lung aerated by
tertiary or segmental bronchus. -Posterior
Gross anatomy
A. Shape: Pyramidal Apical Lateral Middle
Anterior B8asal- | lobe
a. Apex : Directed towards the root of lung Medial
Lower
b. Base: Towards the surface lobe
B. Segment
of lung Lateral Basal
There are 10 segments in each lung. They are described in the following Posterior Basal -

table.
Table 2.3: The table shows bronchopulmonary segments of right and left lung.
Fig. 2.10: Bronchopulmonary segment of right lung.
Right lung Left lung
Ten Ten Superior
Lobes Segment Lobes Segment Apico-posterior Anterior osterio
a. Upper 1. Apical1 a. Upper Upper
2. Anterior
3. Posterior
I. Upper division Apicoposterior lobe

3. Anterior LAnterior
b. Middle 4. Mediall I1. Lingular lobe 4. Superior
5. Lateral 5. Inferior
Lower 6. Superior b. Lower 6. Apical (Superior)
Superior -Apical
(Apical or dorsal) Lingular or
Anterior basal
7. Anterior basal middle lobe
Lower
8. Posterior basal
9. Lateral basal
Anteromedial basal Inferior
Posterior basa' lobe

9. Lateral basal -Lateral basal

10.Medial basal 10. Posterior basal
C. Intersegmental plane : It is the connective tissue
septa between two adjacent lobes. It segment of left lung.
1S continuous on the surface with pulmonary 2.11 : Bronchopuimonary
subpleural connective tissue. Fig.
 T h o r ä
191
Pulmonary artery Intersegmental Thorax ApPonchograp
Anato study of bronchopulmonary
adiopaque dye. Study of
It is the
segments radiologically by
Ainstillatioeeoment of the lung and helpsbronchopulmonary
P l a n e s with
Terminal bronchiole pulmonary veins in postural segments helps to localize
the affe
more common
drainage. in,
Bronchial artery abscess 1S
Lung P = posterior, UL
B. PUL ALL upper lobe
= apical LL =
lower lobe
Posterior segment otupper lobe
of lower lobe
b. Apical segment
endelson's Syndrome the aspiration is common in pneumonia
posterior
segment of upper 1obe and apical segment of lower lobe. Because these
segments
are most dependent in recumbent position).
Each bronchopulmonary segment acts as an independent unit hence infection is
restricted only to respective segment, except in tuberculosis.
The benign neoplasm is restricted to each segment. However malignant growths
d.

M
are not restricted to the respective segment.
Posterior segment of right upper lobe is frequent site for tuberculosis infection.
Anterior segment of upper lobe shows cancerous changes.

SN-10 Mediastinum (Partition)

Introduction Thoracic mediastinum 1s the space between right and left pleural sacs
pulmonary pleura 1.
and limited on each side by mediastinal pleura.
Fig. 2.12: Relations of the bronchiole with the bronchial
artery and pulmonary vessels. Extent It extends vertically from thoracic inlet to diaphragm.
from
Division The mediastinum is divided by an imaginary horizontal plane extending
Superior
thoracic vertebra.
sternal angle to lower border of fourth
mediastinum and
Right A. Superior
Trachea Vertebral column
Interior
Jpero
Right principle. Posterior
bronchus Arch of aorta Anterior

Apical- Left principle bronchus

efio Manubrium
Posterior-
Apico-posterior
Superior
Anterior Anterior mediastinum

Medial Body of
Superior sternum
Lateral-
Anterior basal - Inferior
Lateral basal -
Lateral basal Antenior Posteno
mediastnum
mediastinum
Medial basal -
Anteromedial basal
Posterior basal -
Posterior basal
Xiphisternum
Diaphragm
Middle mediastinum

mediastinum.

Fig. 2.13: The bronchial tree. Fig. 2.14:Subdivisions of the

 | 93
B. Inferior mediastinum t 1s subdivided by pericardium and heart into Thorax Thorax

b.
Intervertebral
discs and

Anterior longitudinal ligament.

a Anterior mediastinum, c.
b. Middle mediastinum and Above: Thoracic inlet
Posterior mediastinum. C. Horizontal plane extending
Horizontal exter from sternal angle to lower border of fourth
Below:
Anterior mediastinum is narrowest; middle mediastinum is
widest whila
D. thoracic vertebra.

mediastinum is longest.
sterior On
each side : Mediastinal pleura.
E.
4. Development It develops from primitive ventral and dorsal meso
oesophagus. 3. Contents:

sternal structures
Retro
A.
SN-11 Superior mediastinum a.
Superior

Veins opening
vena cava

into superior vena cava

b.
1 Definition It I. Right and left brachiocephalic vein
is the area of the thoracic cavity above the
sternal angle to the
imaginary plane
lower border of body of the fourth thoracic extending from II. Keft superior intercostal vein
vertebra. om
Thymus gland
Boundaries C.
tongus uoll
d. Muscles Sterno thyroid, sterno hyoid,
A Anteriorly Manubrium sternum. structures (aorta)
BPosteriorly Superio B.
Intermediate
left.
Arch of aorta and its branches from right to
a Upper four thoracic
vertebrae a.
Brachiocephalic trunk.
Anterior
osterior H. Left common carotid.
Oesophagus JH. Left subclavian.
Interiopr
Trachea b. Nerve

Inlet of thorax Vertebral column IPhrenicnerve,

IKVagus nerve and

Anterior longitudinal
i Cardiac plexus.
Brachiocephalic trunk structures (Trachea and oesophagus)
ligament C. Prevertebral

Manubrium Thoracic duct

A. Trachea,
Oesophagus,
Left recurrent laryngeal nerve,
Supernior d.
Thoracic duct
mediastinum and
Muscle -longus colli lymph node. 9 , brounto ua
HParatracheal and tracheo bronchial

fascia enters
4. Applied: behind prevertebral
vertebra) or bleeding
A. Abscess (caries of cervical
superior mediastinum. in the upper
of veins
rise to engorgement
to superior vena cava gives
Obstruction
B.
half of the body.
trachea causes dyspnoea, and cough.
Pressure over
C. causes dysphagia. of voice.
Pressure on the oesophagus rise to
hoarseness
D. nerve gives
the left
recurrent laryngeal
Pressure on
E. chain c a u s e s
syndrome.Horners which is
nerve,
Pressure over sympathetic involvement of the
sympathetic
F. due to brachia!
It is to the root of
Horner's syndrome cord. There is injury
of the spinal
segment
Fig. 2.15: contributed by T,
Superior mediastinum.
plexus.
 94
95
SN-12 Anterior mediastinum LoNGG NTE Thorax Thorax

Contents

Heart
:

and the
related structures

. Pericardium.
1. Introduction : It is a
potential space present in the anterior part of
Deep cardiac plexus.
Boundaries inferior mediasti. Structures entering pericardium
A.
Superiorly : Imaginary line
istinum. Four pulmanary veins and
. Lo hl 4 SVC

thoracic vertebra. extending from sternal

angle to lower
I.
border II. Arch of azygos vein.
B. Inferiorly The diaphragm. of f
C.
Anteriorly Posterior
fourth d. Structures leaving the pericardium
D. surface of body of sternum. Supeerior X Ascending aorta and
Posteriorly: Fibrous pericardium. Pal monany ontuy
FcAsi mdiostino fRu HPulmonary trunk.
structures
Anterior B. Trachea and
related

osterior a. Right bronchus and

Terlor b. Left bronchus.
Angle of Louis c. Inferior tracheobronchial lymph node.
Manubrium C. Other structures

Phrenic nerve and

Superior stenopericardial-
ligament .
Pericardiacophrenic vessels.
Body of sternum-

Retrosternal lymphnodes Posterior mediastinum (longest)

O stermopericardial Mediastinal branch of
SN-14
ligament internal thoracic artery It is of the inferior mediastinum.
1. Introduction : a longest part
Xiphisternum Anterior mediastinum 2. Boundaries :
Diaphragm A. Superiorly By the plane extending from sternal angle to lower border of fourth
3. Contents Fig. 2.16: Middle mediastinum
Boundaries and contents vertebra.
of anterior
XThymus
B. gland is the mediastinum. B. Inferiorly : The diaphragm.
Mediastinal principal
artery, branch content
C. Anteriorly : From above downward
Ligaments of internal of the anterior ediastinum (chldun a. Bifurcation of trachea.
Retro-sternal Superior and inferior sternothoracic artery. mediastinum
. :
b. Pulmonary vessels.
Loose areolar lymph tissue. node.tun lm h pericardia. Fibrous pericardium.
Applied anatomy d. Posterior surface of the diaphragm.
superior : Abscess or D. Posteriorly :
mediastinum enters the bleeding or
TMP anterior growth in front of the d. Bodies of lower eight thoracic vertebrae.
mediastinum. pretracheal b. Intervertebral discs and
SN-13 Middle mediastinum (widasx)
fascia of the C. Anterior longitudinal ligament.
1. E. On each side : Mediastinal pleura.
Introduction It is
pericardium. a
widest of
all the
3. Contents
Boundaries
A. Superiorly
mediastinum and is
A. Longitudinal structures
occupied by the heart Vagus nerve
B. vertebra. Horizontal plane from sternal
and the b. Descending thoracic aorta DA TES
Inferiorly
C. Anterior : By the angle to
Thoracic duct
D. Posteriorly diaphragm.
5tmu Þinícondid lgow*
lower
border of
fourth
d Azygos vein
Posterior mediastinal lymph nodes
By fibrous pericardium thoracic Oesophagus
g Splanchnic nerve
B. Transverse structures
Superior and inferior hemiazygos vein
Posterior intercostal vein.
Posterior intercostal artery.
 Thorax\ Thorax

-Arch of the aorta

Pericardium Super

Anterior Right >Lert

PT

Oesophagus
Right- Left
Inferior
Fibrous pericardium

Posterior
Lung and pleura -Pericardial cavity

Thoracic duct
Descending thoracic Parietal layer of serous percardium
Azygos vein aorta

Greater splanchnic nerve-

Hemiazygos vein
Visceral layer of serous pericardium
**-----
Lesser splanchnic nerve

Sympathetic trunk- of pericardium.

2.18: General arrangement of parietal and visceral layers
Thoracic vertebra Fig.

2. Relations :
and occasionally by thymus.
Anteriorly: Thoracic wall is separated by lung, pleura
A.
Fig. 2.17: Posteriormediastinum. B. Posteriorly
a. Right and left bronchi
4. Applied anatomy : Abscess b. Oesophagus
or bleeding
between prevertebral and pretracheal fascia enters
Oesophageal plexus of
nerves
superior mediastinum and enters the posterior mediastinum. c.
Descending thoracic aorta
ul laupr
d.
Thoracic duct
e.

eLAQ4 Describe the fibrous pericardium under

f. Azygos vein
Hemiazygos vein
lungs.
1. Gross anatomy 2. Relations 3. Blood supply mediastinal surface of both
h. Posterior part of the
4. Nerve supply 5. Functions 6. Development side:
C. On each lung
a. Cardiac impression of the corresponding
b. Phrenic nerves
Gross anatomy MC 5 .
Pericardiaco phrenic vessels.

ynonymous Outer layer of pericardium. D. Below:

Introduction : It is
shaped open sac and has apex and base. Left lobe of the liver
a cone
a.
a.
Apex: It merges with the
tunica adventitia of Fundus of the stomach.
aorta) and pre tracheal (pulmonary trunk and ascending
layer of the
deep cervical
b. Base : It fuses with the upper surface of centralfascia. Blood supply
left part of the tendon and musculature
diaphragm. of the A. Arterial supply
c. In front: It is attached of internal thoracic artery)
to the
upper and lower a. Pericardiacophrenic artery (branch artery)
ends of the body of internal thoracic
the superior and inferior
sternum by (terminal branch of
C. Structures piercing fibrous sterno-pericardial ligaments respectively. b. Musculophrenic arter
thoracic aorta.
a. Ascending aorta pericardium. C. Branches of descending
b. Pulmonary trunk, B. Venous drainage
C. Azygos vein and
Two venae cavae and a.
d. Four pulmonary veins. b. Internal thoracic vein.
nerve.
sensitive and is supplied by phrenic
Nerve supply Fibrous pericardium is pain
 99
98 Thorax Thorax

Venous end
5. Functions: B.
position. Superior vena cava,
It keeps the heart
in a.
A.
distention of the heart.
b. Inferior vena cava and
It prevents the
over
B. c. Pulmonary vein.

6. Development I t develops
from septum transversum. and situated on the
Locat ation It is present between two layers of serous pericardium
the heart.
of the posterior surface of
part
Describe the serous pericardium under upper
LAQ-5 1. Gross anatomy 2. Blood supply 3. Nerve supply 4. Boundaries :

A. Anteriorly
4. Functions 5. Development & 6. Applied anatomy. Ascending aorta and
a

b. Pulmonary trunk
Gross anatomy B. Posteriorly
A. SVnonymous Inner layer of perIcardium. a. Superior vena cava,
B. Introduction: lt is a closed sac and lies within the tibrous pericardium. It consists of left atrium and
a. Visceral layer (epicardium) and
b. Upper margin of
veins.
C. Four pulmonary
b. Parietal layer. Arterial tube of pericardium
There is a potential sac present between fibrous and visceral layer. The maximum capacit
of the sac is 300 ml. Superior Ascending aorta
Blood supply
A. Arterial supply :Coronary arteries branches of ascending aorta. Pulmonary trunk
Right
B. Venous drainage: Coronary sinus.
Superior vena cava
3. transverse sinus
Nerve supply :
Cardiac plexus. Inferior Arrow in the

4. Functions vein
vein Left superior pulmonary
A. It allows the free movement of the heart within the fibrous pericardium. Right superior pulmonary
B. It keeps the surface moist and slippery.
vein
5. Development Left inferior pulmonary
Right inferior pulmonary vein
A. Parietal layer of the serous pericardium develops from somato pleuriC layer of
pericardial sac. -Arrow in oblique sinus
B. Visceral layer of serous pericardium develops from splanchnopleuric layer of
Interior v e n a cava-

pericardial sac.
6. Applied anatomy
A. The accumulation of fluid in the & transverse sinus.
B. Pericardial
pericardial sac is called
pericardial effusion. Fig. 2.19:Oblique
tamnponade Pericardial effusion compresses the heart and decreases
the diastolic capac1ity of heart. This results trunk.
in diminished cardiac output but increased C. Superiorly: Bifurcation of pulmonary
pulse rate and increased venous of left atrium.
C. Paracentesis:
pressure. D. lnferiorly Upper surface
Aspiration of pericardial fluid
is called paracentesis. It is done E. Each side: Pericardial cavity.
a. Subcostal route and by central cells of dorsal
mesocardium.
b. Parasternal route. develops from degeneration of the
E.Fudlen Rub 5. Development: It
During cardiac surgery
the ligature may be passed through the
6. Applied anatomy trunk.
the aorta and pulmonary
SN-15 Transverse sinus (Inter visceral space) t r a n s v e r s e sinus around

1.
R Fr Bc
Synonymous : Inter visceral
space Oblique Sinus
2. Introduction
tube.
I t is a horizontal gap present between arterial and
venous ends of heart
STG
A. Arterial end I. Synonymous : Parieto visceral space
behind left atrium or it is a space
a.
Ascending aorta and
Introduction : It is a cul-de-sac (blind alley) present
b. Pulmonary trunk. closed all sides except inferiorly.
pulmonary veins. It is
on
between four
 Thorax Thorax 101
of heart between parietal and
l t is located
on the posterior
surtace
visceral
2ation
Superior vena cava

Formmation : It is formed by a reflected part of parietal pericardium. Atrial wall cut

Boundaries Posterior surface of left atrium. Musculi pectinati

A. Anteriorly:
B. Posteriorly: Parietal pericardium. veins and inferior vena cava.
of pulmonary
C. On righ side : Right pair veins.
D. : Left
On-left side pair ot pulmonary parcs
Opening of venarum minimarumm
AbayeUpper margin of
leit atrium. q u o o v s p o
E.

. Functions:
It suspends heart in pericardial cavity. Smooth part Crista terminalls
B. It permits free pulsations of left
atrium. vEnticle a y

: It is developed due to the rearrangement of the veins

at venous end.
7. Development Ca dae

Snall
8. Applied
A. Pericarditis: Inflammation of pericardium. Valve of inferior vena cava
V

B. In pericarditis the pain is referred to epigastrium.

Interior vena cava

Sinun VL naMun
LAQ-6 Describe right atrium under s mooth Postini fautna
2. Re tions 3. Blood supply o
1. Gross anatomy Fig. 2.20: Interior of right atrium.
A t i n

e u h
J t 0 o Stpt
3. Development & 4. Applied anatomy. Interior of the right atrium : It is divided into three parts
E. It shows following
I. Gross anatomy: a. Anterior part (it is also called as pectinate part or rough part).
A. Introduction I t is upper right chamber of heart, which receives venous blood from features : D2vzlo hom pu'm i v 0lal Chomb
Crista terminalis 1s produced by internal muscular ridge.
all parts of the body by following veins.
the appearance
Transverse muscular ridges called musculi pectinati. They give
a. Superior vena cava brings venous blood from upper half of the body. II.
from crista terminalis and inserts on
b. Inferior vena cava brings venous blood from lower half of the body. of teeth of comb. They arise connected to each other and form reticular
C. Coronary sinus brings venous blood from the substance of heart. atrioventricular orifice. areThey
B. Right atrium forms network.

a. Right and upper border of the heart, Superior vena cava

b. Sternocostal surface and base of the heart.
C. Extent: lt extends from the opening of superior vena cava to the opening of inferior
vena cava. It corresponds to right third costal cartilage to right sixth costal cartilage. Crista terminalis
D. External features: It is elongated chamber and presents following features:
a. Right auricle uphx end otuia i prolend fo 4 t o izht tur
I t is an ear like projetion arising from atrium. It covers right Anulus ovalis
KAscending aorta and
Infundibulum of right ventricle -Fossa ovalis
I. Jts margins are notched and interior surface is
sponge like.
HIt prevents free flow of blood but favours thrombosis. It causes pulmonary
-Inferior limbic band
embolism in auricular fibrillation. coronary Sinus
Opening of
b. Sulcus terminalis It extends
. From the angle made Valve of coronary sinus
by superior vena cava and the right margin of right Inferior vena cava
auricle
vhic
rd qo I.
grodII To right border of inferior vena cava. 2.21: Interior of right atrium.
Fig.
shollow
bytund.n) h o v
SA neoe
Thin *oov
urp pod oSul
Tminh S u l u
paoAG
On t
mwwwa
tCmrny
C a l !
 Prre
Gmall v im
miniminunb©

wvdi
t Jung inba ort dikos J,
oll fous cherbtr

Thorax
Thorax

102 is also called sinus vengrum, or smooth Da site: Primitive atrial chamber. 1103
b.Posterior part : It
It demo
I " hoNn 3 t u Vincs
It
is divided into
following features :DvUobud D.
Sources:
of Lower,
I. Intervenous tubercle
. posterior smootn part (sinus vena rum)
i. Site : It is present between superior and inferior vena cava.
horn of Sinus venosus. develops from the
absorption of the
most tb ta ii. Function In foetal life it directs the flow of blood from suneri. right
h Crista terminaliS develops from
cava to right ventricle. vena
Upper part of right venous valve.
ya'ro ob I. Opening of superior vena
cava

I I Opening of inferior vena cava It is guarded by Eustachian valve II. Septum spurium.
which s Valves of the inierior
formed by duplication of the endocardium. ft contains few muscle fibers vena cava and
coronary sinus develop from lower
n of the right venous valve.
foetal life the valve regulates the flow of blood irom the inferior vena caua part
to the left atrium through the foramen ovale. Rough trabeculated part (atrium proper) and
IV. Coronary sinus It is guarded by valve of coronary sinus.Opw opiny TNc of the primitive atrium. right auricle develops from right half
Openings of the vanae sordis minimihebesian vein 0vnta tulon o Most ventral smooth part is derived from right half
of the atrio ventricular canal.
t "t V Upper part of interatrial septum
unbtod
is also called central part'of posterior wall). f. develops
ëpta> wall (It develops from septum primum.
from septum secundum and
lower part
I. Fossa ovalis a shaliow saucer shaped depression, derived from eptum F. Anomalies

primum. a. Atrial septal deiect It is due to the

failure of fusion of the
admixture of arterial and venousprimun
duy I Limbus fossa ovalis I t 1S a prominent margin of tossa ovalis. Its the septum secundum. This results into septum and
anterior blood.
edge is continuous with left end of valve of inferior vena cava. up fi la b. Patent foramen ovale.
2. Relations c. Persistence of foramen primum.
d. Persistence of foramen secundum.
A. Anterior
a. Pericardium Applied anatomy:
APressure in tne rignt ariuin can be measured by recording venous pressure in external
b. Pleura.
Jugular vein.
C. Anterior part of the mediastinul surface of the right lung. B. For the repair ot the
atrial septal defect the right atrium is incised the
B. Posterior
border avoiding the region of SA node.
along right
a. Right : Pair of pulmonary veins.
b. Left : Interatrial septum.
C. Laterally : SN-16 Peculiarities of coronary arteries
a.
Right phrenic nerve and pericardiaco phrenic vessels. The following are the peculiarities of coronary arteries. They can be memorized by the word
b. ediastinal pleura. Functional end arteries FEA
C. Cardiac impression of right lung.
D. Medially filled in diastole
elastic lamina is absent,
a. Root of ascending aorta and artery of artery.
b. Root of pulmonary trunk.
3. Blood supply: . Functional end artery The coronary arteries reveal communications i.c. they do
A. anastomose. Hence structurally they are not end arteries. But in case of blockage of
Arterial Right coronary artery, branch of ascending aorta.
B. coronary artery, the blood received through anastomosing channel is so less they do that
Venous Drains into
coronary sinus. not mect the required demand. Therefore they are called end functional end arteries.
4. Development:
Filled in diastole All the blood vessels in the body filled in systole. However
A.
2 are

Chronological age It devclops at the end of fourth week of intrauterine coronary arteries arc illed in diastole.
B. Germ life (1UL)
layer Mesoderm Elastic lamina is absent Coronary arteries are highly muscular vessels and internal
a. The endocardium
b.
develops from angioblastic tissuc. clastic lamina is discontinuous and po0orly developed.
The myocardium develops from splanchnopleuric mesoderm. intima
4. Coronary arteries demonstrate the longitudinal oriented muscles in the outer part of
C. The pericardium develops from somatopleurie or nner part of ncdia.
intracmbryonic mesoder
D Aia

hall otnio vety y l Con ol bs onbi h ofaun

 104 Thorax / Thorax

artery
LAQ-7 Describe right coronary artery under B.

It supplies
SA node in
It
60% of the
forms
vascular ring around
the
termination
105
1. Origin 2. Course 3. Branches C. Right anterior ventricular brancheshearts. of
superior vena cava.
. Distribution& 5. Applied anatomy. along the sterno-costal surface and They are
three to four in
af ricle. One
right ventricle. One of the branch 1s number. They pass
is lonoest o ey
1. Origin : It arises from anterior aortic sinus of ascending aorta.
It runs along the
longest and is known supply anterior surface
inrerior border of the heart. as
right
marginal
2. Course : D. Posterior inter-ventricular
branch It
passes along
artery
A. It passes between right auricular appendage and the infundibulum of the ape of the heart to suppiy the the inter-ventricular groove towards
AV nodal artery: This supplies AV diaphragmatic surface of right ventricle.
the ht
ventricle. E.
node.
B. It passes vertically downwards in the atrio-ventricular
groove.
C. The artery turns backwards at the inferior border of the heart and 4. Distribution
4. Right atrium,
The terminal part of the right coronary artery 1s Small and
runs
posteriorly AB.
anastomoses with thee SA node,
circumflex branch of left coronary artery. C. Superior parts ot the right ventricle,
D. Peculiarity: Right coronary artery a characteristic loop
posterior inter ventricular artery and AV nodal artery arises.
at the point where the D. Posterior 1/3 of inter-ventricular septum,
E. AV node and
Right AV bundle.
3. Branches F.
A.
Right conus artery 5.
.
APplied anatomy:
a. The word 'conus' means infundibulum of The right coronary artery
right ventricle. It is a first branch of A. 1s a second commonest occluded
right coronary artery. myocardial iniarction. artery in causing
b. It is meant for the nutrition of the conus B. In 20% to
25% ot popuiaion, the Tight coronary artery also supplies diaphragmatic
arteriosus.
C. It may arise as the third surface (substantial) of lert ventricle. This is called 'right dominant'
d.
coronary artery.
It anastomoses with the left conus
coronary surface.
artery, a branch of the anterior inter-ventricular Anterior interventricular
branch of the left coronary artery to form an
anastomotic necklace around the Dranch
infundibulum or the commencement of the
pulmonary trunk.
Aortic orifice

Nodal artery Septal rami -

Superior vena cavva Right coronary artery

Right Ventricle Left Ventricle
S. A. Node

Conus branch
Atrial rami

Ventricular rami Righ t<

A. V. Node

Superior Poste1O Posterior interventricular branch

Recurrent branch
Right Left
--< for A. V. Node
Fig. 2.23: Arterial supply of the
interventricular septum.

level, they
Inferi anastomoses at the arteriolar
arteries have numerous
. Although the coronary is blocked the
Posterior interventricular functional end arteries i.e. when a coronary artery
Dranch Right marginal artery are essentially to meet the required
demand in
collateral channels is inadequate
Fig. 2.22: The course and branches of
blood received by
right coronary artery. required time.
 106
D. The cardiac pain (due to angina pectoris or myocardial infarction) is
is usu
Thorax
usually referred
T h o r a x

hranchesThey are in
to the left precordium and inner aspects of left arm and forearm.
ach
three surtacesthree
corresponding groups I107
The heart is supplicd by
upper 4 thoracic (1.e. 1
2 3 & 4) Spinal segment. The .. Ventricular branches: Thev o Anterior, lateral and
oof the left atrium.
over precordium S supplied by 4 3 and 2 spinal segments. The inner asnes kin
b. V escends
and descends along the left
left hor n number. On posterior ror
border of the Oneof
arm is innervated by T2 spinal segment. And the inner aspect of forearm of marginal artery. heart to the these branches is
innervated by T, Spinal segment.
and hanad is Noda artery for thee SA node apex and is larger
called left
C. in 35% of
cases.
The cardiac pain is therefore referred to the precordium and inner D i s t r i b u t i o n

and forearm because of the same segmental innervation. aspects of the

arm 4 Anterior spects ot both right and left
The cardiac pain 1s usually referred to the left side because:
A.
Anterior 2/5 ot the ventricular septum,
ventricles,
Cardiac lesions mostly occur in the left half of the heart, but L e f t branch of the AV bundle,
if the
right half of the heart, the pain will be lesion Is
referred on the right Side. Hence it Isn D. Left surface oT the left ventricle&
wrong notion that cardiac pain is always referred to the left side E. Posterior aspect ot the left atrium.
*the left arm myth
E. The coronary diseasce in old age is less fatal than in
young age because
increase and collateral channels develop with the
advancement of age. anastomoses
E The slow gradual blocking coronary artery 1s less
dangerous than sudden
pericardiac anastomOSis will dilate and blockage
because the arteries täking part in extra Pulmonary trunk- -Left coronary artery
blood supply to the heart. provide Circumflex branch

Diagonal branch
LAQ-8 Describe left coronary
1.Origin
artery under
2. Course
Rights Left marginal branch
3. Branches
4. Distribution & 5. Applied
anatomy. Interio Septal rami
1. Origin t is shorter but
wider than the right coronary artery and supplies the Anterior interventricular
mass of
myocardium. It arises from left
posterior aortic sinus of ascending aorta. greater branch
Posterior
2. Course : interventricular branch
A. lt passes between left
auricle and the infundibulum of the right ventricle. Right marginal artery
B. After the short course it
divides into two terminal branches Fig. 2.24: The course and branches of left
inter-ventricular branch). (circumflex and anterior coronary artery.
C. The circumflex branch is one of the 5. Applied anatomy:
terminal branch of left
the left border of the heart to the coronary artery, runs from A. Anterior inter-ventricular branch of left coronary artery is the most commonly
back of the heart in the
D. It gives various branches Antrio-ventricular groove. occluded vessel in the myocardial infarction. The circumflex branch of left coronary
to atrium and ventricle and anastomosis with the artery is a third commonly occhuded vessel in myocardial infarction.
Coronary artery. right
The left coronary artery in addition to the usual distribution, supplies blood to the
3. Branches: B.
entire inter-ventricular septum and atriOventricular node. In such cases it is called left
A. Anterior inter-ventricular
artery: It is downward continuation dominant coronary artery.
the anterior inter-ventricular of the main trunk along
groove. It winds round the inferior border of the heart Note: Please write the points of C, D, E and F of
to
anastomose with
the posterior inter-ventricular artery i.e. junction of anterior applied anatomy of right coronary artery.
and posterior
2/3of the posterior inter-ventricular groove. It has following branches 1/3
a. Anterior ventricular branches for
the sternocostal
right ventricles. One of the right anterior ventricular surfaces of both lefi and heart
artery which supplies the conus arteriosus of the branch gives the left conus LAQ-9 Venous drainage of the
anastomotic necklace with the right ventricle and forms
right conus artery, branch of right coronary
b. Septal branches : To supply anterior artery. heart divided in two groups
B. 2/3 of the inter-ventricular septum. The veins draining the are
the p0sterior part of
Circumflex artery It passes along the left is a wide vessel that lies in
part of the posterior atrio-ventricular veins draining coronary sinus: This
into
and opens in the
groove. The branches are as follows, It is covered by thin layer of myocardium
atrio-ventricular groove.
inferior vena cava.
atrium left to the opening of
posterior wall of right
 Thorax Thorax

Oblique vein of left

109
atrium
LAQ-10
pescribe superior vena cava
ororiry Siri Gross anatomy 2. Relations under
ADevelopment & 5, 3. Tributaries
Applied anatomy.
r o s s anatomy

Vein from left

GrossIntroduction
A. a1..ction This is the
ventricle large venous channel which
half of the body
and drains into the right atrium. collects the blood from
the
Forma formed
. [t is
by the union of right and
formed behind left
CSite It 1s 1ormed behind the
the lower border
lower border of first brachiocephalic veins.
right costal cartilage.
Smal cardiac vein Greater cardiac vein Length: 7 cms.
D.
E.
ion
Termination terminates
: It terminates
by opening into the
Middle cardiac vein upper part of the
the third costal cartilage. right atrium behind
2. Relations:

Fig. 2.25: The figure showing veins draining the heart

A. Anterior

a. Chest wall.

The tributar1es of the coronary sinus and their details is b. Internal thoracic vessels.
described in the
Table 2.4: The tabie showing the veins following table Anterior margin OI the right lung and pleura.
draining into coronary sinus. d The vessel is cOvered by pericardium in its lower half.

Particulars Situation Draining area B. Posterior

Artery accompanying aTrachea and rignt vagus (posteromedial to the
the vein upper part of the vena cava).
b. Root of right lung (posterior to the lower part).
A Great cardiac Anterior inter a. Anterior part of inter C. Medial:
Anterior interventricular
ventricular groovec ventricular septum a. Ascending aorta.
artery (left coronary)
b. Anterior part of both b. Brachiocephalic artery.
ventricles D. Lateral
B. Middle cardiac Posterior inter
a. Phrenic nerve (with accompanying vesselis).
a. Posterior part of inter Posterior ventricular b. Right pleura and lung.
ventricular groove ventricular septum
b. Posterior part of both
(Tight coronary artery)
ventricles Intercostal muscles of second space

Internal thoracic vessels

CSmall cardiac Coronary sulcus Margins of right ventricle
Right pleura
D Oblique vein Posterior part of Ascending aorta
of the left left atrium Right lung
Puimonary trunk-
atnum (vein of Right phrenic nerve
Left phrenic nerve-
Marshal) Superior vena cava

Right pulmonary artery

Veins directly opening into the right atrium are described in the following table. Trachea
Right bronchus

Tabie 2.5 The table showing Right vagus nerve

veins directly draining into right atrium. Left vagus nerve- nterion
-Oesophagus
Particulars Situation Draining area Termination Descending aorta-
Azygos vein

Anterior cardiac vein Atrioventricular Thoracic duct

Anterior surface of right Right atrium
groove ventricule Left posterior intercostal
0 Tet
Venae cordac minimi artery
Endocardium Right atrium
(Thebesian vein) vertebra.
at fifth thoracic
Relations of superior vena-cava
Fig. 2.26:
 111
110 Thorax / Thorax

I n t e r n a lt h o r a c i c v e s essels
Manubrium
3. Tributaries Superior Vena
cava at the pyel ooff
level
A. Azygos vein It opens into the Secona
cartilage just
before it enters the
pericardium. costal &
pleura.
Thymus

B. Small mediastinal veins. Left

lung Arch of aorta
C. Pericardial veins. L e f t p h r e n i c n e r v e -

Development L e f ts u p e r i o r

anterior cardinal vein.

vein

A. Upper half develops from right

i n t e r c o s t

Brachiocephalic trunk
common cardinal vein.
B. Lower half develops from right Cardiac nerves

Right phrenic nerve

5. Applied anatomy Superior vena cava
In the obstruction of the superior vena cava above
the opening of azygos Left vagus
A. vein. th
venous blood of the upper half of the body is returned through the through
the azygos
azygoS the
vein and Left
common
carotid artery.
0- Right vagus nerve

the superficial veins are dilated on the chest upto the costal margin.
Trachea
of
B. In the obstruction of the superior vena cava below the opening
blood is returned through the inferior vena cava via the femoral vein.
the azygos vein
ein the Left subclavian artery
Oesophagus
C. Here the superficial veins are dilated on both the chest and abdomen. Deep cardiac p l e x u s -

D. In cases of the mediastinal syndrome, the signs of the superior vena caval Anterior
obstruct.
ion
are first to
appear.
Left recurrent
laryngeal nerve
Left RIg

LAQ-11 Describe the arch of the aorta under Thoracic duct Posterioo
1. Origin level.
2. Course 3. Relations Fig. 2.27: Relations of arch ofaorta at T
4. Branches 5.
Development & 6. Applied
anatomy.
1. Posterior and to the right nodes.
Origin: It is the continuation
of the B. plexus and the
tracheobronchial lymph
situated in the ascending aorta behind the manubrium
sternum. It is Trachea, with the deep
cardiac
superior mediastinum. a.

2. Course b. Oesophagus.
nerve.

A. Left recurrent laryngeal

It begins behind the
B.It runs
upper border of the second right sternochondral d. Thoracic duct.
upwards, backwards and to the left, across joint. e. Vertebral column.
the trachea. Then it the left side of the
passes downwards behind the left bronchus bifurcation of
the body of the fourth
thoracic vertebra. It thus arches over and on the left side of C Superior:
arch of the aorta
C. It ends at the the root of the left a. Three branches of the
lower border of the lung.
continuous with the body of the fourth thoracic vertebra I. Brachiocephalic
Thus descending
aorta. by becoming II. Left c o m m o n
carotid and
the origin and termination the aortic arch is subclavian artery. the left
brachiocephalic
anteriorly and terminates posteriorly. at the same level, III. Left their origin by
3. Relations:
although it begins b. these arteries are crossed, close to
All
A. vein.
Anteriorly and to the left:
D. Inferior
a. Nerves (from before of the pulmonary
trunk.
I. Left phrenic backwards) a.
b.
Bifurcation

Left bronchus. it.

on
II. Lower with superficial
cardiac plexus
cervical cardiac branch of the left C. Ligamentum
arteriosum
II.
Upper cervical cardiac branch of left vagus,
d. Left recurrent laryngeal
nerve.
IV. Left vagus. sympathetic chain,
. Left carotid and right
superior intercostal vein, 4. Branches divides into the right common

vagus nerve. deep to the

phrenic nerve and A. Brachiocephalic artery
which
C. Left pleura and superficial to the
subclavian artery.
d. lung
Remains of thymus.
B. Left c o m m o n carotid artery.
C. Left subclavian artery.
 112 Thorax Thorax

|113
Oesophagus E. Anomalies:

-Left common carotid

artery- artery a. Coarctation ot aorta It takes place due to the congenital stenosis or
Right common
carotid
the arch
of the aorta distal to the atresia ot
origin of left subclavian artery. The stenosis is
due to defect ot the tunica media which may be
Left brachiocephalic vein I. Preductal &&
Left subclavian artery II. Postductal.
vein
-

brachio cephalic
Right . Right sided aortic arch This is common in birds. It is due to the persistence or
Brochio cephalic trunk- Arch of aorta
the right dorsal aorta the seventh
C. Double aortic arch
below
it is
intersegmental artery.
Superior vena cava- common in
frogs. It is due to the persistence ot lert
dorsal aortae.
Patent ductus arteriosus.

6. APplied anatomy
Ascending aorta knuckle A bulging known the left side
Superioor A. Aortic : convex as aortic knuckle is found on
of the sternal angle in a plain X-ray chest. lt is formed by the distal part of the arch
of the aorta.
Right- B. Aortic aneurysm.

Inferior
LAQ-12 Describe oesophagus under
1. Gross anatomy 2. Blood supply 3. Lymphatic drainage
Fig. 2.28 :Branches of the arch of the aorta.
4. Nerve supply 5. Histology & 6. Applied anatomy.
Development: 1: Gross anatomy
tract extending from
A. Chronological age: lt develops at the end of fourth week of intrauterine life (1UL). A. Introduction : It is the longest muscular tube of gastrointestinal
pharynx to stomach.
B. Germ layer: Mesoderm. to
C. Site: Ventral to the foregut. B. Extent I t extends from lower border cartilage of cricoid (sixth cervical vertebra)
D. Sources The arch of the aorta is developed from three sources (from before cardiac orifice of stomach (tenth thoracic vertebra).
following
backward) C. Constriction Normally the oesophagus shows four
constrictions at the
a. Left horn of aortic sac (truncus arteriosus): It forms the part of arch of the aorta levels ABCD
between brachiocephalic trunk and left common carotid artery. a. Where it is crossed by the aortic arch.
b. Left fourth aortic arch: It forms the part between left common carotid artery and b. Where it 1s crossed by the left bronchus.

ductus arteriosus. . At its commencement (caused by cricopharyngeus sphincter).

c. Left dorsal aorta: It forms the rest of the arch upto the descending aorta. d. Where it pierces the diaphragm.

Incisor teeth

Superior

6 Cricopharyngeus
Rights
Left dorsal aorta
th
Interior Left 4 aortic archn Arch of aorta
-Left horn of aortic sac
Left bronchus
11"

Oesopnagea
hiatus in 15
diaphragm
Fig. 2.29 : Development of arch of the aorta.
Fig.2.30:Constrictions of oesophagus
 115
of inferior thyroid
artery
Thoraxx T h o r a x

showing DIOO0 SuPpiy and lymphatic drainage of oesophagus.

Desophageal 2.6 The table
114 Inferiorthyroid artery
T a
l
b l e

Lower (abdominal)
Upper (cervical) Middle (thoracic)
Particulars

Thyrocervical trunk
Blood supply a. Oesophageal branches Oesophageal
A. Arterial
Oesophageal branches of left
branches of inferior of thoracic aorta
supply thyroid arteries b. Oesophageal branches gastric artery.
(subclavian artery) of bronchial arteries
Left subclavian artery
Oesophageal veins Oesophageal veins drainOesophageal vein
B. Venous which drains into left
nfer
Oesophageal of thoracic aorta
drainage drain into into azygos vein
brachiocephalic vein drains into superior vena gastric veins wnicn
Thoracic aorta drains into porta
which drains into cava
vein
Oesophagus superior vena cava

Tracheobronchial lymph Left gastric nodes

3. Lymphatic
Deep cervical nodes and posterior & coeliac lymph
lymph nodes
drainage mediastinal nodes. nodes
Lymphatics of
oesophagus follows
Oesophageal branch of
arteriesS
left gastric artery

spinal cord and form

Coeliac trunk -
4. Nerve supply : These arise from Ts -

Tg segments of the
A. Sympathetic fibers

Fig. 2.31: Arterial supply of oesophagus. the oesophageal plexus. derived from vagi and recurrent laryngeal nerves.
fibers These are
B. Parasympathetic submucous plexuses act as postganglionic
in the myenteric and
The nerve cells
for parasympathetic
fibers only. in peristalsis and
cells produces disturbance
neurons
absence of these nerve
The congenital not ; chalasis relaxation).
cardio-spasm or achalasia (a
the condition is known
as

Posterior mediastinal from inside out.

It is formed by four layers folds. lt
lymph nodes 5. Histology :
It is thick and is in the collapsed
state thrown into longitudinal
A. Mucos a
Supenor consists of

Rignt 2Len Stratified squamous non

keratinised epithelium
enor Basement membrane

Lamina propria
Mucosa

Muscularis m u c o s a e

Submucosal glands
Submucosa

Inner circular layer

Outer longitudinal layer
Muscularis externa

Serosa
Fig. 2.32: Lymphatic drainage
of oesophagus. Fig. 2.33: Oesophagus.
 17
non-keratiniscd. I1 i
Thorax T h o

B.
r a x

Here
it
it
accompanies on the iett side by descending thoracic aorta and on the right
squamous by by azygOS vein.
116 cpithehum
of stratifiedo C s o p h a g c a l j u n c t i o n . side
Surface
epithclum
at the gastro 1ies posterior to oesophagus upto 5 thoracic vertebra.
laver and
circular and at level of thoracic
olumnar
an vertebrae it takes left
rmucosa which
shows
am0ng the
an internal

muscle fibers
ehal
It
ascends upward turn and enters the
at musCularis
ound
D. superior mediastinum.

Thiu A n e r v e piexus may De s p a r s e a n d are found in the

longitud1nal layer.
ure
level of cervical vertebra, it arches 4 above
ii
mucous
contains
Klanas WIC
E. the
the
left clavicle.
7 laterally, which is 3 cms to cms
Na
longitudinal. whick
ends.
outer
inner circular and f
lower
amd of
pper consISts
in the lower part, I
MuNcularIs
esierna smootn
muscie
the T r i b u t a r i e s

the upper partand t

receives contiuence of lymph trunk.
skeletal
muscle in
cells of the body.
A.
A t commencement trunk fromn
it receives 1ymph
muscle
smooth
In thorax
ongest fibrous coat B.
ed hy thick Upper lumbar region
Serosa 1s d.
D the main sites of
Posterior mediastinum and
4pplied anatom is ne of .
intereostal space.
6 Oesophageal
varices
The lower end
ol oesophagus
gastrC Vem ánastomOse profusely with
ith . Upper six
two tributaries
A Here the tributaries oi
leTt In the
neck it receives
caval anastomosis. C. trunk &
Left subclavian Iymph
veins.
hemiazygos
of azygos and portal to caval system
the tributaries blood from
hypertensIOn
there 1s shunting of the channels which is called b. Left jugular lymph trunk.
In portal of these collateral
and tortuosity
There 1s dilatation
into haematemesis (1.e. vomiting of
oesophageai varices. Rupture of these veins results haematemesis arising from perforationn of
Right jugular trunk Thoracic duct
differentiates
This
frank red colored blood). Left interna
black-red in colour. Right subclavian trunk
ulcers which is jugular vein
gastric
to
paintul swalloWing or difficult
oesophagus results into
Obstruction
B Dysphagia can be diagnosed by
barium swallow, Left
called as dysphagia. This subclavian vein
swallowing which Is of the lower
to neuromuscular in-coordination of muscles
Achalasia cardia l t is due & there is a failure of
This results into loss of peristalsis
end of oesophagus. accumulates in the Oesophagus-
relaxation of the lower end
of oesophagus. Consequently
the
food
not Include gastric contents
The regurgitant does
Oesophagus causing regurgitation. the most common oesophageal motility
achalasia is
and is not sour tasting. The Sup OT

disorder, with an incidence of

6 per 100,000 individuals.

Posterior
Right intercostal
lymph nodes

thoracic duct under

LAQ-13 Describe 2. Course and relations 3. Tributaries
ntern
1. Gross anatomy
5. Development & 6. Applied anatomy.
4. Histology
I. Gross anatomy
A. Introduction I t is a lymphatic channel present in the thoracic region draining the Thoracic aorta
lymph from lower half and left upper half of the body. Azygos vein -

Left crus of diaphragm

B. Appearance Beaded
Measurement: Length X width (cm) 45 x 0.5 Cisterna chyli with
intestinal lymph trunk
D. Extent: Lower border of T12 vertebra to 7 cervical vertebra.
E. Commencement : It commences from the cranial end of cisterna chyl
lumbar lymph nodes
F. Termination: It terminates in the left brachiocephalic vein at the junction of left Upper
subclavian and left internal jugular vein.
nodes
2. Course and relations -Lower lumbarlymph
A. Itpasses through the aortic opening of diaphragm which is present at 12" thoracie thoracic duct.
2.34: The course & relations of the
vertebra. Fig.
 118 Thorax Thorax

is gap between lower end of

|119
4. Histologs It has threc layers a
septum primum and septum
A.
B
Tunica externa
Tunica media: lt shows connective tissue fibers arranged along long axis of the
tium primum. Belore 1ower end of intermedium called
septum primum fuses with
ntermedium, upper part brcaks
open and the
gap is formed which is called septum
Vessels. secundum. ostium
C. : It shows well defined
Tunica intima
sub-cndothelial layer. Cntum secundum Another crescentic membrane
B.
mum and on left side of valve of septum arises on right side
Development: It develops from of septum
A. Two longitudinal channcls which are present by the side of primitive vertebral colun
lumn. centum primum and septum secundum which isspurium
oval in
(false). There is a gap between
B. They are connected by transverse channels at the level of 5 thoracic vertebra
ovale. The blood shape
coming rom right atrium passes to left
and is called as foramen
C. Right upper and lefi lower limbs of the original longitudinal channel disappears atrium through foramen
and ovale.
the remaining part gives to thoracic duct.
At birth the left atrium receives blood from lungs by four
pulmonary
the increase in the volume of blood the pressure is increased in veins. Due to
6. Applied anatom left atrium. The
A. Obstruction of duct is caused by septum secundum and septum primum approximates and interatrial
a. Surrounding tumours or by developed. septum is
b. Microfilaria.
B.Rupture of duct leads to leakage of chyle and the condition is called chylothorax Anomalies: Atrial septal defect is common anomaly.
A. Incidence: 0.07%
B. Prevalence: 2 to I in female versus male infant.
C. Types: It is of three types

S-17 Development of inter-atrial septum a. Cor triloculare

septal defect.
biventriculare
There is complete
This is the most serious
absence of the atrial
abnormality of atrial
septum. It is always
. Chronological It develops in the fourth week of intrauterine life (UL).
age: associated with serious defects elsewhere in the heart.
b. Osteum primum defect is caused by
2 Germ ayer: Splanchnic layer of lateral plate mesoderm. I. Defective formation of atrio-ventricular (endocardial) cushion or
Site From the roof of primitive atrial chamber. II. Failure of the septum primum to reach the atrioventricular cushion.
Sources c. Osteum secundum defect : It is a most significant defect. It is caused by
A. I. Failure of development of septum secundum.
Septum primum A thin crescent shaped membrane grows from the roof of
II. Excessive resorption of septum primum.
primitive common atrial chamber. Itgrows downward in the direction of
septum d. Patent foramen ovale is caused by failure of approximation of septum primum
intermedium (fused atrio ventricular cushion). This septum is called septum primum.
and septum secundum after birth. It is clinically not significant as it does not
Roof of primitive atrial chamber
allow shunting of blood.
Septum secundum
Septum spurium -

Ostium secundum
Sino atrial orifice . Development of inter ventricular septumn
SN-18
Septum primum in the seventh week of intrauterine life (TUL).
1. Chronological age
: lt develops
Ostium primum mesoderm.
2. Germ layer Splanchnic layer of lateral plate
Septum intermedium From the floor of the common ventricular chamber (bulboventricular cavity).
3. Site :

4. Sources lt has two parts muscular and membranous part

the interventricular septum. lt arises
as a
A. Muscular part forms the major part of
the primitive ventricular
muscular ridge or fold, the interventricular septum from
chamber. the free
interventricular foramen. It exists between
B. Menbranous part : It is also called It permits
of interventricular septum and
the fused endocardial cusion.
age seventh week. It has
the end of
communication between right and left ventricles upto
Fig. 2.35 two parts
:
Development of inter-atrial
septum.
 ht onfyi'o Cadinal
Vain, cCaudal
tHonsvm anastomo
CaxdingdA
120 Thorax Thorax

Anterior membranous part atrioventricular endocardial

which develops from atrioventricular 121
a.
cushion. It is also called intermediate septum (septum between right at
m SN-19
Development of left atrium
left ventricle). The atrioventricular
canal is formed between the and
the canal is round and changes tVe atrium It
and primitive ventricle. Initially Chronological age :
develops in the fitth to
seventh week of
elevations develop on the anterior and posteriOr
wall of this canal. w: Wo 1.
intrauterine life (IUL).
Mesoderm,
fused and forms septum intermedium. I his communicates withwith right and gets
right 2.
Germ layer
of ventricle.
left side
of atrium to right and lefi side
b. Posterior membranous part is formed by right and lett bulbar septum.
Site: Primitive atrial chamber.
Sources
4. The Dosterior sm0oth part
Anomalies:
fram the incorporation of the(Detween
A. the
openings of the
pulmonary veins) develops
A. Ventricular septal defect (VSD) : This is the most common congenital anomaly af the endocardial cushions of the four
heart. It is because of failure of fusion of endocardial cushion or the atrioventrieute The anterior part which 1s somewhat trabeculated pulmonary veins.
canal. from the left halt of the primitive atrium. including the left auricle
develops
T h e most ventral part develops irom the left half
of the atrio-ventricular cana.
Supeno

Pulmonary trunk SN-20 Development of portal vein

1. Chronological age It develops in the fifth to seventh week of intrauterine life (IUL).
Stenosis of pulmonary trunk Germ layer : Mesoderm.
2.
Overriding of aorta 3. Site: Around the duodenum.

4. Sources
Ventricular septal defet
Table 2.7: The table showing sources of different part of the portal vein.

Part Develops from

Right ventricular hypertrophy
B. Fallot's tetralogy
(Tetralogymeans four
cyanotic heart disease.
narrow pulmonary and
PROv
A. Infra duodenal part Part of left vitelline vein from joining of splenic vein to
dorsal inter vitelline anastomosis.
B. Retro duodenal part Dorsal anastomoses between right and left vitelline veins.
Fig.2.36: Fallot's tetrology. C. Supra duodenal part Right vitelline vein between dorsal anastomosis and
cephalic ventral anastomosis.
defects) It is most common congenital Cephalic part of right vitelline vein cranial to cephalic
The main defect is an
unequal division of the conus
D. Right branch
wide ascending aorta. It is
leading to inter vitelline anastomosis.
characterized by
E. Left branch Cephalic ventral anastomosis and left vitelline cranial to

A. Pulmonary stenosis cephalic ventral inter vitelline anastomosis.

b. Right ventricular hypertrophy.
c.
Overriding
of the aorta.
d. Ventricular septal defect.
The clinical
manifestations are breathlessness inferior vena cava
his activity and lies in on exertion. The child
the knee chest suddenly ceases SN-21 Development of
relief
probably because squatting reducesposition "squatting posture", by doing so he
abdominal veins and increases the the venous return by gets fifth seventh week of intrauterine life (1UL).
Chronological age I t develops in the
to
systemic compressing the
vascular resistance by kinking
and popliteal arteries. the
Both these femoral
through ventricular septal defect andmechanisms tend to decrease the right to left shunt Germ layer Splanchnic layer of lateral plate
mesoderm.

improves
the pulmonary Circulation.
 122
Heart Cranial Thorax
Vein Common hepatic vein
Right
Left

Transverse communication Caudal

between supra and
subcardinal veins
Mesonephros

Sub cardinal veins

-Post renal segment
-Supra cardinal vein

Fig. 2.37: Development of inferior vena-cava.

3.
3. Site : Posterior abdominal wall.
4 Sources
A. Right posterior cardinal vein caudal to joining of right supracardinal vein.
B. Right supracardinal vein caudal to right supra subcardinal anastomosis.
C. Right supracardinal - subcardinal anastomoses.
D. Right subcardinal vein caudal to right subcardino hepatocardiac channel anastomoses
E. Right subcardinal hepatic cardiac channel anastomoses.
F. Hepatocardiac channel.
. Anomalies
A. Absence of inferior vena cava - results when the right subcardinal vein fails to
establish connection with the liver.
Double inferior vena cava - (at lumbar level) - results from persistence of left
B
supracardinal vein.