THORAX

• The superior part of the trunk between the

neck and abdomen.
• Commonly referred as the chest.
• Includes the primary organs of the respiratory
and cardiovascular systems.
 The thoracic wall
• Includes the thoracic cage and the muscles that
extend between its elements, the skin,
subcutaneous tissue, muscles, and fascia.
• Has the shape of a truncated cone, being
narrowest superiorly.
• Its circumference increases inferiorly, reaching its
maximum at the junction with the abdominal
portion of the trunk.
The thoracic cage

• Takes the form of a domed birdcage.

• Formed by the sternum and costal cartilages in
front, the vertebral column behind and the ribs
and intercostal spaces laterally.
• Furthermore, the floor of the thoracic cavity (the
diaphragm) is deeply invaginated inferiorly by
viscera of the abdominal cavity.
• Communicates superiorly with the root of the
neck through the thoracic Inlet.
 Thoracic vertebrae
• T1-12 form the posterior border of the rib cage.
• articulate with the corresponding ribs.
• Classified as typical and atypical.
• Features of typical thoracic vertebrae:
– heart-shaped vertebral body (Centrum)
– circular vertebral foramen
– long sloppy spinous process
– Bilateral demifacets
• Atypical thoracic vertebrae bear whole costal
facets in place of demifacets: these are T1, T10,
T11, and T12.
 The ribs

• curved, flat bones that form most of the thoracic cage

• True (vertebrocostal) ribs (1st-7th ribs): attach directly to
the sternum through their own costal cartilages.
• False (vertebrochondral) ribs (8th, 9th, and usually 10th
ribs): Their cartilages are connected to the cartilage of
the rib above them; thus their connection with the
sternum is indirect.
• Floating (vertebral, free) ribs (11th, 12th): The
rudimentary cartilages of these ribs do not connect even
indirectly with the sternum.
 Typical ribs (3rd – 9th)

These comprise the following features:

• Head: wedge-shaped and has two facets, one facet
for articulation with the numerically corresponding
vertebra and one facet for the vertebra superior to
it.
• Neck: connects the head with the body at the level
of the tubercle.
• Tubercle:
– located at the junction of the neck and body and has
• smooth articular part, for articulating with the
corresponding transverse process of the vertebra, and
• rough non-articular part, for attachment of ligament.
• Body (shaft):
– thin, flat, and curved, most markedly at the costal angle
where the rib turns anterolaterally;
– Has concave internal surface bearing costal groove
paralleling the inferior border of the rib, which provides
some protection for the intercostal nerve and vessels.
Atypical ribs (1st, 2nd, 10th, 11th, 12th)

• The 1st rib

– is short, flat and sharply curved.
– The head bears a single facet for articulation.
– A prominent tubercle (scalene tubercle) on the inner
border of the upper surface represents the insertion
site for scalenus anterior.
– The subclavian vein passes over the 1st rib anterior to
this tubercle whereas the subclavian artery and
lowest trunk of the brachial plexus pass posteriorly.
• Cervical rib
– is a rare ‘extra’ rib which articulates with C7
posteriorly and the 1st rib anteriorly.
– A neurological deficit as well as vascular
insufficiency arise as a result of pressure from
the rib on the lowest trunk of the brachial
plexus (T1) and subclavian artery, respectively.
• The 2nd rib
– Has rough area on its upper surface, the tuberosity for
serratus anterior.
• The 10th rib
– has only one articular facet on the head.
• The 11th and 12th ribs
– are short and do not articulate anteriorly.
– articulate posteriorly with the vertebrae by way of a
single facet on the head.
– devoid of tubercle.
 The sternum
• is the flat, elongated bone that forms the middle
of the anterior part of the thoracic cage.
• The sternum comprises:-
The manubrium
– is the widest and thickest upper part of the sternum
– has facets for articulation with the clavicles, 1st costal
cartilage and upper part of the 2nd costal cartilage.
– It articulates inferiorly with the body of the sternum
at the manubriosternal joint, forming a projecting
sternal angle (of Louis).
• The body
– is composed of four parts or sternebrae which
fuse between 15 and 25 years of age.
– is located at the level of the T5-T9 vertebrae.
– It has facets for articulation with the lower part
of the 2nd and the 3rd to 7th costal cartilages.
• The xiphoid
– articulates above with the body at the
xiphisternal joint, the site of infrasternal angle
(subcostal angle).
– lies at the level of T10 vertebra.
– It is cartilaginous in young people but more or
less ossified in adults older than age 40.
Costal cartilages

• bars of hyaline cartilage which connect the

upper seven ribs directly to the sternum and
the 8th, 9th and 10th ribs to the cartilage
immediately above.
 Intercostal spaces

• separate the ribs and their costal cartilages from one

another.
• named according to the rib forming the superior
border of the space.
• occupied by intercostal muscles and membranes, and
neuro-vascular bundle.
• The space below the 12th rib does not lie between
ribs and thus is referred to as the subcostal space,
and the anterior ramus of spinal nerve T12 is the
subcostal nerve.
• The intercostal spaces are widest anterolaterally, and
they widen with inspiration.
Joints of the thoracic wall
• A typical rib articulates with:
– The bodies of adjacent vertebrae, forming a
joint with the head of the rib (costovertebral
joint)
– The transverse process of its related vertebra,
forming a costotransverse joint.
• The combined movements of all the ribs on the
vertebral column are essential for altering the
volume of the thoracic cavity during breathing.

24
Costovertebral joints
• Synovial joint between the facets on the head
and facets on the body of thoracic vertabrae
• an intra-articular ligament attaches the crest to
the adjacent intervertebral disc.

Costotransverse joints
• synovial joints between the tubercle of a rib
and the transverse process of the related
vertebra.
• stabilized by costotransverse ligaments.

25
Sternocostal joints
• joints between the upper seven costal
cartilages and the sternum.
• The second to seventh joints are synovial.

Interchondral joints,
• synovial joints between the costal cartilages of
adjacent ribs
• provide indirect anchorage to the sternum
Manubriosternal and xiphisternal joints
• Symphysis between the manubrium and body
of sternum and between the body of sternum
and the xiphoid process
• angular movements occur between the
manubrium and body of sternum during
respiration in the young.
28
29
• The joint between the body of sternum and the
xiphoid process often becomes ossified with
age.
• The manubriosternal joint (the sternal angle) is
an important land mark
– can be easily palpated.
– marks the site of articulation of the second
rib with the sternum (reference for counting
ribs).
– lies on a horizontal plane that passes
through the intervertebral disc between
vertebrae 4 and 5. 30
The transverse thoracic plane
• separates the superior mediastinum from the
inferior mediastinum and
• marks the superior border of the pericardium
• marks the beginning and the end of the arch of
the aorta,
• marks the bi-furcation of the trachea

31
Muscles of the Thoracic Wall
• Include:
– The serratus posterior,
– levatores costarum,
– intercostal,
– subcostal, and
– transverse thoracic
Serratus posterior muscles.
• Extend from the vertebrae to the ribs.
– The serratus posterior superior
• lies at the junction of the neck and back.
• Origin: inferior part of nuchal ligament and
the spinous processes of the C6 or C7 through
T2/ T3 vertebrae.
• Insertion: superior borders of the 2nd-5th ribs,
immediately lateral to their angles (by a series
of digitations).
– Serratus posterior inferior
• lies at the junction of the thoracic and
lumbar regions.
• Origin: spinous processes of the last two
thoracic spinous processes and the first two
lumbar spinous processes.
• Insertion: inferior borders of the inferior
three or four ribs, lateral to their angles.
– Both are not primarily motor in function rather
they are proprioceptors.
35
 levatores costarum
• Origin: transverse processes of the C7 and T1-
T11 vertebrae.
• Insertion: ribs, close to their tubercles.
• Action: elevate the ribs; but their role, if any, in
normal inspiration is uncertain. ?? vertebral
movement and/or proprioception.
Typically, each space contains three muscles
comparable to those of the abdominal wall. These
include the:
• External intercostal: (11 pairs)
– fills the intercostal space from the tubercles of
the ribs posteriorly to the costochondral
junction anteriorly where it becomes the thin
anterior intercostal membrane.
– Originate from the inferior border of the rib
above and insert on to the superior border of
the rib below.
– are most active during inspiration.
• Internal intercostal:
– run deep to and at right angles to the external
intercostals.
– fills the intercostal space from the sternum
anteriorly to the angles of the ribs posteriorly
where it becomes the posterior intercostal
membrane.
– most active during expiration
– The interosseous portions depress ribs during
forced expiration .
– The interchondral portion appears to act with
the external intercostals during active
• Innermost intercostals:
– this group comprises
• subcostal muscles posteriorly,
• intercostales intimi laterally and
• transversus thoracis anteriorly.
– The fibres of these muscles span more than
one intercostal space.
• Transverse thoracic muscles
– Origin: posterior surface of xiphoid process, the
inferior part of the body of the sternum, and the
adjacent costal cartilages.
– Insertion: 2nd-6th costal cartilages.
– Action: weak expiratory function.
• subcostal muscles
– Origin: internal surface of the angle of one rib
– Insertion: internal surface of the second or third rib
inferior to it.
– Cross one or two intercostal spaces, and blend with
the internal intercostals.
– act with the internal intercostals
41
42
• The neurovascular space
– is the plane in which the neurovascular
bundle (intercostal vein, artery and nerve-
(VAN) from top to bottom) courses.
– It lies between the internal intercostal and
innermost intercostal muscle layers.
• The intercostal structures course under cover of
the subcostal groove.
 Thoracic Apertures

• These are openings of the thoracic cage

superiorly and inferiorly.
• The much smaller superior opening is a
passageway that allows communication with the
neck and upper limb.
• The larger inferior opening provides the ring-like
origin of the diaphragm, which completely
occludes the opening.
 Superior Thoracic Aperture
• oblique, kidney-shaped
• Is the anatomical thoracic inlet.
• is bounded as follows:
– Posteriorly, by vertebra T1 (convex posterior
boundary).
– Laterally, by the 1st pair of ribs and their costal
cartilages.
– Anteriorly, by the superior border of the
manubrium (anterior landmark).
• Structures that pass through the superior
thoracic aperture include
– trachea,
– esophagus,
– nerves, and vessels that supply and drain
the head, neck, and upper limbs.
 Inferior Thoracic Aperture
• AKA the anatomical thoracic outlet, is bounded as
follows:
– Posteriorly, by the 12th thoracic vertebra
(posterior landmark).
– Posterolaterally, by the 11th and 12th pairs of
ribs.
– Anterolaterally, by the joined costal cartilages
of ribs 7-10, forming the costal margins.
– Anteriorly, by the xiphisternal joint (anterior
landmark).
Fascia of the Thoracic Wall

The deep fascia of the thoracic wall include

• Pectoralis fascia
– associated with the pectoralis major muscle.
– Forms the major part of deep fascia overlying the
anterior thoracic wall.
• The clavipectoral fascia
– a layer of deep fascia suspended from the clavicle and
investing the pectoralis minor muscle.
• Endothoracic fascia.
– thin fibroareolar layer attaching the adjacent portion
of the lining of the lung cavities (the costal parietal
pleura) to the thoracic wall.
• It becomes more fibrous over the apices of the
lungs as the suprapleural membrane (Sibson
fascia).
 Vascular supply of the chest wall

• intercostal spaces receive their arterial supply from:

• anterior intercostal arteries (AIA)
– are branches of internal thoracic artery and its terminal
branch the musculophrenic artery.
– The lowest two spaces have no anterior intercostal supply.
• posterior intercostal arteries (PIA)
– The first 2–3 PIA arise from the superior intercostal branch
of the costocervical trunk, a branch of the 2nd part of the
subclavian artery.
– The lower nine PIA are branches of the thoracic aorta.
• PIA are much longer than the AIA.
Venous drainage
• posterior intercostal veins receive:
– a posterior branch, which accompanies the
posterior ramus of the spinal nerve of that level,
and
– an intervertebral vein draining the vertebral
venous plexuses associated with the vertebral
column.
• The posterior intercostal veins of the 1st intercostal
space enter directly into the right and left
brachiocephalic veins.

54
• The posterior intercostal veins of the 2nd and 3rd
intercostal spaces unite to form a trunk, the
superior intercostal vein.
– The right superior intercostal vein is the final tributary
of the azygos vein.
– The left superior intercostal vein empties into the left
brachiocephalic vein.
• posterior intercostal veins (4-11) end in the
azygos/hemiazygos venous system, which conveys
venous blood to the superior vena cava (SVC)

55
• The anterior intercostal veins drain anteriorly
into the internal thoracic and musculophrenic
veins.
Lymphatic drainage
• Lymphatic vessels of the thoracic wall drain
mainly into
– parasternal nodes
– intercostal nodes,
– diaphragmatic nodes
• Diaphragmatic nodes are posterior to the
xiphoid and at sites where the phrenic nerves
penetrate the diaphragm.

58
59
• Parasternal nodes and Intercostal nodes in the
upper thorax drain into bronchomediastinal
trunks.
• Intercostal nodes in the lower thorax drain into
the thoracic duct.
• Superficial regions of the thoracic wall drain
mainly into axillary lymph nodes in the axilla or
parasternal nodes.

60
Nerve supply of the chest wall

• The intercostal nerves are the anterior primary rami of

the thoracic segmental nerves.
• Only the upper six intercostal nerves run in their
intercostal spaces, the remainder gaining access to the
anterior abdominal wall.
Branches of the intercostal nerves include:
• Cutaneous anterior and lateral branches.
• Collateral branch supplies the muscles of the intercostal
space (also supplied by the main intercostal nerve).
• Sensory branches from the pleura (upper nerves) and
peritoneum (lower nerves).
Exceptions include:
• The 1st intercostal nerve is joined to the brachial
plexus and has no anterior cutaneous branch.
• The 2nd intercostal nerve is joined to the medial
cutaneous nerve of the arm by the
intercostobrachial nerve branch. The 2nd
intercostal nerve consequently supplies the skin
of the armpit and medial side of the arm.
 The diaphragm

• separates the thoracic and abdominal cavities.

• composed of a peripheral muscular portion which
inserts into a central aponeurosis, the central
tendon.
• The muscular part has three component origins:
– A costal part: attached to the inner aspects of the
lower six ribs.
– A sternal part: consists of two small slips arising from
the deep surface of the xiphoid process.
• A vertebral part:
– this comprises the crura and arcuate ligaments.
– The right crus
• arises from the front of the L1–3 vertebral
bodies and intervening discs.
• Some fibres from the right crus pass around
the lower oesophagus.
– The left crus
• originates from L1 and L2 only.
– The medial arcuate ligament
• is made up of thickened fascia which overlies
psoas major and is attached medially to the
body of L1 and laterally to the transverse
process of L1.
– The lateral arcuate ligament
• is made up of fascia which overlies quadratus
lumborum from the transverse process of L1
medially to the 12th rib laterally.
– The median arcuate ligament
• is a fibrous arch which connects left and right
crura.
Openings in the diaphragm
Structures traverse the diaphragm at different levels
to pass from thoracic to abdominal cavities and vice
versa. These levels are as follows:
• T8, the opening for the inferior vena cava:
transmits the
– inferior vena cava and
– right phrenic nerve.
• T10, the oesophageal opening: transmits the
– oesophagus,
– vagi and
– branches of the left gastric artery and vein.
• T12, the aortic opening: transmits the
– aorta,
– thoracic duct and
– azygos vein.
The left phrenic nerve passes into the diaphragm
as a solitary structure.
 Nerve supply of the diaphragm

• Motor supply:
– the entire motor supply arises from the phrenic nerves
(C3,4,5).
– Diaphragmatic contraction is the mainstay of
inspiration.
• Sensory supply:
– the periphery of the diaphragm receives sensory fibres
from the lower intercostal nerves.
– The sensory supply from the central part is carried by
the phrenic nerves.
Movements of Thoracic Wall with respiration

The vertical diameter

• Refers to height of the central part of the thoracic
cavity
• increases during inspiration as contraction of the
diaphragm causes it to descend, compressing the
abdominal viscera
• returns to the neutral position during expiration
71
The AP dimension of the thorax
• Movement of the ribs at the costovertebral joints
causes the anterior ends of the ribs to rise - the
pump - handle movement
• As the ribs slope inferiorly, their elevation results
in anterior - posterior movement of the sternum
• This happens secondary to contraction of the
intercostal muscles (the external IC and the
interchondral portion of the internal intercostals)

72
73
The transverse dimension of the thorax
• increases when the intercostal muscles contract,
raising the middle (lateral-most parts) of the ribs
- the bucket - handle movement

74
75
• The combination of all these movements
moves the thoracic cage
– anteriorly,
– superiorly, and
– laterally

76
Passive (quite) inspiration
• Contraction of diaphragm, external intercostals and
intercondral portion of internal intercostals.
Forced inspiration
• Uses the scalene and the sternocleidomastoid muscles
additionally.
Passive (quite) expiration
• decrement in intrathoracic volume occurs secondary to
relaxation of
– diaphragm,
– intercostal muscles
• The stretched elastic tissue of the lungs to
recoil, expelling most of the air
• intra-abdominal pressure decreases and
abdominal viscera are decompressed.
 Surface Anatomy of Thoracic Wall

• Several bony landmarks and imaginary lines

facilitate anatomical descriptions,
• Anterior median (midsternal) line
– indicates the intersection of the median plane with
the anterior chest wall.
• Midclavicular lines
– pass through the midpoints of the clavicles, parallel
to the anterior median line
• Anterior axillary line
– runs vertically along the anterior axillary fold,
which is formed by the border of the pectoralis
major.
• Midaxillary line
– runs from the apex (deepest part) of the axilla,
parallel to the anterior axillary line.
• Posterior axillary line
– also parallel to the anterior axillary line, is
drawn vertically along the posterior axillary
fold formed by the latissimus dorsi and teres
major muscles.
• Posterior median (midvertebral) line
– is a vertical line at the intersection of the
median plane with the vertebral column.
• Scapular lines
– are parallel to the posterior median line and
cross the inferior angles of the scapulae.
THE THORACIC CAVITY
The thoracic cavity is divided into three
compartments
• pulmonary cavities
– bilateral compartments.
– contain the lungs and pleurae (lining membranes)
• mediastinum
– a compartment separating the two pulmonary cavities
– extends vertically from the superior thoracic aperture
to the diaphragm and anteroposteriorly from the
thoracic vertebral bodies to the sternum.
– contains the heart, the great vessels, trachea,
esophagus, thymus...
 PLEURAL CAVITIES
• These are the potential spaces enclosed
between the visceral and parietal pleurae.
• They normally contain only a thin film of serous
fluid that which lubricates the pleural surfaces
(thereby allowing the layers of pleura to slide
smoothly over each other during respiration)
and provides the cohesion that keeps the lung
surface in contact with the thoracic wall.

87
PLEURAL CAVITIES

88
The visceral pleura (pulmonary pleura)
• is adherent to lung surfaces, including the
surfaces within the horizontal and oblique
fissures.
• provides the lung with a smooth slippery surface
• continuous with the parietal pleura at the hilum
of the lung, where structures (e.g., the bronchus
and pulmonary vessels) enter and leave the lung.
The parietal pleura
• lines adhers to the thoracic wall, the
mediastinum, and the diaphragm.
• consists of four parts: 89
Parietal pleura

90
costal part
• pleura related to the ribs and intercostal spaces is
diaphragmatic part
• pleura covering the diaphragm
mediastinal part
• pleura covering the mediastinum
cervical pleura/dome of pleura/pleural cupola
• dome-shaped layer of parietal pleura lining the
cervical extension of the pleural cavity.

91
pulmonary ligament
• an empty double layer of pleura extending between
the lung and the mediastinum, inferior to the root of
the lung.

Pleural recesses
• areas where two layers of parietal pleura become
opposed to one another.
• e.g. costodiaphragmatic recess between the costal
and diaphragmatic pleura.
• Expansion of the lungs into these spaces occurs only
during forced inspiration.
• Are potential spaces in which fluids can collect.
93
Nerve Supply of the parietal Pleura:
• intercostal nerves provide segmental innervation
to the costal pleura and the periphery of
diaphragmatic pleura
• phrenic nerve supplies the mediastinal pleura
and the pleura overlying the domes of the
diaphragm.
• Thus the parietal pleura is sensitive to pain.
Nerve Supply of the visceral Pleura:
• autonomic nerve supply from the pulmonary
plexus
• sensitive to stretch but is insensitive to pain
94
Pathologies related to the pleura
• Air can enter the pleural cavity following a
fractured rib or a torn lung (pneumothorax).
• This eliminates the normal negative pleural
pressure, causing the lung to collapse.
• Inflammation of the pleura (pleurisy) results
from infection of the adjacent lung
(pneumonia).
• Pus in the pleural cavity (secondary to an
infective process) is termed an empyema.
 The lungs
• are light, soft, and spongy structures occupying
the pulmonary cavities
• are the vital organs of respiration
• are elastic and recoil to approximately one third
their original size.
• Each lung has:
– an apex - blunt superior end ascending above
the level of the 1st rib into the root of the neck
– a base - concave inferior surface of the lung
resting on the ipsilateral dome of the diaphragm
– a mediastinal surface is the medial surface
which is moulded to adjacent mediastinal
structures.
– a costovertebral surface which underlies the
chest wall.
– Three borders (anterior, inferior, and posterior)
– Two or three lobes created by one or two
fissures
98
surfaces:
• costal surface convex, covered by costal pleura
which separates it from the ribs, costal cartilages,
and the innermost intercostal muscles.
• mediastinal surface concave, lies against the
mediastinum and contains the hilum of the lung
through which structures enter and leave.
• diaphragmatic surface concave, forms the base
of the lung, rests on the dome of the diaphragm.
borders:
• inferior border- separates the base from the costal
surface.
• The anterior and posterior borders separate the
costal surface from the mediastinal surface.
• Unlike the anterior and inferior borders, which are
sharp, the posterior border is smooth and
rounded

100
roots of the lungs
• Tubular structures that attach the lungs with the
mediastinum
• Comprises:
– the bronchi (and associated bronchial vessels),
– pulmonary arteries,
– superior and inferior pulmonary veins,
– the pulmonary plexuses of nerves (sympathetic,
parasympathetic, and visceral afferent fibers), and
– lymphatic vessels.
• general arrangement of structures at the hilum
– Pulmonary artery, superior most on left (the
superior lobar bronchus may be superior most on
the right).
– Superior and inferior pulmonary veins, anterior
most and inferior most, respectively.
– Bronchus on posterior aspect.
• invaginations of visceral pleura, called fissures
divide the lungs in to lobes.
• The right lung has three lobes, the left lung has two.
103
 Features of the right lung
• Its shorter, wider and heavier.
• has two fissures, transverse and oblique fissures,
thus it is divided in to three lobes.
– The horizontal fissure: separates the superior
lobe from the middle lobe
– The oblique fissure: separates the inferior lobe
from the superior lobe and the middle lobe of
the right lung.

104
• Its medial surface lies adjacent
– The heart
– Inferior vena cava
– Superior vena cava
– Azygos vein
– Esophagus
– The right subclavian artery and vein.

105
106
 Features of the left lung
• Is smaller than the right lung
• Consists only the oblique fissure thus has two
lobes. (it has no middle lobe)
• The anterior border is notched because of the
heart's projection into the left pleural cavity from
the middle mediastinum.
• This indentation creates a thin, tongue-like
process of the superior lobe, the lingula, which
extends below the cardiac notch.
107
• The mediastinal surface lies adjacent to
– The heart
– Aortic arch
– Thoracic aorta
– Esophagus

108
109
 The tracheobronchial tree
• Beginning at the larynx, the walls of the airway
are supported by horseshoe or C-shaped rings of
hyaline cartilage.
• The sublaryngeal airway constitutes the
tracheobronchial tree.
• The trachea, located within the superior
mediastinum, constitutes the trunk of the tree.
• It bifurcates at the level of the sternal angle into
main bronchi, one to each lung, passing
inferolaterally to enter the lungs at the hila.
110
The bronchi and bronchopulmonary segments
• The right main bronchus is shorter, wider and
takes a more vertical course than the left.
• The left main bronchus enters the hilum and
divides into a superior and inferior lobar
bronchus.
• The right main bronchus gives off superior lobar
bronchus to the upper lobe prior to entering the
hilum and once it enters into the hilum divides
into middle and inferior lobar bronchi.
• Each lobar bronchus divides within the lobe into
segmental bronchi.
• Each segmental bronchus enters bronchopulmonary
segment.
• bronchopulmonary segment
– is pyramidal in shape with its apex directed towards the
hilum.
– 18-20 in number (10 in the right lung; 8-10 in the left
lung)
– It is a structural unit of a lobe that has its own segmental
bronchus, artery and lymphatics.
– The veins draining each segment are intersegmental.
– If one bronchopulmonary segment is diseased it may be
resected with preservation of the rest of the lobe.
113
• Within each bronchopulmonary segment, the
segmental bronchi give rise to multiple
generations of divisions and eventually end in
terminal bronchioles.
• Each terminal bronchiole gives rise to several
generations of respiratory bronchioles, and each
respiratory bronchiole provides 2-11 alveolar
ducts, each of which gives rise to 5-6 alveolar
sacs.

114
Blood supply:
• the bronchi and parenchymal tissue of the lungs
are supplied by bronchial arteries, branches of the
descending thoracic aorta.
• Bronchial veins, which also communicate with
pulmonary veins, drain into the azygos and
hemiazygos.
• The alveoli receive deoxygenated blood from
terminal branches of the pulmonary artery and
oxygenated blood returns via tributaries of the
pulmonary veins.
• Two pulmonary veins return blood from each lung
to the left atrium.
Lymphatic drainage of the lungs:
• lymph returns from the periphery towards the hilar
tracheobronchial groups of nodes and from here to
mediastinal lymph trunks.
Nerve supply of the lungs:
• a pulmonary plexus is located at the root of each lung.
• The plexus is composed of sympathetic fibres (from
the sympathetic trunk) and parasympathetic fibres
(from the vagus).
• Efferent fibres from the plexus supply the bronchial
musculature and afferents are received from the
mucous membranes of bronchioles and from the
alveoli.
117
118
119
The mediastinum

Subdivisions of the mediastinum

• The mediastinum is the space located
between the two pleural sacs.
• it is divided into superior and inferior
mediastinal regions by a line drawn backwards
horizontally from the angle of Louis
(manubriosternal joint) to the vertebral
column (T4/5 intervertebral disc).
• The superior mediastinum
– communicates with the root of the neck through the
‘thoracic inlet’ which is bounded anteriorly by the
manubrium, posteriorly by T1 vertebra and laterally
by the 1st rib.
• The inferior mediastinum is further subdivided
into the:
– Anterior mediastinum: the region in front of the
pericardium.
– Middle mediastinum: consists of the pericardium and
heart.
– Posterior mediastinum: the region between the
pericardium and vertebrae.
The pericardium
• fibroserous membrane covering the heart and the roots of
its great vessels.
• is a closed sac composed of two layers.
– fibrous pericardium
• the tough external layer.
• continuous with the central tendon of the diaphragm.
• lined with the parietal layer of serous pericardium
– serous pericardium
• is composed mainly of mesothelium (a single
layer of flattened cells)
–Parietal and
–Visceral layers
The fibrous pericardium
• Continuous superiorly with
– the tunica adventitia of the great vessels entering and
leaving the heart and
– the pretracheal layer of deep cervical fascia.
• Attached anteriorly to the posterior surface of the
sternum by the sternopericardial ligaments
• Bound posteriorly by loose connective tissue to
structures in the posterior mediastinum.
• Continuous inferiorly with the central tendon of
the diaphragm
The serous pericardium
• lines the fibrous pericardium (parietal layer) and
is reflected at the vessel roots to cover the heart
surface (visceral layer / epicardium).
• provides smooth surfaces for the heart to move
against.
• Sinuses, potential space between the layers of
serous pericardium
• These are the:
– Transverse sinus, located between the
pulmonary trunk and aorta anteriorly and the
superior vena cava posteriorly.
– Oblique sinus, behind the left atrium, the sinus
is bounded by the inferior vena cava and the
pulmonary veins.
129
• Blood supply: from the pericardiacophrenic
branches of the internal thoracic arteries.
• Nerve supply: the fibrous pericardium and the
parietal layer of serous pericardium are supplied
by the phrenic nerve.
• Following thoracic trauma blood can collect in the
pericardial space (haemopericardium) which may,
in turn, lead to cardiac tamponade.
• This manifests itself clinically as shock, distended
neck veins and muffled/absent heart sounds
(Beck’s triad).
• This condition is fatal unless pericardial
decompression is effected immediately.
The heart
• is a double, self-adjusting, suction and pressure
pump, the parts of which work in unison to propel
blood to all parts of the body.
• Its size is slightly larger than a clenched fist.
• The right side receives poorly oxygenated (venous)
blood from the body through the SVC and IVC and
pumps it through the pulmonary trunk to the lungs
for oxygenation.
• The left side receives well-oxygenated (arterial)
blood from the lungs through the pulmonary veins
and pumps it into the aorta for distribution to the
body.
• The heart has four chambers:
– right and left atria and
– right and left ventricles.
• The atria are receiving chambers that pump blood
into the ventricles (the discharging chambers).
• The synchronous pumping actions of the heart's
two atrioventricular (AV) pumps (right and left
chambers) constitute the cardiac cycle.
• The cycle begins with a period of ventricular
elongation and filling (diastole) and ends with a
period of ventricular shortening and emptying
(systole).
• The wall of each heart chamber consists of three
layers:
– Endocardium:
• lining membrane of the heart that also
covers its valves.
• comprises the endothelium and
subendothelial connective tissue
– Myocardium, a thick, helical middle layer
composed of cardiac muscle.
– Epicardium, a thin external layer (mesothelium)
formed by the visceral layer of serous
pericardium.
• The muscle fibers are anchored to the fibrous
skeleton of the heart, complex framework of
dense collagen forming
– four fibrous rings (L. anuli fibrosi) (or two rings
and two “coronets”), that surround the orifices
of the valves.
– a right and left fibrous trigone (formed by
connections between rings), and
– the membranous parts of the interatrial and
interventricular septa.
• Functions of the fibrous skeleton of the heart:
– Keeps the patency of the valvular orifices while
preventing their distension.
– Provides attachments for the leaflets and cusps
of the valves.
– Provides attachment for the myocardium.
– Forms an electrical “insulator” by separating
the myenterically conducted impulses of the
atria and ventricles so that they contract
independently.
• The heart and pericardial sac are situated obliquely,
– approximately two thirds to the left and
– one third to the right of the median plane
• related anteriorly to
– the sternum,
– costal cartilages, and
– anterior ends of the 3rd - 5th ribs on the left side
• shaped like a tipped-over pyramid with
– an apex (directed anteriorly and to the left),
– a base (opposite the apex, facing mostly
posteriorly), and
– four sides (surfaces).
The apex of the heart:
• Is formed by the inferolateral part of the left
ventricle.
• Lies posterior to the left 5th intercostal space in
adults, usually approximately 9 cm from the
median plane.
• Remains motionless throughout the cardiac cycle.
• Is where the sounds of mitral valve closure are
maximal.
The base of the heart:
• Is the heart's posterior aspect (opposite the apex).
• formed by the left atrium (mainly), lesser
contribution by the right atrium.
• Faces posteriorly toward the bodies of vertebrae
T6-T9
• Extends
– superiorly to the bifurcation of the pulmonary
trunk
– inferiorly to the coronary groove.
The heart surfaces
• The anterior (sternocostal) surface
– formed mainly by right ventricle.
• The inferior (diaphragmatic) surface
– formed mainly by the left ventricle and partly by the
right ventricle.
• Right pulmonary surface,
– formed mainly by the right atrium.
• Left pulmonary surface,
– formed mainly by the left ventricle.
• Externally, the atria are demarcated from the
ventricles by the coronary or atrioventricular
groove (L. sulcus), and the right and left
ventricles are demarcated from each other by
anterior and posterior interventricular (IV)
grooves.
Positional Abnormalities of the Heart
• Abnormal folding of the embryonic heart may
cause the position of the heart to be completely
reversed so that the apex is directed to the right
instead of the left “dextrocardia”.
• Dextrocardia is associated with mirror image
positioning of the great vessels and the arch of
the aorta.
• This anomaly may be part of a general
transposition of the thoracic and abdominal
viscera (situs inversus), or the transposition may
affect only the heart (isolated dextrocardia).
The heart chambers

The right atrium

• Forms the right border of the heart.
• right auricle
– ear-like, conical muscular pouch projecting from
the atrium
– overlaps the ascending aorta.
– increases the capacity of the atrium
• The interior of the right atrium has:
– the sinus venarum
• Smooth, thin-walled, posterior part
• Consists openings the venae cavae (SVC and IVC) and
coronary sinus
– pectinate muscles (L. musculi pectinati)
• Rough, muscular anterior wall
– Right AV orifice through which the right atrium
discharges the poorly oxygenated blood it has received
into the right ventricle
• The smooth and rough walls are separated
– externally by, the sulcus terminalis (a shallow vertical
groove) and
– internally by a vertical ridge, the crista terminalis.
• The separating the atria has an, the
• oval fossa (L. fossa ovalis)
– oval, thumbprint-size depression interatrial septum
– is a remnant of the oval foramen (L. foramen ovale)
and its valve in the fetus.
– Its floor is the fetal septum primum.
– The upper ridge is termed the limbus, which represents
the septum secundum.
• Failure of fusion of the septum primum with the
septum secundum gives rise to a patent foramen
ovale (atrial septal defect) that can gives rise to a
left–right shunt.
• Receives deoxygenated blood from the
– superior vena cava at the level of the right 3rd costal
cartilage.
– inferior vena cava at the level of the 5th costal
cartilage.
– coronary sinus between the right AV orifice and the
IVC orifice.
The right ventricle

• forms the largest part of the anterior surface, a

small part of the diaphragmatic surface, and
almost the entire inferior border of the heart.
• Its wall is thicker than that of the atria but not as
thick as that of the left ventricle.
Features of the right ventricle
• Trabeculae carneae
– irregular muscular bundles of interior aspect of inflow part.
• Conus arteriosus (infundibulum)
– funnel-shaped, smooth walled outflow part which leads
into the pulmonary trunk.
• Supraventricular crest
– a thick muscular ridge separating the ridged muscular wall
of the inflow part of the chamber from the of the conus
arteriosus, or the out flow part.
• The moderator band (or septomarginal trabecula)
– a prominent muscle bundle projecting forwards from the
interventricular septum to the anterior wall. contains the
right branch of the atrioventricular bundle.
papillary muscles
• are conical muscular projections with bases
attached to the ventricular wall.
• Three in the right ventricle
– The anterior papillary muscle,
• the largest and most prominent of the three,
• arises from the anterior wall of the right ventricle;
– The posterior papillary muscle,
• arises from the inferior wall of the right ventricle
– The septal papillary muscle
• arises from the interventricular septum
• The inflow part of the ventricle receives blood
from the right atrium through the right AV
(tricuspid) orifice, which is guarded by the
tricuspid valve.
• Tricuspid valve
– has three cusps- anterior, posterior, and septal cusps
– The bases of the valve cusps are attached to the
fibrous ring around the orifice.
– the free edges and ventricular surfaces are attached
to tendinous cords (L. chordae tendineae) that arise
from the apices of papillary muscles.
• Papilary muscles begin to contract before
contraction of the right ventricle, tightening the
tendinous cords and drawing the cusps together.
• the cords are attached to adjacent sides of two
cusps, thus prevent separation of the cusps and
their inversion.
• tension is applied to the tendinous cords and
maintained throughout ventricular contraction
(systole) thus regurgitation of blood (backward
flow of blood) from the right ventricle back into
the right atrium is blocked by the valve cusps.
The interventricular septum (IVS)
• is a strong, obliquely placed partition between the
right and left ventricles, forming part of the walls
of each.
• composed of:
– muscular part
• forms the majority of the septum,
• has the thickness of the remainder of the wall of
the left ventricle and
• bulges into the cavity of the right ventricle.
– membranous part
• Is part of the fibrous skeleton of the heart
• Is situated superiorly and posteriorly
• The pulmonary valve
– is situated at the top of the infundibulum.
– composed of three semilunar cusps.
Left Atrium

• Forms most of the base of the heart.

• Has a slightly thicker wall than that of the right atrium.
• Receives oxygenated blood from four pulmonary veins.
• The cavity is smooth walled except for the tubular,
muscular left auricle, trabeculated with pectinate
muscles.
• A semilunar depression in the interatrial septum
indicates the floor of the oval fossa; the surrounding
ridge is the valve of the oval fossa (L. valvulae foramen
ovale).
• The mitral (bicuspid) valve guards the passage of blood
from the left atrium to the left ventricle.
The left ventricle
• forms the apex of the heart, nearly all of the left
(pulmonary) surface and border, and most of the
diaphragmatic surface.
• two to three times as thick as that of the right
ventricle.
• Trabeculae carneae project from the wall with
papillary muscles attached to the mitral valve cusp
edges by way of chordae tendineae.
• The aortic vestibule is a smooth walled part of the
left ventricle which is located below the aortic
valve and constitutes the outflow tract.
 The heart valves

• The purpose of valves within the heart is to

maintain unidirectional flow.
• The mitral (bicuspid) and tricuspid valves are flat.
– During ventricular systole the free edges of the cusps
come into contact and eversion is prevented by the
pull of the chordae.
• The aortic and pulmonary valves are composed of
three semilunar cusps which are cup shaped.
– During ventricular diastole back-pressure of blood
above the cusps forces them to fill and hence close.
– do not have tendinous cords to support them
• Tricuspid valve is located posterior to the body of
the sternum at the level of the 4th and 5th
intercostal spaces
• Mitral valve is located posterior to the sternum at
the level of the 4th costal cartilage.
• Pulmonary semilunar valve is at the level of the
left 3rd costal cartilage
• Aortic semilunar valve is located posterior to the
left side of the sternum at the level of the 3rd
intercostal space.
Vasculature of the Heart

• most of the myocardium is supplied by coronary

arteries and their accompanying cardiac veins,
• The endocardium and some subendocardial tissue
located immediately external to the endocardium
receive oxygen and nutrients by diffusion or
microvasculature directly from the chambers of the
heart.
• normally embedded in fat, course across the surface of
the heart in grooves (least stretch during systole)
between the four heart chambers just deep to the
epicardium.
• are affected by both sympathetic and parasympathetic
innervation.
Arterial Supply of the Heart

• The coronary arteries

– are functional end-arteries- lacking sufficient
anastomoses from other large branches.
– the first branches of the aorta
– supply the myocardium and epicardium.
– supply both the atria and the ventricles
– The ventricular distribution of each coronary artery is
not sharply demarcated.
The right coronary artery (RCA)
• arises from the right aortic sinus of the ascending aorta
• passes to the right side of the pulmonary trunk, running in
the coronary groove.
• gives off an ascending sinuatrial nodal branch, which
supplies the SA node.
• then descends in the coronary groove and gives off the
right marginal branch, which supplies the right border of
the heart.
• turns to the left and continues in the coronary groove to
the posterior aspect of the heart.
• At the crux (L. cross) of the heart “the junction of the septa
and walls of the four heart chambers” it gives rise to the
atrioventricular nodal branch, which supplies the AV node
• In approximately 67% of individuals it is the
source of gives rise to the posterior
interventricular (IV) branch; which descends in
the posterior IV groove toward the apex of the
heart to supply adjacent areas of both ventricles
and sends perforating interventricular septal
branches into the IV septum.
• The terminal (left ventricular) branch then
continues for a short distance in the coronary
groove. Thus, in the most common pattern of
distribution, the RCA supplies the diaphragmatic
surface of the heart.
169
170
• Typically, the RCA supplies
– The right atrium.
– Most of right ventricle.
– Part of the left ventricle (the diaphragmatic surface).
– Part (usually the posterior third) of the IV septum.
– The SA node (in approximately 60% of people).
– The AV node (in approximately 80% of people).
The left coronary artery (LCA)
• arises from the left aortic sinus
• runs in the coronary groove.
• it divides into
– anterior IV branch (left anterior descending branch)
• passes along the IV groove to the apex of the heart
• supplies adjacent parts of both ventricles and the
anterior two thirds of the IVS (IV septal branches)
• gives lateral (diagonal) branch, which descends on
the anterior surface of the heart.
• anastomoses with the posterior IV branch of the
RCA.
– circumflex branch.
• Gives off the SA nodal branch in approximately 40%
of people
• follows the coronary groove around the left border
of the heart to the posterior surface of the heart.
• Gives left marginal artery, follows the left margin of
the heart and supplies the left ventricle.
• terminates in the coronary groove on the posterior
aspect of the heart before reaching the crux.
• but in approximately one third of hearts it
continues to supply a branch that runs in or
adjacent to the posterior IV groove.
The venous drainage of the heart

• The venous drainage systems in the heart include:

– veins that empty into the coronary sinus and
– small veins that empty into the right atrium.
• venae cordis minimi: begin in the capillary
beds of the myocardium and open directly
into the chambers of the heart, chiefly the
atria
• anterior cardiac veins: begin over the
anterior surface of the right ventricle, cross
over the coronary groove, and usually end
directly in the right atrium.
• The coronary sinus,
– the main vein of the heart
– runs from left to right in the posterior part of the
coronary groove.
– receives
• great cardiac vein drains the areas of the heart
supplied by the LCA
• middle cardiac vein accompanies the posterior
interventricular branch
• small cardiac veins accompanies the right marginal
branch .
• The left posterior ventricular vein and
• left marginal vein.
 Lymphatic Drainage of the Heart

• Lymphatic vessels in the myocardium and

subendocardial connective tissue pass to the
subepicardial lymphatic plexus.
• Vessels from this plexus pass to the coronary
groove and follow the coronary arteries.
• A single lymphatic vessel, formed by the union of
various vessels from the heart, ascends between
the pulmonary trunk and left atrium and ends in
the inferior tracheobronchial lymph nodes,
usually on the right side.
 The conducting system of the heart
• consists of cardiac muscle cells and highly
specialized conducting fibers for initiating impulses
and conducting them rapidly through the heart
• The sinu-atrial (SA) node is the pacemaker of the
heart.
• It is situated near the top of the crista terminalis,
below the superior vena caval opening into the
right atrium.
• Impulses generated by the SA node are conducted
throughout the atrial musculature to effect
synchronous atrial contraction.
• Degeneration of the SA node leads to other sites of
the conduction pathway taking over the pacemaking
role, albeit usually at a slower rate.
• Impulses reach the atrioventricular (AV) node
which lies in the interatrial septum just above the
opening for the coronary sinus.
• From here the impulse is transmitted to the
ventricles via the atrioventricular bundle (of His)
which descends in the interventricular septum.
• The bundle of His divides into right and left
branches which send Purkinje fibres to lie within
the subendocardium of the ventricles.
• The position of the Purkinje fibres accounts for the
 The nerve supply of the heart

The heart receives both a sympathetic and a

parasympathetic nerve supply so that heart rate
can be controlled to demand.
• The parasympathetic supply (bradycardic effect):
is derived from the vagus nerve.
• The sympathetic supply (tachycardic effect): is
derived from the cervical and upper thoracic
sympathetic ganglia by way of superficial and
deep cardiac plexuses.
 Great vessels of the thorax

Aorta
• The ascending aorta
– arises from the aortic vestibule behind the
infundibulum of the right ventricle and the
pulmonary trunk.
– Its only branches are the coronary arteries
– continuous with the aortic arch
• Aortic arch
• lies posterior to the lower half of the manubrium
and
• arches superiorly, posteriorly and to the left, and
then inferiorly.
• The ligamentum arteriosum, the remnant of
fetal ductus arteriosus (fetal shunt that bypasses
the prefunctional lungs), passes from the root of
the left pulmonary artery to the inferior surface
of the arch of the aorta.
• Its branches are the brachiocephalic trunk, left
common carotid artery, and left subclavian
artery.
• The descending thoracic aorta
– is continuous with the arch.
– begins at the lower border of the body of T4.
– It initially lies slightly to the left of the midline
and then passes medially to gain access to the
abdomen by passing beneath the median
arcuate ligament of the diaphragm at the level
of T12.
– branches are:
• Oesophageal, bronchial, mediastinal, posterior
intercostal and subcostal arteries.
• From here it continues as the abdominal aorta.
The subclavian arteries
• divided into three parts by scalenus anterior:
– 1st part:
• the part of the artery that lies medial to the
medial border of scalenus anterior.
• It gives rise to three branches:
–vertebral artery,
–thyrocervical trunk and
–internal thoracic (mammary) artery.
• internal thoracic (mammary) artery
– courses on the posterior surface of the anterior chest
wall one fingerbreadth from the lateral border of the
sternum.
– it gives off anterior intercostal, thymic and
perforating branches.
– The ‘perforators’ pass through the anterior chest wall
to supply the breast.
– divides behind the 6th costal cartilage into superior
epigastric and musculophrenic branches.
• The thyrocervical trunk terminates as the inferior
thyroid artery.
• 2nd part:
– the part of the artery that lies behind scalenus
anterior.
– It gives rise to the costocervical trunk.
• 3rd part:
– the part of the artery that lies lateral to the
lateral border of scalenus anterior.
– This part gives rise to the dorsal scapular
artery.
• become the axillary arteries at the outer border
of the 1st rib.
 The great veins
• The brachiocephalic veins are formed by the
confluence of the subclavian and internal
jugular veins behind the sternoclavicular joints.
• The left brachiocephalic vein traverses diagonally
behind the manubrium to join the right
brachiocephalic vein behind the 1st costal
cartilage thus forming the superior vena cava.
• The superior vena cava receives only one
tributary, the azygos vein.
 The azygos system of veins
The azygos vein:
• commences as the union of the right subcostal vein
and one or more veins from the abdomen.
• It passes through the aortic opening in the
diaphragm, ascends on the posterior chest wall to
the level of T4 and then arches over the right lung
root to enter the superior vena cava.
• It receives tributaries from the:
– lower eight posterior intercostal veins,
– right superior intercostal vein and
– hemiazygos veins.
The hemiazygos vein:
• arises on the left side in the same manner as the
azygos vein.
• It passes through the aortic opening in the
diaphragm and up to the level of T9 from where
it passes diagonally behind the aorta and
thoracic duct to drain into the azygos vein at the
level of T8.
• It receives venous blood from the lower four left
posterior intercostal veins.
The accessory hemiazygos vein:
• drains blood from the middle posterior intercostal
veins (as well as some bronchial and mid-
oesophageal veins).
• The accessory hemiazygos crosses to the right to
drain into the azygos vein at the level of T7.

• The upper four left intercostal veins drain into the

left brachiocephalic vein via the left superior
intercostal vein.
The nerves of the thorax
The phrenic nerves
The phrenic nerves arise from the C3, C4 and C5
nerve roots in the neck.
• The right phrenic nerve
– descends along a near vertical path, anterior to the
lung root, lying on sequentially:
• right brachiocephalic vein,
• superior vena cava, and
• right atrium
– it enters the caval opening at the level of T8.
• The left phrenic nerve
– descends alongside the left subclavian artery.
– in front of the left lung root onto the pericardium overlying
the left ventricle.
– The left phrenic then pierces the muscular diaphragm as a
solitary structure.
• Note: the phrenic nerves do not pass beyond the
undersurface of the diaphragm.
• The phrenic nerves are composed mostly of motor fibres
which supply the diaphragm. However, they also
transmit fibres which are sensory to:
– fibrous pericardium,
– mediastinal pleura and
– peritoneum
– central part of the diaphragm.
Irritation of the diaphragmatic peritoneum is
usually referred to the C4 dermatome. Hence,
upper abdominal pathology such as a perforated
duodenal ulcer often results in pain felt at the
shoulder tip.
The vagi
The vagi are the 10th cranial nerves.
• The right vagus nerve
– descends adherent to the thoracic trachea
– passes behind the lung root to form the posterior
pulmonary plexus.
– It finally reaches the lower oesophagus where it forms
an oesophageal plexus with the left vagus.
• anterior and posterior vagal trunks descend
(carrying fibres from both left and right vagi)
from the plexus to pass into the abdomen
through the oesophageal opening.
• The left vagus nerve
– crosses the arch of the aorta and its branches.
– It is itself crossed here by the left superior
intercostal vein.
– Below, it descends behind the lung root to reach
the oesophagus where it contributes to the
oesophageal plexus.
Vagal branches
• The left recurrent laryngeal nerve
– arises from the left vagus below the arch of the aorta.
– It hooks around the ligamentum arteriosum and
ascends in the groove between the trachea and the
oesophagus to reach the larynx.
• The right recurrent laryngeal nerve
– arises from the right vagus in the neck and hooks
around the right subclavian artery prior to ascending
in the groove between the trachea and the
oesophagus before finally reaching the larynx.
• branches to the cardiac and pulmonary plexuses.
• The recurrent laryngeal nerves supply:
– mucosa of the upper trachea and oesophagus
– motor supply to all of the muscles of the larynx
(except cricothyroid) and
– sensory fibres to the lower larynx.
The thoracic sympathetic trunk
• The thoracic sympathetic chain
– is a continuation of the cervical chain.
– It descends in the thorax behind the pleura
immediately lateral to the vertebral bodies and
passes under the medial arcuate ligament of the
diaphragm to continue as the lumbar sympathetic
trunk.
• The thoracic chain bears a ganglion for each spinal
nerve; the first frequently joins the inferior
cervical ganglion to form the stellate ganglion.
• Each ganglion receives a white ramus
communicans containing preganglionic fibres
from its corresponding spinal nerve and sends
back a grey ramus, bearing postganglionic fibres.
Branches:
• Sympathetic fibres are distributed to the skin with
each of the thoracic spinal nerves.
• Postganglionic fibres from T1–5 are distributed to
the thoracic viscera, the heart and great vessels,
the lungs and the oesophagus.
• Mainly preganglionic fibres from T5–12 form the
splanchnic nerves, which pierce the crura of the
diaphragm and pass to the coeliac and renal ganglia
from which they are relayed as postganglionic
fibres to the abdominal viscera.
• These splanchnic nerves are the:
– greater splanchnic (T5–10),
– lesser splanchnic (T10–11) and
– lowest splanchnic (T12).
The cardiac plexus
divided into superficial and deep parts. It consists of
sympathetic and parasympathetic efferents as well as
afferents.
• Cardiac branches from the plexus supply the heart
where they: accompany coronary arteries for
vasomotor control and supply the sinu-atrial and
atrioventricular nodes for cardio-inhibitory and
cardioacceleratory purposes.
• Pulmonary branches supply the bronchial wall
smooth muscle (controlling diameter) and
pulmonary blood vessels for vasomotor control.
Trachea
• A fibroelastic tube kept patent by horse shoe shaped
bars (rings) of hyaline cartilage embedded in its wall.
• Commenses at the level of cricoid cartilage.
• The posterior free ends of the cartilage are
connected by smooth muscle, the trachealis
muscle.
Relations of Trachea
• Anteriorly: The sternum, the thymus, the left
brachiocephalic vein, the origins of the
brachiocephalic and left common carotid arteries,
and the arch of the aorta
• Posteriorly: The esophagus and the left recurrent
laryngeal nerve.
• Right side: The azygos vein, the right vagus nerve,
and the pleura.
• Left side: The arch of the aorta, the left common
carotid and left subclavian arteries, the left vagus
and left phrenic nerves, and the pleura

213
Blood Supply of the Trachea
• The upper two thirds are supplied by the inferior
thyroid arteries and
• the lower third is supplied by the bronchial
arteries
Lymph Drainage of the Trachea
• The lymph drains into the pretracheal and
paratracheal lymph nodes and the deep cervical
nodes
Nerve Supply of the Trachea
• The sensory nerve supply is from the vagi and the
recurrent laryngeal nerves
• Sympathetic nerves supply the trachealis muscle.
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The oesophagus
Course:
• commences as a cervical structure at the level of
the cricoid cartilage at C6 in the neck.
• In the thorax it passes initially through the
superior and then the posterior mediastina.
• Slightly deviated to the left in the neck
• returns to the midline in the thorax at the level of
T5.
• passes downwards and forwards to reach the
oesophageal opening in the diaphragm (T10).
Structure: It is composed of four layers:
• An inner mucosa of stratified squamous
epithelium.
• A submucous layer.
• A double muscular layer,
– longitudinal outer layer and circular inner layer.
– striated in the upper two-thirds and smooth in
the lower third.
• An outer layer of areolar tissue.
Relations:
• crossed by the azygos vein and the right vagus
nerve on the right side.
Arterial supply :
– Upper third inferior thyroid artery.
– Middle third oesophageal branches of thoracic aorta.
– Lower third left gastric branch of coeliac artery.

Venous drainage varies throughout its length:

• Upper third inferior thyroid veins.
• Middle third azygos system.
• Lower third both the azygos (systemic system) and left
gastric veins (portal system).
• The dual drainage of the lower third forms a site
of porto-systemic anastomosis.
• In advanced liver cirrhosis, portal pressure rises
resulting in back-pressure on the left gastric
tributaries at the lower oesophagus.
• These veins become distended and fragile
(oesophageal varices). They are predisposed to
rupture, causing potentially life-threatening
haemorrhage.
Lymphatic drainage:
• is towards a peri-oesophageal lymph plexus and
then to the posterior mediastinal nodes.
• From here lymph drains into supraclavicular
nodes.
• The lower oesophagus also drains into the nodes
around the left gastric vessels.
The thoracic duct

• The cisterna chyli is a lymphatic sac that

receives lymph from the abdomen and lower
half of the body.
• It is situated between the abdominal aorta
and the right crus of the diaphragm.
• The thoracic duct, the largest lymphatic
channel in the body, carries lymph from the
cisterna chyli through the thorax to drain into
the left brachiocephalic vein.
• Receives tributaries from
– left jugular,
– subclavian and
– mediastinal lymph trunks,
• On the right side the main lymph trunks from the
right upper body usually join and drain directly
through a common tributary, the right lymph
duct, into the right brachiocephalic vein.
The thymus gland

• Is a primary lymphoid organ,

• is located in the inferior part of the neck and the
anterior part of the superior mediastinum.
• It lies posterior to the manubrium and extends into
the anterior mediastinum, anterior to the fibrous
pericardium.
• After puberty, the thymus undergoes gradual
involution and is largely replaced by fat.
• arterial supply is derived from the
– anterior intercostal and
– anterior mediastinal branches of the internal thoracic
arteries.
• veins drain to
– left brachiocephalic
– internal thoracic, and
– inferior thyroid veins.
• The lymphatic vessels terminate at
– parasternal,
– brachiocephalic, and
– tracheobronchial lymph nodes.