Thorax

MUDr. Veronika Němcová, CSc.

Thorax• Borders, lines, borders of lungs and pleura, heart projection,

auscultation• Topography of the wall of thorax, intercostal spaces – chest

drainage, surgical approaches – sternotomy, thoracotomy• Diaphragm – structures, nerve supplying, hernias• Presternal region – sternal puncture• Regio pectoralis, breast lymph nodes• Clavipectoral triangle, subclavian puncture• Pleural cavity, parietal pleura, recesses, cupula pleurae,

scalenovertebral triangle, pneumothorax• Lungs – segments, impressions,pulmonary hilum, lymph nodes• Superior mediastinum, crossection - schema, retrosternal

goitre, thymoma, superior vena cava syndrome - cavo-cavalanastomoses

• Inferior mediastinum (anterior, middle, posterior), transoesophageal ECHO, oesophageal varices– porto-cavalanastomoses

Shapes of the thorax

Emphysema Pectus excavatum

Muscles of the thorax

m.latissimusdorsi

m.serratusanterior

m.pectoralismajor

m.trapezius

m.latissimusdorsi

Long thoracic nerve palsy

scapula alata(winged scapula)

Mamma

Parasternal l.n.Supraclavicular l.n.

Lateral axillary l.n.

Central axillary l.n.

Apical axillary l.n.

Pectoral axillary l.n.(Sorgius lymph node)

Breast - lymph nodes

Bordes of the lungs and pleura

area thymica

area pericardiaca

VII

VI

VIII

II

IV

IX X

Lower borders of the parietal pleuraare „+1 rib“

pneumothorax

pars diaphragmatica

pars costalis

Pleura parietalis et pleura visceralis

cupulapleurae(5cm abovethe thoracisinlet)

pars mediastinalis

recessuscostodiaphragmaticus

parasternal anterior axillary paravertebral line

VANA

1-f.thoracica spf.2- fascia endothoracica3-pleura parietalis4-membrana intercostalis ext.5-m.intercostalis int6-m.intercostalis ext7-m.intercostalis intimus8-membrana intercostalis int9-m.transversus thoracis

Section throughthe intercostalspace in

Chest drainage – posterior axillary line above the level of the inferiorangle of scapule (Th7)

anterior axillary line

costodiaphragmaticrecess

abovethe rib

!diaphragm, liver, spleen! lungs! long thoracic nerve, lateral thoracic vessels! intercostal nerv and vessels

Thorax - anterior wall (posterior aspect)vessels

Median sternotomyapproach to thymus, pericardium, heart and roots of greatvessels, and anterior mediastinum CT 14 days after sternotomy for bypass grafting

post surgerywire migration-sign of mediastinitis3 weeks after sternotomy

wound dehiscention

• sternal puncture is a rapid and safe method to ensure the diagnosis of post-sternotomy mediastinitis

Thorax – posterior wallvessels and nerves

Ductus thoracicus

V.azygos

Tr.sympaticus

Nn.splanchnici

V.intercostalis supremaAo

4. intercostal space 5. intercostal spaceCentral tendon

lumbocostal triangle ofBochdalek

Thorax –inferior wall -diaphragm

Diaphragm –inferior aspect

Lumbar part

psoasmajor

quadratuslumborum

Oesophagus+vagus nerves

Inferior v.cava+frenic nerve

Central tendon

aorta + thoracic duct

Lumbocostaltriangle(Bochdaleki)

Sternal part

Azygos vein+ splanchnicnerves

Hemiazygos vein+ splanchnicnerves

Costal part

sympathetictrunc

Mediastinum

Superius

Inferius

A

M

P

n. frenicus

aorta diaphragma

oesophagus

angulus sterni

spatium retrovisceralespatium paravisceralespatium previscerale

abdominal cavity

Mediastinum superius(thoracic inlet) sternum

rest of the thymusveinsnervesarteriestracheaoesophaguslungs (laterally)

Layers:

Superior mediastinumSchema of the crossection

• sternum• rest of the thymus• vrstva žil• nerves• arteries• trachea• oesophagus• pleuras

v.brachiocephalica sin

v.brachiocephalica dx

n. frenicus n. frenicus

vasa thoracica int.

tr. brachiocephalicus

n.vagus dx

n.vagus sin

n.laryngeusreccurens sin

a.carotis comm sin

a. subclavia sin

ductus thoracicus

tr. sympathicus

pleuraparietalis

pleuravisceralistr. sympathicus

Th3

Repetition

Th3

Superior vena cava syndrome

v.jugularisexterna edema of the

face, neck andupper chest,

distension ofaxillary, subclavian andjugular veins

v.thoracica lat.

v.thoracoepigastrica

v.brachiocephalica dx(compression)

v.cava inferior

v.cava superior

A 75-year-old man smoker, stage IV non–small-cell carcinoma of the lung-progressive cough, hoarseness, andswelling of the face and arms.- On examination: plethoric, with a ruddycomplexion, suffusion, pitting edema of theface and upper torso, and prominent spidery telangiectasia on his face andchest (Panel A). The jugular veins werenonpulsatile and distended.- Contrast-enhanced CT: markedlycompressed superior vena cava (SVC)- venogram: (Panel B) severe compressionof both the right and left subclavian veins(RSV and LSV), a thrombus in the leftsubclavian vein and multiple venouscollaterals (arrowheads). -After stent placement, extending fromthe left subclavian vein into the superior vena cava, the patient felt better within a day, and was back to baseline at 27 days(Panel C), the venogram (Panel D)-14 months after the procedure andchemotherapy, remains free of symptomsresulting from the obstruction of SVC.

Cavo-caval anastomoses

thoracoepigastric vein - superficial epigastric vein

superior epigastric vein – inferior epigastric vein

lumbal veins – azygos and hemiazygos veins

Subclavian Vein Cannulation

Retrosternal goitrex-ray picture

Reccurent laryngealnerves

Young woman with dysphony

left reccurent laryngeal nerve palsy

pulmonary artery dilatation

Ortners syndrome is a rare cardiovocal syndrome and refers to reccurentlaryngeal nerve palsy from cardiovascular disease (mitral stenosis, pulmonaryhypertension)

v. azygos

ductus thoracicus

truncus sympathicus

oesophagus

n.splanchnicus major

n.vagus sin

Posteriormediastinum

Mediastinum right veiw

n.frenicus

n.vagus

eparterialbronchus

n.splanchnicus minor

n.splanchnicus major

ductus thoracicus

Mediastinum right view

n.frenicus+ vasa pericardiacofrenica

n.vagus

n.laryngeusreccurens sin.

hyparterial bronchus

Mediastinum left veiw

Th6

n. frenicus dxn. frenicus sin

truncus pulmonalis

bronchus principalis dx

bronchus principalis sin

v.cava superior

v. azygos

v. hemiazygostr. sympathicus dx

tr. sympathicus sin

aorta ascendens

aorta descendensductus thoracicus

oesophagus nn.vagi

Mediastinumtransverse section (Th6)

Th8

tr. sympathicus dxv. azygos

ductus thoracicus

aorta descendens

vv. pulmonalesn.vagus sin

oesophagus

n.frenicus sin

n.frenicus dx

n.vagus dx

Mediastinumtransverse section (Th8)

1-lobus sup. dx2-fissura horizontalis3-facies sternocostalis4-facies diaphragmatica5-sulcus interventricularis ant.6-tr.brachiocephalicus7-trachea8-a.carotis communis sin9-a.subclavia sin

Lungs and the heart – anterior aspect

1-lobus inf.dx2-lobus inf.sin3-aorta4-jícen5-trachea

Lungs – posterior aspect

basispulmonis

apex

sulcus a. subclaviae

sulcus v.azygos

fissura obliqua

fissura horizontalis

1.rib impressionsulcus v.cavae sup.

lig. pulmonale

impressio cardiacasulcus oesophageussulcus v.azygos

bronchus principalis dxa.pulmonalis dxmesopneumonium

vv.pulmonales

Medial wall ofthe right lung

Medial wall ofthe right lung

fissura obliqua

apex

sulcus a. subclaviaesulcusv.brachiocephalicae sin

1.rib impressionsulcus aorticus

vv.pulmonales sin

impressio cardiaca

lig. pulmonale

lingula pulmonis

impressiooesophagea

mesopneumoniumbronchus principalis sin

a.pulmonalis sin

basis pulmonis

Medial wall ofthe left lung

Medial wall ofthe left lung

n.l.paratracheales sinn.l.paratracheales dx

n.l. tracheobronchiales sup sinn.l. tracheobronchiales sup dx

n.l. tracheobronchiales inf

n.l.bronchopulmonales(v hilu)

n.l.pulmonales

truncus tracheobronchialis

truncus bronchomedistinalis

subpleural + peribronchial

perilobular

Lymph of the lungs

Regional lymph node classification for lungcancer staging adapted from the AmericanThoracic Society mapping scheme

• Superior Mediastinal Nodes (1-4)• 1. Highest Mediastinal: above the left

brachiocephalic vein. • 2. Upper Paratracheal: above the aortic arch,

but below the left brachiocephalic vein. • 3. Pre-vascular or Pre-vertebral: these nodes

are not adjacent to the trachea like the nodesin station 2. They are either anterior to thevessels (3A) or behind the esophagus, which isprevertebral (3P).

• 4. Lower Paratracheal (including AzygosNodes): below upper margin of aortic arch down to level of main bronchus.

•

• Aortic Nodes (5-6)• 5. Subaortic (A-P window): nodes lateral to

ligamentum arteriosum. These nodes are not located between the aorta and the pulmonarytrunk, but lateral to these vessels.

• 6. Para-aortic (ascending aorta or phrenic): nodes lying anterior and lateral to theascending aorta and the aortic arch.

•

• Inferior Mediastinal Nodes (7-9)• 7. Subcarinal. • 8. Paraesophageal (below carina). • 9. Pulmonary Ligament: nodes lying within

the pulmonary ligaments.•

• Hilar, Interlobar, Lobar, Segmental andSubsegmental Nodes (10-14)

• 10-14: these are located outside of themediastinum.They are all N1-nodes.

Lymph nodes in thesuperior mediastinum

4R, 3A

44-year-old HIV-positive man presents with progressivedysphagia, epigastric pain, and post-prandial vomiting

Lymphoma of the esophagus

Oesophagus- endoskopy

G-E junction, 2 cm above cardiaora serrata, Z-line)squamocolumnar junction

columnar epithelium

squamous epithelium

Transverse ridging of the normal esophagusbecoming evident during retching

vein

Main porto-cavalanastomoses

vv. oesophageae-vv.gastricae! esophageal varices-bleeding

v.rectalis superior-v.rectalis mediahemorrhoids-bleeding

vv.paraumbilicales - caput Medusae

Thorax – x-ray picture

CT - adenocarcinoma, emphysema

CT – thymoma in the anterior mediastinum

CT – thymoma in the anteriormediastinum

CT – aspirated tooth filling in the left lower bronchus

CT- ganglioneuroma in the posteriormediastinum

CT- ganglioneuroma in the posteriormediastinum

???

Breast implants

Sources• Grim, Základy anatomie, 5.díl• Petrovický et al., Anatomie II• Elišková, Naňka, Přehled anatomie• Schwarzenegger, Encyklopedie kulturistiky• http://anatomy.med.umich.edu/atlas• http://www.auntminnie.com• http://www.radiologyassistant.nl• http://jtcs.ctsnetjournals.org/cgi/content/full/125/3/611/FMTC03164002• http://www.breastcancer.org/treatment/surgery/lymph_node_removal/lymph_nodes.jsp• Mukesh Tripathi, MD, Mamta Tripathi, MBBS, Subclavian Vein Cannulation: An

Approach With Definite Landmarks• An anatomic landmark to simplify subclavian vein cannulation: the "deltoid tuberosity".

von Goedecke A, Keller C, Moriggl B, Wenzel V, Bale R, Deibl M, Moser P, Lirk P.Department of Anesthesiology and Critical Care Medicine, Medical University ofInnsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. achim.von-goedecke@uibk.ac.at