The thoracic cavity is a hollow space surrounded by the rib cage and the diaphragm that contains

the heart, lungs, esophagus, thymus, sympathetic trunk, and the great vessels. It comprises three
compartments: two pleural cavities and the mediastinum, which is located behind the sternum.
The mediastinum is divided into the superior and inferior mediastinum, the latter of which is
further subdivided into the anterior, middle, and posterior mediastinum. Inflammation of the
mediastinum (mediastinitis) can result from spreading retropharyngeal infections or
contamination from perforated mediastinal organs. The mediastinum is also a potential site for
teratoma, lymphoma, thymoma, and thyroid neoplasm. The pleural cavity is the potential space
between the parietal pleura (which covers the thoracic wall and the mediastinum) and the
visceral pleura (which lines the lung). The pleura secrets fluid that prevents the development of
friction between the two pleural membranes. Excessive build-up of fluid in the pleural cavity
results in pleural effusion, while the entry of air results in pneumothorax. The diaphragm is a
musculotendinous structure that separates the thoracic cavity from the abdominal cavity. It has
hiatuses for the passage of the inferior vena cava (caval hiatus), esophagus (esophageal hiatus),
and the aorta (aortic hiatus) at the 8th, 10th, and 12th thoracic vertebrae respectively. The
diaphragm is innervated by the phrenic nerve. Phrenic nerve palsy or injury to the diaphragm
results in impaired respiration.

Overview
 Boundaries: demarcated by the rib cage, and separated from the abdominal cavity by the
diaphragm [1]
 Divisions

  The centrally located mediastinum

 Two laterally located pleural cavities

 Contents


o Organs: heart, lungs, esophagus, thymus
o Nerves: sympathetic trunk
o Vessels (e.g., aorta, thoracic trunk)

Mediastinum
Overview

 Definition: The mediastinum is the central space of the thoracic cavity located behind the
sternum and between the two lungs and their respective pleura.

 [1]
 Boundaries
 Anterior: sternum and transversus thoracis muscles
 Posterior: vertebral column
 Superior: thoracic inlet


o Inferior: diaphragm
o Lateral: pleura of the lung

Compartments of the mediastinum

[1]

Structure
Causes of
Boundar
Organs Vessels Nerves mediastinal
ies
masses
 Superi
or:  Left
first common
rib carotid
 Inferi artery
 Phre
or:  Left
nic
line subclavia
nerve
that n artery
 Cardi
course  Arch of
 Thym ac
s from the aorta
us nerve
the  Superior
(prepu s  Thymom
sterna vena cava
bertal)  Vagu as
Superior l (SVC)
 Trach s  Lympho
mediastinum angle  Brachioce
ea nerve mas
to the phalic
 Esoph  Left
4th artery
agus recur
and  Brachioce
rent
5th phalic
laryn
verteb veins
geal
ral  Thoracic nerve
levels duct and
(transt right
horaci lymphatic
c duct
plane)

Inferior Anterior  Anteri  Remn  Internal  NA  Thymom

mediasti mediasti or: ants of thoracic as (most
num num body the vessels common
of the thymu anterior
 Causes of
Boundar
Organs Vessels Nerves mediastinal
ies
masses
mediasti
nal mass
in
children)
 Lympho
sternu mas
m and
s  Germ
transv
(postp cell
ersus
uberta  Lymphati tumors
thorac
l) cs and (e.g.,
is
 Conne parasterna teratoma
muscl
ctive l lymph )
es
tissue nodes  Retroster
 Poster
and nal
ior:
fat thyroid
perica
(substern
rdium
al goiter)
[2]

 Lung
cancer
 Abscess

 Lympho
 Root of
 Heart mas
the aorta
and  Broncho
 Anteri  Pulmonar
perica genic
or and y trunk
rdium cysts
poster  Pericardia
 Trach  Hiatal
ior cophrenic
eal hernia
perica artery
bifurc  Metastas
rdium  Superior  Phre
Middle ation es
 Betwe and nic
mediasti and  Lung
en the inferior nerve
num the cancer
two vena cava
left  Abscess
pleura  Arch of
and  Bilateral
l the
right hilar
caviti azygos
main lymphad
es vein
bronc enopathy
hi  Pulmonar
 Vascular
y veins
masses

Posterio  Anteri  Esoph  Thoracic  Vagu  Neuroge

 Causes of
Boundar
Organs Vessels Nerves mediastinal
ies
masses
or:
fibrou
s
perica
rdium
and
poster
ior
slopin
g
surfac
e of
diaphr s
portion of
agm nerve
the aorta
 Poster  Sym
 Azygos nic
ior: pathe
vein, tumors
r the tic
agus hemiazyg (most
mediasti bodies trunk
os vein, common
num of the  Splan
and )
verteb chnic
thoracic
ral nerve
duct
colum s
n
from
the
lower
border
of the
5th–
12th
thorac
ic
verteb
ra


o Neuroendocrine tumors
o Neurofibromas
 Esophageal cancer
 Multiple myeloma [3]
 Lymphoma
 Lung cancer
 Abscess
  Aneurysm

The most common causes of inflammation of the mediastinal space (mediastinitis) include
spreading of retropharyngeal infections into the mediastinum, chest trauma, and perforation of
mediastinal organs, e.g., the esophagus in the course of a gastroscopy or due to esophageal
cancer.
The trachea bifourcates at the level of T4.
The 4 T's of a mediastinal mass: Thymoma, Teratoma (and other germ cell tumors), Thyroid
neoplasm, and Terrible lymphoma.

Vasculature of the mediastinum [1]

Arteries

The pulmonary trunk, which is located in the middle mediastinum and conveys deoxygenated
blood to the lungs, is discussed in airways and lungs.
Branches of aorta in thoracic cavity
Structure Anatomy Location Branches Supplies
 Originates
from the
aortic orifice  At the level of
from the left the aortic valve
ventricle  Middle o Left
 Courses mediastinum coronar
Ascending  Heart
within the : posterior to y artery
aorta
pericardium the sternum o Right
 Ends at the coronar
level of the y artery
angle of
Louis

Arch of  Continuatio  Superior  Brachiocephali  Head

the aorta n of the mediastinum c trunk which  Upper
ascending then splits into extremities
aorta right subclavian
 Arches artery and right
superiorly, common
posteriorly, carotid artery
and to the  Left common
left before carotid artery
moving
Structure Anatomy Location Branches Supplies
inferiorly
 Connected
to the
pulmonary
trunk by the
ligamentum
arteriosum
 Aortic
isthmus:
narrowing at
the final
section of
the aortic
arch, just
distal to the  Left subclavian
origin of the artery
left
subclavian
artery at the
insertion site
of the
ligamentum
arteriosum
(former
ductus
arteriosum)
 Forms the
aortic knob
(on chest x-
ray)

Thoracic
aorta
(Part of
the
descending
aorta)
 Continuation of the  Posterior  Bronchial  Lungs
arch of the aorta mediastinum arteries  Mediastinum
 Begins at the level  Left side of the  Mediastinal  Esophagus
of T4 thoracic vertebral arteries  Pericardium
 Leaves the thorax column and  Esophageal  Diaphragm
via the aortic hiatus behind the arteries  Chest wall
in the diaphragm at esophagus at its  Pericardial
the level of T12, origin arteries
  Superior
phrenic
 Midline of the arteries
thoracic vertebral  Posterior
where it becomes
column at its intercostal
the abdominal aorta
passage through arteries (9
the aortic hiatus pairs)
 Subcostal
arteries

Veins

The pulmonary veins, which are located in the middle mediastinum and transfer oxygenated
blood from the lungs to the heart, are discussed in airways and lungs.
Veins in the thoracic cavity
Structure Formation Characteristics Tributaries
 Drains blood from
structures above the
diaphragm → right
atrium of the heart
 The SVC can be
divided into two
 Formed by the  Mediastinal
main parts:
junction veins
o The upper
between the left  Esophageal
Superior vena cava half is
and right veins
(SVC) located in
brachiocephalic  Pericardial
the superior
veins veins
mediastinum
o The lower
half is
located in
the middle
mediastinum

Brachiocephalic  Formed by the  Receive blood from  Vertebral

veins convergence of the chest wall, neck, veins
the jugular vein esophagus, lungs,  Internal
and the and pericardium thoracic veins
subclavian vein  The right  Inferior
at the venous brachiocephalic vein thyroid veins
angle is short and is more
vertically oriented,
while the left
 Veins in the thoracic cavity
Structure Formation Characteristics Tributaries
brachiocephalic vein
is long and has more
horizontal
orientation.
 The right and left
vein merge to form
the superior vena
cava.

Azygos  Hemiazygos
venous vein
system  Courses along the  Bronchial
right side of the veins
thoracic vertebral  Pericardial
column veins
 Unpaired vein that  Esophageal
 Formed by the
drains into superior veins
right subcostal
vena cava  Right
Azygos vein and ascending
 Enters the thorax via posterior
lumbar veins
the aortic hiatus of intercostal
the diaphragm veins (run
 Connected to the along the
inferior vena cava undersurface
(IVC) inferiorly of the
corresponding
rib)

 Courses along the

left side of the
vertebral column
 9th–11th left
and passes behind
posterior
the aorta
intercostal
 Formed by the  Unpaired vein that
veins
ascending drains into the
Hemiazygos  Left superior
lumbar and left azygos vein
vein phrenic vein
subcostal veins  Enters the thorax via
 Accessory
aortic hiatus or the
hemiazygos
left crus of the
vein
diaphragm
 Connected to the left
renal vein inferiorly

Accessory  Formed by the  Unpaired vein that

 Veins in the thoracic cavity
Structure Formation Characteristics Tributaries
th th
4 to 8 left
usually drains into
posterior
hemiazygos the azygos vein at
intercostal
vein the level T8
veins

 Located on the left side of the vertebral  4th–8th left posterior intercostal
column veins

The azygos vein connects the inferior and superior vena cava and can be an alternative pathway
for deoxygenated blood to return to the right atrium if the SVC or the IVC are obstructed.

Lymphatics

See “Thoracic duct” and “Right lymphatic duct.”

Pleura
Overview [1]

Definition: Pleura is a thin double layer of tissue that surrounds the lungs and the thoracic wall
and divided into a visceral and parietal layer.
Layers of pleura
Structure Parietal pleura Visceral pleura
 Lines the inner surface of the
thoracic wall and the mediastinum
 Divided into the following parts
o Cervical (projects above the  Lines the outer surface of the
lungs and follows the contour
first cervical rib into the
Location of the lungs, including the
neck)
fissures
o Mediastinal
o Costal
o Diaphragmatic

 Internal thoracic artery

 Posterior and superior intercostal
 Bronchial arteries
Blood supply arteries
 Superior phrenic artery
 Layers of pleura
Structure Parietal pleura Visceral pleura
 Pulmonary plexus derived
 Costal part: intercostal nerve (very from the sympathetic trunk
sensitive to pain) and vagus nerve (not
Innervation
 Diaphragmatic part: phrenic nerve sensitive to pain,
temperature, or touch)

 Rib fractures, pleuritis, and pleural  Intrapulmonary pathologies

masses (e.g., mesotheliomas) cause (e.g., lung cancer) do not
Clinical
sharp chest pain that is worse with cause pain and remain
significance
inhalation (pleuritic). unnoticed for a long time.

Pleural cavity [1]

 Location: potential space between the parietal and visceral pleura of the lungs

Content: pleural fluid (secreted by serous membranes in the pleura)

 Lubricates and prevents friction between the parietal and visceral pleura
 Produces a surface tension that draws the two pleura layers together, ensuring
simultaneous extension of the thorax and lungs during respiration

Recesses

 Costomediastinal recess: region where the mediastinal and costal pleura meet
 Costodiaphragmatic recess: region where the costal and diaphragmatic pleura meet

 Provides potential space for the lungs to expand during inspiration and movement of the
diaphragm
 Potential space for air, blood, and/or fluid accumulation (e.g., pleural effusion,
pneumothorax, hemothorax)
If air enters the pleural cavity, the surface tension between the parietal and visceral pleura of the
lungs is lost, letting the lungs collapse due to their natural tendency to collapse or recoil
(pneumothorax).
Excessive fluid in the pleural cavity results in pleural effusion.

Diaphragm
Overview [1]

 Structure

 C-shaped musculotendinous structure that separates the thoracic cavity from the abdominal
cavity
 Forms a dome between the two cavities, with the superior surface making the floor of the
thoracic cavity, and the inferior surface making the roof of the abdominal cavity
Anatomically, the diaphragm is divided into a right and left hemidiaphragm; however, the
diaphragm is a continuous structure.

  The right hemidiaphragm is higher than the left due to the presence of the liver.

 Function

 Separates the thoracic cavity from the abdominal cavity

 Key muscle of inspiration

Parts of the diaphragm [1]

Crura of the diaphragm

 Definition: musculotendinous bundles that attach to the anterior surface of the vertebral
column, intervertebral disc, and the anterior longitudinal ligament
 Origin: lumbar vertebrae (L1, L2, L3) and medial and lateral arcuate ligaments (on the
sides)
 Insertion: central tendon
 Structure
o Right crus: longer
o Left crus: shorter
o The right and left crura join together via the median arcuate ligament.
o The diaphragm also attaches to the medial and lateral arcuate ligaments

Costal diaphragm

 Origin: lower six ribs and xiphoid process

 Insertion: central tendon

Central tendon of the diaphragm

 Location: point of convergence of the peripherally located muscles that make up the
diaphragm

Structures passing through the diaphragm

 Openings of the diaphragm
Opening Level Structure
 IVC
 T8
Caval hiatus  Right phrenic nerve

Esophageal hiatus
 Esophagus
 T10
 Vagus nerve (anterior and posterior trunk)

Aortic hiatus
 Aorta
 T12  Thoracic duct
 Azygos vein

I ate (read 8) ten Eggs At twelve: Inferior vena cava passes the diaphragm at T8, the Esophagus
at T10, and the Aorta at T12.
The vagus nerve (CN X) passes through the diaphragm at T10.
The protrusion of an abdominal structure/organ into the thorax through a lax diaphragmatic
esophageal hiatus is referred to as a hiatal hernia.

Vasculature and innervation of the diaphragm

Anatomy
 Superior and inferior phrenic arteries (branches of the thoracic aorta)
Arterial supply
 Branches of the internal
thoracic artery
o Musculophrenic
arteries
o Pericardiacophrenic
artery

 Superior and inferior phrenic veins

Venous drainage
 Phrenic nerve (C3–C5)
 Inferior intercostal nerves and subcostal nerves
(sensory innervation to peripheral parts of the
diaphragm)
Innervation  Pain is referred to the trapezius ridge (C3, C4) or
the shoulder (C5) with diaphragm irritation of the
respective side (e.g., pneumoperitoneum,
hematoperitoneum, peritonitis, peritoneal abscess,
cholecystitis, splenic rupture).
C3, C4, C5 keeps the diaphragm alive.
Injuries to the diaphragm or phrenic nerve palsies result in respiratory abnormalities because the
diaphragm is the primary muscle of respiration.

Clinical significance
Mediastinum

Brachiocephalic vein obstruction [4][5]

 Etiology: thrombosis (e.g., due to central vein catheter), stenosis, external compression,
or vascular tumor invasion (e.g., due to apical lung tumor, lymphoma, thymoma,
seminoma)
 Clinical features
o Unilateral upper extremity swelling, pain, and weakness
o Unilateral facial and neck swelling, venous dilatation
 Treatment
o Balloon angioplasty with or without stenting
o Surgical bypass in resistant cases

Others

 Mediastinitis
 Pneumomediastinum
 Retrosternal thyroid (substernal goiter)
 Bilateral hilar lymphadenopathy
 Mediastinal tumors
o Thymoma (most common primary anterior mediastinal tumor)
o Lymphomas (Hodgkin lymphoma, non-Hodgkin lymphoma)
o Pheochromocytoma
o Extragonadal germ cell tumors (e.g., teratoma)
 Mediastinal vessels
o Aortic dissection
o Aortic rupture
o Aortitis
o Aortic aneurysm
o Aortic coarctation
o Superior vena cava syndrome
o Chylothorax
Pleura

 Pleural effusion
 Pleural empyema
 Pleural fibrosis
 Pleural drain
 Mesothelioma

Diaphragm

 Diaphragm paralysis
 Congenital diaphragmatic hernias
 Acquired diaphragmatic hernias
 Diaphragmatic eventration