The pleura

Surface anatomy
St. : Sternoclavicular joint S.A: Sternal angle 4th C.C.: 4th costal cartilage O.F.: Oblique fissure H.F.: Horizontal fissure 1.: 6th costal cartilage 2: 6th rib mid clavicular 3.: 8th rib mid axillary 4.: 7th costal cartilage 5.: 8th rib mid clavicular 6: 10th rib mid axillary

Med. 1/3

Med. 1/3 St. St. S.A. O.F 4th C.C. . 1 1 4 2 4 2 5 6 3 Pleura Lung

O.F. H.F.

3

5 6

The pleura
Features and parts
Cervical pleura Hilum of the lung Costal pleura Parietal layer Pleural cavity Visceral layer Lung Lung Mediastinal pleura

Diaphragmatic pleura

Lung invaginates the pleural sac

The pleura
Features and parts
The pleura is a closed sac invaginated by the lungs Formed of visceral and parietal layers continuous with each other at hila of the lungs The visceral layer adheres closely to the lungs The parietal layer lines thoracic wall, diaphragm and mediastinal structures The pleural cavity is a potential space between the 2 layers, it contains a thin film of serous fluid which prevents friction between the 2 layers. The left pleural cavity is smaller than the right because the heart extends further to the left.

The pleura
Parts of pleura Parietal pleura
1.Cervical pleura: Extends in the neck above the med. 1/3 of clavicle 2.Costal pleura (costovertebral pleura): Lines the sternum, ribs and sides of vertebral bodies 3. Diaphragmatic pleura: covers most of upper surface of diaphragm 4. Mediastinal pleura: Covers the structures in the mediastinum. At the hilum it forms a tube( pulmonary lig.) to enclose the hilar structures and continues with the visceral layer

Visceral pleura
Adherent to the lung lobes & fissures. Absent at hilum & site of pulmonary ligament.

The pleura
Pulmonary ligament
The parietal and visceral layers of pleura are continuous with each other at the hilum of the lung where a tube of pleura encloses the hilar structures and is prolonged downwards to the diaphragm as the pulmonary ligament. It acts as a dead space allowing distension of the pulmonary veins.
Pulmonary ligament

The pleura
Pleural recesses

lung Costmediastinal recess

Diaphragm

Costodiaphragmatic recess

Are parts of pleural cavity not filled by lungs in quiet inspiration, lungs fill them only in forced inspiration 1. Costomediastinal recess: Along anterior borders of the lungs 2. Costodiaphragmatic recess: Along inferior borders of

The pleura
Nerve supply Parietal pleura
-Lower 7 intercostals: Supply costal pleura and peripheral parts of diaphragmatic pleura -Phrenic nerve: Supply central parts of diaphragmatic pleura and mediastinal pleura

Visceral pleura
supplied by sympathetic fibers that accompany bronchial vessels. The visceral pleura is insensitive to exteroception (pain, temperature and touch) but is very sensitive to visceral sensations (tension and ischaemia).

The pleura
Arterial supply
-Intercostal arteries -Musculophrenic -Internal mammary artery -Bronchial arteries ( Visceral pleura )

-Pleurisy : Inflammation of pleura, Friction leads to severe pain -Pleural effusion : Watery fluid accumulates in the pleural cavity -Pyothorax ( empyema ): Pus accumulates in thoracic cavity. -Hemothorax : Blood accumulates in the pleural cavity -Pneumothorax : Air accumulates in the pleural cavity

aspects

Clinical

Drainage of any accumulated fluid by a needle passing along upper border of ribs (4-7 ribs) in midaxillaryline

The lungs
Surface anatomy

The lungs
Surface anatomy of fissures

3 --- 3 3 --- 3

M . AX .

4 c.c 3 --- 6 3 --- 6

The lungs
General features
Apex Apex
Rounded post . bord er

Rounded post . bord er

Sharp ant . border

Sharp ant . border Costal surface

Costal surface

Base

Base

The lungs
General features

Vertebra l S. Mediastinal S. Vertebra l S. Mediastinal S.

Hilu m Hilu m

The lungs
Structures in the hilum

BE A VU

A

B
VL

B
VL

VU

Hilum of right lung and hilar structures

Hilum of left lung and hilar structures
A.: Pulmonary artery B.: Bronchus (hypoarterial bronchus) VL.: Lower pulmonary vein VU.: Upper pulmonary vein B.E.: Bronchus (epiarterial bronchus)

The lungs
Differences between right and left lungs left lung Right lung
Larger, wider, shorter & heavier 3 lobes 2 fissures No cardiac notch More concave diaphragmatic surface In order to know a given lung put it in the anatomical position Smaller, taller and lighter 2 lobes One fissure cardiac notch less concave diaphragmatic surface In order to know a given lung put it in the anatomical position

Relations of mediastinal surface of right lung
Above hilum (4)
1. Arch of azygos. 2. Trachea, right vagus nerve 3. Esophagus 4. Right brachiocephalic vein &S.V.C. 5. Vena azygos. 6. Esophagus, right vagus.

2 10 4 8 7 1

3

Behind hilum (2)

In front of hilum (4)

7. Right atrium. 8. Right phrenic nerve. 9. I.V.C. 10. Ascending aorta.

5 6 9

Relations of mediastinal surface of right lung
Above hilum (4)
1. Arch of azygos. 2. Trachea, right vagus nerve 3. Esophagus 4. Right brachiocephalic vein &S.V.C. 5. Vena azygos. 6. Esophagus, right vagus.

4 10 8 7 9

2 3 1 5 6

Behind hilum (2) In front of hilum (4)

7. Right atrium. 8. Right phrenic nerve. 9. I.V.C. 10. Ascending aorta.

Above hilum (4) 1. Aortic arch.

Relations of mediastinal surface of left lung
4 3 1 5 6 8 2 10 9

2. Left common carotid artery. 3. Left subclavian artery. 4. Esophagus. Behind hilum (3) 5. Descending aorta. 6. Left vagus. 7. Esophagus. In front of hilum (3) 8. Left ventricle 9. Left phrenic. 10. Thymus gland

7

Above hilum (4) 1. Aortic arch.

Relations of mediastinal surface of left lung
2. Left common carotid artery. 3. Left subclavian artery. 4. Esophagus.

4 1

3 2 10 9 8

Behind hilum (3) 5. Descending aorta. 6. Left vagus. 7. Esophagus. In front of hilum (3) 8. Left ventricle 9. Left phrenic. 10. Thymus gland

5 6 7

Each lung is divided into segments, each segment is

Bronchopulmonary segments of the lungs

-Wedge-shaped, its apes lies at the hilum while its base lies at the surface of the lung. -Each segment is covered with C.T. and is a functionally separate unit having its segmental bronchus, blood vessels and lymphatics any segment does not affect other segments -Removal of

Bronchopulmonary segments of the right lung
Upper lobe 1. Apical

1 2 6 5 7 8 4 4 7 3 3

1

2 6 9 8

2. Posterior 3. Anterior Middle lobe 4. Medial 5. Lateral Lower lobe 6. Superior 7. Anterior basal. 8. Lateral basal 9. Posterior basal 10. Medial basal

10

Bronchopulmonary segments of the left lung
Upper lobe 1. Apical

1 2,3 4 5 7,1 0 8 6 6 9 8

1 2,3 4 5 7 , 10

2. Posterior 3. Anterior 4. Superior lingular 5. Inferior lingular Lower lobe 6. Superior 7. Anterior basal 8. Lateral basal 9. Posterior basal 10. Medial basal 7+10= Anteromedial basal

Arterial supply of the lungs
From bronchial arteries
A .2 left bronchial arteries from descending aorta B. One right bronchial artery from 3rd right posterior intercostal artery
3 rd posterior intercost al

One right bronchial artery 2 left bronchial arteries

Venous drainage of the lungs
Into hemiazygos and azygos veins
-Right bronchial vein into azygos vein -Left bronchial veins into Accessory hemiazygos vein

Right bronchial vein

Left bronchial vein

Azygos vein

Accessory hemiazygos vein

Nerve supply of the lungs
From pulmonary plexus
A .Sympathetic ( From 2,3,4 thoracic ganglia) produces bronchial dilatation B. Parasympathetic (From vagi) produces i. Bronchial spasm ii. Increases bronchial secretion

Lymph drainage of the lungs
Right lymph trunk Lymph vessels pass from the periphery to the intrapulmonary nodes (I . P.) ----broncho pulmonary lymph nodes (B . P .) in the hilum of the lungs  to tracheobronchial lymph nodes (T . B . )at bifurcation of the trachea  efferents ascend upon the trachea to form right and left bronchomediastinal lymph trunks ( B . M .) which drain in the right lymph trunk and thoracic duct B.M. Thorac ic duct

T.B. B.P. I.P.

Mediastinum
Thoracic inlet

T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12

Manubrium

Superior mediastinum

Anterior mediastinum Middle mediastinum Inferior mediastinum

Posterior mediastinum

Diaphragm

Mediastinum
Is the partition lying in the median plane between the 2 pleural sacs.
It extends from the sternum in front to vertebral column behind & from thoracic inlet above to It is divided into superior thoracic outlet (diaphragm) mediastinum & inferior below mediastinum by an imaginary line passing between the sternal angle and the lower border of T4 vertebra

S

I

Mediastinum
The inferior mediastinum is divided by the heart into A .Anterior mediastinum in front of the heart B .Middle mediastinum containing the heart B .Posterior mediastinum behind the heart

A.

P.

M.

Boundaries :

The superior Mediastinum

Above: Thoracic inlet Below: Imaginary line extending from lower border of manubrium sterni to lower border of T4 vertebra Anteriorly: Manubrium sterni Posteriorly: Upper 4 thoracic vertebrae laterally: Mediastinal pleurae

Contents :

The superior mediastinum

A. Retro-manubrial compartment: 1.Lower parts of sternohyoid & sternothyroid muscles 2. Remains of thymus gland. 3. Right and left brachiocephalic veins. 4. Upper half of S.V.C. 5. Left superior intercostal vein. B. Intermediate compartment: 1. Arch of aorta. 2. The 3 arteries arising from aortic arch (brachiocephalic, left common carotid, and left subclavian arteries). 3. Right and left phrenic nerves. 4. Right and left vagus nerves.

Contents :

The superior mediastinum

C. Prevertebral structures: 1.Trachea 2. esophagus. 3. Left recurrent laryngeal nerve. 4. Thoracic duct. 5.Both sympathetic chains 6.Longus coli muscles. 7.Anterior longitudinal ligament.

Contents :

The anterior mediastinum

1 . Remains of thymus gland . 2 . Loose areolar tissue . 3 . Upper and lower sternopericardial ligaments 4 . Two to three lymph nodes .

The middle mediastinum
Contents :
1 . Pericardium & heart . 2 . Bifurcation of trachea into 2 bronchi . 3 . Tracheobronchial lymph N . 4 . Both phrenic nerves 5 . Deep cardiac plexus . 6 . Arteries ( ascending aorta & pulmonary trunk ). 7 . Veins ( lower ½ of

The posterior mediastinum
Contents :
1 . Esophagus . 2 . Thoracic duct . 3 . Descending aorta . 4 . Azygos and hemiazygos veins . 5 . Nerves : A . Esophageal plexuses from both vagi . B . Both sympathetic chains and their splanchnic nerves . 6 . Mediastinal lymph nodes .

Variations of position of the mediastinum
Body built: Tall, thin -------- Low diaphragm ( mediastinum is lower) Short obese-------- High diaphragm( Higher mediastinum Position: Erect posture-------- )Mediastinum is lower Supine posture------- Mediastinum is higher State of abdominal viscera Pregnancy, abdominal distension, ascites------Mediastinum is higher

respiration: During inspiration ----- Diaphragm & mediastinum descend

Pericardium
The pericardium is formed of 2 sacs A. Outer sac: Fibrous pericardium Conical sac made of tough connective tissue. It surrounds the heart completely without being attached to it. Apex Anterior surface Posterior surface Bas e

Pericardium A. Outer sac: Fibrous pericardium: Has

Base :

Attached to central tendon of the diaphragm & is pierced by the I.V.C. Apex : Surrounds S.V.C., ascending aorta & pulmonary trunk & continues above with the pre-tracheal fascia Anterior surface : Connected to back of sternum by sternopericardial ligaments. posterior surface : pierced by the 4 pulmonary veins.

Pericardium
Heart Pericardium Heart V. Pericardium P. Pericardium

B. Inner sac: Serous pericardium: Lines the fibrous sac & covers the heart The heart invaginatesthe serous sac from above and behind and almost obliterates its cavity, the space being a potential space lying between the parietal and visceral layers. It allows the free movements of the heart within the fibrous pericardium.

Pericardium
Serous pericardium : Lines the fibrous pericardium,
invagination of the heart to it divides it into parietal and visceral layers Parietal serous pericardium : Lines the inner surface of the fibrous pericardium

Visceral serous pericardium ( Epicardium ): Covers the heart and great vessels and is reflected from the great vessels to form the parietal layer. - The portion which covers the great vessels is arranged in 2 tubes First tube : Closes the aorta and pulmonary trunk Second tube: Closes the S.V.C., I.V.C., the 4 pulmonary veins. The tube surrounding the veins has the shape of an inverted J . Thus 2 recesses of serous pericardium are formed:

Pericardium
Primary heart tube In pericardial sac A Transient dorsal mesocardium V

Heart Pericardiu m

Heart
A

Heart

T

V

T

A. : Arterial end of heart tube B. : Venous end of heart tube T. : Transverse sinus of pericardium O. : Oblique sinus of pericardium

S.V.C T T Left pulmonary veins O. Right pulmonary veins I.V.C

Pericardium

Right pulmonary veins

Transverse sinus of pericardium Left pulmonar y veins

Oblique sinus of pericardium

Pericardium
Pericardial sinuses :
Oblique sinus of pericardium : is the space between the limbs of the inverted J , it has the following relations : Anteriorly : Back of left atrium Posteriorly : Parietal serous pericardium, fibrous pericardium separating it from posterior On mediastinum: The corresponding pulmonary veins each side Superiorly : The reflection of visceral pericardium on back of left atrium to become parietal Inferiorly : Opening to oblique sinus, between I.V.C. and lower left pulmonary vein

Pericardium
Pericardial sinuses :
Transverse sinus of pericardium : is the passage between the 2 tubes of pericardium , It has the following boundaries : Anteriorly : ascending aorta & pulmonary trunk Posteriorly : Both atria mainly the left atrium

Pericardium
Arterial supply of pericardium :
1. Pericardial branches of internal mammary artery 2. Pericardiophrenic artery 3. Musculophrenic 4. Pericardial branches from descending aorta

Nerve supply of pericardium :

Vagi, phrenic nerves and sympathetic chains

The heart
Surface anatomy of the heart : A . Surface anatomy of the heart itself
4cm 3cm

3cm

5th space

The heart
Surface anatomy of the heart : B . Surface anatomy of A / V and I / V grooves

The heart
Surface anatomy of the heart : C . Surface anatomy of cardiac valves
Arrows: Indicate areas where auscultation of heart sounds is done

The heart
Position of the heart :
The heart is a hollow fibromuscular organ with conical or pyramidal shape. It lies in middle mediastinum enclosed in the pericardium. It is placed obliquely behind the body of the sternum, costal cartilages and ribs. Approximately 1/3 of its mass lies to the right of the middle line.

Cardiac size and weight : 1 . Length of heart from base to apex is 12 cm 2 . The broadest transverse diameter is 9 cm 3 . The anteroposterior diameter is 6 cm . 4 . The weight of the heart is 250 gm in females and 300 gm in males ( weight achieved at 17 - 20 years

General features of the heart
S.V.C. A.A. R.A. Right atrium Right border 1a Right ventricle 1C 2b Inferior surface 1b 1a 1C P.T. L.A. 1b A.A.: Ascending aorta P.T. : Pulmonary trunk R.A.: Right auricle L.A.: Left auricle 1.Atrioventricular groove 1a Anterior part 1b Left part 1c Posterior part 2. Interventricular groove 2a Anterior part 2b Inferior part

Left surface

2a

Left ventricle

I.V.C.

Apex

2b

2a

General features of the heart Position of the heart :
The heart lies obliquely in the middle mediastinum with its axis directed downwards , forwards & to the left The cavity of the heart is divided obliquely into right and left halves by an oblique longitudinal septum Each half consists of receiving chamber (atria) behind and pumping chamber (ventricles ) in front. The heart is similar to a cone having:
Apex: Lies anteriorly in the 5 th left intercostal space. Base (Posterior surface): Lies posteriorly and to the right from 5-8 T vertebrae Anterior surface: Sternocostal surface

General features of the heart Position of the heart :
Inferior diaphragmatic surface: Left pulmonary surface: Right pulmonary surface: Four borders: Upper , lower, right and left Atrioventricular groove. Has 3 parts: anterior, posterior (inferior) and left parts Interventricular groove. Has 2 parts: anterior and inferior parts Shallow interatrial groove

General features of the heart S.V.C. Surfaces of the
1 . Sternocostal surface : - Formed by the 4 chambers mainly the right ventricle - The anterior part of A / V groove crosses it obliquely to anterior - The the right part I / V . groove divides its ventricular part into larger right ( 2 / 3 ) and smaller left ( 1 / 3 ) parts

heart :

A.A. R.A.

P.T.

L.A. 1b

Left surface

1a

Right ventricle 1C 2b

2a

Left ventricle Apex

I.V.C.

Inferior surface

General features of the heart S.V.C. Surfaces of the
2 . Inferior surface : - Formed by the 2 ventricles : 2 / 3 left ventricle & 1 / 3 right ventricle - Separated from the base of the heart by the posterior A / V groove - Rests on central tendon of the diaphragm 3 . Left surface :

heart :

A.A. R.A.

P.T.

L.A. 1b

Left surface

1a

Right ventricle 1C 2b

2a

Left ventricle Apex

I.V.C.

Inferior surface

- Formed by left ventricle & left auricle - Rests on mediastinal surface of left lung

General features of the heart S.V.C. Surfaces of the
4 . Base :

heart :

- Formed by both atria mainly the left - The pulmonary veins , S.V.C. & I . V . C . enter the base - Posteriorly lies the esophagus 5 . Apex : - Formed by the left ventricle
I.V.C.

A.A. R.A.

P.T.

L.A. 1b

Left surface

1a

Right ventricle 1C 2b

2a

Left ventricle Apex

Inferior surface

Borders of the heart :

1 . Right border : Formed by right atrium , S.V.C. & I.V.C 2 . Left border : formed by left

3 . Upper border : Formed by both atria but concealed by ascending aorta & pulmonary 4 . Lower border : formed trunk by both ventricles

Borders of the heart :

General features of the heart S.V.C.
A.A. R.A. Right ventricle 1C 2b I.V.C. Inferior surface P.T. L.A. 1b

Left surface

1a

2a

Left ventricle Apex

1 . A . V . groove : Formed of 3 parts - A . Anterior part : passes to right obliquely from pulmonary trunk to lower border - B . posterior part : separates the base of the heart from the diaphragmatic surface - C . left part : passes from in between the pulmonary trunk and left auricle to left border

Grooves of the heart :

General features of the heart
C B

A

2 . I / V . groove : Formed of 2 parts - A . Anterior part : crosses the anterior surface being parallel to left border - B . Inferior part : crosses the inferior surface till it meets the posterior part of A / V . groove

Grooves of the heart :

General features of the heart

A. B.

Interior of the heart
Interior of the right atrium
right auricle S.V.C . I. Atrial septum Annulus ovalis Fossa ovalis I.V.C . Valve of Pectinat e muscles Crista terminali s Tricuspi d Coronary orifice sinus Valve of coronary sinus

Interior of right atrium
S.V.C .

I.V.C .

Annulus ovalis Fossa ovalis Coronary sinus Valve of coronary sinus Valve of

Tricuspid valve

S. P.

A.

Closing tricuspid valve

Closed tricuspid valve

Interior of right ventricle
Pulmonary trunk Infundibulum Supraventricu lar crest Ant . cusp Septal pap . muscle Septomargin al trabecula Post . Pap . muscle Moderator band Ant . Pap . muscle

Trabecula e carni

Tricuspid valve

Tricuspid orifice
Sept . cusp Ant . cusp Post . cusp

Septal pap . M. Septomarginal

Post . pap . Ant . pap . M . M.

Pulmonary valve

Closing pulmonary valve

Closed pulmonary valve

Left atrium

P.

P. P.

P.

Left atrium

Interior of left ventricle
Aort a

Ant . Pap . muscle Trabeculae carni post . Pap . muscle Anterior cusp Posterior cusp

Mitral valve

Mitral orifice
Ant . cusp Post . cusp

Ant . Pap . M

post . Pap . M

Ant . Pap . M

Left ventricle

Vest .

Aortic orifice

Left ventricle

Wall of ventricles

R.

L.

Right ventriclee

Differences between the ventricles
Left ventricle
1. Forms whole left border, 2/3 inf. Surface, 1/3 ventricular part of ant. Surface 2. Wall 8-12 mm Circular in cross section 3. Trabeculae carni multiple & fine 4. Mitral valve has 2 cusps 2 papillary muscles

Forms 1/3 inf. Surface, 2/3 ventricular part of ant. surface

2.

Wall 3-5 mm Semilunar in cross section

3. Trabeculae carni few & rough 4. Tricuspid valve has 3 cusps 3 papillary muscles

The arterial supply is formed of :
Circle : The coronary arteries form
this circle, grooves they run in the A/V

Coronary arteries

Loop : The I/V branches of coronary arteries form this loop, they run in the I.V. grooves.

Coronary arteries
Aortic cusps Left post . sinus Left coronary artery

Ant . sinu s Right coronary artery

Coronary arteries
Origin of right coronary Anterior sinus Aortic sinuses

Origin of left coronary Left post . sinus

Coronary arteries
R. Coronary L. Coronary

Ant . I / V . A

Post . I/V. A

Blood supply of the heart
Coronary arteries
left coronary artery Right coronary artery Circumflex A. Ant . I / V artery

Marginal artery

Coronary arteries

Right coronary artery Post .( inf .) I / V artery

Right coronary artery

Right coronar y artery

Anterio r sinus Margin al artery

Left coronary artery
Left posteri or sinus Ant . I / V . artery Left coronar y artery Circumf lex artery

Branches of right coronary artery 1.Inferior I/V artery: Runs in the inferior I/V groove till the
apex. 3.Marginal artery: Runs along lower margin of anterior surface. 3. Small unnamed branches. Typically the right coronary artery supplies: •The right atrium. •Most of right ventricle. •The diaphragmatic surface of left ventricle. •The posterior third of A/V septum. • S .A . node (in about 60% of peoples). • A .V. node (in about 80% of people).

Coronary arteries

Branches of left coronary artery 1 . Anterior I / V artery . It descends in the
anterior I / V groove till apex . 2 . Circumflex artery . 3 . Small unnamed branches . Typically the left coronary artery supplies : - The left atrium . - Most of the left ventricle . - Part of the right ventricle . - Most of the I / V septum ( anterior 2 / 3 including the A / V bundle ). - S . A . Node in about 40 % of people .

Coronary arteries

Venous drainage of the heart G. : Great cardiac vein
M. : Middle cardiac vein S.V.C.
Ascending aorta Pulmonary trunk

S.: Small cardiac vein G G

Right auricle Right atrium Coronary sinus

G M. S

I.V.C.

Venous drainage of the heart Mainly : into coronary sinus
2 - 3 cm in length lying in the posterior part of A / V groove , its right end opens in right atrium between I . V . C . and tricuspid orifice and is guarded by a valve while its left end is joined by the great cardiac vein . Tributaries of coronary sinus: 1. Great cardiac vein. 3. Small cardiac vein. 4. Oblique vein of left atrium (vein of Marshal). 5. posterior vein of left ventricle 2. middle cardiac vein.

Coronary sinus :

Venous drainage of the heart into the coronary sinus are: The veins which do not drain
( 2 - 3 in number ), They ascend on the sternocostal surface of the heart to end in the right atrium . They drain the anterior part of the right ventricle . 2 . Venae cordis minimi : Drain in the different chambers ( mainly the right atrium ). These veins are found within the myocardium

1 . Anterior cardiac veins

Into

Lymph drainage of the heart

: 1 . Posterior mediastinal lymph nodes 2 . Brachiocephalic lymph nodes

S . A . of ascending aorta and aortic arch
2 3 AA 2

Arteries in the mediastinum

A.:
3

Ascending aorta

AA.: Aortic arch
A

Ascending aorta

Ascending aorta S.V.C. Right auricle Right atrium Pulmonary trunk

I.V.C.

Ascending aorta
A .: Ascending aorta P . T . Pulmonary trunk R . P .: Right Pulm . A. R . B .: Right bronchus

R.B. R.P. S.V.C A. . P.T. S.V.C . A. P.T.

Aortic arch S . A . of aortic arch
2 3 AA 2

3

C

A

Aortic arch
Sternum 1 2

5 B A

2 1 3 4

Lung

B A C Vertebr a

Lun g

Anteriorly: 1. Left phrenic. 2. Left vagus. 3. Cardiac branch from left vagus. 4. Cardiac branch from left sympathetic chain 5. Left superior intercostal vein. Posteriorly: A. Left recurrent laryngeal nerve. B. Bifurcation of trachea. C. Esophagus. Below: A. Left recurrent laryngeal nerve.

Aortic arch

Branches of aortic arch

Left subclavian Left C . carotid Brachioceph alic

Descending thoracic aorta

A. Descendin g aorta

Esophagus Thoracic duct

Relations of descending thoracic aorta

Hilum of left lung Descending aorta Esophagus Azygos vein

Descending thoracic aorta Anteriorly: From above downwards:
- Hilum of left lung. - Pericardium and left atrium. - Esophagus (crossing it at level of T8 vertebra). - Diaphragm. Posteriorly: - Vertebral column. - Hemiazygos and accessory hemiazygos veins crossing behind it opposite T8 To the right:
1. Vena azygos. 2. Thoracic duct. 3. Esophagus (high up).

To the left:
1. Left lung and pleura. 2. Esophagus (lower down).

1. Nine pairs of posterior intercostal arteries 2. Pair of subcostal arteries 3. Two left bronchial arteries 4. Four to five esophageal arteries

Branches of descending thoracic aorta

5. pericardial, mediastinal and diaphragmaticarteries

Pulmonary trunk S . A . of pulmonary trunk
2 3 P.T. 2

3

Pulmonary trunk
Anteriorly: Left lung,left pleura, pericardium

P.T.

Posteriorly: Ascending aorta left coronary artery Left atrium Transverse sinus of pericardium To the right: Right auricle, ascending aorta To the left: left auricle

Above: Aortic arch, lig. Arteriosum superf.cardiac plexus

Relations of right pulmonary artery
Relations : That of right hilum Anteriorly : - Ascending aorta (1). - S.V.C.(2) - Right phrenic nerve(3). Posteriorly: - Right bronchus (4). - Esophagus (5).

1

2 3 R.P.A .

4

5

Relations of left pulmonary artery
Relations : That of left hilum Anteriorly : - Left phrenic nerve (1). Posteriorly : - Left bronchus (2). - Descending aorta (3). Inferiorly: Upper border of left atrium.

3

2

1

L.P.A .

Pulmonary arteries Left pulmonary artery Right pulmonary artery
- Longer

(2 inches), wider, more - Shorter (1 inch) narrower, runs vertical horizontally above the left atrium Relations: That of left hilum Anteriorly : Posteriorly :
- Left phrenic nerve. - Left bronchus . - Descending aorta. Upper border of left

Relations: That of right hilum Anteriorly :

- Ascending aorta. - S.V.C. and right phrenic nerve. - Upper right pulmonary vein.

Posteriorly :

Inferiorly :
atrium.

- Right bronchus. - Esophagus .

Brachiocephalic veins Beginning and end:

Right brachiocephalic vein

1 2 3

1 2

Left brachiocephalic vein

S.V.C.

3

Brachiocephalic Right brachiocephalic vein Left brachiocephalic vein veins
- 2.5 cm - 6 cm - Vertically downwards - Obliquely to the right - Begins at right sternoclavicular joint - Begins at left sternoclavicular joint by union of right internal jugular & by union of left internal jugular & right subclavian veins left subclavian veins Both veins end at first right Both veins end at first right costal cartilage by uniting costal cartilage by uniting together to form the S . V . C . together to form the S . V . C . Relations : Relations To the right : Right phrenic Behind : The 3 big arteries of nerve . the aortic To the left and posteriorly : arch , The 4 nerves between Brachiocephalic artery & left right vagus common carotid and left subclavian arteries .

Relations of brachiocephalic vein : To the right : Right phrenic Right phrenic Right nerve . vagus To the left and posteriorly : Right brachioBrachiocephalic artery & cephalic vein right vagus

Brachiocephalic right veins

Left brachiocephalic vein

S.V.C.
Relations of left brachiocephalic vein: Behind : The 3 big arteries of the aortic arch , The 4 nerves between left common carotid and left subclavian arteries . Below : Aortic arch .

tributaries:

Brachiocephalic veins
Left internal mammary vein. Left vertebral vein. Left inferior thyroid vein. Thoracic duct. Left 1st posterior intercostal vein. 6. Left superior intercostal vein.

Right internal mammary vein Right vertebral vein. Right inferior thyroid vein. Right lymph trunk. Right 1st posterior intercostal vein.

Beginning and end:

S.V.C.

Right brachiocephalic vein

1 2 3

1 2

Left brachiocephalic vein

S.V.C.

3

cm in length , it has no valves .

S.V.C.

ns at 1st right sternocostal junction by union of the two ocephalic veins .

at 3rd right sternocostal junction by entering the right atriu - Its upper half lies in the superior mediastinum , while its lower half lies in the middle mediastinum within the fibrous pericardium .level of the second costal cartilage , it - At the receives the arch of the azygos vein which enters its right side . - The azygos vein is the only tributary .

Anteriorly: Anterior border of right lung , right pleura and pericardium. Right phrenic Posteriorly: Hilum of right lung To the right: Right phrenic nerve. Right pleura and lung. To the left: Ascending aorta (Anteriorly) Trachea and right vagus (Posteriorly )

S.V.C.

1 - It is the common trunk of all lymph vessels of the body except : - Right side of head and neck . - Right side of the thorax . - Right upper limb . - Upper surface of right lobe of liver . 2 - It begins in the abdomen at L2 vertebra from the tapering upper end of cisterna chyli 3 - It .enters thorax by passing through aortic opening of diaphragm between aorta and azygos vein 4 - It. ascends in posterior mediastinum between descending aorta and azygos vein and behind the right border of the esophagus till the level of T5 vertebra . Thoracic duct

duct

Thoracic

Azygos vein

5 - At level of T5 vertebra it crosses from right to left behind the aorta and esophagus to ascend in the superior mediastinum along the left border of the 6 - It esophagus behind of the neck , arch . enters the root the aortic arches laterally behind left subclavian artery then descends downwards in front of 1st part of subclavian artery to end in left brachiocephalic vein at its beginning .

duct

Thoracic
Thoracic duct

Azygos vein

Thoracic duct
7 - The thoracic duct is about 18 inches long ( 45 cm ), it has a beaded appearance , and it has several valves especially at it

duct Tributar
ies :

Thoracic

1.Right & left lumbar lymph trunks(they pierce the corresponding crus of the diaphragm). They drain upper lateral aortic lymph nodes. 2. Left bronchomediastinal trunk ( Drains left half of the thorax) 3. Left jugular lymph trunk ( Drains left half of head and neck) 4. Left subclavian lymph trunk ( Drains left upper limb) 5. Bilateral descending thoracic lymph trunks from intercostal lymph nodes of lower 6-7 intercostal spaces

Right lymph trunk
- One cm in length - It opens in the right brachiocephalic vein at its beginning

Tributar ies :

1. right bronchomediastinal trunk ( Drains right half of the thorax)

2. Right jugular lymph trunk ( Drains right half of head and neck) 3. Right subclavian lymph trunk ( Drains right upper limb)

Lymph drainage of the thorax anterior thoracic Lymph drainage of
wall : Into : Pectoral ( Anterior) group of axillary lymph nodes. Lymph drainage of posterior thoracic wall : Into : Subscapular (Posterior) group of axillary lymph nodes. Lymph drainage of deeper structures : Into : Internal thoracic, intercostal and diaphragmatic nodes.

Right Phrenic nerve C3
C4 Right phrenic Right brachiocephalic S.V.C vein . Right atrium Right phrenic I.V. C. Abdominal surface of the diaphragm Scalenus anterior C5

1 st part of subclavian artery

Left phrenic nerveC3
C4 C5 Left phrenic Scalenus anterior C . C . & left Left subclavian Aortic arch Left ventricle

Abdominal surface

Both of subclavian artery . The right phrenic ( shorter and vertical ) is related to venous side of the heart The left phrenic is related to arterial side of the heart The phrenic nerves arises in the neck and supply abdominal structure ( diaphragm ) ---- why? The diaphragm develops in the neck from the septum transversum and migrates caudally taking its nerve with it . The phrenic nerve supplies the abdominal surface of the diaphragm due to folding of the a embryo nerve ( motor to the The phrenic nerve is mixed diaphragm and sensory to pleura and pericardium ).

About phrenic nerves enter the thorax by crossing first part

The right vagus nerve
Right vagus Subclavian artery Trache a Right posterior pulmonary plexus Posterior esophageal plexus Posterior gastric nerve

The left vagus nerve
Left C . C . & Left subclavian Left vagus

Aortic arch Left pulmonary plexus Anterior esophageal plexus Anterior gastric nerve

- Anterior pulmonary branches to join anterior pulmonary plexus - posterior pulmonary branches to join posterior pulmonary plexus - Esophageal branches to join esophageal plexus - Cardiac branches to join superficial and -Left cardiac plexuses deep recurrent laryngeal nerve ( from left vagus ). It arises on the left side of the aortic arch , curves below it immediately behind the ligamentum arteriosum to reach the concavity of the aortic arch . It ascends to the left between the trachea and esophagus .

in the thorax

Branches of vagus

Autonomic plexuses in theSuperficial cardiac thorax
Site: In concavity of aortic arch Mode of formation •Sympathetic : Cardiac branch from left superior cervical ganglion. •Parasympathetic: Lower cervical cardiac branch of left vagus. Communications: With - Deep cardiac plexus
- Right coronary plexus - Left ant. Pulm. plexus
t i ac lef ion rd . a m l l c gus fro ang a h g vi c f t va P . r nc cal S ra vi ce f le b r er o ac r ce w h i rd rio Lo anc • r Ca pe b su
Superficial cardiac plexus

plexus

Autonomic plexuses in the thorax cardiac Deep
Site: In front of bifurcation of trachea Communication : with : Superficial cardiac plexus . Left anterior pulmonary plexus . Left coronary. plexus . Sup . G M. G.
V 1 V 2 V 3 Inf . G .

plexus

V 1 V 4 M. G. V 3 Inf . G .

2,3,4 Symp .

Deep cardiac plexus

2,3,4 Symp .

Autonomic plexuses in the thorax Pulmonary
Anterior and posterior pulmonary plexuses: In front of and behind corresponding hilum of the lung Symp. : 2,3,4 thoracic ganglia Parasymp. : Corresponding vagus Anterior esophageal plexuses: In front of esophagus Symp. : Greater splanchnic nerve. Parasymp. : Left vagus posterior esophageal plexuses: Behind the esophagus Symp. : Greater splanchnic nerve. Parasymp. : Right vagus

plexuses

Thoracic part of sympathetic chain
Neck of 1 st rib Necks of ribs

1 2 3 4 5 6 7 8 9 1 0 1 11 2

Sides of bodies of vertebrae

Med . arcuate lig .

Thoracic part of sympathetic chain
1. Each ganglion receives white ramus and gives grey ramus communicans to corresponding spinal nerve. 2. From 1-5 ganglia to aortic plexus 3. From 2,3,4 ganglia to pulmonary & cardiac plexuses plexus 4. From 5-9 ganglia --- Greater splanchnic n. (preganglionic), it pierces the corresponding crus of diaphragm to reach celiac plexus in the abdomen 5. From 9,10 ganglia --- lesser splanchnic n. (preganglionic), it pierces the corresponding crus of diaphragm to reach sup. mesenteric plexus in the abdomen 6. From 11,12 ganglia --- least splanchnic n. (preganglionic), it pierces the diaphragm to reach renal plexus in the abdomen

Branches :

Thoracic part of trachea
Cricoid cartilage Trach ea 16 - 20 C shaped cartilages

Sternal angle Right bronchus

Left bronchus

Thoracic part of trachea
Relation Anteriorly: s
E 2 3 1. Manubrium sterni 2. Left brachiocephalic 3. Arch of aorta 4. Deep cardiac plexus, lymph ns Posteriorly: E. Esophagus R. Left recurrent laryngeal nerve

R

Thoracic part of trachea
Relation To the right : s
1. Right mediastinal pleura 2. Right vagus 3. Azygos vein To the left: 4. Left mediastinal pleura 5. Arch of aorta 6. Left common carotid 7. Left subclavian 2 3 5 6

7

in thorax :

Thoracic part of trachea Arterial supply

Bronchial arteries

Venous drainage :
Into azygos & hemiazygos veins B B B

Right bronchus

Bronchi

Left bronchus

Wider Shorter (One inch) More vertical Gives its epiarterial bronchus before entering the hilum. Relations: That of the hilum Anteriorly: Pulmonary artery Posteriorly: Pulmonary plexus Above: Arch of azygos Below: Tracheobronchial L.Ns.

Narrower Longer (2 inches) Oblique  Gives its sup. Division within the lung

Relations: That of the hilum Anteriorly: Pulmonary artery Posteriorly: Pulmonary plexus Above: Arch of aorta Below: Tracheobronchial L.Ns.

Azygos arch

Bronchi

Aortic arch

BE A VU A

B
VL

A

B
VL

VU

Right bronchus
Anteriorly: Pulmonary artery Posteriorly: Pulmonary plexus Above : Arch of azygos Below : Tracheobronchial L.Ns.

Left bronchus
Anteriorly : Pulmonary artery Posteriorly : Pulmonary plexus Above : Arch of aorta Below : Tracheobronchial

Course :

esophagus

The

muscular tube about 25 cm in length . - It begins at the lower border of cricoid cartilage ( C6 ) as the continuation of the pharynx . Its beginning lies in neck in - It descends in the the middle line . of vertebral front column , then in the superior mediastinum and finally in the posterior - It passes through the mediastinum . esophageal opening of the diaphragm . The right crus forms a sphincter around it at lower border of T10 - It ends at the cardiac end of vertebra one inch to the left themiddle line . of stomach a the lower border of T11 one inch to the left of the middle line .

esophagus Curves of the esophagus :

The

Anteroposterior curve : Follows the vertebral column
B. Returns to the middle line at T5 C. Curves to the left at T7 D. Remains left till it passes through

Left curves : A. Slight curve at the root of the neck
the diaphragm.

Sites of constrictions : (sites of impaction of foreign

bodies): - At its beginning (6 inches from lower incisor teeth). - Opposite 4th thoracic vertebra As it is crossed by the arch of aorta. (9 inches from lower incisor teeth). -Opposite the 5th thoracic vertebra where it is crossed by left bronchus (11 inches from lower incisor teeth). - As it traverses the diaphragm (16 inches from lower incisor teeth).

downwards 1 - Trachea . 2 - Right pulmonary artery 3 - Left 4bronchus Pericardium 5 - Base of the 6 . Diaphragm heart Posteriorly :

esophagus Relations in the thorax : : From above Anteriorly

The

1 3

- Thoracic duct - Descending aorta - Hemiazygos veins - Vertebral column

6

To the right : From above downwards : - Right vagus .
-

esophagus

The
Thoracic duct

Azygos vein . Thoracic duct .

To the left : From above downwards : Thoracic duct . Azygos vein ch of aorta , left subclavian . Left pleura . Thoracic duct Descending aorta .

ophageal arteries from descending aorta .

Arterial supply :

esophagus

The

Venous drainage : Azygos vein

1 . Sternal angle .

Events at T4 vertebra
S.V.C.

Bifurcation of trachea . End of ascending aorta .

4 5 Pulmonary
trunk

7

3 6

Beginning and end of aortic arch .

Beginning of descending aorta . 7 . Arch of azygos joins S.V.C.. 8 . Plane between superior & inferior mediastinum

. End of pulmonary trunk .

1

2

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