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-caval anastomoses
•
Inferior mediastinum (anterior, middle, posterior),
transoesophageal ECHO, oesophageal varices– porto-caval
anastomoses
Shapes of the thorax
Emphysema Pectus excavatum
Muscles of the thorax
m.latissimus dorsi
m.serratus anterior m.pectoralis
major
m.trapezius
m.latissimus dorsi
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 pleura are „+1 rib“
pneumothorax
pars diaphragmatica pars costalis
Pleura parietalis et pleura visceralis
cupula pleurae (5cm above the thoracis inlet)
pars mediastinalis
recessus
costodiaphragmaticus
parasternal anterior axillary paravertebral line
VANA
1-f.thoracica spf.
2- fascia endothoracica 3-pleura parietalis
4-membrana intercostalis ext.
5-m.intercostalis int 6-m.intercostalis ext 7-m.intercostalis intimus 8-membrana intercostalis int 9-m.transversus thoracis
Section through
the intercostal
space in
Chest drainage – posterior axillary line above the level of the inferior angle of scapule (Th7)
anterior axillary line
costodiaphragmatic recess
above the rib
!diaphragm, liver, spleen
! lungs
! long thoracic nerve, lateral thoracic vessels
! intercostal nerv and vessels
Thorax - anterior wall (posterior aspect) vessels
Median sternotomy approach to thymus, pericardium,
heart and roots of great vessels,
and anterior mediastinum CT 14 days after sternotomy for bypass grafting
post surgery
wire migration
-sign of mediastinitis 3 weeks after sternotomy
wound dehiscention
• sternal puncture is a rapid and safe
method to ensure the diagnosis of post-
sternotomy mediastinitis
Thorax – posterior wall vessels and nerves
Ductus thoracicus V.azygos
Tr.sympaticus
Nn.splanchnici V.intercostalis suprema
Ao
4. intercostal space 5. intercostal space Central tendon
lumbocostal triangle of Bochdalek
Thorax –inferior wall -diaphragm
Diaphragm –inferior aspect
Lumbar part
psoas major quadratus
lumborum
Oesophagus +vagus
nerves Inferior v.cava
+frenic nerve
Central tendon
aorta +
thoracic duct
Lumbocostal triangle
(Bochdaleki) Sternal part
Azygos vein + splanchnic nerves
Hemiazygos vein + splanchnic
nerves Costal part
sympathetic trunc
Mediastinum
Superius
Inferius
A M P
n. frenicus
aorta
diaphragma oesophagus
angulus sterni spatium retroviscerale
spatium paraviscerale spatium previscerale
abdominal cavity
Mediastinum superius
(thoracic inlet)
sternumrest of the thymus veins
nerves arteries trachea
oesophagus lungs (laterally) Layers:
Superior mediastinum
Schema 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.laryngeus reccurens sin a.carotis comm sin
a. subclavia sin
ductus thoracicus
tr. sympathicus
pleura parietalis pleura visceralis
tr. sympathicus
Th3
Repetition
Th3
Superior vena cava syndrome
v.jugularis
externa edema of the
face, neck and upper chest,
distension of axillary,
subclavian and jugular 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, and swelling of the face and arms.
- On examination: plethoric, with a ruddy complexion, suffusion, pitting edema of the face and upper torso, and prominent
spidery telangiectasia on his face and chest (Panel A). The jugular veins were nonpulsatile and distended.
- Contrast-enhanced CT: markedly compressed superior vena cava (SVC) - venogram: (Panel B) severe compression of both the right and left subclavian veins (RSV and LSV), a thrombus in the left subclavian vein and multiple venous collaterals (arrowheads).
-After stent placement, extending from the 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 and
chemotherapy, remains free of symptoms resulting 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 goitre
x-ray picture
Reccurent laryngeal
nerves
Young woman with dysphony
left reccurent laryngeal nerve palsy
pulmonary artery dilatation
Ortners syndrome is a rare cardiovocal syndrome and refers to reccurent
laryngeal nerve palsy from cardiovascular disease (mitral stenosis, pulmonary hypertension)
v. azygos ductus thoracicus truncus sympathicus
oesophagus n.splanchnicus major
n.vagus sin
Posterior
mediastinum
Mediastinum right veiw
n.frenicus n.vagus
eparterial bronchus
n.splanchnicus minor n.splanchnicus major
ductus thoracicus
Mediastinum right view
n.frenicus
+ vasa pericardiacofrenica
n.vagus
n.laryngeus reccurens sin.
hyparterial bronchus
Mediastinum left veiw
Th6
n. frenicus dx
n. frenicus sin truncus pulmonalis
bronchus principalis dx
bronchus
principalis sin v.cava superior
v. azygos
v. hemiazygos tr. sympathicus dx
tr. sympathicus sin aorta ascendens
aorta descendens ductus thoracicus
oesophagus nn.vagi
Mediastinum
transverse section (Th6)
Th8
tr. sympathicus dx v. azygos ductus thoracicus
aorta descendens vv. pulmonales
n.vagus sin
oesophagus
n.frenicus sin
n.frenicus dx
n.vagus dx Mediastinum
transverse section (Th8)
1-lobus sup. dx
2-fissura horizontalis 3-facies sternocostalis 4-facies diaphragmatica
5-sulcus interventricularis ant.
6-tr.brachiocephalicus 7-trachea
8-a.carotis communis sin 9-a.subclavia sin
Lungs and the heart – anterior aspect
1-lobus inf.dx 2-lobus inf.sin 3-aorta
4-jícen 5-trachea Lungs – posterior aspect
basis
pulmonis apex
sulcus a. subclaviae
sulcus v.azygos
fissura obliqua fissura horizontalis
1.rib impression sulcus v.cavae sup.
lig. pulmonale
impressio cardiaca sulcus oesophageus
sulcus v.azygos
bronchus principalis dx a.pulmonalis dx
mesopneumonium vv.pulmonales
Medial wall of
the right lung
Medial wall of
the right lung
fissura obliqua
apex
sulcus a. subclaviae sulcus
v.brachiocephalicae sin 1.rib impression
sulcus aorticus
vv.pulmonales sin
impressio cardiaca
lig. pulmonale
lingula pulmonis impressio
oesophagea mesopneumonium bronchus principalis sin
a.pulmonalis sin
basis pulmonis
Medial wall of
the left lung
Medial wall of
the left lung
n.l.paratracheales sin n.l.paratracheales dx
n.l. tracheobronchiales sup sin n.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 lung cancer staging adapted from the American Thoracic 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 nodes in station 2. They are either anterior to the vessels (3A) or behind the esophagus, which is prevertebral (3P).
• 4. Lower Paratracheal(including Azygos Nodes): 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 pulmonary trunk, but lateral to these vessels.
• 6. Para-aortic(ascending aorta or phrenic):
nodes lying anterior and lateral to the ascending 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 and Subsegmental Nodes (10-14)
• 10-14: these are located outside of the mediastinum.
They are all N1-nodes.
Lymph nodes in the superior mediastinum
4R, 3A
44-year-old HIV-positive man presents with progressive dysphagia, epigastric pain, and post-prandial vomiting
Lymphoma of the esophagus
Oesophagus- endoskopy
G-E junction, 2 cm above cardia ora serrata, Z-line)
squamocolumnar junction
columnar epithelium squamous epithelium
Transverse ridging of the normal esophagus becoming evident during retching
vein
Main porto-caval anastomoses
vv. oesophageae-vv.gastricae
! esophageal varices-bleeding
v.rectalis superior-v.rectalis media hemorrhoids-bleeding
vv.paraumbilicales - caput Medusae
Thorax – x-ray picture
CT - adenocarcinoma, emphysema
CT – thymoma in the anterior mediastinum
CT – thymoma in the anterior
mediastinum
CT – aspirated tooth filling in the left lower bronchus
CT- ganglioneuroma in the posterior
mediastinum
CT- ganglioneuroma in the posterior
mediastinum
???
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 of
Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. achim.von-goedecke@uibk.ac.at
