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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. [email protected]