Ingrid Hodorová, Assoc. Prof., MD, PhD., Zuzana Kováčová MD

THORAX – SKELETON, , MUSCLES, ARTERIAL BLOOD SUPPLY, VENOUS AND LYMPHATIC DRAINAGE, INNERVATION, REGIONAL

THORAX:

- upper part of the trunk - box for vital organs

Boundaries:  external upper: 1/ jugular notch 2/ clavicule 3/ acromion of 4/ spine of C7 ( prominens)

 external lower: 1/ xiphoid process 2/ left and right costal arches 3/ vertebra Th12

 internal upper: 1/ superior thoracic aperture (made from jugular notch, 1st pair of , vertebra Th1)

 internal lower: 1/ inferior thoracic aperture (full filed by diaphragm, which extends on the right side to the 4th intercostal space (ICS), on the left side extends to the 5th ICS)

ARTEFICIAL LINES ON THE THORAX:

 unpaired: 1/ 2/ posterior median line

 paired: 1/ sternal line 2/ 3/ mid-clavicular line 4/ anterior axillary line 5/ midddle axillary line 6/ posterior axillary line 7/ 8/ paravertebral line

THORACIC WALL:

 1st layer (proper thoracic wall): 1/ osteothorax (ribs, , Th vertebrae + their joints) 2/ proper mm. of thoracic wall (intercostal muscles, transversus thoracis m., subcostalis m.) 3/ intrinsic mm. of the back (erector spinae m.) 4/ intercostal neuro-vascular bundle (, artery, nerve) 5/ endothoracic fascia 6/ parietal pleura  2nd layer (middle): 1/pectoral fascia 2/ thoracohumeral mm. 3/spinohumeral mm. 4/spinocostal mm.  3rd layer (superficial): 1/ skin 2/ subcutaneous tissue + mammary gland 3/ superficial structures (supraclavicular nn., intercostobrachial nn., thoracoepigastric vv.)

OSTEOTHORAX:

(12): 1/ body - costal facets, 2/ arch - vertebral notches – intervertebral foramen, vertebral foramen 3/ processes – transverse, sup. and inf. articular, spinous

 Ribs (12 pairs): 1/ head - articular facet of the head 2/ neck 3/ body – tubercle, articular facet, costal crest, costal sulcus

1st - groove for subclavian artery, tubercle for scalenus anterior m., groove for True ribs: 1st to 7th False ribs: 8th to 10th Floating ribs: 11th to 12th

 Sternum: 1/ manubrium ̶ jugular notch, clavicular notch, st nd costal notch (1 and 2 ribs) 2/ body (costal notches 2nd to 7th ribs) 3/ xiphoid process - attachment the 2nd pair of ribs

JOINTS OF THE RIBS:

: 1/ joints of the heads of the ribs (head of the ribs to the body of the thoracic vertebrae) 2/ costotransverse joints (costal tubercle and transverse process)  : 1st to7th ribs to sternum  Interchondral joints: costal arch ( of the 7th to 10th rib) 

CONNECTIONS OF THE :

Syndesmosis:  short : interspinous, intertransverse, flava  long ligaments: anterior and posterior longitudinal ligaments

Synchondrosis:  Intervertebral discs, - between vertebral bodies - nucleus pulposus, anulus fibrosus - total number 23, 1st between C1-C2, last one between L5-S1

Synostosis:  sacrum

Joints of vertebral column: between superior et inferior articular processes

Curvatures of vertebral column:  in - lordosis - cervical and lumbar - kyfosis - thoracic and sacral

 in frontal plane - scoliosis

MUSCLES OF THE THORAX:

Thoracohumeral muscles: 1/ pectoralis major 2/ pectoralis minor 3/ serratus anterior 4/ subclavius

Mm. of proper thoracic wall: 1/ intercostal (external, internal, intimi) 2/ transverse thoracis m. 3/ subcostal mm.

Diaphragm:  muscular portion - sternal part, costal part, lumbar part oesophageal hiatus (Th10) – , vagus nn., oesophageal vv., phrenocoabdominal br. of left phrenic n. aortic hiatus (Th12) – thoracic duct,

 central tendon opening for inferior vena cava (Th8) – inferior vena cava, phrenocoabdominal br. of right phrenic n.

through crus of lumbar parts pass: azygos v., hemiazygos v., sympathetic trunk, splanchnic nn. (greater, lesser and least)

 innervation - phrenic nerve

MUSCLES OF THE BACK:

Spinohumeral mm.:  1st layer: 1/ trapezius 2/ latissimus dorsi

 2nd layer 1/ levator scapulae 2/ rhomboid major 3/ rhomboid minor

Spinocostal mm: 1/ posterior superior serratus 2/ posterior inferior serratus

Intrinsic mm. of the back: 1/ m. erector spinae

ARTERIAL BLOOD SUPPLY OF THE THORAX:

Thoracic aorta:  posterior intercostal aa. (for 3rd to 11th intercostal spaces)  subcostal a.

Subclavian artery :  internal thoracic a. - anterior intercostal aa. - musculophrenic a. - superior epigastric a. (anastomoses with inferior epigastric a.)  costocervical trunk - supreme intercostal a. (for 1st and 2nd intercostal spaces)

Axillary artery:  thoracoacromial a.  lateral thoracic a.  thoracodorsal a.

VEINOUS DRAINAGE OF THE THORACIC WALL:

Azygos v. - right posterior intercostal vv., right superior intercostal v., arch of azygos v., drains into

Right supreme intercostal v. - drains into right brachiocephalic v.

Hemiazygos and accessory hemiazygos - left posterior intercostal vv., drain into azygos v.

Left superior intercostal v. - drains into left brachiocephaliv v.

Left supreme intercostal v. - drains into left brachiocephalic v.

Internal thoracic vv. - left drains into left brachiocephaic v., right drains into superior vena cava

Thoracoepigastric vv. - they form lateral thoracic v., it drains into axillary v. Vertebral venous plexus - external and internal

Veins of the thoracic wall form important cavo-caval and porto-caval anastomoses!

NEUROVASCULAR BUNDLE IN INTERCOSTAL SPACES – VAN:

VAN is made from (in kranio-caudal direction)  posterior intercostal Vein  posterior intercostal Artery  intercostal Nerve

Runs between (in dorso-ventral direction):  endothoracic fascia and internal intercostal membrane  inside internal intercostal mm., separates innermost (intimi) intercostal mm.  between endothoracic fascia and internal intercostal mm.

LYMPHATIC DRAINAGE OF THE THORACIC WALL:

Parietal lymph nodes:  intercostal l. nn.  parasternal l. nn.  phrenic l. nn.

INNERVATION OF THE THORACIC WALL:

Thoracic wall is supplied from nerves of brachial plexus and from intercostal nn.

Sensory: 1/ intercostals nerves 2/ supraclavicular nerves 3/ intercostobrachial nerves

Motor: 1/ phrenic n. (diaphragma) 2/ intercostals nn. (intercostal mm., transverse thoracic m., subcostal m.) 3/ long thoracic n. (serratus anterior m.) 4/ medial and lateral pectoral nn. (pectoralis major and minor) 5/ thoracodorsal n. (latissimus dorsi m.) 6/ dorsal brr. of spinal nerves (intrinsic muscles of the back) 7/ accessory n. (trapezius m.) 8/ subclavian n. (subclavius m.)

MAMMARY GLAND:

Blood supply: 1/ pectoral brr. of thoracoacromial a. 2/ lateral mammary brr. of lateral thoracic a. 3/ medial mammary brr. (perforating brr.) of internal thoracic a.

Innervation: 1/ lateral mammary br., from intercostal nn. 2/ medial mammary br., from intercostal nn. 3/ medial and intermediate supraclavicular nn., from cervical plexus

Lymphatic drainage: 1/ axillary (predominantly pectoral) lymph nodes (important for metastases) 2/ parasternal lymph nodes 3/ supraclavicular (deep cervical) lymph nodes 4/ superficial inguinal lymph nodes

MEDIASTINUM

- part of the thoracic cavity between two pleural cavities (right and left)

Borders:  ventral: sternum + costal cartilages + transverse thoracis m.  dorsal: thoracic vertebrae (bodies)  caudal: diaphragm  lateral: mediastinal pleura right and left  cranial: superior thoracic aperture

Division: - horizontal line, which connects sternal angle and between Th4-5 into:  superior  inferior mediastinum – by is divided into: - anterior mediastinum - middle mediastinum - posterior mediastinum

SUPERIOR MEDIASTINUM:

- communicates with anterior mediastinum and posterior mediastinum

Content:  thymus  right  left brachiocephalic vein + its tributaries  superior vena cava + its tributaries  right and left phrenic nerve – different passage  right and left vagus nerve – different course,  left recurrent laryngeal n.  aortic arch – course, branches: brachiocephalic trunk, left common carotid a., left subclavian artery, bronchial aa.  (thoracic part)  oesophagus  thoracic duct  superficial cardiac plexus  sympathetic trunk (covered by endothoracic fascia)  anterior mediastinal lymph nodes

ANTERIOR MEDIASTINUM:

- fissure behind the body of sternum and in front of pericardium, - it communicates with superior mediastinum

Content:  thymus  parasternal lymph nodes  superior et inferior sternopericardiac ligaments

MIDDLE MEDIASTINUM:

- it is separated by pericardium from other parts of mediastinum (from posterior mediastinum is also separated by bronchopericardiac membrane)

Content:  + pulmonary trunk  ascending aorta  left and right pulmonary veins  superior et inferior vena cava  deep cardiac plexus  left and right phrenic nerves + pericardiacophrenic vessels (between pericardium and mediastinal pleura)  tracheal bifurcation  tracheobronchial lymph nodes

POSTERIOR MEDIASTINUM:

Borders:  anterior - pericardium, bronchopericardiac membrane  posterior - Th5-Th12  inferior - diaphragm  superior - imaginary line: intervertebral disc Th4-5 and sternal angle, direct communication with superior mediastinum (important for the spreading of inflammation to the neck and to the abdominal cavity)

Content:  thoracic aorta  oesophagus  anterior et posterior vagal trunk  thoracic duct  azygos vein  hemiazygos vein  accessory hemiazygos vein  sympathetic trunk (covered by endothoracic fascia!)  greater, lesser et least splanchnic nerve  posterior mediastinal lymph nodes

THE HEART

FUNCTION: it pumps blood throughout the body via the Systemic circulation: LV (left ) → AORTA → Human body → SUPERIOR ET INFERIOR VENA CAVA → RA (right ) : RV (right ventricle) → PULMONARY TRUNK → → PULMONARY VV. → LA (left atrium)

 in middle mediastinum  in sac which is called = PERICARDIUM

Pericardium:  fibrous pericardium – fixation through: - superior and inferior sternopericardial ligg. - pericardiacophrenic ligg. - bronchopericardial membrane - vertebropericardial ligg.

 serous pericardium – parietal layer/visceral layer (epicardium) → reflexion of serous pericardium creates: - arterial opening (porta arteriarum) - around ascending aorta and pulmonary trunk - venous opening (porta venarum) - around superior vena cava and inferior vena cava and pulmonary vv. - transverse pericardial sinus - between porta venarum and porta arteriarum - oblique pericardial sinus

Heart wall – layers:  → endocardial duplications = valves  myocardium → atrial myocardium has 2 layers ventricular myocardium has 3 layers  epicardium (= visceral layer of serous pericardium) → pericardial cavity is between epicardium and pericardium

Cardiac skeleton:  right fibrous ring  left fibrous ring  aortic ring  pulmonary ring - right fibrous trigone (central fibrous body) → between right fibrous ring and left fibrous ring and aortic ring - left fibrous trigone → between left fibrous ring and aortic ring - tendon of infundibulum (tendo infundibuli) → connects pulmonary ring and aortic ring

External features of the heart:  base of the heart  apex of the heart  right auricle/left auricle  sternocostal (anterior)/diaphragmatic (inferior)/pulmonary (left) surface  acute (right) margin - cardiac notch /obtuse (left) margin  (groove)/ anterior interventricular sulcus (groove)/ posterior interventricular sulcus (groove)/ terminal sulcus (groove)

Chambers of the heart:  right atrium  right ventricle  left atrium  left ventricle

Right atrium:  true atrium → right auricle - pectinate mm.  - oval fossa () with limbus fossae ovalis  opening of superior vena cava (superior vena cava)  opening of inferior vena cava (inferior vena cava) - valve of inferior vena cava  opening of coronary sinus - valve of coronary sinus (on posterior wall)  openings of smallest cardiac veins

Right atrioventricular orifice - right atrioventricular valve (tricuspid):  anterior cusp/ posterior cusp/ septal cusp

Right ventricle:  inflow tract → trabeculae carnae anterior and posterior papillary m., septal papillary mm. tendinous cords (chordae tendinae)  supraventricular crest (border between inflow and outflow tract)  outflow tract → septomarginal trabecula () - contains right crus of atrioventricular bundle conus arteriosus opening of pulmonary trunk (pulmonary trunk) with : - anterior semilunar cusp(valvula) - right semilunar cusp (valvula) - left semilunar cusp (valvula)

Left atrium:  true atrium → left auricle - pectinate mm.  interatrial septum – valvula of foramen ovale (falx septi)  openings of pulmonary veins (superior and inferior pulmonary veins)  openings of smallest cardiac veins

Left atrioventricular orifice - left atrioventricular valve (bicuspid, mitral):  anterior cusp/ posterior cusp

Left ventricle:  inflow tract → trabeculae carnae anterior and posterior papillary m. tendinous cords (chordae tendinae)  outflow tract → opening of aorta (ascending aorta) with : - posterior semilunar cusp (valvula) posterior - right semilunar cusp (valvula) right aortic sinus (dilation with beginning of right coronary a.) - left semilunar cusp (valvula) left aortic sinus (dilation with beginning of left coronary a.)

Interventricular septum:  membranous part (between inflow part of right ventricle and outflow part of left ventricle)  muscular part

Arterial blood supply: - branches of ascending aorta  right coronary a. - SA nodal br. - br. for conus arteriosus - atrial brr. - right marginal br. - AV nodal br. - right, anterior and posterior ventricular brr. - posterior interventricular br. → septal interventricular brr.

 left coronary a. → circumflex br. - left marginal br. - atrial brr. - left posterior ventricular br.

→ anterior interventricular br. - br. for conus arteriosus - lateral (diagonal) br. - septal interventricular brr. - left anterior ventricular brr.

Venous drainage:  coronary sinus (in coronary sulcus, on posterior side of the heart) and its tributaries: ← great cardiac v. (= ant. interventricular v.) - its tributaries: - left marginal v. - oblique v. of left atrium - left posterior ventricular v. ← middle cardiac v. (= posterior interventricular v.) ← small cardiac v. - right marginal ventricular v.  right anterior ventricular vv.  the smallest cardiac vv.

Innervation of the heart:  cardiac conducting system (heartbeat) – parts: - sinuatrial node – SA node (in right atrium between opening of superior vena cava and beginning of right auricle) - – AV node (in right atrium; near to opening of coronary sinus) - atrioventricular bundle – - right and left – Tawara branches - subendocardial branches – Purkynje fibres

→ between SA node and AV node/ SA node and myocardium of left atrium are connections

 autonomic nervous system (influences frequency of rate and force of contractions) sympathetic fibers - increase heart rate and causes dilatation of - cardiac nn. (from cervical and thoracic ganglia)

parasympathetic fibers - decrease heart rate and causes constriction of coronary arteries - cardiac brr. (from vagus n.)

→ together create: superficial cardiac plexus - in superior mediastinum, on aortic arch deep cardiac plexus - in middle mediastinum, on the bifurcation of the trachea

Lymphatic drainage:  subendocardial, myocardial, subepicardial lymphatic network → right collector = right lymphatic trunk of heart (truncus lymphaticus cordis dx.) left collector = left lymphatic trunk of heart (truncus lymphaticus cordis sin.)  lymph from right collector → praeaortic l. n. → anterior mediastinal l. nn. → thoracis duct→ left venous angle  lymph from left collector → retroaortic l. n. → inferior tracheobronchial l. nn.→ right lymphatic duct → right venous angle

Auscultation of heart - Testut´s points:  aortic valve (point A)– right 2nd IC space near the sternum  (point B) – right 5th IC space near the sternum  bicuspid valve (point C) – left 5th IC space in midclavicular line  pulmonary valve (point D) – left 2nd IC space near the sternum

RESPIRATORY SYSTEM FUNCTION: transport air into the lungs and to facilitate the diffusion of oxygen into the blood stream; phonation; thermoregulation

DIVISION:

 UPPER - NASAL CAVITY - NASAL SINUSES - NASOPHARYNX, OROPHARYNX (functionally these two parts are inserted in )  LOWER RESPIRATORY TRACT - - TRACHEA - BRONCHI  PROPER RESPIRATORY ORGAN - LUNGS

NASAL SINUSES:  MAXILLARY SINUS  FRONTAL SINUS  ETHMOIDAL SINUS - consists of: anterior air cells middle air cells posterior air cells  SPHENOIDAL SINUS

EXTERNAL NOSE: - pyramid-shaped

External features:  root of nose, dorsum of nose, tip of nose (apex nasi), wings of nose, nares (nostrils) Bones of external nose - bony framework:  nasal bones  the frontal processes of the maxillae  nasal part of frontal bone → piriform aperture

Cartilages of external nose:  lateral nasal cartilages  major alar cartilages - medial and lateral crus  minor alar cartilages  accesory nasal cartilages  vomeronasal

NASAL CAVITY: - is divided by the nasal septum

Parts of the nasal cavity:  nasal vestibule (the border is limen nasi)  proper nasal cavity

Cross-section:  superior nasal concha - part of the ethmoid bone - superior nasal meatus (sphenoethmoidal recess) ← here is opening of: posterior air cells sphenoidal sinus  middle nasal concha - part of the ethmoid bone - middle nasal meatus (ethmoidal bulla, semilunar hiatus, ethmoidal infundibulum) ← here is opening of: maxillary sinus frontal sinus anterior air cells middle air cells  inferior nasal concha - separate bone - inferior nasal meatus ← here is opening of: nasolacrimal duct

→ common nasal meatus - near the nasal septum ← interconnects: superior and middle and inferior nasal meatus

→ nasopharyngeal meatus ← here is common opening of: superior and middle and inferior nasal meatus

Nasal septum - parts:  bony part - consists of: vomer, perpendicular plate of ethmoidal bone  cartilaginous part - consists of: septal cartilage  membranous part

PHARYNX: - extends from the base of the cranium to the level of cricoid cartilage (C6 vertebra) Parts:  Nasal part of pharynx - NASOPHARYNX - functionally this part is inserted in respiratory system (in the level C1-C2; opens into the nose through two choanae)  Oral part of pharynx - OROPHARYNX - functionally this part is inserted in respiratory system (in the level C2-C4; opens into the oral cavity through isthmus of fauces)  Laryngeal part of pharynx - LARYNGOPHARYNX (in the level C4-C6; opens into the larynx via laryngeal inlet) Nasopharynx:  fornix of pharynx - pharyngeal tonsil (adenoids), pharyngeal recess, pharyngeal opening of auditory (Eustachian) tube, torus tubarius – tubal tonsil, torus levatorius, salpingopharyngeal fold, salpingopalatine fold

Oropharynx:  isthmus of fauces, median/lateral glossoepiglottic fold, vallecula epiglottica

LARYNX: Cartilaginous skeleton of larynx:  unpaired cartilages: - thyroid cartilage (laryngeal prominence, left and right lamina, superior et inferior thyroid notch, superior and inferior horns, oblique line) - cricoid cartilage (lamina – arytenoid/thyroid articular surface, arch) - epiglottis (petiolus, lamina)  paired cartilages: - arytenoid cartilage (apex, base – muscular and vocal process), - corniculate cartilage - cuneiform cartilage - tritiate cartilage - in lateral thyrohyoid lig.

Connections of larynx:  fibrous joints - extrinsic ligaments: thyrohyoid membrane – reinforced by median and lateral thyrohyoid lig. cricotracheal lig.

- intrinsic ligaments: median cricothyroid lig.- continues laterally as a conus elasticus vestibular ligg. (false vocal cords; covered by mucosa = vestibular folds) vocal ligg. (true vocal cords; medially are covered by mucosa membrane = vocal folds, laterally are surrounded by vocalis m.)

→ fibroelastic membrane : membrane composed of a dense elastic fibernet which lies below the mucous membrane of larynx; has 2 parts: quadrangular membrane and conus elasticus

 synovial joints - cricothyroid - cricoarytenoid joint

Laryngeal cavity - parts:  vestibule of larynx - between aditus laryngis = laryngeal inlet (bounded by epiglottis, aryepiglotic folds, cuneiform tubercles, corniculate tubercles, interarytenoid notch) and vestibular folds  ventricle of larynx - a slit between vestibular and vocal folds  infraglottic cavity - between vocal folds and cricoid cartilage

Muscles of larynx:  ventral group - cricothyroideus m. - has straight and oblique part - stretches the vocal cord - innervation: superior laryngeal n.  dorsal group - cricoarytaenoideus posterior (posticus) m. - widens the rima glottidis - innervation: reccurent laryngeal n.

- arytenoideus m. - assits in constricting of the rima glottidis - innervation: reccurent laryngeal n.

- aryepiglotticus m. - assits in narrowing of laryngel inlet (aditus laryngis) - innervation: reccurent laryngeal n.  lateral group - cricoarytaenoideus lateralis m. - narrows the rima glottidis - innervation: reccurent laryngeal n. - thyroarytenoideus m. - narrows the rima glottidis - innervation: reccurent laryngeal n. - thyroepiglotticus m. - widens the entrance into larynx (laryngeal inlet/aditus laryngis) - innervation: reccurent laryngeal n.

Glottis: extended from the rima vestibule (which is between vestibular folds) to the rima glottidis (which is between vocal folds)

TRACHEA: - extends from C6 ̶ Th4-5 - in the level Th4-5 – bifurcation of trachea (inside: carina of trachea) → around bifurcation of trachea: right/left superior tracheobronchial l. nn. inferior tracheobronchial l. nn. - consists of 15 ̶ 20 tracheal cartilages – connected by annular ligg. - its dorsal wall is membranous = paries membranaceus

Parts:  cervical part  thoracic part – in superius and middle mediastinum BRONCHI: - right principal is shorter, wider and more vertical than left principal bronchus Right principal bronchus - division:  superior lobar bronchus (is divided into 3 segmental bronchi)  middle lobar bronchus (is divided into 2 segmental bronchi)  inferior lobar bronchus (is divided into 5 segmental bronchi)

Left principal bronchus - division:  superior lobar bronchus (is divided into 5 segmental bronchi)  inferior lobar bronchus (is divided into 5 segmental bronchi)

LUNGS: External features (common features):  apex, base  costal surface, diaphragmatic surface, medial surface (mediastinal and vertebral surface)  anterior margin (border), inferior margin (border), posterior margin (border)  root of the , hilum of the lung, pulmonary lig. (is a fused triangular-shaped sheet of parietal and visceral pleura)  oblique fissure, horizontal fissure (right lung!)

Differences between right and left lung:  right lung - 3 lobes: upper lobe, middle lobe, lower lobe - between upper and middle lobe is horizontal fissure - in right hilum of the lung: right principal bronchus – epiarterial ↑ right pulmonary a. - caudally right pulmonary vv. - ventrocaudally  left lung - 2 lobes: upper lobe, lower lobe - on the anterior margin (border): cardiac notch - lingula of left lung (structure of upper lobe) - in left hilum of the lung: left pulmonary a. – superiorly left principal bronchus – hyparterial ↓ left pulmonary vv. – ventrocaudally

Impressions - right lung:  impression for 1st rib, cardiac impression, sulcus for superior vena cava, sulcus for subclavian a., sulcus for esophagus, sulcus for azygos v.

Impressions - left lung:  impression for 1st rib, cardiac impression, impression for esophagus, sulcus for left brachiocephalic v., sulcus for subclavian a., sulcus for aorta

Blood supply - lungs:  functional vessels - pulmonary aa. and pulmonary vv.  nutritive vessels - bronchial br. (thoracic aorta, aortic arch, 3rd and 4th right posterior intercostal a.) bronchial vv.

VISCERAL AND PARIETAL PLEURA: Parietal pleura:  is lining the internal surface of the thoracic wall  innervation: sensitive innervation by intercostal and phrenic n.  costal pleura/ mediastinal pleura/ diaphragmatic pleura  cervical pleura (pleural cupula = dome) - 5 cm above superior thoracic aperture  costodiaphragmatic recess/costomediastinal recess

Visceral pleura:  forms a cover over the lungs  innervation: autonomic innervation by vagus n. and sympathetic trunk

→ between parietal and visceral pleura is pleural cavity