University of Bahr El Ghazal UBG

College of Medicine
Anatomy Department
14. Dcember.2023
Thorax
Presented by: Dr Aurelio Manyang Kuot.
Human anatomy: is the identification and description of the structures of
living thing or the science that studies the structure of the human body.
Types of Anatomy
1. Human Anatomy.
2. Phytotomy (Botany): anatomy of internal plant
3. Zootomy: Internal structure of animal
4. Comparative anatomy: compare the human anatomy structures with
animal

Human anatomy:

1. Gross anatomy.
2. Microscopic anatomy. (histology)
3. Surface anatomy (the external body).
4. Radiology anatomy.
5. Embryology.
6. Cytology and cytogenetic

Who is the father of Anatomy? Herophilus is the father of anatomy and

Aristotle is the father of Biology.

Thoracic cage
The thoracic cage (chest) is formed by:
1. Thoracic vertebrae and intervening discs posteriorly
2. 12 (twelve) pairs of ribs and theirs costal Cartilage and intercostal
spaces posteriorly and Anterolaterally.
 3. The sternum in the midline anteriorly.
The thorax cage: is the area of of the human body lies between the
Neck and Abdomen.it communication, superiorly with the Neck and
inferiorly by diaphragm it is separated from Abdomen.
The thoracic wall: is covered on outside by skin, muscles attaching
the shoulder girdle to the trunk, and skeleton. It is line with parietal
pleura.

opening of the thorax cage.

Are two

A. Thoracic inlet (roof) which connects the thoracic cavity with neck is formed by
the suprapleural membrane which covered the apical of the lung.

B. Thoracic outlet (lower end) which closed by diaphragm.

The thoracic cavity contents

A- Respiratory system (lungs).

B- Heart.
Functions of the thoracic cage are:
1. Prevents the Lungs and Heart.
2. Affords the attachment for the muscles of the Thorax, Upper
limbs, abdomen, and back.
Thoracic cage cavity partitions:
The thoracic cage cavity is divided into partitions as following:
1. Mediastinum (median partition).
2. Pleural and lungs.
NB. Pleural are two membranes the visceral pleural and parietal
pleural.
 Sternum (breastbone)

The sternum is the axial bone located in the midline of the front of chest. It is a
flat bone consisting of spongy bone marrow.

Parts of sternum:
the sternum consists of three

1.Manubrium sterni

2.Body of the sternum

3.Xiphoid process

Manubrium
the manubrium is the upper broadest and thick piece of sternum. The concave
center of its upper margin (suprasternal notch, Jugular notch).

A manubrium opposite T3 & T4 Thoracic vertebrae which articulates with the

clavicle and with one costal cartilage and a half costal cartilage {the upper
part of 2} and a sternal angle called {angle of Louis) is a secondary
cartilaginous joint, lies opposite T4 & 5 Thoracic vertebrae

Clinical important of the manubrium is for bone marrow puncture (to

withdrew red bone marrow for hematological examination) and angle of
Louis for counting the ribs.
Ossification of the sternum

occur from the 5th -9th fetal months (manubrium-stern brae).

Between 15-25 of age Sterne brae fuse from below upward. The xiphoid
process fuses with the body at 40 years of age and the body and manubrium
fuse in old age.
 The Body of the sternum

it is formed by union of four (4) Sternebrae. It is longer, narrow and thinner

than manubrium. It present anterior surface and a posterior surface, its lateral
margin is irregular due to presence of costal notches and has the two joints,
manubriosternal joint above with the manubrium and the xiphosternal joint
with xiphoid process. on both side it joins with the 2-7 costal cartilage

The Xiphoid process

it is the lower part of sternum which is very thinner and tapering. It is

cartilaginous in young age but by the age of 40 it ossifies. No ribs or costal
cartilage are attached to it.

the xiphisternum joint located opposite of body of theT9 Thoracic vertebra

Vertebral levels

1. Upper margin of manubrium corresponds to third thoracic vertebrae.

2. Lower manubrium corresponds to lower margin of 4th thoracic vertebra.
3. The sternal body lies opposite to the 5th -9th thoracic vertebra.
4. The xiphoid joint corresponds to 9th thoracic vertebra.

Joints of sternum

1. Sternoclavicular joint: is a synovial joint between manubrium and medial

end of the clavicle.
2. Manubriosternal joint (an angle of Louis, sternal angle) between
manubrium and body sternum is a secondary cartilaginous joint
(symphysis). Clinical: surface land mark for counting ribs in the person
(patient).
3. Xiphoid joint: is secondary cartilaginous joint which can change into
synostosis by40 years.
4. Manubriocostal joint (first sternocostal joint): is between the first costal
cartilage and the manubrium. It is a synchondrosis (primary cartilaginous
joint.
5. : Sternocostal joint (from second- seventh): between the costal cartilages
and side of the body of sternum synovial {are synovial joint). The second
costal cartilage is attached to the costal notch at angle of Louis.

Posterior Relations.

A. Posterior surface of manubrium forms

1. the anterior wall of superior mediastinum.

2. The arch of aorta and its three branches.
3. The left brachiocephalic vein crosses in front of mentioned
branches.
4. The anterior margins of lungs.
5. Lateral aspect of posterior surface: the interior margins of lungs
and anterior lines of pleural reflect.

B. The posterior surface of the body of sternum forms the following

structures:

1. Anterior boundary of anterior mediastinum

2. heart in close relation of the body of sternum.

 Clinical
a- External cardiac massage in the cardiopulmonary resuscitation (CRP).
b- Midline sternotomy.
Muscles attached to sternum
A- Anterior attachment of sternum.
1- sternocleidomastoid.
2- pectoralis major.
3- external oblique abdominis
4- attachment of linea alba
B- Posterior attachment of sternum.
1- Sternohyoid
2- Sternothyroid.
3- Line of left pleural reflection
4- Line of right pleural reflection
5- Sternocostalis
6- Diaphragm.

The ribs
There are:

12 pairs OF ribs _ 7 True, 3 false, and 2 floating.

NB: Occasionally a normal subject has only 11pairs.

NB: Interchondral joints connect surfaces of costal cartilages 6 & 7 ,7 & 8 and 8 &
9 are joined to each other by synovia joint.

9 & 10 are connected by ligament

SUMMERY
 University of Bahr El-Ghazal

College of Medicine

Second 2023

Course: Female breast

Presented by Dr: Aurelio Manyang Kuot.

Breast (Mammary) gland

The adult breast female is a pair of modified sweet gland in the
superficial fascia anterior to the pectoral muscles and to the anterior thoracic wall
, derived from ectoderm as branching epithelial cord which form lactiferous ducts.

about 15-20 lobe develop during puberty, each of which drain into a single
lactiferous duct.

True secretory alveoli develop during pregnancy and lactation under the influence
of

1.Oestrogen. ductal proliferation .

2.Progesteron. glandular proliferation, and

3.Prolaction. Milk secretion.

The breast is covered with: the skin, areola, and nipple.

Location of the breast

It located in the subcutaneous tissue (superficial of the anterior thoracic
wall), which separates breast lobes and form suspensory ligament cooper
(Foramen of Langar) and fixed to the base of the breast.

Shape: is hemispherical & pendulous in an adult woman.

 Extension
I. vertically: it extends from the second -sixth (2 -6) ribs & their costal
cartilages in the midline – Clavicular line but in child and men, the breast
is rudimentary
Base of breast (bed of the mammary gland).
The base of the breast is in contact with pectoral fascia and rests on
three muscles as following:

1. pectoralis major muscle

2. serratus anterior muscle, and

3. external oblique muscle aponeurosis.

NB.

A .2/3 of the breast rest upon pectoralis major.

B .1/3 rest upon serratus anterior between the breast and pectoral fascia there is
a retro mammary space found filled with loose CT and fat allows free movement
of the breast to all directions.

Clinical important of retromammary.

Is drainage of the pus collection (retromammary) abscess.
II. Horizontally:

From the side of sternum to the mid – axillary line.

Parts of breast (Quadrants of breast}
1.lower medial.
2. Lower lateral.
3. Upper lateral.
4. Upper medial

Nipple
The nipple lies in the fourth intercostal space from the mid line in
males & immature unless the breast is pendulous, in females no permenant.it
covered with:

A. Thick hairless skin.

B. Involuntary muscles.

C. Sensory receptors needed for the sucking reflex.

The areola
Is the rounded zone of pigmented skin that encircles the nipple. Permanent
darkening of the areola & nipple occurs during pregnancy.

Contents:
1. Involuntary muscles.
2. Sebaceous glands which enlarge during pregnancy as (subcutaneous
tubercle –Montgomery).
 3. Sweet glands.

Arterial supply to the breast.

The breast receives arteries mainly from different sources.

1.Branches of lateral thoracic artery, supply the lateral part of breast.

2. Branches of internal thoracic artery, supply the medial part of the gland.

3. Branches of acromiothoracic and superior thoracic, supply to the upper of

breast.

4. Branches of 2nd ,3rd and 4th posterior intercostal arteries, supply the breast
from it base

Venous drainage
1. axillary vein.

2.internal thoracic vein.

3. intercostal veins.

4. the communication of posterior internal veins with the inter vertebral venous
plexus {Via internal vein}. It is main cause cancer spreads from the breast to
vertebra than the spinal cord
 UBG
College of medicine
Second year 2023
Course: thorax
Topic thoracic cage aperture inlet
Presented by: Dr Aurelio Manyang Kuot
thoracic aperture inlet.
Boundaries of thoracic inlet.
1. posteriorly, body of thoracic vertebra T1.
2. lateral inner margins of the first rib and their costal cartilage.
3. Anteriorly, upper margins of manubrium sterni.
Structures passing through thoracic inlet.
I. midline structures.
II. laterally on each side.
In the midline:
A. two strap muscles ( sternothyroid and sternohyoid ) of the
neck.
B. inferior thyroid vein.
C. trachea and
D. the esophagus.
Laterally:
1. apex of the lung.
2. the cervical pleura project upward.
3. the Sibson’s fascia passes from the inner margin of the first
rib to transverse process of C7.
The apex of the lung close to the following structures.
1.posterior to the lung apex (anterior to the neck of first rib}:
i-Sympathetic chain.
ii-Superior intercostal artery.
iii-ventral ramus of the first thoracic nerve.
2. The internal thoracic artery, vague nerve & phrenic nerve
descends in relation to the medial aspect of the lung.
3. the subclavian vessels (artery and vein) pass in front of the
lung apex in lateral direct.
The scalenus anterior and medius muscles descend to inserted
into the first rib.
4. on the right of the midline:
i- a brachiocephalic.
ii- the right brachiocephalic vein.
5. on the left of midline:
i- left common carotid artery.
ii- left brachiocephalic vein.
iii- left recurrent laryngeal nerve.
Iv. the thoracic duct.

Scalene triangle.
The scalene triangle is a narrow triangular space bounded by:
i- Anteriorly by the scalenus anterior.
ii- posterior by scalenus medius.
iii. inferiorly by upper surface of the first rib.
Its contents are:
1. the lower trunk of the brachial plexus.
 2. the subclavian artery.
Scalenus medius muscle it origin from C2 and insertion to rib1.
Scalenus anterior origin from C 3 –C6 and insertion on rib 1
Cervical rib syndrome
The lower trunk of the brachial plexus.
-the subclavian artery

Intercostal spaces
The intercostal space between two ribs and their costal
cartilage.
There are 11 intercostal spaces bounded by twelve (12) ribs on
each side.
The upper nine spaces are close anteriorly, but the short tenth
and eleventh spaces have open anterior ends which reach the
level of mid axillary line.

Contents of intercostal space.

1. Intercostal muscles
2. Intercostal nerve
3. Intercostal vessels.
Intercostal muscles (superficial to deep)
1. External intercostal muscles
2. Internal intercostal muscle
3. Intermost intercostal muscle
External intercostal muscle.
Origin from the lower margin of the ribs above. inserted: to the
upper margin of the rib below.
Parts of external intercostal muscle.
1. Interosseous part between the ribs.
2. Anterior intercostal membrane (membranous
interchondral) between to the near costal cartilage.
Internal intercostal muscle.
Origin from the costal groove of the rib above, inserted into the
upper margin of the rib down.
Parts
1. Anterior end of intercostal space to angle the rib
posteriorly, it is divided into
a) Intercartilaginous part
b) Interosseous part
2. Posterior intercostal membrane (the short membrane
located behind the angle of the rib)
It is a discontinuous muscle layer which is separated from costal
pleura by endo thoracic fascia, it is divided into:
a) . The intercostalis (tranversus thoracic) lies posterior
sternum and cartilage
Origin: posterior aspect of the lower part of body of
sternum, xiphoid process and from fourth to seven
costal cartilage
Insertion: posterior of costal cartilage of second to six
ribs
b) .The intercostalis intermus
Origin: above the costal groove of the upper rib
Insertion: upper of the lower rib.
C) the sub costalis muscles: are found in the posterior
of lower intercostal space only
Nerve supply. From intercostal nerve
I. Posterior ramus of thoracic nerve
II. Intercostal nerve
III. Lateral cutaneous branch
IV. Anterior cutaneous branch.
Mediastinum
The mediastinum is a midline narrow and elongation space
(containing heart and great vessels) between the right and left
pleura cavities.
Boundaries of mediastinum
The mediastinum is bounded by:
I. Sternum anteriorly
II. Thoracic vertebrae posteriorly from T1 – T12
III. Mediastinal pleura on either side.
Extent: the mediastinum extents from the inlet of the thorax to
the diaphragm
Subdivisions
The mediastinum is divided by an imaginary plane passing
from manubriosternal joint (sternal angle) anterior to the lower
of the body the T4 & T5 INT divided into two parts:
1. Superior mediastinum.
2. inferior mediastinum
Subdivision of the inferior mediastinum
1. The anterior mediastinum
2. The posterior mediastinum
3. the middle mediastinum

Boundaries of superior mediastinum

 It is bounded by
1. manubrium sterni anteriorly.
2. upper four thoracic vertebrae (TI, T2, T3, and T4).
3. thoracic inlet superiorly.
4. inferiorly the plane imaginary passing via the disc between
the T4 & T5.
5. The mediastinal pleura laterally.
Contents of superior mediastinum
i. The sternohyoid and sternothyroid muscles originate from the
back of manubrium and the longus colli muscle is present on the front
of upper thoracic vertebrae.

ii. The arch of aorta and its branches (left subclavian, left common
carotid and brachiocephalic).

iii. The veins are the superior vena cava, right and left brachiocephalic
veins and the terminal part of azygos vein. The left superior intercostal
vein courses upwards to open in to the left brachiocephalic vein.

iv. The remnant of the thymus is usually present.

v. The nerves on the right side are the right vagus and right phrenic
nerves

vi. The nerves on the left side are the left vagus, left phrenic and left
recurrent laryngeal nerves.
vii. The esophagus and trachea enter from the neck into the
mediastinum and the thoracic duct enters the neck from the
mediastinum.

viii. Lymph nodes.

Boundaries of Anterior Mediastinum

The anterior mediastinum is a narrow space.

1. Anteriorly—Body of sternum
2. Posteriorly—Fibrous pericardium
3. . Superiorly—An imaginary plane passing through sternal angle
4. Inferiorly—Diaphragm.

Contents
i. Sternopericardial ligaments

ii. Remains of thymus

iii. Lymph nodes

iv. Areolar tissue.

Boundaries of Middle Mediastinum

It is bounded by the following.
 1. anteriorly by anterior mediastinum,
2. posteriorly by posterior mediastinum,
3. superiorly by superior mediastinum,
4. inferiorly by diaphragm and
5. laterally by mediastinal pleura.

Contents
I. . Fibrous pericardium
II. Heart enveloped in serous pericardium inside the fibrous
pericardium iii.
III. Pulmonary vessels
IV. Tracheal bifurcation and terminal bronchi
V. Deep cardiac plexus vi.
VI. Phrenic nerves
VII.

Boundaries of Posterior Mediastinum.

It is bounded anteriorly by

i. tracheal bifurcation, pulmonary vessels, and fibrous pericardium,

ii. posteriorly by lower eight thoracic vertebrae,

iii. inferiorly by diaphragm,

iv. superiorly by superior mediastinum and laterally by mediastinal

pleura.

Contents
i. Esophagus
 ii. Descending thoracic aorta

iii. Azygos and hemiazygos veins

iv. Thoracic duct

V. Vagus nerves

vi Lymph nodes

vii. Splanchnic nerves, branches of sympathetic chain. (Note that

sympathetic chain lies outside the mediastinum beh

Trachea (windpipe)
Definition
The trachea is a tube that conducts air from the larynx into and out the lungs
through the principal bronchi.
1. Inferior

i. Thyroid veins

ii.Strap muscles: sternohyoid and sternothyroid

2.Posterior:

i. Esophagus and

ii.recurrent laryngeal nerves; and •

3. Lateral:

i. lobes of thyroid gland

ii. Common carotid artery.

Length
In the adult, the trachea is about 15 cm long and 2 cm in diameter.
 Location
It is situated partly in the neck and partly in the superior mediastinum. The trachea lies in the
midline in its cervical course at the lower border of the cricoid cartilage at the level of the C6 but is
deviated slightly to the right in its thoracic course.

Extent.
It extends from the lower border of the cricoid cartilage (level with C6) to the carina at the level
at the of sternal angle ( opposite lower border of T4 T5 - the super border of the T5 thoracic
vertebra, on T4 inspiration and T6 expiration).

Carina is a location, where trachea it divides into right and left principal bronchi.

Mobility.
Its upper end moves with larynx and the lower end moves with respiration. During deep inspiration,
the tracheal bifurcation may descend to the level of the sixth (T6) thoracic vertebra.

Tracheal Patency
The walls of trachea are kept patent by 15 to 20 incomplete rings of cartilage .it is C-shaped
cartilaginous. The posterior ends of the cartilaginous rings are bridged together by smooth muscle
called trachealis, which flattens the posterior wall of the trachea. The soft posterior wall of the
trachea allows for the expansion of the esophagus during swallowing.

The trachea is lined by pseudostratified columnar epithelium with goblet.

The trachea in children is very pliable. It may be deviated to the right at almost 90° in a normal
expiratory film. It only deviates to the left if the aortic arch is on the right side.

Relations of the trachea cervical

A. Anterior Relations of Cervical Part of Trachea.
The identification of anterior relations is essential in the operation of tracheostomy.

i. The following layers are seen from superficial to deep aspect, skin, superficial fascia with platysma,
investing layer of deep cervical fascia.
ii. The sternohyoid and stern thyroid muscles overlap the trachea.
iii. The isthmus of the thyroid gland anterior to the 2nd ,3rd and 4th rings and the arterial anastomosis
along its upper margin, cross the second to fourth (2- 4) or second to third (2- 3) tracheal rings.
 iv. The inferior thyroid veins descend from the isthmus into the superior mediastinum. The thyroidea
ima artery, when present is related below the isthmus.

iv. The jugular venous arch crosses the trachea in the suprasternal space.

vi. The brachiocephalic artery is very closely related on the right side at the thoracic inlet.

vii. The pretracheal lymph nodes are scattered on the anterior aspect.

B. Posterior Relations

Posteriorly, the trachea lies on the esophagus with recurrent laryngeal nerve in the groove
between trachea and esophagus.

c. Lateral Relations
The trachea is related laterally to the

i. lobes of the thyroid gland.

ii. inferior thyroid arteries and
iii. common carotid artery in the carotid sheath.

Relations of thoracic part trachea

1. Anterior Relations of Thoracic Part of Trachea
i. The arch of aorta and its two branches, brachiocephalic and left common carotid arteries
are in close relation.

Ii. The left brachiocephalic vein crosses the trachea from left to right and receives the inferior
thyroid veins, which descend in front of the trachea.

Iii. Remains of thymus are in contact with anterior surface.

iv. At the tracheal bifurcation, the deep cardiac plexus and tracheobronchial lymph nodes are
seen.

2 Posterior Relations of thoracic part trachea.

The trachea is in contact with the esophagus.

B. Left recurrent laryngeal

3. Left Lateral Relations

The trachea is related to the

1. arch of aorta
2. left common carotid artery and left subclavian artery.
3. left recurrent laryngeal nerve.
Right Lateral Relations
The trachea is in contact with the mediastinal surface of right lung and pleura.
Its vascular relations on the right side are
a. venous (right brachiocephalic vein, SVC and azygos arch
b. right vagus nerve.
c. right pleura and lung.
d. upper part of innominate artery.

The 3 normal constrictions of the trachea

1.at its upper end by thyroid gland.
2 .at its middle on the right side by right innominate artery.
3 .at its lower end on the left side by the arch of the aorta

Blood Supply.
i. The cervical part is mainly supplied by inferior thyroid arteries.
ii. The thoracic part of the trachea is supplied by the bronchial arteries
(supply the thoracic part & the bronchial tree).
iii .The tracheal veins drain into the inferior thyroid venous plexus.

Lymph Drainage.
The lymph vessels drain into the:

1. pretracheal
2. paratracheal and
3. tracheobronchial lymph nodes, which lie in close vicinity of the trachea
from above downward

Nerve Supply.
The nerve supply to the mucosa, tracheal glands and trachealis muscle is
from

1. the vagus nerves

2.recurrent laryngeal nerves and

3. the sympathetic trunks.

esophagus

The oesophaus is a muscular tube of the digestive. its lumen opens only during deglutition. The
esophagus develops from the endoderm of the foregut.

The main function of the esophagus: is to transport food from the pharynx to the stomach.

Length: 25 cm (10 inches).

Beginning: in the neck, at the lower border of C6 (the lower border of pharynx).

Termination: below the oesophaus opening of the diaphragm (opposite the lower end of T10 ,1 inch
to the left of middle line) by connecting the cardiac end of the stomach at T11.

Parts:

(1).cervical part ,the upper 5 cm in the lower part of neck .

(2) .thoracic part ,the longest part , descending in the superior mediastinum then in the posterior
mediastinum .

(3) .abdominal part ,the shortest part which lies under diaphragm

Course

It descends in the middle line the following the vertebral column except at 2 sites where ir deviates
to the left :

1.at the inlet of the thorax .

2.near its lower end ( opposite T8 ,9 & 10 ) where it deviates to the left to the oesophaus opening of
diaphragm which lies to the left of the middle line .

Constrictions
 Normally the oesophaus has 4 constrictions

1.at the pharyngoesophageal junction in the neck.

2.at the crossing of the aorta arch .

3.at the crossing of the left bronchus .

4.at the esophageal opening in the diaphragmatic .

Relations of Cervical Esophagus

i. Anteriorly, the esophagus is related to

1. the trachea and

2. the recurrent laryngeal nerves.

ii. Posteriorly, it is related to the

1. prevertebral fascia and

2.vertebral column.

iii. the common carotid artery and lateral lobe of thyroid are its lateral relations. on the left side it
is related to : the thoracic duct at the root of the neck .

Relations of Thoracic Esophagus:

1. Anterior relations (from above downwards) are

i. trachea

ii. arch of aorta

iii.right pulmonary artery

iv. left principal bronchus

v. fibrous pericardium and oblique sinus (separating it from left atrium) and diaphragm. The close
anterior relation of esophagus to left atrium is useful for trans-esophageal echography to examine the
base of the heart.

2. The left lateral realations of esophagus are as follows:

i. In the upper part of the superior mediastinum, it is related to

a. left subclavian artery.

b. thoracic duct.
c. left recurrent laryngeal nerve and left pleura and upper lobe of left lung.

ii. In the lower part of the superior mediastinum, its left edge is related to the arch of aorta.

3. In the posterior mediastinum, the descending aorta is on the left side in the upper part. The
esophagus is also related to the left lung and pleura, where it makes an impression on the mediastinal
surface of left lung behind the lower end of pulmonary ligament.

4. The right lateral relations of esophagus are as follows:

i. The esophagus produces a shallow vertical groove behind the hilum and pulmonary ligament of
right lung.

ii. The arch of azygos vein is related at the level of sternal angle.

iii. The descending thoracic aorta is on the right side below the level, where the esophagus crosses in
front of the aorta.

5. The posterior relations of esophagus are as follows:

i. In the superior mediastinum, the esophagus is related to thoracic vertebrae

ii. In the posterior mediastinum at the level of (T5) fifth thoracic vertebra, the thoracic duct crosses
behind the esophagus.

iii. Lower down

A. the descending aorta at T7-T9.

B. thoracic duct T5 and.

C. the azygos vein. A ,B,& C are posterior to the esophagus.

Abdominal Part of Esophagus:

This part it very shortest and is the only part of the esophagus covered with peritoneum.

It is related to the posterior surface of left lobe of liver anteriorly and to the left crus of diaphragm
posteriorly. The right and left gastric nerves enter the abdomen lying along the posterior and anterior
surfaces respectively.

Arterial Supply

Several arteries at different levels supply the esophagus through an anastomotic chain on its surface.
i. The inferior thyroid arteries supply the cervical part of esophagus.

ii.The descending thoracic aorta and bronchial arteries supply the thoracic part of esophagus.
iv. The left gastric and left inferior phrenic arteries supply the abdominal esophagus.

Venous Drainage
i. The cervical part of esophagus drains into inferior thyroid veins.
ii. The thoracic part of esophagus drains into the.
a. azygos and.
b. hemiazygos veins.

Lymphatic Drainage:

1.The cervical part of esophagus drains into deep cervical lymph nodes
2.its thoracic part drains into posterior mediastinal nodes and
3. its abdominal part drains into left gastric nodes

CLINICAL INSIGHT
There are two crucial events in the development of the esophagus.
i. Separation from the laryngo-tracheal tube by formation of a laryngo-tracheal septum.
ii. Recanalization of obliterated lumen. (Note: The muscle of the upper third of
esophagus is striated like that of pharynx, the muscle of the middle third is the mixture
of both striated and non-striated and that of the lower third is non-striated only).
Anomalies
i. Esophageal atresia is due to failure of recanalization of the esophagus. It is associated
with hydramnios because the fetus is unable to swallow the amniotic fluid.
ii. Tracheoesophageal fistula (TEF) is due to maldevelopment of the septum between
the esophagus and the trachea. They are invariably associated with localized atresia of
esophagus and hence hydramnios is a constant feature. In one type of fistula, the upper
segment of the esophagus is blind but the lower segment communicates with the
trachea just above the bifurcation by a narrow channel. This type occurs in 90 percent
of cases. This fistula is characterized by cyanotic coughing attacks in neonate. The infant
may cough up bile and the stomach is distended with air. In another type, the upper
segment of esophagus communicates with the trachea and the lower segment ends
blindly.
iii. Anomalous blood vessels (aberrant right subclavian artery may cause dysphagia or
may remain symptomless. E

THE PLEURA AND PLEURAL CAVITIES

The pleura

is a smooth shining serous membrane that covers the lungs.

It is divisible into two parts:

i. visceral pleura {}an inner layer) and
ii. parietal pleura (an outer layer). Is lines internal surfaces of the thorax wall
The visceral pleura covers the lung surface and give it a glistening appearance.
The visceral and the parietal layers of the pleura are continuous with each other along the
root of the lung and at the pulmonary ligament, which extends downwards from the hilum as a
double-layered pleural fold.
The pleural cavity is a potential space enclosed between the visceral and parietal pleura and
contains a small amount of serous fluid.

Visceral Pleura
i. The visceral pleura is inseparable from the lung.

ii. It dips into the fissures of the lungs.

iii. It shares the blood supply and nerve supply (autonomic nerves) with that of the
lung.
iv. It is insensitive to pain.
V. It develops from splanchnopleuric mesoderm.

Parietal Pleura
i. The parietal pleura is more extensive than the visceral pleura.
ii. It lines the walls of thoracic cavity internally and is supported on its external surface
by a thick layer of endothoracic fascia.

iii.It develops from somatopleuric mesoderm, hence is supplied by

iv. It is pain sensitive.

Subdivisions of Parietal Pleura

It is subdivided into four parts depending on the location

1. costal (costovertebral) pleura

2. mediastinal pleura
3. diaphragmatic pleura
4. . cervical pleura (dome pleura)

Costal Pleura
The costal pleura lines the inner aspect of the thoracic wall including

1. ribs.
2. intercostal spaces

3. sternum, and

4. sides of thoracic vertebral bodies.

Anterior Relations
1. the internal thoracic vessels directly rest on the pleura in the first intercostal space.

2. the sternum

3. costal cartilages.

4. ribs, and

5. intercostal muscles.

Posterior Relations
The costal pleura is related to the

1. sympathetic chain and its branches.

2. At the posterior end of the intercostal space, the intercostal nerve lies between the costal pleura and
the posterior intercostal membrane.

Mediastinal Pleura
It extends down the lug hilum as pulmonary ligament.
1. it covers the anterior part of the medial surface of the lung.
2. inside the lung root and becomes continuous with the visceral pleura at the hilum of lung.
ligament is a connecting bond between the mediastinum and the medial surface of the lung below
the hilum.

Diaphragmatic Pleura
The diaphragmatic pleura covers the superior surface of the diaphragm. Superiorly, it is related to
the base of the lung (cost mediastinal recess of pleural cavity intervening between the two).

Cervical Pleura
 The cervical pleura is the continuation of costal pleura above the level of inner margin of first rib
(above the thoracic inlet). it covers the apex of the lung.

Extention:
The cervical pleura extends posteriorly up to the neck of first rib, which is at a higher level.
The suprapleural membrane (Sibson’s fascia) protects the cervical fascia.
The Sibson’s fascia extends from the tip of transverse process of seventh cervical vertebra to the
inner margin of first rib.

Relations of Cervical Pleura

I. Anteriorly: subclavian vessels and scalenus anterior muscle .
II. Posteriorly: sympathetic chain, superior intercostal artery and ventral ramus of first thoracic
spinal nerve.

Lines of Pleural Reflections

i. Anteriorly: the costal pleura is continuous with the mediastinal pleura at the back of the
sternum along the cost mediastinal line of pleural reflection.

i. Inferiorly: the costal pleura is continuous with the diaphragmatic pleura along the
costodiaphragmatic line of pleural reflection.

iii. Posteriorly: the costal pleura is continuous with the mediastinal pleura by the side of the
vertebral column along the costovertebral line of pleural reflection.

Surface Marking The surface marking of the lines of pleural reflection is important because any

1. puncture (incision) at or inside these lines is likely to result in pneumothorax (air in pleural
cavity) or hemothorax (blood in pleural cavity).
Costomediastinal Line On both sides
the costomediastinal lines begin behind the sternoclavicular joints and descend in medial
direction to come closer to each other at the midpoint of sternal angle. Further course of the
lines is different. On the right side it runs vertically downward up to the midpoint of
xiphisternal joint. On the left side it descends vertically up to the level of fourth costal cartilage
and then deviates laterally to the margin of the sternum and descends close to the sternum up
to the left sixth costal cartilage.

Costodiaphragmatic Line
On the right side, the costodiaphragmatic line begins at the midpoint of xiphisternal joint and
turns laterally along the seventh costal cartilage to reach the eighth rib in the midclavicular
line, tenth rib in the maxillary line, and twelfth rib in the scapular line to finally end at the level
of spine of twelfth thoracic vertebra about two centimeters from the midline. On the left side,
 the line begins at the left sixth costosternal joint, beyond which it follows the course similar to
that of right side. The noteworthy feature about this line of reflection is that it extends below
the costoxiphoid angle on the right side only.

Costovertebral Line

This line extends from a point two centimeter lateral to the seventh cervical spine to a point two
centimeters. lateral to the twelfth thoracic spine.

Cervical Pleura
On the anterior aspect, the cervical pleura is represented by a curved line starting from the
sternoclavicular joint and reaching a point 2.5 cm above the sternal end of clavicle. From here the line
curves down to meet a point at the junction of medial and middle-third of clavicle.

Pleural Recesses
The pleural recesses are the extensions of the pleural cavities along the lines of pleural reflections.
These spaces are unoccupied by lung during quiet breathing. The recesses are present because the
pleural cavities are larger than the lung volumes.

They are present at two locations.

i. The costomediastinal recesses are present along the costomediastinal lines of pleural reflect.
The right recess is very narrow and of uniform size. The left recess is wide at the level of fourth
to sixth costal cartilages. The deviation of the anterior margin of the lung (due to the presence
of cardiac notch) is much more compared to that of the pleural line, at this site. The left
costomediastinal recess is responsible for the presence of the area of superficial cardiac
dullness. Except for the wider part of the left recess the rest of the costomediastinal recesses
are filled with lung during deep inspiration.
ii. The costodiaphragmatic recesses are present along the costodiaphragmatic lines of pleural reflection.
Along this line the lower margin of the pleura is two-rib distance below the lower margin of the
lung. This recess is bounded by the costal and diaphragmatic pleurae and is unoccupied by the
lung in quiet breathing. In deep inspiration, the recesses of both sides are partially filled. The
right recess is related to the liver and posterior surface of right kidney and the left recess to the
fundus of stomach, spleen and posterior surface of left kidney.

Nerve Supply of Pleura

I. The visceral pleura receives innervation from autonomic nerves, hence it is pain
insensitive.
 II. The parietal pleura is supplied by somatic nerves; hence it is sensitive to painful stimuli.
The pain is referred to the thoracic and abdominal walls or to the neck and shoulder. The
costal pleura receives twigs from intercostal nerves.
iii. The peripheral part of diaphragmatic pleura receives branches from the intercostal nerves whereas
its central part from the phrenic nerves.

The mediastinal pleura

is supplied by the phrenic nerve.

Arterial Supply of Pleura

The visceral pleura is supplied by the bronchial arteries and the parietal pleura by the
intercostal and internal mammary arteries.

Functional Importance of Pleural Cavity

When the lungs expand and contract during normal breathing, they slide back-and-forth within
the pleural cavity. To facilitate this, the mesothelial cells of the serous membrane (pleura)
secrete a small quantity of interstitial fluid continuously into the pleural space. The total
amount of fluid is kept at the minimal level by a unique method of pumping out the excess fluid
by lymphatic vessels. This mechanism of continuous turnover of the fluid is responsible for
maintaining the cavity as a potential space and for maintaining the negative pressure in the
pleural cavity, which is necessary to retain the visceral pleura in contact with the parietal
pleura. If there is positive pressure in the pleural cavity (for example, pneumothorax) the
inherent elastic recoil of the lung tissue pulls the visceral pleura away from the parietal pleura
causing collapse of the lung.

The thoracic outlet

It is the lower opening of the thoracic cage at its connect with abdomen.

Boundaries:
1. Anteriorly: the xiphoid process.
2.Posteriorly: T12 thoracic vertebra and 11th & 12th ribs of
both side.
3. Laterally: costal margin (7th ,8th, 9th and 10th), costal
cartilage fuse together.
The thoracic outlet is closed by the diaphragm which is
penetrated by many structures on their way to or from
the abdomen.

DIAPHRAGM
The diaphragm is a movable partition between the thoracic and abdominal cavities. It is partly
muscular and partly tendinous called (a large dome – shaped musculo –tendinous).
It is the chief muscle of inspiration.
The diaphragm descends during inspiration and ascends during expiration. During quiet
breathing it descends for a distance of 1.5 cm.
In supine position, the diaphragm is highest and shows maximum movements but reverse is
the case in sitting position.

Parts and Relations

i. The superior surface of the diaphragm projects as two domes or cupola into the
thoracic cavity. The domes are covered with diaphragmatic pleura. The base of each
lung fits into the corresponding dome.
ii. The central tendon is a depressed area between the two domes of diaphragm. The
central tendon is fused with the base of the fibrous pericardium.
iii. the deeply concave inferior surface of the diaphragm forms the roof of the
abdominal cavity. It is covered with parietal peritoneum.
The right side of the inferior surface is related to the
i . right lobe of the liver.
ii. right kidney and right suprarenal gland.

The left side of the inferior surface is related to the

1. left lobe of the liver.
2. fundus of stomach.
3. spleen.
4. left kidney and left suprarenal gland.
 Surface Marking
i. Anteriorly, the right dome reaches a point as far as the upper border of the right
fifth rib in the midclavicular line and the left dome reaches as far as the lower border of the left
fifth rib.

ii. Posteriorly, the right dome is level with a point 1.25 cm below the inferior angle of
scapula and the left dome is level with a point 2.5 cm below the inferior angle of
scapula. Thus, the right dome is at a higher level due to the presence of a large right
lobe of the liver under it.

iii. The central tendon is at the level of a line joining the xiphisternal joint to the spine of
th
eighth (8 ) thoracic vertebra.

Origin of the diaphragm

is attached circumferentially to the margins of thoracic outlet.
Origin According to the site of origin, the diaphragm is subdivided into three parts.

i. Sternal origin part: arises as two muscular slips from the back of the xiphoid process.

ii. Costal origin part: arises as six muscular slips from the inner surfaces of the costal
cartilages and adjacent parts of the lower six ribs.

iii. Vertebral origin part: arises by 2 muscular bands called (right and left crura) and from 5
arched ligaments (one median ,2 medial, & 2 lateral) called arcuate ligaments on each side.

1. The right crus is attached to the front of the bodies of the upper three lumbar vertebrae
(L1 ,L 2 , L3) and the intervening intervertebral discs.
The right crus is larger in size because of the presence of heavy liver on the right side. A few
fibers of the right crus deviate to the left of the midline to encircle the lower end of the
esophagus. Some fibers of the right crus are attached to the duodenojejunal flexure as
suspensory ligament of duodenum (muscle of Treitz).
2. The left crus is attached to the part of upper two lumbar vertebrae (L1 and L2 and the
intervening disc.
3. The median arcuate ligament is a tendinous arch joining the two crura across the lower
border of the twelfth thoracic vertebra.
The medial and lateral arcuate ligaments or lumbocostal arches give origin to the diaphragmatic
muscle.
4.The medial arcuate ligament
is the thickening of fascia covering psoas major muscle stretching from the side of the body of
the first lumbar vertebra (L 1) to the middle of the front of the transverse process of the same
vertebra.
5. The lateral arcuate ligament
is the thickening of upper margin of the anterior layer of thoracolumbar fascia in front of the
quadratus lumborum muscle. It stretches from the transverse process of first lumbar vertebra
to the twelfth rib on each side.
Insertion of the diaphragm
From this circumferential origin, the fibers of muscular diaphragm converge towards the
central tendon for insertion. The central tendon has no bony attachments. It is trifoliate in
shape and is inseparably fused with the base of the fibrous pericardium.

Apertures in Diaphragm
There are three major apertures and a number of minor apertures in the diaphragm for the
passage of structures between thorax and abdomen.

Major Apertures (openings in the diaphragm).

i.The quadrilateral vena caval aperture

lies at the level of eighth thoracic vertebra T8. It is located in the central tendon to
the right of the midline. The wall of the inferior vena cava is fused with the margins of
the opening. The contraction of the diaphragm enlarges the caval opening thereby
dilating the vein and promoting the venous return. The branches of the right phrenic
nerve pass through this opening along with IVC.

ii. The elliptical esophageal hiatus

is located in the muscular part of the diaphragm just posterior to the central
tendon and to the left of the midline. The fibers of the right crus encircle it. It is at the
level of the tenth (T10) thoracic vertebra. The contraction of the diaphragm has a
sphincteric effect on the hiatus (pinchcock effect).
The vagal trunks and the esophageal branches of left gastric vessels pass through the
hiatus along with esophagus.
iii. The rounded aortic opening
lies posterior to the median arcuate ligament at the level of twelfth thoracic
vertebra (T12).
The contraction of the diaphragm has no effect on this opening. The thoracic duct and
vena azygos pass through the opening along with the aorta.

Minor Apertures
i. Superior epigastric vessels: pass through a gap (space of Larry) between sternal
origin and costal origin from seventh costal cartilage.
ii. Musculophrenic vessels:
pass through the interval between slips of origin of diaphragm from the seventh and
eighth ribs. The seventh intercostal nerve and vessels also pass through this interval.
 iii. The eighth to eleventh intercostal nerves and vessels pass through intervals
between the adjacent costal origins from subsequent ribs.
iv. Subcostal nerves and vessels pass behind the lateral arcuate ligament.
v. Sympathetic chains pass behind the medial arcuate ligaments.
vi. Greater, lesser and least splanchnic nerves pierce the crus of the corresponding
side.
vii. Hemiazygos vein pierces the left crus.
viii. Right phrenic nerve passes usually through the IVC opening and the left phrenic
nerve through the muscular part in front of the central tendon.

Motor Nerve Supply

The phrenic nerves supply the muscle of the diaphragm. They pierce the diaphragm and
ramify on its abdominal surface before entering the muscle.
The right phrenic nerve supplies the right half of the diaphragm up to the right margin
of the esophageal opening.
Left phrenic nerve supplies the left half of the diaphragm up to the left margin of the
esophageal opening. Since the fibers of the right crus encircle the esophageal opening,
it receives branches from both phrenic nerves.
Sensory Nerve Supply
i.The central part of diaphragm and related pleura and peritoneum are supplied
by sensory fibers of phrenic nerves. Irritation of the pleura or the peritoneum of
the central part of diaphragm gives rise to referred pain in front of and at the
tip of the shoulder, which is the area of cutaneous supply of supraclavicular
nerves (C3, C4).
ii. The peripheral part of diaphragm is supplied by lower intercostal nerves.

Arterial Supply
i.Superior phrenic arteries (called phrenic arteries), which are the last
branches of thoracic aorta, are distributed to posterior part of the
superior surface of the diaphragm.
ii. The musculophrenic and pericardiacophrenic branches of the
internal thoracic artery supply anterior part of the superior surface of
diaphragm. iii. Inferior phrenic arteries, which are the first branches of
abdominal aorta, supply the inferior surface of the diaphragm.

Lymphatic Drainage

1. The thoracic surface drains as follows:

i. Its anterior part drains into the anterior diaphragmatic nodes and
parasternal nodes.
 ii. The middle part drains into right and left lateral diaphragmatic
nodes, parasternal nodes and posterior mediastinal nodes. iii. The
posterior part drains into posterior diaphragmatic nodes and posterior
mediastinal nodes.
2. The abdominal surface drains as follows:
i. The right half of diaphragm drains into lymph nodes lying along
inferior phrenic artery and in the right para-aortic lymph nodes.
ii. The left half drains in preaortic nodes and in nodes around lower
end of esophagus.
Actions
i. The diaphragm is a muscle of inspiration. When the
diaphragm contracts, the domes of the diaphragm along with
the central tendon descend; thereby increasing the vertical
diameter of the thoracic cavity. Once the limit of the descent is
reached the central tendon becomes a fixed point around
which the muscular diaphragm contracts. This contraction
Diaphragm and Phrenic Nerves 233 26 elevates the lower ribs
thereby pushing forwards C h a p t e r the sternum and the
upper ribs, which increases the transverse and anteroposterior
diameters of the thoracic cavity.
ii. The contraction of the diaphragm raises the intraabdominal
pressure, which is useful in all expulsive activities like
micturition, defecation and parturition. It also helps in
weightlifting when the raised intraabdominal pressure is kept
sustained by closure of the glottis after taking a deep breath.
This maintains the vertebral column in extended position, thus
helping the trunk muscles in lifting heavy weights.
iv. The contraction of the diaphragm facilitates venous and lymph return. The rise in the intra-
abdominal pressure and decrease in the intrathoracic pressure compress the blood in the
inferior vena cava and lymph in the cisterna chyli. This results in upward movement of the
blood towards the right atrium and of the lymph towards the thoracic duct.

Developmental sources of diaphragm

The diaphragm is entirely mesodermal. It develops in the neck of the embryo from four
different sources as follows:
i. Septum transversum
ii. ii. Right and left pleuroperitoneal membranes

iii .Dorsal mesentery of the esophagus

iv. Body wall mesoderm

v. The muscle of the diaphragm develops from the third, fourth and fifth cervical myotomes and hence,
its motor innervation is from the phrenic nerve. When the diaphragm descends from the neck
to its definitive position, its nerve supply is also dragged down. This explains the long course of
the phrenic nerves.
Congenital Diaphragmatic Hernia

i .The retrosternal hernia occurs through foramen of Morgagni, which is an enlarged

space of Larry.

ii. The posterolateral hernia occurs through the vertebrocostal triangle (also called foramen of
Bochdalek). It is a gap between the costal and vertebral origins of the diaphragm. This gap
results due to failure of closure of the pleuroperitoneal canals on account of non-development
of pleuroperitoneal membrane. This occurs more commonly on the left side. The abdominal
viscera may herniate through this defect into the thorax producing hypoplastic lung (Fig. 26.4)
and respiratory distress soon after birth. Figure 26.5 shows a child with congenital
diaphragmatic hernia (CDH) with typical scaphoid or sunken abdomen. The radiograph of chest
shows herniated intestines and hypoplastic lung and shift of mediastinum to the right (Fig.
26.6). The surgical repair of hernia and closure of foramen of Bochdalek is shown in Figure 26.7.