Download Thorax

Thorax
MUDr. Veronika Němcová, CSc.
Thorax
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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.pectoralis
major
m.serratus
anterior
m.latissimus
dorsi
m.trapezius
m.latissimus
dorsi
Long thoracic nerve palsy
scapula alata
(winged scapula)
Mamma
Breast - lymph nodes
Apical axillary l.n.
Central axillary l.n.
Lateral axillary l.n.
Pectoral axillary l.n.
(Sorgius lymph node)
Supraclavicular l.n.
Parasternal l.n.
Bordes of the lungs and pleura
area thymica
II
IV
VI
VII
VIII
IX
area pericardiaca
X
Lower borders of the parietal pleura
are „+1 rib“
Pleura parietalis et
pleura visceralis
cupula
pleurae
(5cm above
the thoracis
inlet)
pneumothorax
pars costalis
pars mediastinalis
pars diaphragmatica
recessus
costodiaphragmaticus
parasternal anterior axillary paravertebral line
Section through
the intercostal
space in
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
VANA
Chest drainage – posterior axillary line above the level of the inferior
angle of scapule (Th7)
anterior axillary line
above
the rib
costodiaphragmatic
recess
!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 poststernotomy mediastinitis
Thorax – posterior wall
vessels and nerves
Ao
V.intercostalis suprema
V.azygos
Tr.sympaticus
Ductus thoracicus
Nn.splanchnici
Thorax –inferior wall -diaphragm
4. intercostal space
5. intercostal space
Central tendon
lumbocostal triangle of
Bochdalek
Diaphragm –inferior aspect
Sternal part
Central tendon
Inferior v.cava
+frenic nerve
Oesophagus
+vagus
nerves
Azygos vein
+ splanchnic
nerves
Lumbocostal
triangle
(Bochdaleki)
Costal part
Lumbar part
quadratus
lumborum
psoas
major
aorta +
thoracic duct
Hemiazygos vein
sympathetic + splanchnic
nerves
trunc
Mediastinum
oesophagus spatium retroviscerale
spatium paraviscerale
spatium previscerale
Superius
P
Inferius
A
M
aorta
diaphragma
abdominal cavity
angulus sterni
n. frenicus
Mediastinum superius
(thoracic inlet)
Layers: sternum
rest of the thymus
veins
nerves
arteries
trachea
oesophagus
lungs (laterally)
Superior mediastinum
Schema of the crossection
v.brachiocephalica dx
vasa thoracica int.
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sternum
rest of the thymus n. frenicus
vrstva žil
tr. brachiocephalicus
nerves
n.vagus dx
arteries
trachea
oesophagus
pleuras
tr. sympathicus
v.brachiocephalica sin
n. frenicus
a.carotis comm sin
n.vagus sin
a. subclavia sin
n.laryngeus
reccurens sin
ductus thoracicus
Th3
tr. sympathicus
pleura
visceralis
pleura
parietalis
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.brachiocephalica dx
(compression)
v.cava superior
v.thoracica lat.
v.thoracoepigastrica
v.cava inferior
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
Ortners syndrome is a rare cardiovocal syndrome and refers to reccurent
laryngeal nerve palsy from cardiovascular disease (mitral stenosis, pulmonary
hypertension)
pulmonary artery dilatation
Posterior
mediastinum
n.vagus sin
v. azygos
ductus thoracicus
truncus sympathicus
n.splanchnicus major
oesophagus
Mediastinum right veiw
n.vagus
n.frenicus
ductus thoracicus
n.splanchnicus major
n.splanchnicus minor
eparterial
bronchus
Mediastinum right view
Mediastinum left veiw
n.vagus
hyparterial bronchus
n.frenicus
+ vasa pericardiacofrenica
n.laryngeus
reccurens sin.
Mediastinum
transverse section (Th6)
truncus pulmonalis
aorta ascendens
n. frenicus sin
n. frenicus dx
v.cava superior
nn.vagi
bronchus
principalis sin
oesophagus
bronchus
principalis dx
v. azygos
ductus thoracicus
tr. sympathicus dx
Th6
aorta descendens
v. hemiazygos
tr. sympathicus sin
Mediastinum
transverse section (Th8)
n.frenicus sin
n.frenicus dx
vv. pulmonales
n.vagus sin
n.vagus dx
ductus thoracicus
v. azygos
tr. sympathicus dx
Th8
oesophagus
aorta descendens
Lungs and the heart – anterior aspect
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 – posterior aspect
1-lobus inf.dx
2-lobus inf.sin
3-aorta
4-jícen
5-trachea
Medial wall of
the right lung
apex
sulcus a. subclaviae
sulcus v.cavae sup.
1.rib impression
sulcus v.azygos
a.pulmonalis dx
bronchus principalis dx
mesopneumonium
sulcus v.azygos
sulcus oesophageus
impressio cardiaca
vv.pulmonales
fissura horizontalis
fissura obliqua
lig. pulmonale
basis
pulmonis
Medial wall of
the right lung
Medial wall of
the left lung
fissura obliqua
apex
sulcus a. subclaviae
sulcus
v.brachiocephalicae sin
1.rib impression
sulcus aorticus
a.pulmonalis sin
bronchus principalis sin
vv.pulmonales sin
mesopneumonium
impressio cardiaca
impressio
oesophagea
lig. pulmonale
lingula pulmonis
basis pulmonis
Medial wall of
the left lung
Lymph of the lungs
truncus bronchomedistinalis
truncus tracheobronchialis
n.l.paratracheales dx
n.l. tracheobronchiales sup dx
n.l.paratracheales sin
n.l. tracheobronchiales sup sin
n.l. tracheobronchiales inf
n.l.pulmonales
perilobular
subpleural + peribronchial
n.l.bronchopulmonales
(v hilu)
Regional lymph node classification for lung
cancer staging adapted from the American
Thoracic Society mapping scheme
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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.
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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.
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Inferior Mediastinal Nodes (7-9)
7. Subcarinal.
8. Paraesophageal (below carina).
9. Pulmonary Ligament: nodes lying within
the pulmonary ligaments.
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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
vein
Transverse ridging of the normal esophagus
becoming evident during retching
squamous epithelium
columnar epithelium
Main porto-caval
anastomoses
vv. oesophageae-vv.gastricae
! esophageal varices-bleeding
vv.paraumbilicales - caput Medusae
v.rectalis superior-v.rectalis media
hemorrhoids-bleeding
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
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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. [email protected]