THORAX (22)

Write short notes on the venous drainage of the thorax

Write short notes on the right pleura and associated spaces.
Mediastinum
Thymus
Thyrocervical trunk
Thoracic innervation

Write short notes on the anatomy of the left ventricle of the heart.

Thickest walled chamber of the heart. (2-3x the size of the right ventricle)
Situated between the mitral valve, apex of the heart and the aortic valve
Forms part of the lateral and the posteriolateral surface of the the heart and the apex
Ascending aorta arises from its superior part
Cavity is conical in cross section

Outer surface
Forms the anterior, diaphragmatic and left pulmonary surfaces of the heart and the apex
Anteriormedially - anterior intraventricular sulcus containing anterior descending and great cardiac
vein
Superior and posteromedial - AV groove containing the L) circumflex, great cardiac vein and
coronary sinus
Inferiorly - the posterior intraventricular sulcus running from the AV groove to the apex containing
the middle cardiac vein and right coronary artery

Interior
AV orifice, guarded by the mitral valve

Aortic orifice, guarded by the aortic valve

Well developed trabecullae carneae, finer and more numerous to the right ventricle

Two large papillary muscles (anterior and posterior) connected to the anterior and posterior leafs of
the mitral valve via chordae tendinae

Outflow tract below the aortic orifice is the aortic vestibule and is posterior to the infundibulum of
the right ventricle

Intraventricular septum has two parts - proximal membranous part and larger, thicker muscular part
Margins correspond to the anterior and posterior inter ventricular grooves on the surface of the
heart
Small oval membranous area is the common site of a ventricular septal defect

Mitral valve
Bicuspid atrioventricular valve - anterior and posterior cusps attached to the fibrous ring of the
cardiac skeleton
Chordae tendinae attach papilllary muscles to the free edges of the cusps
Anterior cusp is larger and forms a partition between the AV orifice and the aortic orifice

Aortic valve
Closes the aortic vestibule from the ascending aorta
Three semilunar cusps - right, left and posterior - projecting upward into the lumen of the
ascending aorta
Pocket like sinuses between the cusps and the ascending aorta form the right, left and posterior
aortic sinuses
 THORAX (22)
Right and left coronary arteries originate from the right and left aortic sinuses
Located obliquely, posterior and to the left side of the the sternum at the level of the 3rd intercostal
space

Relations
Ant - IV septum and right ventricle
Post - pericardium, descending aorta
L) Lateral - pericardium, pleura, lung, L) phrenic nerve

Arterial supply- R) coronary a (posterior interventricular a) and L) coronary a (anterior

interventricular a and circumflex a)

Venous drainage
Thesebian a
Great vein
Middle cardiac vein

Innervation
L) bundle branch
Cardiac plexus

Lymph
To tracheobronchial LNs

Write short notes on the anatomy of the coronary arterial circulation and normal variations
Write short notes on the anatomy of the coronary arterial circulation and venous drainage.

Coronary artery circulation

Two coronary arteries arise from the aortic sinuses in the initial portion of the ascending aorta and
supply the muscles and other tissues of the heart
Circle the heart in the coronary sulcus with marginal and inter ventricular branches (in the IV sulk)
converging towards the apex of the heart
Course just deep to the epicardium and are covered by fat
Endocardium receive blood directly from diffusion or microvasculature directly from the chambers
of the heart

Right coronary artery

Originates from the right aortic sinus of the ascending aorta

Terminates at the junction of the AV sulcus and the posterior IV groove - anastamoses with
circumflex

Passes anteriorly then descends vertically in the coronary sulcus between the right atrium and right
ventricle
On reaching the inferior margin of the heart it turns posteriorly and continues in the coronary sulcus
onto the diaphragmatic surface and base of the heart

Branches
Early atrial branch passes in the groove between right auricle and ascending aorta giving off a
sinoatrial nodal branch
Right marginal branch at the inferior margin of the heart and continues along this border toward the
apex
Atrioventricular nodal branch from base of heart
 THORAX (22)
Posterior interventricular branch is final major branch which lies in the posterior IV sulcus

Supplies
Right atrium, right ventricle, sinoatrial and AV nodes, inter atrial septum and postero inferior 1/3 of
the IV septum and a portion of the posterior left ventricle

Left coronary artery

Originates at the left aortic sinus of the ascending aorta
Passes between the pulmonary trunk and the left auricle before entering in the coronary sulcus
Divides into two terminal branches after emerging fro the pulmonary trunk

Anterior interventricular branch (LAD)

- continues around the left side of the pulmonary trunk and descends obliquely towards the apex
of the heart in anterior IV sulcus
- One or two diagonal branches may arise and descend diagonally along the anterior ventricular
surface

Circumflex branch
- courses toward the left in the coronary sulcus and onto the base/diaphragmatic surface
- left marginal artery, large branch that continues along the obtuse/left border of the heart
- SA nodal a arises from circumflex in 40%
- circumflex artery usually ends before reaching the posterior IV sulcus

Supplies the left atrium, left ventricle, most of the IV septum including AV bundle and bundle
branches

Variations
Dominance patterns
Single coronary artery
Right coronary artery is a continuation of the circumflex and right marginal branch comes from it
Circumflex arising from the right aortic sinus
Accessory coronary artery - 4%
Right coronary occ arises from the pulmonary trunk
Branches of the LCA may arise as a common trunk or both from the same aortic sinus

RCA variations
Partial supply of the posterior IV artery by marginal branches
Double posterior IV a
Early origin of the posterior IV a
Absent posterior IV a > supplied by small arteries or continuation of left IV artery around apex

LCA variations
LCA trifucation in 30% - intermediate artery (ramus medianis) arises between Left IV and
circumflex and supplies anterior left ventricular wall
20% LAD does not reach apex
Septal branch may run parallel to LAD
Separate LAD and circumflex origins

Anastamoses
RCA and circumflex in coronary sulcus (AV groove)
Post IV and ant IV in IV septum
Circumflex and right coronary artery in AV groove

Dominance
Defined by which artery gives rise to the Post IV
 THORAX (22)
Right dominant if it arises from the RCA (85%)
Left dominant if it arises from an enlarged circumflex a (7-10%)
Co-dominant 7% - arise from both posterior IV and circumflex

Coronary veins

Heart is mainly drained by veins that empty into the coronary sinus and partly by small veins that
empty directly into the right atrium

Coronary sinus is a wide venous channel; 3cm long

Originates as a continuation of the great cardiac vein
Courses from left to right in the posterior part of the coronary groove
Ends in the right atrium at the coronary sinus orifice between IVC and right AV orifice
Protected by the valve of the coronary sinus (valve of Thebesius)

Coronary sinus receives four major tributaries:

Great cardiac vein (aka LAD)

Main tributary
Begins near apex of heart
Ascends with the anterior IV branch
At coronary groove turns left and runs with the left circumflex a to reach/become the coronary
sinus
Drains LCA territory

Middle cardiac vein (post IV vein) (aka post IV a)

Accompanies posterior IV a
Enters coronary sinus at right near termination of sinus
Drains RCA territory

Small cardiac vein (aka right marginal a)

Accompanies marginal branch of RCA and runs posteriorly in coronary groove
Drains RCA territory
Enters coronary sinus at right end

Posterior cardiac vein (aka L) marginal a)

Lies on posterior surface of the left ventricle to the left of the middle cardiac vein
Enters coronary sinus directly or joins great cardiac v

NOT TRIBUTARIES
Anterior cardiac veins
Small veins arising on anterior surface of RV
Enter anterior wall of right atrium
Drain anterior surface of heart

Smallest cardiac veins (venae cordis minimae/veins of Thebesius)

Minute vessls in myocardium which drain directly into cardiac chambers
Mostly right atrium and ventricle

Variations
Oblique vein of left atrium
Small cardiac vein may drain directly into wall of right atrium
Coronary sinus tribulatries are variable and may receive all veins
Obliterated or absent coronary sinus
Persistent left SVC
 THORAX (22)
May open into left atrium

Write short notes on the anatomy of the aortic arch and normal variants.

Aortic arch runs from the ascending aorta at the level of T4/5
Ternminates at the level of T4 vertebral body where it becomes the descending (thoracic) aorta

Course
Passes superiorly from its origin, both posterosuperiorly and to the left
Passes over the left main bronchus
Highest level at T3/T4 (midpoint of manubrium) where it gives off three main branches
Branches (from closest to origin)
Right brachicephalic
- branches anterior to trachea and posterior the left brachiocephalic v
- divides into right common carotid and subclavian aa
- Supplies right side of head and right upper limb

Left common carotid

- branch comes off posterior and left of brachiocephalic trunk
- initially anterior to trachea and then to its left
- supplies left side of head
- crossed anteriorly by left brachiocephalic v

Left subclavian
- arises from posterior arch, distal to L) CCA
- crossed anteriorly by left brachiocephalic v

Anastamoses

Relations
Anterior/Left - left vagus n. left phrenic n., thymus, pleura
Inferior - ligamentum arteriosum, left recurrent laryngeal n, bifurcation of pulm trunk, left main
bronchus
Post/Right - trachea, oesophagus, thoracic duct, left recurrent laryngeal n, SVC, right phrenic n

Variants
Bovine configuration - common origin of BCT and LCCA
"Left brachiacephalic trunk" as common oriigin
Left common carotid from brachiocephalic trunk (on right)
Absence of BCT
Left vertebral originating from arch
Coarctation
Right aortic arch with mirror image branching or aberrant left subclavian passing retro-
esophageally
Rarely doubled

Write short notes on the anatomy of the pericardium and its recesses. Write short notes on
the anatomy of the pericardium. Write short notes on the anatomy of the pericardium
including sinuses and recesses.

Closed fibroserous sac consisting of parietal and visceral layers that enclose a potential space
containing 20-25ml of fluid. Composed of fibrous and serous layers

Structure
 THORAX (22)

Fibrous pericardium
Tough CT layer that defines boundaries of middle mediastinum
Cone shaped bag with base at diaphragm and apex continuous with the adventitia of the great
vessels
Encloses heart and roots of the great vessels
Broad base attached the central diaphragmatic tendon and to a small muscular area of the
diaphragm on the left
Anteriorly attached to the posterior surface of the sternum by the sternopericardial ligaments
Stabilises the heart and prevents in from overdialating

Contains:
Phrenic nerves (innervate it)
Pericardiacophrenic vessels

Serous pericardium
Layer of serosa that lines the fibrous pericardium
Made up of parietal and visceral layers

Sinuses
Reflexions around the roots of the great vessels

Transverse pericardial sinus - superiorly

- surrounding arteries, aorta and pulmonary trunk ;
- creates a space between the aorta and pulmonary a
- separates arteries from veins
- Bound by: SVC ant, pulm trunk and ascending aorta post; atria superioly
- Divided into following recesses

1. Superior pericardial/aortic recess

Superior extent of the transverse sinus (in front and around ascending aorta)

Posterior portion
Semicircular fluid filled region adjacent to the posterior to the ascending aorta and main pulmonary
s

Anterior portion
Anterior to the aorta and PA forming characteristic cleft as it indents between great vessels
Sometimes called AP window recess

2. Left and right pulmonic recesses (behind the pulmonary trunk

Lateral margins of the transverse sinus
Right - inferior to the proximal right PA; bounded by reflections of the pericardial extending from
RPA to the SVC

Left - between the left pulm artery and the left superior pulm vein; anterior to LUL bronchus

3. Post caval recesses (between SVC and right pulm a)

Posterolateral to the SVC btw the right pulm a and the right superior pulm vein

4. Left and Right pulmonary venous recess (between the 4 veins)

Between the superior and inferior pulmonary veins; project superiorly and medially poster to the left
atrium
 THORAX (22)

SAR - superior aortic region (anteiror, posterior and right lateral portion)
LPR - left pulmonic recess
RPR - right pulmonic recess
PPR - posterior pericardial recess (in oblique sinus)

Oblique pericardial sinus - posteriorly (behind the veins)

- surrounding veins, SVC, IVC and pulmonary veins;
- J-shaped cul de sac
- Can be entered inferiorly but not exited
- Ant - posterior wall of left atrium between the four pulmonary veins
- Post - pericardium overlying anterior wasll of the oesophagus
- Laterally - pericardial reflections surrounding the pulm veins and IVC

Arterial supply
- pericardiacostophrenic artery (branch from internal thoracic)
- Musculophrenic (internal thoracic)
- Bronchial, oesophageal and superior phrenic aa
- Coronary arteries (visceral layers only)

Venous drainage - internal thoracic and superior phrenic

Tributaries of azygous system

Innervation - phrenic, Vagus, Sympathetic trunks

Variants
Pericardial cyst - non communicating outpouching of parietal pericardium
Congenital absence - often life threatening

Write short notes on the anatomy of the diaphragm. Write short notes on the anatomy of the
diaphragmatic hiatuses and their contents. Write short notes on the anatomy of the major
and minor openings of the diaphragm and list structures transmitted.

Dome shaped musculotendinous partition separating the thoracic and abdominal cavities
Principal muscle of respiration
Forms floor of the thoracic cavity (inferior thoracic aperture) and roof of abdominal cavity

Structure
Curves superiorly into right and left domes
Has a central tendon and muscular periphery
Right and left posterior parts descend into paravertebral gutters
 THORAX (22)

Muscular periphery parts:

Sternal - two muscular slips that attach to the posterior xipoid; sternocostal hiatus (foramen of
Morgagni (at ~T8/T9)

Costal part - wide muscular slips that attach to internal surfaces of the inferior costal cartilages (6)
and adjoining ribs; forms right and left domes; interdigitate with transverses abdomens

Lumbar part - arises from the lumbar vertebrae by 2 musculo-tendinous crura; attached to
anterolateral lumbar bodies (L1-3 on right; L1-2 on left)

Crura blend with anterior longitudinal ligament; unite opposite the T12-L1 disc by tenidinous band
called median arcuate ligament
Right crura broader and longer than the left and fibres form a sling around the oesophagus

Medial arcuate ligament - thickenings of the thoracolumbar fascia over superior part of psoas
muscle; runs from crus, over the psoas to attach to TP of L1

Lateral arcuate ligament - Thickening of the thoracolumbar fascia over superior part of quadrates
lumborum muscles; runs from TP of L1 to the 12th rib

Pericardiophrenic ligaments - attach to inferior surface of fibrous pericardium

Hiatuses

Caval - T8
at junction of right and left central tendon
2-3cm to the right of median plane
Fused with adventitial wall of IVC
IVC and right phrenic pass through

Oesphageal - T10
Formed by right crus which form a muscular sphinctor
2-3cm to the left of the median plane
Contains - esophagus, vagus nerve, branches of left gastric vessels, lymphatics

Aortic - T12
Formed by the left and right crus and the median arcuate ligament
Passes behind diaphragm and to the left of the median plane
Contains aorta, thoracic duct and azygous vein

Behind the:
Medial arcuate - sympathetic trunk
Lateral arcuate - subcostal n and vessels
Sternocostal hiatus - superior epigastric vessels

Piercing structures:
L) phrenic n (central tendon)
Splanchnic nerves
Hemiazygous - left crus
Lymph

Relations
Right and left dome
Anterior lateral and post - costodiaphragmatic recess, body wall
Medially - central tendon, fibrous pericardium
 THORAX (22)
Sup - diaphragmatic pleura
Inferior - right - peritoneal ligaments and bare area of liver; left - spleen, stomach

Arterial supply
Superior phrenic (from thoracic aorta)
Inferior phrenic aa (from the abdominal aorta)
Internal thoracic branches ( pericardacophrenic and musculophrenic aa)
Small intercostal contribution

Venous drainage
Parallels arteries to brachicephalic, azygous and abdominal veins

Innervation - phrenic (C3,4,5)

Lymph drainage - lymphatic plexuses on superior and inferior surfaces

Sup> parasteral, posterior mediastinal and phrenic nodes
Inf> anterior diaphragmatic, phrenic and superior lumbar nodes

Variants
Partial duplication
Accessory phrenic n
Slip of 12th rib may be absent
Eventration - abnormal elevation of a component of the diaphragm
Hernias R>L
Bochdaleks foramen - failure of fusion btw lumbar and costal elements
Morgagnis foramen - failure of closure of the sternal and costal elements

Write short notes on the segmental anatomy of the lungs, with normal variants. Write short
notes on the segmental anatomy of the left lung. Write short notes on the segmental
anatomy of the right lung

The lung is divided into brochopulmonary segments each supplied by a segmental bronchus and
its accompanying pulmonary artery branch. Intersegmental parts of the pulmonary vein drain. Gas
and fluid drain between due to pores of Kohn and canals of Lambert

Each segment is shaped like an irregular cone with the apex at the origin of the segmental
bronchus and the base projecting peripherally on to the surface of the lung

Smallest functioning independent region of the lung and smallest area that can be removed
Divided from adjacent segments by CT septa

Each main bronchus divides into lobar bronchi (3R, 2L) and lobar into segmental
Each segment takes its name from that of its supplying bronchus

Right lung
Right main bronchus above the artery
2.5cm long, 1.5cm diameter
More vertical
Subdivided into three lobes with ten segments
Horizontal fissure is transverse and separates the upper and middle lobes
Obliques fissure separates middle and lower lobes inferiorly and upper and lower lobes superiorly

Upper lobe - apical, posterior and anterior segements

 THORAX (22)
Middle lobe - lateral and medial segments
Lower lobe - Superior, anterior, posterior, medial, lateral

Left lung
Left main bronchus below the artery
5cm long, 1.2cm diameter
45 degree angulation
Divides after entering hilum

Divided into two lobes with 8 segments (two combined segment)

Oblique fissure divides into upper and lower lobes

Upper lobe
Apicoposterior
Anterior
Superior lingual
Inferior lingual

Lower lobe
Superior
Anteromedial
Lateral
Posterior

Variants
Right apical segment bronchi originates from trachea
Right anterior bronchus may originate from the middle lobe stem
Carina at T7 instead of T5 or T6
Cardiac bronchus - short blind ending bronchial stump arises from bronchus intermedius; does not
supply parenchyma
Oesophageal bronchus - from main bronchus giving rise to oesophageal lung or lobar bronchus

Write short notes on the anatomy of the trachea. Write short notes on the anatomy of the
trachea and bronchial tree.

Flexible airway tube connecting the larynx to the bronchi in the lungs
Commences in the neck at the lower border of the cricoid cartilage at the level of C6
Ends at the bifurcation into right and left main bronchi at the level of T4/5(the carina)

Structure
15x2cm
Held open by C-shaped transverse cartilage rings embedded in wall (open part facing posteriorly)
Fibroelastic membrane makes up wall
Posterior gap closes by a sheet of muscle (trachealis)
Courses verticality to enter the thoracic inlet in the midline where it lies in contact with the
manubrium
Bifurcates at the carina level with the sternal angle (lower border of T4)

Relations
Cervical
Ant - cervical fascia, infrahyoid m., isthmus of the thyroid gland (adherent to 2-4th trachea rings),
jugular venous arch, pretracheal fascia and LNs
 THORAX (22)
Post - oesophagus and thoracic duct, B/L recurrent laryngeal nerve in groove btw trachea and
oesophagus

Lateral - lateral lobe of thyroid, inferior thyroid aa, carotid shealth, pleura and lung at root of neck

Thoracic relations
Ant - manubrium, thymus, L) brachiocephalic v., origin of brachiocephalic and L) CCA, aortic arch,
anterior marigins of pleura, pretracheal LNs

Post - oesphagus, thoracic duct, L) recurrent laryngeal n. T1-T4

Left - aortic arch, L) CCA, L) subclavian, vagus and phrenic nerves, pleura and LUL

Right - brachiocephalic a, SVC, vagus n.

At carina
Ant - bifuraction of pulm trunk, aortic arch, tracheobronchial LNs

Arterial supply
Upper - inferior thyroid a
Lower - Branches of bronchial aa

Venous - brachiocephalic v; inferior thyroid plexus

Innervation
Middle cervical sympathetic ganglion
Vagus via R) recurrent laryngeal

Lymph - pre and para tracheal LNx

Variation
Tracheal bronchus (accessory bronchus originating from supracarinal trachea)
Pig bronchus - where entire upper lobe is supplied by right tracheal bronchus
Diverticulum - posteriorly where tracheal rings are deficient
Atresia
Stenosis
Inferior bifurcation (T7)

Relations of the lungs

Right
Costal - thoracic wall
Base - right lobe of liver
Apex - TP of C7 and inner border of 1st rib, subclavian vessels, T1 nerve to brachial plexus
Medial - (post to ant) descending and arch of aorta, esophagus, L) subclavian a, L) CCA, L)
brachiocephalic vein, left ventricle

Left
Costal - thoracic wall
Base - left lobe of liver, stomach, spleen
Apex - TP of C7 and inner border of 1st rib, subclavian vessels, T1 nerve to brachial plexus
Medial - (post to ant) - Azygous vein, esophagus, IVC, R) subclavian a. SVC, L) brachiocephaic v,
right brachiocephalic v, subclavian v

Innervation
 THORAX (22)
Anterior and posteior pulmonary plexuses (at ant and post root of lung)
Sympathetic
Parasympathetic - vagus

Lymph
Superificial plexus > deep to visceral pleura, drain to bronchopulmonary LNs in the hilum; drain
lung and pleura > posterior mediastinal nodes

Deep plexus > Submucossa of the bronchi and peribronchial CT >drain along the large
branches of the main bronchi to the bronchopulmonary nodes of the hilum

Variants
Hypoplasia of lobes or entire lung
Accessory inferior lobes on either side
Rudimentary lung tissue (ectopic lung) from tracheal diverticula or rarely below the diaphragm
Azygous fissure
Small process of right lung above the base behind IVC termination can become isolated as the
lobus cava

Write short notes on the anatomy of the pulmonary veins including normal variants. Write
short notes on the anatomy of the pulmonary venous drainage and normal variants.

Pulmonary veins carry oxygenated blood back to the heart

Typically four
- right superior - drains upper and middle lobes
- right inferior - drains right lower lobe
- left superior - drains upper lobe
- left inferior - drains left lower lobe

Begin in capillaries, unite into larger and larger vessels that run in lobular septae (dont follow
bronchi)
A main vein drains each bronchopulmonary segment, usually on the anterior surface of the
corresponding bronchi
Communication with the deep bronchial veins within the lung

The named veins (as above) begin at the hilum pass through the root of the lung
Short intrapericardial segment
Covered by a short myocardial layer
Drain into the superior and posterior confluence of the left atrium

Relations
Right sup - anterior and slightly inferior to pulm a
Right inf- posterior and inferior the the pulm artery and bronchus
Both pass posterior to SVC and Right atrium

Left veins pass anterior to the descending aorta

Variants
70% have 4 pulm veins
One solitary vein from left or right
3 from right - Right middle lobe directly drains into atrium
Partial anomalous pulmonary venous return - drain into a structure besides the left atrium
 THORAX (22)
Bronchial veins are counterparts to the bronchial arteries
Drain the bronchi, hilar structure, mid portion of the oesophagus
Typically a single bronchial vein at each hilum formed from the superficial bronchial vv with the
deep bronchial veins draining into the pulmonary veins

Deep bronchial veins

- form from intrabronchial venouss plexuses which untie to form venous trunks that run along the
bronchi near the hilum and form the deep veins
- drain either directly into the left atrium or into pulmonary veins
- significant anastamoses with intrapulmonary veins within the lung

Superficial bronchial veins

- Consist of a sub pleural venous network which receives tributaries from extrapulmnonary
bronchi, hilar LNx and vasovasorum of hilar pulmonary vessels
- unite to form single bronchial vein at each hilum
- right bronchial v > azygous v
- left bronchial v > accessory homozygous or left brachiocephalic or left superior intercostal

Drain large subdivisions of the bronchi but drain only part of ht elbow delivered by the bronchial
aa/some is drained by pulmonary veins.

Write short notes on the pulmonary and systemic blood supply to the lungs

Blood supply to the lungs is dual, including deoxygenated blood from the right ventricle via the
pulmonary trunk, and oxygenated systemic blood supply from bronchial arteries exiting the thoracic
aorta

Pulmonary trunk
Begins at the base of the right ventricle at the pulmonary valve - level T5, to the left of the midline
Short and wide
3cm diameter, 2cm length

Supplies
Deoxygenated blood to the capillary-alveolar interface for oxygenation

Course
Arches to the left of the aorta; both enclosed in a serous pericardium sleeve
Bifurcates in the concavity of the aorta to the left of the midline at the T4/5 level; in front of left main
bronchus
Connected to aortic arch by ligamentum arteriosum
Right and left pulm arteries enter the lung roots with their bronchi

Right pulm artery

Longer than left, passes horizontally across the mediastinum
Anterior and inferior to the tracheal bifurcation
Ant to right main bronchus
Posterior to the ascending aorta, SVC and upper right pulm vein

Enters root of lung and gives off large branch to upper lobe, main vessel continues through hilum
and gives off second (recurrent branch) to upper lobe and then divides into middle and inferior lobe
supplies

Left pulm artery

Shorter than right
Lies anterior to the descending aorta and posterior to the superior left pulm vein
 THORAX (22)
Passes through the root and hilum and branches within the lung

Variants
Truncus arteriorus
Transposition
Double outlet right ventricle (aorta and pulm trunk arise arise from RV
Aberrent left pulm artery (wraps behind the right main bronchus)
Absent
Double right or left branches
Left supplies branch to left subclavian; right supplies branch to brachiocephalic trunk
Accessory pulm artery from abdominal aorta
Anolomous right or left coronary artery
Retrotracheal pulm artery
Idiopathic dilatation of the pulm trunk (rare)

Bronchial arteries
Nutritive vascular system of the pulmonary tissues
Interconnect within the lung with the branches of the pulmonary arteries and veins

Arise from thoracic aorta at level of T5/T6

Single right bronchial a
- often arises as common trunk with the 3rd or 5th posterior intercostal a
- from right posterolateral thoracic aorta

Two left bronchial arteries

- arise from anterior aspect of thoracic aorta
- Superior left bronchial a - arises from anteromedial aorta, lateral to carina, posterior to left main
bronchus
- Inferior left bronchial a - arises from thoracic aorta inferior to the left main bronchus

Bronchial arteries run on the posterior surfaces of the bronchi and ramify in the lungs to supply
pulmonary tissues

Supply
CT of trachea and bronc
LNs
Visceral pleura
Middle third of oesophagus
Posterior mediastinum
Vagus n

Variants
Classical pattern of two on left and one on right only occurs in 60%
Anomalous origin - aortic arch, internal thoracic, thyrocervical trunk, subclavian a
Common bronchial trunk
Single artery bilaterally
Single on left and two on right
Right and left originate from same stem

Write short notes on the anatomy of the visceral and parietal pleura, with normal variants.
Serous membrane that covers the lungs
Two layers create a potential space called the pleural cavity that aids in movement of the lungs>
contains only a capillary layer of serous fluid secreted by pleura
 THORAX (22)

Visceral pleura - closely covers/invests the lungs; extends into the depths of the interlobar
fissures
Smooth, slippery surface enables it to move freely on the parietal pleura

Parietal pleura - lines the thoracic cavity and mediastinum; adherent to the thoracic wall and
diaphragm and pericardium by CT

Meet at the root of the lung where they surround the bronchi and vascular structures entering the
lung
An empty fold of pleura hangs down from the hila > forming the pulmonary ligament which helps
to support the lung

Right and left pleura only touch behind sternum

Limits Visceral Parietal

Ant 6th costal cartilage 7th costal cartialge
Mid axillary 8th rib 10th rib
Post T10 T12

Parts of parietal pleura

Costovertebral - lines internal surface of thoracic wall and vertebral bodies
Diaphragmatic - adheres to diaphragm
Cervical - thickeniing supeirorly called supra pleural membrane attached to 1st rib and TP of C7
receiving muscle fibres from scalenes - provides apical support for pleural cavity in root of neck
Mediastinal - Continuous with all other layers

Fissures
Double fold of viscera pleura extends into oblique and horizontal fissures; often incomplete

Pleural recesses
Costodiaphragmatic - slit like recesses btw costal and diaphragmatic pleura
Costomediastinal - anterior margin of pleura between the 4-5th intercostal spaces; lingula
slides in and out of left recess

Arterial supply
Parietal from thoracic wall supply - intercostals, internal thoracic/musculophrenic
Visceral from bronchial aa from thoracic aorta

Venous - parietal to systemmic vv in adjacent thoracic wall; visceral to pulm veins

Lymphatics - parietal (thoracic wall); visceral (hila)

Innervation
Parietal - costal and diaphragmeatic from intercostal nn; central from phrenic nn
Visceral - visceral afferents accompanying bronchial vessels

Variants
Azygous fissure containing azygous v crossing RUL from chest wall to tracheobronchial angle
Inferior accessory lobe - on medial surface in front of pulmonary ligament
Superior accessory lobe - separates the superior segment of either lobe from basal segments
Left horizontal fissure (10%) and hemiazygous fissure (rare)
Absent (21%) or incomplete (67%) horizontal fissure
Incomplete oblique fissure (30%)
 THORAX (22)
Write short notes on the relations of the oesophagus. Write short notes on the anatomy of
the oesophagus. Write short notes on the anatomy of the cervical oesophagus.
Muscular tube extending from the cricoid cartilage (C6) to the cardiac orifice of the stomach (T11 or
7th costal cartilage)
Continuous with the pharynx superiorly and the stomach inferiorly
25cm long
Approximately in the midline anterior to the vertebral bodies but deviates to the left in the neck and
to the left at T7; slopes ventrally to the esophageal aperture at T10

5 layers:
Superficial mucosa (hyperechoic)
Deep muscosa/lamina propria (hypoechoic)
Submucosa (hyperechoic)
Muscularis propria (hypoechoic)
Adventitia (hyperechoic)

Constrictions
Upper oesophageal sphincter - caused by impression of the cricopharyngeus
Where it is crossed by the aortic arch (22cm from teeth)
Where it is crossed by the left main bronchus
At the oesophageal hiatus in the diaphragm

Relations by sections

Cervical
Ant - CT connecting to trachea, trachea, recurrent laryngeal n runs in groove btw
Post - prevertebral fascia, ALL, longus colli m
Right carotid sheath, cervical pleura
Left - carotid sheath, thoracic duct

Thoracic
Superior mediastinum
Ant - trachea, aortic arch, left brachiocephalic v, thymus, manubrium
Post - vertebral bodies, longs colli
Right - cervical pleura, azygous arch
Left - subclavian v., thoracic duct

Posterior mediastinum
Ant - trachea and bifurcation, trachiobronchial LNs, right pulm a. L) vagus n, left atrium
Post - vertebral column, longus colli, right intercostals aa. azygous v., thoracic duct below T5,
thoracic aorta
Right - mediastinal pleura, azygous
Left - left recurrent laryngeal, thoracic aorta, left pleura

Oesphageal hiatus
Ant - fibrous pericardium
Post - thoracic aorta
Right - IVC
Within the hiatus - anterior and posterior vagal trunks, ascending oesophageal branch of left
gastric a and veins

Abdominal - retroperitoneal
Ant - anterior vaga ltrunk, peritoneaum, esophageal groove on left lobe of liver
Post - posterior vagal trunk, diaphragm, gastrophrenic lig
Right - lesser curvature, upper margin of lesser omentum, right crus, IVC
Left - right crus and ring
 THORAX (22)

Arterial supply
Upper third - inferior thyroid arteries from thyrocervical trunk, branch of subclavian
Middle third - from aorta bronchial branches, oesophageal branches
Lower third - ascending left gastric branch from coeliac a, inferior phrenic from abdo aorta

Venous drainage
Upper third - inf thyroid to brachiocephalic
Middle third - azygous, hemiazygous
Lower third - left gastric vein to portal venous (portosystemic anastomosis)

Innervation
Vagus nerves and sympathetic trunks
Esophageal plexus
Splanchinic

Recurrent larygneal nerve in neck

Lymph
Cervical - paratracheal, inferior deep cervical
Thoracic - posterior mediastinal nodes
Abodminal - left gastic and priority nodes of coeliac group

Variants
Diverticuli
Duplication
Fistula

Write short notes on the anatomy of the superior vena cava and its variants. Write short
notes on the anatomy of the superior vena cava.
Drains the head, neck and upper limbs into the right atrium
Returns blood from all structures superior to the diaphragm except the heart and lungs
8cm long
Large, valveless venous channel formed by the union of the brachiocephalic veins

Origin
Formed by confluence of the brachiocephalic veins behind the lower border of the right 1st costal
cartilage

Course
Passes inferiorly posteriorly to the right sternal border
Pierces pericardium at the 2nd costal cartilage
Terminates in the middle mediastinum where in enters the right atrium at the lower border of the
third costal cartilage.
Forms the boundary of the transverse pericardial sinus

Termination
Right atrium at the level of the third costal cartilage
Enters without a valve

Tributaries
Azygous vein behind sternal angle at level of right 2nd costal cartilage after arching forward over
the root of the lung

Relations
Ant - right internal thoracic vessels, sternum, 1st and second intercostal spaces
 THORAX (22)
Post - azygous vein, right main bronchus, right lung, trachea, right vagus nerve
Medial - ascending aorta, brachiocephaic trunk
Lateral - right phrenic nerve, right scalene muscle

Variants
Brachiocephalic vein enters RA seperately
Persistant right cardinal vein
Double SVC (0.16%)
Left SVC
Agenesis and drainage into IVC via azygous (rare)
Unusual tributaries - R internal thoracic, right supreme intercostal, thyroid ima

Write short notes on the anatomy of the thoracic duct.

Main conduit for lymphatic drainage of he body excluding lungs and RUQ of body
Connects the cisterna chyli to the great veins in the root of the neck
Chyle cistern is a lymphatic sac which drains lymph from abdominal viscera and walls, pelvis,
perineum and lower limbs

Origin
Extends from cistern chyli at L2, behind the median arcuate ligament/Right crus via the aortic
aperature to become the thoracic duct (T12)

Course
Ascends between azygous vein and aorta in the posterior mediastinum (to the right of the aorta
and to the left of the azygous, anterior to the vertebral column
Posterior to the oesophagus
At T5, the thoracic duct moves to the left of the midline and enters superior mediastinum
Passes laterally posterior to the carotid vessels and at C7 arches anteriorly across the left lung
apex about 3-4cm above the clavicle

Enters the left brachiocephalic vein at the junction of the left subclavian and internal jugular

Valves - within duct but not at termination

Tributaries
Chyle cistern
Upper intercostal and posterior mediastinal nodes and posteior diaphragmatic nodes
Descending thoracic trunks lower 6 intercostal spaces
Left jugular trunk and left subclavian trunk (LU Limb)

Relations
Ant diaphragm, esophagus, pericardium, aortic arch, left subclavian
Post sympathetic trunk, vertebral and subclavian aa, intercostal branches from aorta
Right azygous vein
Left aorta until T5

Variants
May join left internal jugular
May drain to IVC or azygous
May have several terminal divisions
Doubled
Lie on right of the aorta throughout entire length and open into right system

Right lymphatic duct

3 converging trunks
 THORAX (22)
- right subclavian
- right jugular
- right bronchomediastinal (right hemithorax, right heart, right lung and part of liver)
Drains into right internal jugular subclavian junction
Two valves at entry

Write short notes on the anatomy of the superior thoracic aperture.

Communication between thoracic cavity and the neck, head and limbs
6x12cm (AP to TV)
Kidney bean shaped
Slopes anterioinferiorly due to obiquity of the 1st ribs

Borders
Ant - supeiror manubrium border
Lateral -paired first ribs and their costal cartilages
Post - T1
Sup - dome of pleura and brachial plexus
Inf - superior mediastinum

Structures traversing:

Median plane (ant to post)

sternohyoid
sternothyroid
thymic remnants
inferior thyroid veins
trachea
tracheo-esophageal sulcus containing recurrent laryngeal nn
oesophagus
thoracic duct displaced to left
longus colli mm

Bilaterally

Cervical pleura overlying apex of lung

- extends 4cm above medial third of clavicle and anterior first rib but no higher than post first rib

Vessels (great vessels)

- left common carotid a
- subclavian arteries
- Right brachiocephalic trunk
- Brachicephalic veins
- Internal thoracic a and v

Nerves
- Sympathetic trunk
- Phrenic
- Vagus
- Ventral ramus of first thoracic nerves

LNs and pleura

Variants
Cervical rib
Thyroid may extend below aperture
 THORAX (22)

Inferior thoracic aperature - thoracic outlet

Connection between thoracic and abdominal cavities
Borders - T12, 11-12th ribs, costal margin, xiphisternum

Write short notes on the anatomy of the right phrenic nerve. Write short notes on the
anatomy of the left phrenic nerve.

Conveys motor and sensory and sympathetic information to the diaphragm

Pericardiacophrenic aa and veins travel with respective nerves

Origin - C3,4,5

Course
Decends obliquesly with the internal jugular vein in the neck across anterior scalene deep to
prevertabal fascia

Right
Lies anterior to anterior scalene muscle
Crosses over second part of subclavian a
Passes over brachiocephalic a posterior to subclavian vein
Continues along the right side of the SVC and along the right side of the pericardial sac
Passes anterior to the root of the lung and leaves the thorax through the caval opening

Left
Crosses anterior to the to the first part of subclavian
Lateral to the left vagus neve
Descends along the left lateral surface of the aortic arch, superrficial to the left vagus n
Follows the left side of the pericardial sac within the fibrous pericardium, anterior to the root of the
lung
Pierces diaphragm separately near the apex of the heart

Supply - motor sensation to diaphragm, mediastinal pleura, pericardium, diaphragmatic peritoneum

Write short notes on the anatomy of the right vagus nerve

Tenth cranial nerve, mixed motor and sensory
More course and distribution than any other cranial nerve
Traverses and supplies the neck, thorax, abdomen

Nuclei
Dorsal nuclus, nucleus ambiguus, solitary nucleus, spinal trigeminal nucleus

Origin
Arises from medulla between the olive and inferior cerebellar peduncle

Course
Extends through jugular foramen, accompanying the accessory nerve
Passes into the carotid sheath posterior to internal carotid and internal jugular v

Right vagus
 THORAX (22)
Right vagus nerve gives rise to the right recurrent laryngeal n which hooks around the right
subclavian artery and ascends the neck between the trachea and oesophagus
Enters mediastinum and lies between right brachiocephalic v and brachiocephalic trunk
Crosses lateral surface of the of the trachea and passes posterior to the root of the right lung to
reach the oesophagus
Crossed by the arch of the azygous
Contributes to cardiac, pulmonary and esophageal plexuses
Enters diaphragm through oesophageal hiatus

Left vagus
Enters thorax between the left CCA and left subclavian a
Descends on the aortic arch
Gives rise to the left recurrent laryngeal which hooks around the aortic arch to the left of the
ligaments arteriosum
Ascends between the trachea and oesophagus
Descends posterior to the root of the lung to reach oesophagus
Left vagus gives off thoracic cardiac and pulm branches then continues as the oesophageal plexus

Both
Joins the contralateral vagus nerve to form the esophageal plexus - enters abdomen in
oesophageal hiatus
Nerves then reform as the anterior and posterior vagal trunks (terminal branches)

Anterior vagal trunk > anteiror aspect of stomach and branches to the lesser momentum
supplying liver, pyloric canal, D1, D2 and head of pancreas

Posterior vagal trunk > posterior aspect of stomach and ends in coeliac ganglia adjacent plexus

Branches
Meningeal - dura in posterior cranial fossa
Auricular n (sensory) - EAM and auricle
Pharyngeal n (motor) - soft palate and pharynx (except stylopharygeus and tensor veli palatine)
Carotid branches - carotid sinus
Sup laryngeal n - larynx
Superior cervical cardiac branches
Recurrent laryngal
Thoracic cardiac branches
Pulmonary plexus branches
Esophageal plexus branches
Hering-Breurer reflex in alveoli
Anterior and posterior vagal trunk (terminal branches)

Function/Supply
Sensory infr about state of bodies organs
Parasymp to heart to lower HR
Motor parasymp to organs except adrenals from neck to second part of transverse colon
Taste
EAM sesnory
Pharynx and larynx

Write short notes on the anatomy of the left subclavian artery.

Paired major arteries of the upper thorax, below the clavicle

Receives blood from the aortic arch
 THORAX (22)
Supplies the posterior head circulation, neck, chest and abdominal wall, breast, shoulder and
upper limb

Divided into three parts:

1st > from origin to medial border of scalene anterior
2nd> behind scalene anterior
3rd > from lateral border of scalene anterior and outer border of first rib

Origin
Right - bifurcation of brachiocephalic trunk behind right SCJ (T2)
Left - third branch of the aortic arch

Course
Travels laterally passeing between anterior and middle scalene mm
Descends laterally to the outer border of the 1st rib where it becomes the axillary a

Branches VIT C, D
1> Vertebral a, internal thoracic, thyrocervical trunk
2> Costocervical trunk
3 > dorsal scapular a

Supplies
Vertebral - runs cranially in vertebral foramina to join partner as basilar - COW
Internal thoracic - caudally behind ribs giving anterior intercostal branches and terminating as the
superior epigastric and musculophrenic a
Thyrocervical trunk - divides into inferior thyroid a, supra scapular a and transverse cervical a (trap,
lat, serratus, lev scapulae, rhomboids)
Costocervial turnk - divides into superior intercostal a (1st and second intercostals) + deep cervial
arteries (posteiror neck m)
Dorsal scapular a - supplies levator scapulae and rhomboids

Relations
Anterior - L) CCA, L) brachiocephalic v, subclavian vein, scalene anterior
Post - esophagus, thoracic duct, lung, scalene medius
Med- trachea, RLN, oesophagus
Lat - 1st rib

Variants
Common origin of left subclavan and left vertebral
Bilateral brachiocephalic trunks
Abberrant right subclavian (arises directly from arch)
Can divide at medial border of scalene ant to two branches that travel down the arm as radial and
ulnar
Perforates or passes in front of scalene ant

Write short notes on the anatomy of the left first rib. Write short notes on the anatomy of
rib 1.
Shortest, broadest and most curved rib
Forms border of superior thoracic aperture
Large scalene tubercle for attachment of scalene anterior on superior aspect of internal border
anteriorly

Features:
- Head - wedge shaped
- Single facet articulation with the body of T1 upper part
 THORAX (22)
- Neck - stout flattened part between head and tubercle
- Tubercle - articulates directly with TP; attachment for costotransverse lig
- Shaft/body - thin, flat, curved, greater curvature called angle of rib; 45 degrees
- Costal groove inferiorly for nerve and vessels
- Costal cartilage - articulates with manubrium

Crossed by:
Subclavian a posteiror to scalene tubercle; Quadrangular flat space for attachment
Subclavian vein anterior to scalene tubercle
Inferior trunk of brachial plexus posteior to subclavian a
Sympathetic trunk in contact with anterior border of neck
Superior intercostal artery
Posterior intercostal vein
Serratus anterior
Scalene anterior and medius
Subclavius m
Costoclavicular lig
Subpleural membrane attached to inner surface

Variation
Cervical rib
Bifid rib

Write short notes on the anatomy of the internal thoracic artery and its branches
Paired artery running alongside the sternum supplying the anterior chest wall and breasts

Origin - arises in the root of the neck from inferior surface of the 1st part of the subclavian a
- at the medial border of the scalenes anterior muscle

Course
- descends into thorax through the superior thoracic aperture posterior to the clavicle and 1st
costal cartilage
- runs on the internal surface of thorax 1cm lateral to the sternum posterior to the costal cartilages
of the upper six ribs
- At 6th intercostal space it divides into terminal branches

Termination
- divides into superior epigastric (continues inferiorly into ant abdo wall) and musculphrenic
arteries( passes along costal margin, through diaphragm and ends near last intercostal space

Branches
- mediastinal
- thymic
- pericardiacophrenic a (travels with phrenic n)
- sternal branches
- perforating branches to the external thoracic wall
- anterior intercostal branches (12) two to each of the top six intercostal spaces >superior
branch passes below the margin of the upper rib; inferior branch passes above the margin of the
lower rib and meets collateral branch of posterior intercostal aa
 THORAX (22)
Relations
Post - pleura, transversus thoracic from 3rd CC
Ant - crossed by phrenic n, superior 6 CCs and IC muscles

Write short notes on the anatomy of the azygos and hemiazygos venous systems
Azyous vein

Drains the posterior chest and abdominal walls and mediastinum

Potential collateral pathway between the SVC and IVC in cases of venous obstruction

Origin - L2 (the level of the renal vein) by the confluence of the right ascending lumbar and right
subcostal veins (may arise from IVC)

Tributaries
- drains all but the 1st intercostal vein on the right (supreme intercostal goes to BCV)
- right superior intercostal v - 2,3,4th intercostals drain via common channel
- hemiazygous mid thoracic level
- accessory hemiazygous drain into azygous at the mid thoracic level
- Right bronchial v
- Oesophageal,
- pericardial and
- mediastinal veins

Course - through aortic opening or posterior to right crus

- ascents to the right of vertebral bodies in posterior mediastinum; usually to the right of thoracic
duct
- at ~T4, arches anteriorly over the root of the right lung to join the SVC prior to it entering the
pericardial sac

Termination - drains into SVC at T4

Drains - posterolateral wall of thorax and abdomen on right; parts of lung and mediastinum; middle
esophagus; hemi and accessory homozygous vv

Relations
Ant - right crus, oesophagus, right pleura, right posteriolateral aorta
Post - L1/L2, thoracic vertebrae, ALL, right posterior intercostal aa
Right - lung and pleura, greater splanchnic
Left - aorta, thoracic duct, oesophagus (sup), trachea, right vagus

Variants
azygous fissure (grooves through right lung vetoer entering SVC
May drain into hemiazygous
Absent/doubled
Pulm vein may open into azygous
Receive supreme intercostal v

Hemiazygous vein
Drains posterior chest and abdominal walls and mediastinum, left posterior thorax and lumbar
regions, lower oesophagus

Origin - confluence of left ascending lumbar and left subcostal at the level of the left renal vein (L2)
may have connection to left renal v
 THORAX (22)
Pierces left crus at T12 (not through aortic hiatus)
Ascends to the left of the vertebral column in the posterior mediastinum to ~T9 then crosses
vertebral column posterior to thoracic aorta, oesophagus and thoracic duct to enter azygous at T8
where it terminates

Tributaries
Lowest 4-5 left posterior intercostal vv
Oesophageal vv
Mediastinal veins

Relations
Ant - aorta, oesophagus, thoracic duct
Post - thoracic vertebrae
Left - L) lung and pleura
Right - vertebral bodies, aorta, thoracic duct oesophagus prior to crossing midline

Variants
Hypoplasia - branches open directly into azygous vein
Absent azygous and hemiazygous - posterior IC vv open into midline azygous

Accessory hemiazygous vein

Origin - arises at level of 5th IC vein of left and runs inferiorly to level of T7

Courses inferiorly in the posterior mediastinum to the left of the vertebral bodies
Crosses the midline to join azygous (posterior to aorta and thoracic duct)

Relations
Ant - left lung and pleura
Post - crosses T7
Right - vertebral bodies

Variants - absence, hypoplastic, may join hemiazygous prior to joining azygous together
Frequently comnected to left superior intercostal v

Drains - left posterior intercostal veins (4/5-8) and sometimes left bronchial veins

Draw a clear and well labelled diagram of a cross section through the thorax at the level of
T5

BREAST (4)
Write short notes on the anatomy of the breast.
Write short notes on the lymphatic drainage of the female mammary gland and normal
variants.
Write short notes on the anatomy of the lymphatic drainage of the breast
Write short notes on the anatomy of the mammary glands and normal variants

Structure
Lie in the superficial fascia of the chest wall. Extends from 2nd rib superiorly to 6th intercostal
space; medially from sternal edge to mid-axillary line laterally
Deep aspect separated from pectoralis by the deep fascia
Retromammary space containing loose CT and fat lies between the breast and deep fascia and
allows movement
 THORAX (22)

Mammary gland consists of the series of ducts and associated secretory lobules. Converge to
form 15-20 lactiferous ducts which open independently on the nipple (conical elevation of skin on
anterior, central breast with bands of smooth muscle)
Nipple is surrounded by round pigmented skin called areola

Mammary gland duct and lobules are surrounded by well developed connective tissue stroma.
Condensation forms the suspensory ligament of Cooper which attaches to the skin and supports
the breast

In non-lactating women the predominant component of breast is fat; glandular tissue more
abundant in lactating women

Divided into quadrants - upper outer contains axillary tail

Arterial supply
Laterally from axillary artery branches (lateral thoracic, superior thoracic, thoraco-acromial,
subscap)
Medially from internal thoracic a
2-4th intercostal aa which pierce fascia

Venous drainage
Axillary, internal thoracic

Nerve supply
2-6th intercostal nerves convey sensory fibres to skin, sympathetic to blood vessels and smooth
muscle in skin and nipple

Lymphatic drainage
Superficial lymphatics under skin particularly concentrated in the subareolar plexus beneath nipple
--> drain to deep nodes unidirectionally
Deep nodes drain to axillary (75%) and internal mammary (25%) chains
Axillary nodes- mainly pectoral group along border of pec minor
Parasternal nodes drain medial part along internal thoracic vessels --> bronchomediastinal trunk
Few LNs follow the intercostal aa to posterior intercostal nodes

Surgical levels
1- inferolateral to pec minor (anterior, posterior and lateral)
2 - deep to pec minor (central, interpectoral)
3 - superomedial to pec minor (apical)

Relations
Post - medial 2/3 overlies pec major; lateral 1/3 overlies serratus ant and external oblique

Variants
Asymmetry
Accessory nipple
Polymastia
Accessory glandular tissue (in axilla and separate to axillary tail)
Congenital nipple absence
Amastia (no breast or nipple) --> rare
Amazia - nipple but no breast
Hypoplasia - may be linked to underdevelopment of underlying chest wall structures
Congenital nipple inversion

Mediastinal LNs
 THORAX (22)

Supraclavicular nodes

1. Low cervical, supraclavicular and sternal notch nodes

From the lower margin of the cricoid to the clavicles and the upper border of the manubrium.
The midline of the trachea serves as border between 1R and 1L.

Superior Mediastinal Nodes 2-4

2R.Upper Paratracheal
2R nodes extend to the left lateral border of the trachea.
From upper border of manubrium to the intersection of caudal margin of innominate (left
brachiocephalic) vein with the trachea.

2L.Upper Paratracheal
From the upper border of manubrium to the superior border of aortic arch.
2L nodes are located to the left of the left lateral border of the trachea.

3A. Pre-vascular
These nodes are not adjacent to the trachea like the nodes in station 2, but they are anterior to the
vessels.

3P.Pre-vertebral
Nodes not adjacent to the trachea like the nodes in station 2, but behind the esophagus, which is
prevertebral.

4R. Lower Paratracheal

From the intersection of the caudal margin of innominate (left brachiocephalic) vein with the
trachea to the lower border of the azygos vein.
4R nodes extend from the right to the left lateral border of the trachea.

4L. Lower Paratracheal

From the upper margin of the aortic arch to the upper rim of the left main pulmonary artery.

Aortic Nodes 5-6

5. Subaortic
These nodes are located in the AP window lateral to the ligamentum arteriosum.
These nodes are not located between the aorta and the pulmonary trunk but lateral to these
vessels.

6. Para-aortic
These are ascending aorta or phrenic nodes lying anterior and lateral to the ascending aorta and
the aortic arch.

Inferior Mediastinal Nodes 7-9

7.Subcarinal

8. Paraesophageal
Nodes below carina.

9. Pulmonary Ligament
Nodes lying within the pulmonary ligaments.
 THORAX (22)
Hilar, Lobar and (sub)segmental Nodes 10-14
These are all N1-nodes.

10. Hilar nodes

These include nodes adjacent to the main stem bronchus and hilar vessels.
On the right they extend from the lower rim of the azygos vein to the interlobar region.
On the left from the upper rim of the pulmonary artery to the interlobar region.

Write short notes on the anatomy of the azygous and hemiazygous veins.
Write short notes on the anatomy of the pericardium
Write short notes on the anatomy of the trachea
Write short notes on the anatomy of the superior thoracic aperture (thoracic outlet)
Write short notes on the anatomy of the superior thoracic aperture (thoracic outlet).
Write short notes on the coronary arterial circulation.
Write short notes on the anatomy of the superior thoracic aperture (thoracic outlet).
Write short notes on the anatomy of the oesophagus.
Write short notes on the anatomy of the superior thoracic aperture (thoracic outlet).
Write short notes on the anatomy of the coronary arterial circulation.
Write short notes on the anatomy of the breast.
Write short notes on the anatomy of the aortic arch and its variation
Write short notes on the pericardium
Write short notes on the anatomy of the pericardium
Write short notes on the anatomy of the aortic arch and variations
Write short notes on the anatomy of the coronary arteries.
Draw a cross-section of the thorax at T5 level
13. Write short notes on the anatomy of the left ventricle.
5 Write short notes on the anatomy of the superior aperture of the thorax
6 Write short notes on the anatomy of the thoracic duct
Write short notes on the superior thoracic aperture.
Write short notes on the thoracic duct.
Write short notes on the anatomy of the superior thoracic aperture (thoracic outlet).
Write short notes on the anatomy and normal variants of the lymphatic drainage of the mammary
gland.
Write short notes on the pulmonary veins and anatomical variants.
Write short notes on the anatomy of the thoracic duct