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Thorax III Flashcards

1
Q

What are the boundaries of the superior mediastinum?

A

Sup - superior thoracic aperture
manubrium of sternum, 1st rib, 1st thoracic vertebrae
Post - thoracic vertebrae 1 - 4
Ant - manubrium of sternum
Lateral = lungs and mediastinum
Inf = transverse thoracic plane
T4/5 intervertebral disc - separates superior mediastinum to rest

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2
Q

What structures lie posterior and anterior to the sup mediastinum?

A 
Post = sympathetic trunk
Ant = remnants of thymus
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3
Q

What does the superior mediastinum contain?

A

Great vessels:
Arch aorta - brachiocephalic trunk, left common carotid, left subclavian
Returning brachiocephalic veins

Oesophagus
Phrenic and vagus nerves

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4
Q

What structures come off the arch of aorta?

A
  1. brachiocephalic artery
    branches into right common carotid and right subclavian
    Trunk passes posterior to the manubrium between trachea and right brachiocephalic veins
  2. Left common carotid
  3. Left subclavian
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5
Q

List some variations of the arch of aorta

A

Left common carotid may come off the brachiocephalic trunk

Some people may fail to form a brachiocephalic trunk - so have a left vertebral artery (originates from arch)
or they have 2 brachiocephalic trunks - R+L

Few people have arch going over root right lung and passing inferiorly to the right (forms a right arch)
or have abnormal arch passing over root right lung, passes posterior to oesophagus to reach usual position on left

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6
Q

Describe the positioning of the right and left pulmonary arteries

A

Right pulmonary passes posterior to ascending aorta and SVC before entering root right lung

Left pulmonary artery runs below the aortic arch and anterior to descending thoracic aorta to enter root left lung

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7
Q

What is the ligamentum arteriosum?

A

Band of fibrous tissue connecting top of pulmonary bifurcation to bottom aortic arch
Remnant of artery patent before birth which diverted blood flow to lungs before baby begins to breathe

Identify between left pulmonary artery in root of lung and arch of aorta

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8
Q

What level does the descending thoracic aorta begin?

Describe its course

A

Begins at T4/T5 from arch of aorta

Descends into posterior mediastinum and passes through aortic hiatus of diaphragm at T12

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9
Q

What are the branches of the thoracic aorta?

A 
Bronchial 
Oesophageal
Pericardial 
Mediastinal 
Posterior intercostal (9)
Subcostals
Sup. phrenic arteries
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10
Q

What point do the right and left brachiocephalic veins join to form the SVC?

A

Inferior border of the 1st right costal cartilage

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11
Q

Describe the location of structures in the thorax

A

Most anterior and superior vessel in the mediastinum is brachiocephalic and subclavian veins
Behind have arch of aorta and branches
Middle = thorax
Behind thorax = oesophagus
Thoracic duct - arches over to come back into brachiocephalic vein
thoracic duct = drainage for lymphatic system

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12
Q

What does the azygous vein drain?

A

Drains posterior thoracic wall and runs over root of right lung
Provides potential connection between SVC and IVC

Arch of azygous leaves impression on right lung

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13
Q

Where does the azygous vein originate?

A

In the abdomen

Passes posteriorly, then anteriorly

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14
Q

Where does blood from the hemiazygous and accessory hemiazygous veins drain into?

A

Drain into azygous vein on right

Hemi and accessory act together to serve as left side equiv azygous vein

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15
Q

What do accessory hemi-azygous veins drain?

A

Middle, left and posterior intercostal veins

Drains 3-5 intercostal veins

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16
Q

At what level does the acccessory hemiazygous vein cross posterior to the aorta?

A

Level T7

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17
Q

What does the hemiazygous vein drain?

A

9-11 posterior intercostal veins and subcostal veins on left side
some oesophageal and mediastinal veins

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18
Q

What level does the hemiazygous vein drain into the azygous vein?

A

T8
Begins in abdomen and travels up
Forms H sign over vertebral bodies as crosses over to right

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19
Q

How do the hemiazygous and accessory hemiazygous drain into the azygous vein?

A 
Drain separately 
Hemi - inferior 
Accessory - superior 
thoracic duct passes over them 
behind brachiocephalic and loop around
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20
Q

What level does the thoracic duct begin?

A

T12 - aortic hiatus of diaphragm

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21
Q

What does the thoracic duct drain?

A

Lymph from the body except for drainage from superior portion RHS (lung, chest, upper limb) - right lymphatic duct drains this into right subclavian

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22
Q

What is the cisterna chyli?

A

Dilated sac where lymph from middle portion and abdominal content collects
eg. lumbar lymph trunk (lower limbs), intestine
Runs along the aorta?

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23
Q

Describe the course of the thoracic duct

A

Lymph from the cisterna chyli drains into the thoracic duct - begins at T12
Continues superiorly where shifts left (T5) to be behind oesophagus
At level C7 drains in between left internal jugular vein and left subclavian vein to join systemic circulation

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24
Q

Describe the course of the right phrenic vein

A

Behind the clavicle
It descends lateral to the brachiocephalic vein and SVC
Runs anterior to root of right lung, across pericardium to diaphragm
Goes through the diaphragm with the vena cava

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25
Describe the course of the left phrenic nerve
Descends along the left side of the left subclavian artery Crosses left vagus nerve superficially as approaches aortic arch Passes over intercostal vein in front of arch of aorta Over the lateral, posterior aspect of the pulmonary trunk Runs along anterior, lateral aspect borders of the pericardial sac to innervate diaphragm - attaches to it Origin = C3,4,5
26
Describe the course of the right vagus nerve
Comes down inferiorly in the carotid sheath alongside the right common carotid Passes anterior to the brachiocephalic trunk (right subclavian) Runs posterior to the root of the right lung Runs more latero-posteriorly along the oesophagus - to become the bulk of the posterior vagal trunk
27
Describe the course of the right recurrent laryngeal nerve
Branches off the right vagus nerve and loops posterior and inferior to the subclavian artery before going up to the larynx (along the tracheo-oesophageal groove)
28
What are the branches of the right vagus?
Oesophageal, pulmonary and deep cardiac plexus
29
Describe the course of the left vagus nerve
Descends between common carotid and subclavian arteries Passes down anterior to arch of aorta Goes posterior to root of the left lung Runs anteriorly along the oesophagus to then give rise to the majority of the anterior vagal trunk
30
Describe the course of the left recurrent laryngeal nerve
Branches off the left vagus Loops under the arch of the aorta, posterior to ligamentum arteriosum Runs superiorly into lower neck along tracheo-oesophageal groove to supply larynx
31
What are the branches of the left vagus nerve?
Cardiac, pulmonary and oesophageal plexus
32
What is apical lung cancer?
Involves phrenic nerve - may paralyse half diaphragm May also affect recurrent laryngeal nerves Causes hoarseness associated w/ paralysis of the vocal folds - as recurrent laryngeal nerves supplies most laryngeal muscles
33
Where is the sympathetic chain located?
On the posterior aspect of the superior mediastinum Lie near the head of the rib in upper thorax Moving medially against vertebral bodies lower down
34
Where does sympathetic thoracic nerve supply to parietal structures come from?
Comes from rami communicantes (connect nerves to other nerves) Connect trunks to spinal/intercostal nerves
35
What do nerves of T1-T4 origin supply?
Supply superficial and deep cardiac plexus
36
What are the thoracic splanchnic nerves, their spinal nerve roots and what do they supply?
T5-T9 - Greater splanchnic nerves - foregut Coeliac ganglia and adrenal glands T10-T11 - Lesser splanchnic nerves - hindgut Superior mesenteric and aortico-renal ganglia T12 - Least splanchnic nerves - kidneys (terminates in renal plexus)
37
How is this significant to referred pain?
All splanchnic nerves help refer pain and share dermatome level Shows why there is referred pain - why when visceral pain comes back and shares a dermatome level
38
Describe the cardiac plexi
Composed of sympathetic and parasympathetic nerve fibres Superficial cardiac plexus - lies most left - inferior to aortic arch Posterior to ligamentum arteriosum Deep cardiac plexus - lies anterior to tracheal bifurcation, posterior aortic arch, superior to bifurcation pulmonary trunk Helps innervate trachea and bronchioles w/ expansion and contraction
39
What are the symptoms of Horner's syndrome?
Affects along the nerve roots: Droopy eyelid Constricted pupil Anhydrosis - lack sweating on one side face as nerves also supply facial muscles
40
Where does the diaphragm initially develop?
At level of C2
41
Describe the course of differential growth of the diaphragm
Begins at level C2, differentially grows and descends past C3, C4, C5 Tendon picks up parts of myotomes and innervation from C3, C4, C5 Muscle diaphragm innervated by phrenic nerve
42
What are the hiatuses through the diaphragm?
T8 - Vena Cava T10 - Oesophageal T12 - Aortic hiatus
43
What structures additionally go through the hiatuses of the diaphragm?
Thoracic duct comes up w/ aorta at level T12 Right vagus goes through oesophageal hiatus Splanchnic nerves run alongside
44
What level are the attachments of the right and left crus?
Right crus attaches at - L3 | Left crus attaches at - L2
45
Describe the course of the phrenic nerve through the diaphragm
Right phrenic pierces through with inferior vena cava to supply the RHS Left phrenic penetrates and pierces through left part of diaphragm (attaches to it) - helps supply functionality phrenic nerve to LHS
46
What occurs in paralysis of hemidiaphragm?
Due to injury of motor supply from phrenic nerve - half of diaphragm paralysed Doesn't affect other half because each dome has a separate nerve supply Paralysed dome is pushed superiorly on inspiration by abdominal viscera being compressed by active side Diaphragm falls in expiration due to positive pressure in throax
47
What is a congenital diaphragmatic hernia?
Failure of pleuroperitoneal membranes to close canals .˙. content goes through diaphragm Quite common
48
What is a diaphragmatic hernia?
Have problem with development - diaphragm gains weakness overtime Can cause protrusion eg. sliding/rolling hernia due to weakness in crus Patients present with GORD + acid content regurgitation issues.
49
What is a hiatus hernia?
Abdominal contents from stomach protruding through cardiac orifice/oesophageal opening .˙. herniates through Stomach may get trapped w/in arcuate ligament ˙.˙ crus weak it can protrude through
50
How can a hernia be visualised?
Ask patient to swallow contrast - can see if any issues with oesophagus or top portions
51
What do the arcuate ligaments help support?
Help keep structures lateral to crus | Arcuate ligaments are attachment point of muscle or or to vertebral bodies themselves (transverse process)
52
How can the phrenic nerve be damaged and what is the significance of its damage?
Can be damaged in surgery or tumour can damage it Diaphragm ends up raised because pushing.of visceral organs If cut phrenic at C3/4/5 patient won't be able to breathe at all
53
What is the location of the sympathetic chain?
Lies near head of rib in upper thorax | Moves medially against vertebral bodies lower down
54
What do the ganglia associated with T1-T5 supply?
Cardiac branches to heart
55
What is the importance of rami communicantes?
Connect trunks to spinal (intercostal) nerves | Provide sympathetic thoracic supply to parietal structures
56
Where do splanchnic branches come off?
Anterior sympathetic trunks Splanchnic branches travel inferiorly, alongside vertebral bodies and pierce the posterior aspect of diaphragm to enter abdomen
57
How can cancer cause Horner's syndrome?
Cancer in the lung can press on the sympathetic trunk
58
What are the thoracic splanchnic nerves?
Provide sympathetic supply to the abdomen
59
List the thoracic splanchnic nerves and their vertebral level
``` Greater - T5-T9 Coeliac ganglia and adrenal glands Lesser - T10 -T11 Superior mesenteric and aortico-renal ganglia Least - T12 Terminates in renal plexus ```
60
What do the cartilaginous rings in the trachea allow for?
C-shaped rigs allow expansion eosophagus and prevent closure of trachea
61
What is the positioning of the trachea?
Midline of neck, passes right to superior mediastinum Terminates at level of T4 (transthoracic plane) Bifurcates into left and right main bronchi T4
62
What is special about the surface of the carina?
Has mucous membrane - involved in cough reflex
63
Where does the oesophagus lie in relation to the trachea and the left atrium?
Usually flattened - lies posterior to trachea Has squamous columnar epithelial cells Fibromuscular tube Lies just posterior to left atrium - may see indentation on barium swallow
64
At what level is the oesophageal hiatus of the diaphragm?
T10
65
What is the primary function of the lower oesophageal sphincter?
Bundle of muscle at low end of oesophagus - prevents acid and stomach content from travelling backwards
66
What are the 3 constrictions of the oesophagus?
1. upper/pharyngeal constriction 2. middle/aortic constriction - where arch aorta presses 3. inferior/diaphragmatic constriction
67
What is the difference in the pain of GORD and a heart attack?
GORD = Burn sensation | Heart attack = Crush
68
What is aspiration pneumonia?
Food in trachea | Can happen in stroke ˙.˙ can aspirate by tube
69
What is dysphagia?
Difficulty swallowing
70
What are the possible causes of dysphagia?
1. Condition affecting NS eg. dementia, stroke, head injury, multiple sclerosis 2. Cancer - mouth/oesophagus 3. GORD
71
What is Barrett's oesophagus?
Where normal cells lining oesophagus replaced w/ abnormal cells Begins where oesophagus meets stomach and grow upwards

Clinical Anatomy (10 decks)

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