THORAX

Pleurae; Lungs; Tracheobronchial Tree;

Breasts; Surface Anatomy and Markings

Ismail Mk ABDULLAHI
The Pleurae
The pleurae refer to the serous membranes that line the lungs and
thoracic cavity.

Structure of the Pleurae

A layer of simple squamous cells supported by connective tissue also
known as the mesothelium.

Divisions
Visceral pleura
Parietal pleura
Parietal Pleura
The parietal pleura covers the internal surface of the thoracic cavity. It
is thicker than the visceral pleura

• Mediastinal pleura – Covers the lateral aspect of the mediastinum.

• Cervical pleura – Lines the extension of the pleural cavity into the
neck.
• Costal pleura – Covers the inner aspect of the ribs, costal cartilages,
and intercostal muscles.
• Diaphragmatic pleura – Covers the thoracic (superior) surface of the
diaphragm.
Visceral Pleura

 The visceral pleura covers the outer surface of the lungs, and extends
into the interlobar fissures.

 It is continuous with the parietal pleura at the hilum of each lung.

Pleural Cavity

 Potential space between the parietal and visceral pleura.

 It contains a small volume of serous fluid which has two major

functions:

It lubricates the surfaces of the pleurae allowing them to slide

over each other.

It produces a surface tension pulling the parietal and visceral

pleura together.
Pleural Recesses
 Remaining pleural cavity not completely filled by the lungs.
 The opposing surfaces of the parietal pleura touch.

Two recesses:
Costodiaphragmatic
Costomediastinal

These recesses are of clinical importance as they provide a location

where fluid can collect (e.g in a pleural effusion).
Neurovascular Supply

The two parts of the pleurae receive a different neurovascular supply:

Parietal Pleura
Innervation: The parietal pleura is sensitive to pressure, pain, and
temperature, produces a well localised pain, and it is innervated by the
phrenic and intercostal nerves.

Blood supply: derived from the intercostal arteries.

Visceral Pleura
Innervaton: Its sensory fibres only detect stretch and receives autonomic
innervation from the pulmonary plexus

Blood supply: is via the bronchial arteries (branches of the descending aorta)
which also supply the parenchyma of the lungs.
Clinical Significance
Pneumothorax
• A pneumothorax (commonly referred to a collapsed lung) occurs
when air or gas is present within the pleural space.
• This removes the surface tension of the serous fluid present in the
space, reducing lung extension.
• Clinical features include chest pain, and shortness of breath, and
asymmetrical chest expansion.
• There are two main classes of pneumothorax – spontaneous and
traumatic.
The Lungs
• The lungs are the organs of respiration.

• Location: in the thorax on either side of the mediastinum.

• Function: oxygenate blood.

They achieve this by bringing inspired air into close contact with
oxygen-poor blood in the pulmonary capillaries.
Anatomical Position and Relations
 The lungs lie either side of the mediastinum within the thoracic cavity
surrounded by a pleural cavity.
 They are suspended from the mediastinum by the lung root – a
collection of structures entering and leaving the lungs
 The medial surfaces of both lungs lie in close proximity to several
mediastinal structures:

Left Lung Right Lung

Heart Oesophagus
Arch of aorta Heart
Thoracic aorta Inferior vena cava
Oesophagus Superior vena cava
Azygous vein
Lung Structure
 The lungs are roughly cone shaped.
 The left lung is slightly smaller than the right

 Each lung consists of:

Apex: The blunt superior end of the lung.
Base: The inferior surface of the lung.
Lobes (2/3): Separated by fissures within the lung.
Surfaces (3): Costal, mediastinal and diaphragmatic.
Borders (3): Edges of the lungs - anterior, inferior and posterior
borders.
Lobes
 Right lung: three lobes - superior, middle and inferior divided from each
other by the two lung fissures
 The left lung contains superior and inferior lobes separated by only the
oblique fissure.

Fissures
 Oblique fissure – Runs from the inferior border of the lung in a
superoposterior direction, until it meets the posterior lung border.

 Horizontal fissure– Runs horizontally from the sternum, at the level of

the 4th rib, to meet the oblique fissure.
Surfaces

 Mediastinal surface of the lung faces the lateral aspect of the middle
mediastinum. The lung hilum (where structures enter and leave the lung) is
located on this surface.

 Diaphragmatic surface. It rests on the dome of the diaphragm, and has a

concave shape. This concavity is deeper in the right lung, due to the higher
position of the right dome overlying the liver.

 Costal surface is smooth and convex. It faces the internal surface of the
chest wall. It is related to the costal pleura, which separates it from the ribs
and innermost intercostal muscles.
Borders

 The anterior border of the lung is formed by the convergence of the

mediastinal and costal surfaces and on the left lung it is marked by a
deep notch called the cardiac notch.

 The inferior border separates the base of the lung from the costal
and mediastinal surfaces.

 The posterior border is smooth and rounded formed by the costal

and mediastinal surfaces meeting posteriorly.
Root and Hilum

 The lung root is a collection of structures that suspends the lung from
the mediastinum.

 Each root contains: bronchus, pulmonary artery, two pulmonary

veins, bronchial vessels, pulmonary plexus of nerves and lymphatic
vessels.

 All these structures enter or leave the lung via the hilum – a wedge
shaped area on its mediastinal surface.
Lung Segments
Right Lung Left Lung
Superior lobe Superior lobe
 Apical  Apical
 Posterior  Posterior
 Anterior  Anterior
 Superior
Middle lobe  Inferior
 Lateral
 Medial

Inferior lobe Inferior lobe

 Superior  Superior
 Anterior basal  Anterior basal
 Medial basal  Medial basal
 Lateral basal  Lateral basal
 Posterior basal  Posterior basal
Tracheobronchial Tree
The tracheobronchial tree is a series of passages that supplies air to the alveoli
of the lungs.
 Trachea
 2 Main bronchi (right and left): Each bronchus enters the root of the lung
 Lobar bronchi: one supplying each lobe.
 Several tertiary segmental bronchi. Each segmental bronchus provides air to a
bronchopulmonary segment
 Conducting bronchioles
 Terminal bronchioles.
 Respiratory bronchioles
 Alveoli: the site of gaseous exchange.
Vasculature
• The lungs are supplied with deoxygenated blood by the paired
pulmonary arteries.
• Once the blood has received oxygenation, it leaves the lungs via four
pulmonary veins (two for each lung).

 The bronchi, lung roots, visceral pleura and supporting lung tissues
require an extra nutritive blood supply delivered by the bronchial
arteries arising from the descending aorta.

 The bronchial veins provide venous drainage.

• The right bronchial vein drains into the azygos vein
• The left drains into the accessory hemiazygos vein
Nerve Supply
The nerves of the lungs are derived from the pulmonary plexuses featuring
sympathetic, parasympathetic and visceral afferent fibres:

• Parasympathetic – derived from the vagus nerve: stimulate secretion from

the bronchial glands, contraction of the bronchial smooth muscle, and
vasodilation of the pulmonary vessels.

• Sympathetic – derived from the sympathetic trunks: stimulate relaxation of

the bronchial smooth muscle, and vasoconstriction of the pulmonary
vessels.

• Visceral afferent – conduct pain impulses to the sensory ganglion of the

vagus nerve.
• Lymphatic Drainage
The lymphatic vessels of the lung arise from two lymphatic plexuses:

• Superficial (subpleural) – drains the lung parenchyma.

• Deep – drains the structures of the lung root.

Both these plexuses empty into the trachebronchial nodes – located

around the bifurcation of the trachea and the main bronchi then into
the right and left bronchomediastinal trunks.
Clinical Correlates
Pulmonary Embolism
• A pulmonary embolism refers to the obstruction of a pulmonary artery by a
substance that has travelled from other places in the body.

The most common emboli are:

• Thrombus – responsible for the majority of cases and usually arises in a
distant vein.
• Fat – following a bone fracture or orthopaedic surgery.
• Air – following cannulation in the neck.

The effect of a pulmonary embolism is a reduction in lung perfusion.

The Breasts
• The breasts are paired structures located on the anterior thoracic wall
in the pectoral region.

• They are present in both males and females bu more prominent in

females following puberty.

• In females, the breasts contain the mammary glands – an accessory

gland of the female reproductive system.

• The mammary glands are the key structures involved in lactation.

Surface Anatomy
 It extends horizontally from the lateral border of the sternum to the mid-axillary line.
 Vertically, it spans between the 2nd and 6th costal cartilages. It lies superficially to the
pectoralis major and serratus anterior muscles.

Regions:
Circular body – largest and most prominent part of the breast.
Axillary tail – smaller part, runs along the inferior lateral edge of the pectoralis
major towards the axillary fossa.

The nipple located at the centre of the breast is composed mostly of smooth muscle
fibres.

Surrounding the nipple is a pigmented area of skin termed the areolae with numerous
sebaceous glands (enlarged during pregnancy ) secreting an oily substance that acts as a
protective lubricant for the nipple.
Anatomical Structure
The breast is composed of mammary glands surrounded by a connective tissue
stroma.

Mammary Glands
 The mammary glands are modified sweat glands. They consist of a series of
ducts and secretory lobules (15-20).
 Each lobule consists of many alveoli drained by a single lactiferous duct.
 These ducts converge at the nipple like spokes of a wheel.

Connective Tissue Stroma

The connective tissue stroma is a supporting structure which surrounds the
mammary glands. It has a fibrous and a fatty component.
• The fibrous stroma condenses to form suspensory ligaments (of Cooper).
These ligaments have two main functions:
• Attach and secure the breast to the dermis and underlying pectoral fascia.
• Separate the secretory lobules of the breast.

Pectoral Fascia
 The base of the breast lies on the pectoral fascia It acts as an attachment
point for the suspensory ligaments.
 There is a layer of loose connective tissue between the breast and
pectoral fascia called the retromammary space - a potential space often
used in reconstructive plastic surgery.
Vasculature
 Arterial supply
 Medial aspect: internal thoracic artery (also known as internal mammary
artery)
 Lateral part : Lateral thoracic and thoracoacromial branches
 Lateral mammary branches: originate from the posterior intercostal arteries
(derived from the aorta) supplying the lateral aspect of the breast in the 2nd
3rd and 4th intercostal spaces.
 Mammary branch – originates from the anterior intercostal artery.

The veins of the breast correspond with the arteries, draining into the axillary
and internal thoracic veins.
Lymphatics
The lymphatic drainage of the breast is of great clinical importance due to its
role in the metastasis of breast cancer cells.
There are three groups of lymph nodes that receive lymph from breast tissue
Axillary nodes (75%)
Parasternal nodes (20%)
Posterior intercostal nodes (5%).

The skin of the breast also receives lymphatic drainage:

Skin – drains to the axillary, inferior deep cervical and infraclavicular nodes.
Nipple and areola – drains to the subareolar lymphatic plexus.
Nerve Supply

 The breast is innervated by the anterior and lateral cutaneous

branches of the 4th to 6th intercostal nerves.
 These nerves contain both sensory and autonomic nerve fibres (the
autonomic fibres regulate smooth muscle and blood vessel tone).

Note: These nerves do not control the production and secretion of milk
rather it is regulated by the hormones prolactin and oxytocin secreted
from the pituitary gland.
 Clinical Relevance
Breast Cancer
 Common presentations associated with breast cancer are due to blockages of the
lymphatic drainage.
 Excess lymph builds up in the subcutaneous tissue, resulting in clinical features such
as nipple deviation and retraction and prominent skin between small dimpled pores
 Larger dimples are generally caused by cancerous invasions and fibrosis. This causes
traction of the suspensory ligaments, causing them to shorten.
 Metastasis commonly occurs through the lymph nodes. It is most likely to be the
axillary lymph nodes that are involved.
 They become stony hard and fixed and following this, the cancer can spread to
distant places such as the liver, lungs, bones and ovary.
Surface Markings of the Thorax
Planes
• The anterior median line (AML)
• The midclavicular line (MCL)
• The anterior axillary line (AAL)
• The midaxillary line (MAL)
• The posterior axillary line (PAL)
• The posterior median line (PML)
• The scapular lines (SLs)
 The Trachea: Lower border of the cricoid cartilage (C6) to the level of sternal angle
of Louis (T4/5)

 The Jugular notch: Inferior border of the body of T2 vertebra and the space
between the 1st and 2nd thoracic spinous processes.

 The manubrium (approximately 4 cm long): Bodies of T3 and T4 vertebrae

 The sternal angle: T4–T5 IV disc and the space between the 3rd and 4th thoracic
spinous processes.

 The left side of the manubrium is anterior to the arch of the aorta, and its right side
directly overlies the merging of the brachiocephalic veins to form the superior vena
cava (SVC).
 The SVC passes inferiorly deep to the manubrium and manubriosternal junction
and enters the right atrium of the heart opposite the right 3rd costal cartilage

 The body of the sternum (approximately 10 cm long): lies anterior to the right
border of the heart and vertebrae T5–T9.

 The intermammary cleft overlies the sternal body.

 The xiphoid process lies in a slight depression called the epigastric fossa.

 The xiphisternal joint is palpable and is often seen as a ridge at the level of the
inferior border of T9 vertebra.
 Diaphragm:
 The central tendon of the diaphragm lies directly behind the xiphisternal joint.
 In the midrespiratory position, the summit of the right dome of the diaphragm
arches upward as far as the upper border of the 5th rib in the midclavicular line but
the left dome only reaches as far as the lower border of the 5th rib.

 Nipple
 In the male, the nipple usually lies in the fourth intercostal space about 4 in. (10 cm)
from the midline.
 In the young adult female, it overlies the 2nd to 6th ribs and their costal cartilages
and extends from the lateral margin of the sternum to the midaxillary line. Its upper
lateral edge extends around the lower border of the pectoralis major and enters the
axilla.
 In the full grown-up female, its position is not constant.
 Thoracic Blood Vessels

 The arch of the aorta and the roots of the brachiocephalic and left
common carotid arteries lie behind the manubrium sterni.
 The superior vena cava and the terminal parts of the right and left
brachiocephalic veins also lie behind the manubrium sterni.

 The internal thoracic vessels run vertically downward, posterior to the

costal cartilages, 0.5 in. (1.3 cm) lateral to the edge of the sternum as far as
the sixth intercostal space.