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Topographical Anatomy - ANATOMIA TOPOGRAFICA DEL MEDIASTINO

Structure/Space Description/Boundaries Significance
mediastinum, posterior between pericaridal sac and vertebral bodies contains esophagus, descending thoracic aorta, azygos system, thoracic duct, and lymph nodes

Muscles

Muscle Origin Insertion Action Innervation Notes
innermost intercostal upper borders of ribs at midportion fibers course up and medially to insert on the inferior margin of the rib above keeps intercostal space from blowing out or sucking in during respiration intercostal nerves (T1-T11) innermost intercostal, subcostalis, and transversus thoracis mm. lie deep to the intercostal neurovascular bundle
internal intercostal upper border of rib lower border of rib above, coursing up and medially in front keeps intercostal space from blowing out or sucking in during respiration intercostal nerves (T1-T11) continuous posteriorly with the internal intercostal membrane at rib angles
subcostalis angle of ribs angle of rib 2-3 ribs above origin compresses intercostal spaces intercostal nerves subcostalis, transversus thoracis & innermost intercostal mm. make up the innermost intercostal muscle layer

Nerves

Nerve Source Branches Motor Sensory Notes
vagus medulla: dorsal motor nucleus (preganglionic parasympathetic) and nucleus ambiguus; superior and inferior ganglia auricular br., pharyngeal br., superior laryngeal, superior & inferior cervical cardiac brs., recurrent laryngeal, thoracic cardiac brs., brs. to pulmonary plexus, esophageal plexus, anterior & posterior vagal trunks intrinsic muscles of larynx, pharynx (except stylopharyngeus), & palate (except tensor veli palatini); preganglionic processes synapse in small ganglia within or near viscera of thorax and abdomen; postganglionic processes from these ganglia supply smooth muscles of respiratory tree & gut (proximal to splenic flexure), heart or are secretomotor to mucous glands of larynx, respiratory tree, pharynx & gut, digestive glands skin of external auditory meatus; viscera of head, neck, thorax & abdomen proximal to splenic flexure; taste to epiglottis also known as: CN X, 10th cranial nerve; passes through jugular foramen; vagus means "wanderer" in reference to its extensive distribution to the body cavities
splanchnic, thoracic neurons in intermediolateral cell column of spinal levels T5-T12; nerves appear to arise by multiple contributions from sympathetic trunk greater thoracic splanchnic (formed by union of brs. emerging from ganglia T5-T9); lesser thoracic splanchnic (formed by union of brs. emerging from ganglia T10-T11); least thoracic splanchnic (formed by union of brs. emerging from ganglion T12) to pre-aortic or prevertebral ganglia in abdomen; postganglionic processes from prevertebral ganglia supply smooth muscles of vessels and adrenal medulla which releases epinephrine and norepinephrine pain from abdominal viscera pass through crura of diaphragm; greater thoracic splanchnic synapses in celiac & superior mesenteric ganglia; lesser thoracic splanchnic synapses in aorticorenal ganglion; least thoracic splanchnic synapses in renal plexus (Greek, splanchna = viscera)
sympathetic chain ganglia pregang. symp. via white rami communicans of VPR of T1-L2 postgang. symp. via gray rami communicans to all spinal ns.; internal & external carotid ns.; cervical cardiac brs.; thoracic visceral brs.; greater, lesser & least thoracic splanchnic ns.; lumbar splanchnic ns.; sacral splanchnic ns. dilator pupillae, vascular smooth muscle, arrector pili muscles, sweat glands, adrenal medulla, heart, lungs & gut (moderate muscle contractions, not initiate) pain from viscera located parallel & lateral to vertebral bodies in neck, thorax & abdominopelvic cavity
stellate ganglion pregang. symp. via white rami communicans of T1 postgang. symp. via gray rami communicans to C8& T1; thoracic visceral br. vascular smooth muscle, arrector pili muscle, sweat glands of C8 & T1 cutaneous distribution on chest & upper limb; vascular smooth muscle of lungs pain from lungs stellate is the frequent fusion of inferior cervical ganglion & T1 ganglion of sympathetic trunk
Laryngeal, recurrent vagus esophageal brs., tracheal brs., cardiac brs., pharyngeal brs., inferior laryngeal n. upper esophagus, lower pharynx, laryngeal ms. (except cricopharyngeus); smooth muscle of trachea; secretomotor to mucous glands in upper esophagus, lower pharynx, larynx below vocal fold, trachea; cardiac muscle of heart (slow rate, decrease force of contraction) upper esophagus, lower pharynx, larynx below vocal folds, GVA from heart right recurrent hooks posteriorly around right subclavian a.; left recurrent hooks posteriorly around aortic arch & ligamentum arteriosum
intercostal VPR of T1-11 lateral & anterior cutaneous brs. intercostal muscles, abdominal wall muscles (via T7-11), muscles of forearm & hand (via T1) skin of chest & abdomen anterolaterally, skin of upper limb medially (via T1-2) travels below post. intercostal a. in the intercostal space
esophageal plexus right & left vagus nn.; thoracic visceral brs. of sympathetic trunk anterior & posterior vagal trunks parasympathetic from vagus supplies smooth muscle & glands of thoracic esophagus & abdominal gut proximal to splenic flexure; sympathetics from thoracic visceral brs. supply vascular smooth muscle in esophageal vessels vagus: GVA from esophagus & abdominal gut proximal to splenic flexure; thoracic visceral brs.: pain from esophagus  
cardiac plexus cardiac brs. of vagus & cervical sympathetic trunk, thoracic visceral ns. continuous with coronary & pulmonary plexus moderate heart muscle (parasymp. decreases rate & force of contraction; symp. increases rate & force of contraction); vascular smooth muscle of heart & lungs (symp.); smooth muscle & mucous glands of bronchial tree (parasymp.)    
cardiac vagus, cervical sympathetic trunk   heart (parasymp.: decrease rate & force of contraction; symp.: increase rate & force of contraction); bronchial tree & lungs via pulmonary pleuxs heart, bronchial tree & lungs vagus has 2 (sup. & inf.) cervical cardiac brs. & 1 or more thoracic br.; cervical symp. trunk usually gives 3 (sup., middle & inf.) cardiac brs.
pulmonary plexus continuous with cardiac plexus, thoracic visceral ns., pulmonary brs. of vagus   smooth muscle & glands of bronchial tree (parasymp.); vascular smooth muscle of lungs (symp.) located along pulmonary vessels & primary bronchi in root of lung  

Arteries

Artery Source Branches Supply Notes
aortic arch continuation of ascending aorta brachiocephalic trunk, left common carotid, left subclavian, continues as descending thoracic aorta entire body except heart  
aorta, descending thoracic continuation of aortic arch posterior intercostal aa. 3-11, subcostal aa., left bronchial aa. (2), esophageal aa. (~3), mediastinal brs., superior phrenic aa. thoracic wall, lungs, posterior mediastinum, body below diaphragm  
brachiocephalic trunk aortic arch right common carotid, right subclavian right side of head & neck; right upper limb and right side of chest wall  
bronchial, left descending thoracic aorta right bronchial (occasionally) lower trachea, bronchial tree usually 2 in number
carotid, common brachiocephalic trunk (right), aortic arch (left) external & internal carotid (terminal brs.) most of head & upper neck  
costocervical trunk subclavian deep cervical & supreme intercostal muscles of neck posteriorly, first 2 posterior intercostal arteries  
esophageal descending thoracic aorta   lower 2/3rds of thoracic esophagus there are usually two, although there may be three esophageal brs. of aorta; anastomoses with esophageal brs. of left gastric a.
intercostal, posterior supreme/highest intercostal (upper 2 spaces), descending thoracic aorta (3rd-11th spaces) posterior br., spinal br., anterior br., collateral br., lateral cutaneous br. intercostal muscles posteriorly & laterally & overlying muscles, spinal cord & vertebral column & back muscles, skin & superficial fascia posteriorly & laterally  
phrenic, superior descending thoracic aorta (2 small brs.)   diaphragm  
pulmonary trunk right ventricle right & left pulmonary lungs  
subclavian brachiocephalic (right), aortic arch (left) 1st part: vertebral, thyrocervical trunk, internal thoracic; 2nd part: costocervical trunk; 3rd part: dorsal scapular (70%); continuous with axillary a. at lateral border of rib 1 neck, brain, spinal cord, thyroid gland & larynx, shoulder, chest muscles, upper limb anterior scalene muscle passes anterior to subclavian a., dividing it into 3 parts
subcostal decending thoracic aorta spinal br., collateral br., lateral cutaneous br. vertebra & spinal cord; muscles, skin & fascia of upper abdominal wall  

Veins

Vein Tributaries Drains Into Region Drained Notes
pulmonary lobar vv. left atrium lungs usually two pulmonary vv. per side, superior & inferior; empty into left atrium
brachiocephalic formed by union of subclavian & internal jugular vv.; tributaries: vertebral, thymic, inferior thyroid, internal thoracic, 1st posterior intercostal, left superior intercostal (to left brachiocephalic) left & right brachiocephalic vv. unite to form superior vena cava head, neck, upper limb, anterior chest wall at its origin, left brachiocephalic v. receives thoracic duct; at its origin, right brachiocephalic v. receives right lymphatic duct
vena cava, inferior formed by union of paired common iliac vv; tributaries: lumbar vv. 4-1, right. ovarian/testicular, renal vv., right suprarenal v., right inferior phrenic v., hepatic vv. right atrium body below diaphragm  
vena cava, superior formed by union of paired brachiocephalic vv.; tributary: azygos arch right atrium body above diaphragm except for pulmonary vv. & coronary vv.  
azygos formed by union of ascending lumbar & subcostal vv.; tributaries: posterior intercostals 11-2 (right superior intercostal), hemiazygos, accessory hemiazygos, esophageal, right bronchial superior vena cava lateral & posterior abdominal/chest wall, esophagus, bronchial tree may connect with inferior vena cava; arch of azygos passes superior to root of lung
intercostal, posterior lateral cutaneous v. 1st: brachiocephalic; 2nd-4th: superior intercostal; right 5th-11th: azygos; left 5th-7th or 8th: accessory hemiazygos; left 9th-11th: hemiazygos intercostal space including skin, muscles & adjacent ribs; spinal cord segment & corresponding vertebra  
intercostal, superior 2nd-4th posterior intercostal vv. right: arch of azygos; left: left brachiocephalic intercostal spaces 2-4  
hemiazygos formed by union of left ascending lumbar & subcostal vv.; tributaries: left posterior intercostal vv. 11-9 or 8, esophageal vv. azygos v. lower posterolateral chest wall on left side levels drained may vary
hemiazygos, accessory left posterior intercostal vv. 4-7 or 8, left bronchial vv., esophageal vv. azygos v. middle posterolateral chest wall on left side levels drained may vary
esophageal   azygos & hemiazygos vv. esophagus connect with esophageal brs. of left gastric, forming potential portal-caval venous anastomosis (esophageal varices when enlarged)

Lymphatics

Structure Location Afferents from Efferents to Regions drained Notes
bronchomediastinal trunk along brachiocephalic v. union of efferents from paratracheal nodes, parasternal nodes, anterior mediastinal nodes left: thoracic duct; right: right lymphatic duct thoracic wall & viscera, medial part of breast right bronchomediastinal trunk receives lymph from lower lobe of left lung; bronchomediastinal trunk may drain to venous system separately on either side
bronchopulmonary nodes hilum of lung pulmonary nodes tracheobronchial nodes lung also known as: hilar nodes
hilar nodes at hilum of lung pulmonary nodes tracheobronchial nodes lung also known as: bronchopulmonary nodes
mediastinal nodes, anterior posterior aspect of sternum   bronchomediastinal trunk thymus, anterior diaphragm & pericardium, some heart  
mediastinal nodes, posterior along azygos system of veins & esophagus   thoracic duct & inferior & superior tracheobronchial nodes posterior mediastinum, posterior aspect of heart & pericardium, posterior diaphragm  
paratracheal nodes lateral to trachea & esophagus superior tracheobronchial nodes bronchomediastinal trunk lungs, trachea, upper esophagus, larynx below vocal folds  
pulmonary nodes within the lung parenchyma   bronchopulmonary/hilar nodes lung parenchyma, bronchial tree within lungs  
tracheobronchial nodes, inferior inferior to tracheal bifurcation bronchopulmonary nodes right superior tracheobronchial nodes lower lobes of lungs, middle & post. mediastinum  
tracheobronchial nodes, superior superolateral to tracheal bifurcation bronchopulmonary nodes, inferior tracheobronchial nodes (to right) paratracheal nodes lungs, middle & post. mediastinum inferior tracheobronchial nodes drain lymph from lower lobe of left lung to right superior tracheobronchial nodes
horacic duct between esophagus & thoracic vertebral bodies union of lumbar lymph trunks, sometimes dilated to form cisterna chyli junction of left internal jugular v. and left brachiocephalic v. body below diaphragm, left side of body above diaphragm largest lymph vessel; passes up through aortic hiatus on right side of aorta, swings to left side of esophagus at T4-T5 disc

Viscera/Fascia

Organ Location/Description Notes
fascia, endothoracic connective tissue between inner aspect of chest wall & costal parietal pleura equivalent to transversalis fascia layer of the abdomen
pleura, visceral serous lining on the surfaces of the lungs; extends into oblique & horizontal fissures does not have pain fibers
esophagus connects: superiorly with laryngopharynx at lower border of cricoid cartilage; inferiorly it passes through diaphragm at T10 vertebral level to reach stomach upper third is skeletal muscle innervated by recurrent laryngeal, lower 2/3rds is smooth muscle innervated by vagus via esophageal plexus
trachea lies anterior to the esophagus; extends from vertebral level C6 to T4/T5 disc; connects above to cricoid cartilage via cricotracheal ligament bifurcation into primary bronchi is marked by the carina
carina keel-shaped cartilage lying within tracheal bifurcation  
bronchi   bronchi may be classified as primary, secondary (lobar), and tertiary (segmental)
bronchi, primary extend from tracheal bifurcation at T4/T5 intervertebral disc to hilum of lung  
bronchi, secondary branch from primary bronchi; 3 on right: upper, middle & lower; 2 on left: upper & lower also known as: lobar bronchi; right primary bronchus is shorter, larger in diameter and more vertically oriented than the left so that aspirated foreign bodies tend to lodge in the right primary bronchus
bronchi, tertiary or segmental branch from secondary (lobar) bronchi in following pattern: r. upper lobar: apical, anterior & posterior; r. middle lobar: medial & lateral; r. lower lobar: superior, anterior basal, post. basal, medial basal, lateral basal; l. upper lobar: apicoposterior, anterior, superior lingular, inferior lingular; l. lower lobar: superior, anteromedial basal, posterior basal, lateral basal also known as: segmental bronchi
lungs right divided into three lobes: upper, middle & lower; left has two lobes: upper & lower  
fissure, oblique separates upper lobe from lower lobe (both lungs), and middle lobe from lower lobe (right lung) extends from level of T3 vertebra posteriorly to 6th costochondral junction anteriorly
fissure, horizontal separates middle lobe from upper lobe (right lung only) extends from 5th rib at mid-axilla along 4th rib to sternum anteriorly
lobe, inferior right: possesses 5 bronchopulmonary segments - superior, anterior basal, posterior basal, medial basal, lateral basal; left: possesses 4 bronchopulmonary segs. - superior, anteromedial basal, posterior basal, lateral basal  
lobe, middle right lung only; possesses 2 bronchopulmonary segments: medial & lateral  
lobe, superior right: possesses three bronchopulmonary segments - apical, anterior & posterior; left: possesses four bronchopulmonary segments - apicoposterior, anterior, superior lingular, inferior lingular  
cardiac notch concavity or notch along anterior border of left lung separates lingula below from upper portion of superior lobe of left lung
lingula lower portion of superior lobe of left lung; below cardiac notch  

Clinical Terms

Term Definition
chylothorax accumulation of chyle (lymph from the GI tract) in the thoracic cavity
mediastinal emphysema presence of air in the mediastinal tissues due to leakage of air from the tracheobronchial tree, usually as a result of trauma. Air from the mediastinum can track cephalically and may sometimes be palpated in the subcutaneous tissues of the neck and upper torso.
tracheo-esophageal fistula (upper esophageal atresia) congenital anomaly in which the upper esophagus ends (atresia) and does not connect with the stomach, and the lower esophagus connects to the trachea (tracheoesophageal fistula); a common complication seen shortly after birth is an aspiration pneumonia - infants will demonstrate excessive salivation, gagging, and coughing with feeding, poor feeding and a bluish discoloration of the skin (cyanosis); treatment involves the surgical repair of the esophagus before the child can take anything by mouth
visceral pain pain relating to the viscera (i.e., splanchnic); mediated by the autonomic nervous system
referred pain pain that is felt somewhere other than a region from which it originates; mediated by the autonomic nervous system
carcinoma any of the various types of malignant (invasive) neoplasm derived from epithelial tissue in several sites, occurring more frequently in skin, bronchi, stomach, and prostate gland in men, and in the breast, cervix, and skin in women
tachycardic patient with a rapid beating of the heart, defined as over 100 beats/minute
edematous swollen due to excessive fluid accumulation in the intercellular tissue space
hematoma a collection of blood that is confined and usually clotted, due to a break in the wall of a blood vessel
radical neck dissection a common major operation performed to remove malignancies of the head and neck; the neck must be opened laterally and the majority of the sternocleidomastoid muscle is removed along with the regional cervical lymph nodes, the jugular vein, accessory nerve, submaxillary and parotid glands


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