1
Department of Anatomy
CLINICAL ANATOMY OF THE NECK AND
CHEST
MUDr. Marek Joukal, Ph.D.
Against head:
protuberantia occipitalis ext.
linea nuchae sup.
porus acusticus ext.
Base of mandible
Against chest:
Incisura jugularis sterni
clavicula
acromion
vertebra prominens
Against nuchal region:
processus mastoideus
Margine of the m. trapezius
acromion
Regiones coli - limitation
regio colli ant.
trigonum omotracheale
(infrahyoideum)
trigonum submandibulare
trigonum submentale
trigonum caroticum
regio sternocleidomastoidea
regio colli laterale
trigonum omoclaviculare
trigonum omotrapezoideum
trigonum scalenovertebrale
Regiones coli Cervical fascia
Lamina superficialis fasciae cervicalis
Lamina praetrachealis fasciae cervicalis
Lamina praevertebralis fasciae cervicalis
Trigonum omotracheale (regio infrahyoida)
Superficial layers:
skin (prominentia laryngea)
m. platysma (ansa cervicalis spf.)
lamina spf. fasciae cervicalis
vena jugularis ant.
lamina praetrachealis fasciae cervicalis
Spatium suprasternale
(above the sternum, between lamina spf. and
praetrachealis)
Fatty tissue
arcus venosus juguli
Trigonum omotracheale (visceral layer)
Infrahyoid muscles (ansa cervicalis prof.)
larynx, trachea (C6)
pharynx, oesophagus (C6)
a., v. thyroidea sup. et inf,
a., v. laryngea sup.
n. laryngeus sup. (ramus int. et
ext.)
n. laryngeus inf.
gl. thyroidea
ggl. parathyroidae
pharynx, oesophagus (C6)
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Trigonum submandibulare
Borders: m. digastricus
mandibule
tractus angularis - divides gl.
parotis and gl. submandubularis
Content: platysma, superficial lamina of cervical f.
glandula submandibularis
a.,v. facialis (a., v. submentalis)
n. mylohyoideus
n. lingualis + ggl. Submandibulare
n. hypoglossus (arcus)
n. lymphatici submandibulares
Trigonum submandibulare
Trigonum Pirogowi (ligation of lingual a.):
m. digastricus
n. hypoglossus
m. mylohyoideus
Béclard´s angles (beggining of lingual a.):
cornu majus ossis hyoidei
n. hypoglossus
Trigonum submentale
Borders: m. digastricus – anterior belly (bilat.)
hyoid bone
Content:
m. platysma
Spf. lamina of cervical fascia
nodi lymphatici submentales
Trigonum caroticum
Borders:
Anterior margine of m. sternocleidomastoideus
venter superior m. omohyoidei
venter posterior m. digastrici
Major content:
bifurcatio carotidis (C4)
(a. carotis com. -> a. carotis ext. et int.)
glomus caroticum
Trigonum caroticum – vessels
vena jugularis int. and tributaries
(nodi lymphatici cervicales prof.)
a. carotis com.
a. carotis int. – dorsomedially (no branches!!!)
a. carotis ext.
a. thyroidea sup.
a. lingualis
a. facialis
a. pharyngea sup.
a. occipitalis
a. auricularis post
Trigonum caroticum – nerves
n. vagus
n. laryngeus sup.
n. hypoglossus (arcus)
radix sup. ansae cervic. prof.
ansa cervicalis prof.
(infrahyoid mm.)
truncus sympaticus
(praevertebral fascia)
ggl. cervicale sup. et med.
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Regio sternocleidomastoidea
Borders: m. sternocleidomastoideus
(fossa supraclavicularis minor)
Layers: skin and m. platysma
v. jugularis ext. + n. lymph. cevicales spf.
punctum nervosum
lamina spf. fasciae cervicalis + m. sternocleidomastoideus
n. accesorius + a. sternocleidomastoidea (a. carotis ext.)
Regio colli laterale – superficial layer
Borders: post. margin of m. sternocleidomastoideus, ant. margin of m. trapezius, clavicula
venter inferior m. omohyoidei -> trigonum omoclaviculare and trigonum omotrapezium
Skin and m. platysma
v. jugularis ext. + n. lymph.
cevicales spf.
punctum nervosum
n. transversus coli
(r. coli n. facialis – ansa
cervicalia spf.)
n. auricularis magnus
n. occipitalis minor
nn. supraclaviculares
lamina spf. fasciae cervicalis
Regio colli laterale – deep layer
n. accesorius (m. trapezius)
plexus cervicalis (n. phrenicus)
supraclavicular part of plexus brachialis
n. dorsalis scapulae
n. suprascapularis
n. thoracicus longus
nn. pectorales
nn. subscapulares
n. thoracodorsalis
Arteries (braches of a. subclavia):
a. cervicalis ascendens
a. cervicalis spf.
a. transversa coli
a. suprascapularis
nodi lymph. cervicales prof.
Regio coli laterale – deep layer
v. subclavia
fissura
scalenorum:
a. subclavia
plexus
brachialis
Trigonum scalenovertebrale (trigonum a. subclaviae)
Borders:
caudal: cupula pleurae (2 cm above the clavicle)
lateral: m. scalenus ant.
medial: organs (trachea, thyroid gland, esophagus)
dorsal: m. longus coli
ventral: m. sternocleidomastoideus
Content:
angulus venosus –v. subsclavia + v. jugularis int.
(dx. tr. lymphaticus dx.; sin. ductus thoracicus)
a. subclavia and branches (dx. tr. brachiocephalicus)
n. vagus – n. laryngeus reccurens
tr. symphaticus and branches – ansa subclavia
ggl cervicale inf.
n. phrenicus
Glandula thyroidea
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• Ramus externus n. laryngei sup.,
vasa laryngea sup.
• Ramus externus n. laryngei sup.
• Vasa thyroidea superiora (rr.
Glandulares
• Nervus laryngeus recurrens
• Vasa thyroidea inf.
• Glandulae parathyroideae
Tracheostomia
Coniotomia Laryngocele
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Laryngectomia totalis
Electrolarynx
IIa-IIb – n. XI
II-III – bifucration of carotis, os
hyoideum
III-IV – m. omohyoideus,
cartilago cricoidea
Lymphatic nodes dissection Pharynx
Trigonum Kiliani
Trigonum Laimer-Haeckerman
Zencker´s diverticulum Swallow
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Hypoglossus – Facialis anastomosis Local anesthesia of the cervical plexus
Block of the brachial plexus Central venous catheter
Vena subclavia
Central venous catheter – vena jugularis
interna
Thoracic outlet syndrome
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Cervical rib Subclavian steal fenomen
CHEST
Superficial border against neck:
Incisura jugularis sterni
clavicula
acromion
vertebra prominens (C7)
Superficial border against
abdomen:
arcus costarum
Deep border against neck:
apertura thoracis superior
Deep border against abdomen:
diaphragm
Orientation lines on the chest
Linea mediana anterior
Linea sternalis
Linea parasternalis
Linea medioclavicularis
Linea axillaris ant.
Linea axillaris media
Orientation lines on the chest
Linea mediana post.
Linea paravertebralis
Linea scapularis
Linea axilaris post.
Regiones thoracis
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Thoracic wall
Skin and subcutaneous tissue
v. thoracoepigastrica
rr. cutanei ant. et lat. (nn. intercostales)
fascia pectoralis
Heterochtonous muscles of the chest
mm. intercostales:
ext. + membrana intercostalis ext.
int. + membrana intercostalis int.
intimi
v., a., n. intercostalis (VAN) v sulcus costae
fascia endothoracica
A parasternal
B anterior axillary
C paravertebral
1 Fascia thoracica spf.
2 fascia endothoracica
3 pleura parietalis
4 membrana
intercostalis externa
5-7 mm. Intercostales
int., ext. et intimus
8 membrana
intercostalis int.
9 m. transversus
thoracis
Puncture of the chest
Presternal region
Borders:
sternum
Content:
skin – hairs, glands
Subcutaneous tissue
innervation nn. supraclaviculares
periost (membrana sterni ext.)
sternum
membrana sterni int.
m. transversus thoracis
fascia endothoracica
Trigonum deltoideopectorale (clavipectorale)
Borders:
clavicula
m. deltoideus
m. pectoralis major
Content:
Skin and subcutaneous tissue
v. cephalica (sulcus deltoideopectoralis)
innervation nn. supraclaviculares
fascia clavipectoralis
a. thoracoacromialis (a.axillaris)
nn. pectorales
Regio mammaria
Breast morphology:
skin
areola mammae
(gll. areolares mammae)
papilla mammae
(area cribriformis, ductus lactiferi)
Subcutaneous tissue:
m. subareolaris
praemammary fat
corpus mammae with proc.
axillaris
retromammary fat
fascia pectoralis
mm. pectorales
Borders:
from 3rd to 6th intercostal space
linea axillaris ant. – linea parasternalis (sinus
mammarum)
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Arteries:
a. thoracica interna (rr. mammarii med.)
a. thoracica lateralis (rr. mammarii lat.)
a. thoracica suprema
aa. intercostales post. (from 4. – Piet´s papillary
artery)
Veins
circulus venosus Halleri
Innervation:
nn. intercostales
Regio mammaria
nll. axillares
Sorgius l.n. (m. serratus ant.)
nll. parasternales
nll. supraclaviculares
nll. intercostales
nll. mediastinales ant.
Regio mammaria – lymphatic drainage
cupula pleurae (2 cm above clavicle)
pleura parietalis:
costalis, diaphragmatica, mediastinalis
pleura parietalis et visceralis
cavitas pleuralis dextra et sinistra
lig. pulmonale, mediastinum
Cavitates pleurales Recessus pleurales
recessus costodiaphragmaticus, costomediastinalis, phrenicomediastinalis
Projection of the pleura and lungs
cupula pleurae – 2 cm above clavicle
art. sternoclavicularis – 2nd sternocostal connection
area interpleuralis sup. (thymica)
4th sternocostal connection –incisura cardiaca (left) to 6th rib
area interpleuralis inf. (pericardiaca)
linea medioclavicularis – 7th rib
linea axillaris ant. – 8th rib
Lungs
ventrally – similar to pleura
caudally –1 to 2 intercostal
spaces canially
Pleura:
linea medioclavicularis – 7th rib
linea axillaris ant. – 8th rib
linea axillaris med. – 9th rib
linea axillaris post. – 10th rib
Lungs:
1 or 2 intercostal spaces cranially
Projection of the pleura and lungs
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Caudal border - pleura:
linea axillaris post. – 10th rib
linea scapularis – 11th rib
linea paravertebralis – 12th rib
Posterior border - pleura:
From 12th rib in paravertebral line to cupula pleurae
Th12 - Th4 on the right – recessus retrooesophageus
Caudal border - lungs:
1 or 2 intercostal spaces cranially
Posterior border:
Paravertebral line (bilat.)
Projection of the pleura and lungs
valva aortae
valva
tricuspidalis
valva trunci
pulmonalis
valva
bicuspidalis
Projection of the heart
Auscultation points:
A 2nd right intercostal space – 1 cm
from sternum
B 5th right intercostal space – next to
the sternum
C 5th left intercostal space– 1cm
medially from linea medioclav.
D 2nd left intercostal space – 2cm from
sternum
Coronary arteries
Arteria coronaria cordis dextra
r. coni arteriosi
r. nodi sinuatrialis
r. nodi atrioventricularis
rr. atriales dx.
rr. ventriculares dx.
r. marginalis dx.
r. interventricularis post.
Arteria coronaria cordis sinistra
r. interventricularis ant.
r. coni arteriosi
r. lateralis
rr. interventriculares septales
r. circumflexus
r. marginalis sin.
rr. atriales
r. nodi sinuatrialis
r. nodi atriovetricularis
facies sternocostalis
facies diaphragmatica
a. coronaria cordis sin. a. coronaria cordis dx.
RCx – ramus circumflexus
RIM – ramus intermedius
RIA – ramus interventricularis
anterior
RD – ramus diagonalis
RCA – right coronary artery
RIVP – ramus interventricularis
posterior
RPLD – ramus posterolateris dexter
Coronarography Percutaneous transluminal coronary angioplasty
(PTCA)
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Coronary artery bypass surgery
Mediastinum
Space between pleaural cavities
Mediastinum superius
apertura thoracis sup. –> plane of sternal angle and 4th
intervertebral disc
Mediastinum inferius:
anterius – between sternum and pericardium
medium – pericardiac sac with heart
posterius – between pericardium and vertebrae
thymus
Venous layer
vv. brachiocephalicae + v. cava sup.
Arterial layer
tr. pulmonalis, aorta asc., arcus aortae +
branches
tr. symphaticus + branches
n.vagus – n. laryngeus recurrens !
n. phrenicus
trachea – bifurcatio + bronchi
esophagus
nnl. mediastinales anteriores
Mediastinum superius Superior vena cava syndrome
Mediastinum anterius
ligg. pericardiacophrenica
vasa thoracica int. – branches and tributaries
nnl. parasternales
vasa pericardiacophrenica
n. phrenicus
nll. mediastinales ant.
Mediastinum medium
hilus pulmonis dx. (BAV)
bronchus principalis dx.
a. pulmonalis dx.
vv. pulmonales dx.
hilus pulmonis sin. (ABV)
a. pulmonalis sin.
bronchus principalis sin.
vv. pulmonales sin.
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Mediastinum posterius
oesophagus
n. vagus
plexus oesophageus
aorta thoracica
v. azygos
Th7-Th9 v. hemiazygos, v. hemiazygos acc.
ductus thoracicus
between v. azygos, aorta
truncus sympaticus
nn. splanchnici
major (Th6-9), minor (Th10-11), imus (Th12)
nll. mediastinales post.
SEGMENTA BRONCHOPULMONALIA
SEGMENTA BRONCHOPULMONALIA DEXTRA
1
2
3
4
6
7
8 9
10
1
2
3
4
5
6
8
910
LOBUS SUPERIOR
(1) seg. apicale
(2) seg. posterius
(3) seg. anterius
LOBUS MEDIUS
(4) seg. laterale
(5) seg. mediale
LOBUS INFERIOR
(6) seg. apicale
(7) seg. basale mediale
(8) seg. basale anterius
(9) seg. basale laterale
(10) seg. basale posterius
SEGMENTA BRONCHOPULMONALIA SINISTRA
LOBUS SUPERIOR
(1+2) seg.
apicoposterius
(3) seg. anterius
(4) seg. lingulare superius
(5) seg. lingulare inferius
LOBUS INFERIOR
(6) seg. apicale
(7) seg. basale mediale
reduced
(8) seg. basale anterius
(9) seg. basale laterale
(10) seg. basale posterius
1 + 2
3 3
44
5
5
6
6
10
109
9
8
7+8
2 + 1
Approaches to the chest Video-assisted thoracoscopic surgery
(VATS)
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MECHANISM OF BREATHING
INSPIRATION
Diaphragmatic contraction
(abdominal type)
mm. intercostales externi
(costal type)
Capacity of thoracic cavity is increased:
EXSPIRATION
Capacity of thoracic cavity is decreased:
• Diaphragm and mm. intercostales externi are relaxed
• Contraction of mm. intercostales interni a intimi
• Weight of thorax
• Elasticity of rib cartilages
• Elasticity of lungs
• Pressure of abdominal organs
Forced breathing
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Putz, R. et al.: Atlas of Human Anatomy Sobotta. Elsevier Books, (2008).
Netter, F. H.: Interactive Atlas of Human Anatomy. Windows Version 2.0. (1999).
Čihák R: Anatomie 2 (Splanchnologia). Avicenum, zdravotnické nakladatelství, Praha, (1988).
Čihák, R.: Anatomie 3. Praha, Grada, (2004).
Platzer, W. et al.: Atlas topografické anatomie. Grada Publishing, (1996).
Grim, M. a kol.: Základy anatomie. 5. Anatomie krajin těla. Galén, (2002).
Moore, K. L.: Clinical oriented anatomy. Third edition. Williams & Wilkins, A Waverly Company, (1992).
Gilroy, A. M. et al.: Atlas of Anatomy. Thieme New York, Stuttgart. (2009).
Sobotta, J.: Atlas of Human Anatomy Vol 1–2 Munich, Urban und Schwarzenberg, (1993)Wiliams,
P. & Warvick, R.: Gray´s Anatomy, 37 ed, Churhill Livingstone, (1996).