The thorax, tracheobronchial tree and lungs

Question 1

Which bony anomaly could cause injury to the vessels passing in and out of the superior thoracic aperture?

What symptoms might they get?

Answer 1

An extra cervical rib

Patient may present with a cold limb, weak pulse, or tingling in the upper limb

Question 2

Compression of which nerves can cause atrophy of the 1st dorsal webspace?

Answer 2

C6 + C7

Question 3

Which nerve provides motor and sensory innervation to the diaphragm?

Answer 3

Phrenic nerve (C3,4,5)

Question 4

Which specific element of cardiac surgery could cause injury to the phrenic nerve?

Answer 4

Saline slush from myocardial preservation

Question 5

Which pathology would unilateral phrenic nerve injury cause?

Answer 5

Hemidiaphragmatic palsy

Question 6

At which vertebral level does the IVC pass through the diaphragm?

Answer 6

T11

Question 7

At which vertebral level does the oesophagus pass through the diaphragm?

Answer 7

T11-12

Question 8

At which vertebral level does the aorta pass through the diaphragm?

Answer 8

T12

Question 9

What are the two types of diaphragmatic hernia, where do they occur, and what do they involve?

Answer 9

Posterolateral herniation - abdominal organs such as liver push through the diaphragm into the chest cavity

Retrosternal herniation - abdominal contents push through the diaphragm near the sternum

Question 10

What kind of condition / movement might a patient present with when breathing with broken ribs?

How does this movement differ from usual conditions?

Answer 10

Flail chest – paradoxical breathing where the detached portion of rib cage moves inward during inhalation and outward during exhalation

Question 11

What is the vertebral level of the jugular (suprasternal) notch?

Answer 11

T2 or T3

Question 12

The sternal angle sits at which IV disc?

Answer 12

T4-T5 IV disc

Question 13

What is the vertebral level of the xiphoid process?

Answer 13

T9

Question 14

Which costal cartilage is lateral to the manubriosternal joint?

Answer 14

2nd costal cartilage

Question 15

The mediastinum can be divided into superior and inferior parts by what?

Answer 15

Sternal plane – T4-T5 IV disc

Question 16

What are the 3 rib classifications + which ribs do they include?

Answer 16

Vertebrosternal – ribs 1-7

Vertebrocostal – ribs 8-10

Floating – ribs 11 + 12

Question 17

Between which muscles is the thoracic neurovascular bundle?

Answer 17

Internal + innermost intercostal muscles

Question 18

Which area of the intercostal space should chest drains be inserted and why?

Answer 18

Inferior part of the intercostal space to avoid damaging the main neurovascular bundle

Question 19

What are the 2 sensory branches of the intercostal nerves?

Answer 19

Lateral cutaneous branches
Anterior cutaneous branches

Question 20

Describe the blood supply to the thorax.

Answer 20

Posterior intercostal arteries arise from the descending aorta and anastomose with the anterior intercostal arteries which arise from the internal thoracic artery and the musculophrenic artery

Question 21

Chronic use of collateral flow through the intercostal arteries can cause which radiological finding?

Why does this occur?

Answer 21

Rib notching – where the extra pressure in the intercostal arteries causes the inferior rib edges to remodel

Question 22

Describe the venous drainage of the thorax.

Answer 22

Right sided structures drain into the azygous vein, which drains into the SVC

Left sided structures drain into either the accessory azygous vein or the hemiazygous vein, which cross the midline to drain into the azygous vein, and into the SVC

The very upper spaces drain straight into the right and left brachiocephalic veins, which unit to form the SVC

Question 23

The respiratory diverticulum, which is an outgrowth of the gut tube, appears at what stage in gestation?

Answer 23

4 weeks

Question 24

Name 2 embryological defects that can occur during the separation of the oesophagus from the trachea.

Answer 24

Proximal oesophageal atresia with a distal fistula

Fistula

Question 25

At which week gestation does respiratory epithelia begin developing in the lungs?

Answer 25

Week 26

Question 26

What are the fissures of each lung?

Answer 26

Right – oblique + horizontal Left – oblique

Question 27

What is atelectasis?

Answer 27

The partial or complete collapse of the lung or section of the lung

Question 28

What kind of blood do the pulmonary arteries carry and from where?

Answer 28

Pulmonary arteries carry deoxygenated blood from the right ventricle of the heart to the lungs

Question 29

What kind of blood do the pulmonary veins carry and from where?

Answer 29

Pulmonary veins carry oxygenated blood from the lungs to the heart

Question 30

The pulmonary veins enter which section of the heart?

Answer 30

Left atrium

Question 31

Which nerves pass anterior and posterior to the hilum of the lungs?

Answer 31

Phrenic nerves pass anterior to the hilum Vagus nerves pass posterior to the hilum

Question 32

The right recurrent laryngeal nerve could be compressed by what?

Answer 32

Apical pancoast lung tumour

Question 33

What is the position that the right recurrent laryngeal nerve recurs?

Answer 33

Right lung apex, under the right subclavian artery

Question 34

What is the position that the left recurrent laryngeal nerve recurs?

Answer 34

Under the aortic arch

Question 35

The left recurrent laryngeal nerve could be compressed by what?

Answer 35

Aortic arch aneurysm

Question 36

Where is a needle decompression to correct a tension pneumothorax carried out?

Answer 36

2nd intercostal space at the midclavicular line

Question 37

At which vertebral level does the trachea bifurcate?

Answer 37

T6

Question 38

Which muscle completes the posterior aspect of the trachea?

Answer 38

Trachealis

Question 39

If food is aspirated, which bronchus is it more likely to pass into and why?

Answer 39

Right – because it is wider and more vertical than the left bronchus

Question 40

What are bronchopulmonary segments?

Answer 40

The smallest functionally independent regions of the lungs that can be resected without affecting other regions

Question 41

How many bronchopulmonary segments does the right lung have?

Answer 41

10

Question 42

How many bronchopulmonary segments does the left lung have?

Answer 42

8-9

Question 43

How do pulmonary arteries travel within the bronchopulmonary segments?

Answer 43

With bronchi & bronchioles

Question 44

How do pulmonary veins travels within the bronchopulmonary segments?

Answer 44

Between segments

Question 45

When a patient is supine, which segment of the lungs will struggle to drain the most since it is positioned most inferior?

Answer 45

The superior segment of the lower lobe

Question 46

What is the key difference between the composition of the walls of bronchi and bronchioles?

Answer 46

Bronchi contain cartilage, bronchioles do not

Question 47

How do parasympathetics affect the bronchioles?

Answer 47

Constricts bronchioles

Question 48

How do sympathetics affect the bronchioles?

Answer 48

Dilates bronchioles

Question 49

Which arteries supply oxygenated blood to the lung tissues (not for ventilation)?

Answer 49

Bronchial arteries

Question 50

What is the lymph drainage route from the lungs?

Answer 50

Hilar nodes Subcarinal nodes Paratracheal nodes All to right lymphatic duct, which dumps into the right subclavian vein, except for the left superior lobe, which drains into the thoracic duct and dumps into the left subclavian vein

Question 51

What are the 3 articulation points of a rib with the vertebral column?

Answer 51

The body of its own vertebra The body of the vertebra above The transverse process of its own vertebra

Question 52

What is the order of the vessels in the thoracic neurovascular bundle, from superior to inferior?

Answer 52

Vein Artery Nerve

Question 53

The anastomoses of the anterior and posterior intercostal arteries is especially helpful in which pathology?

Answer 53

Aortic coarctation

Question 54

In aortic coarctation, what is the route of the redirected blood heading into the abdominal cavity?

Answer 54

Internal thoracic - anterior intercostals - posterior intercostals - descending aorta

Question 55

What are the surface anatomy marking of the parietal pleura?

Answer 55

6th rib - costal cartilage 8th rib - midclavicular line 10th rib - midaxillary line 12th rib - posterior

Question 56

What are the surface anatomy markings of the right lung?

Answer 56

6 7 8 10

Question 57

What are the surface anatomy markings of the left lung?

Answer 57

5 5 8 10

Question 58

The oblique fissure can be roughly mapped out using which posterior landmark?

Answer 58

Medial border of scapula

Question 59

Where is the middle lobe of the right lung best auscultated?

Answer 59

4th intercostal space along the anterior axillary line

Question 60

If a chest tube is inserted too posterior, it is at risk of damaging which structure?

Answer 60

Long thoracic nerve