102 CHAPTER 3 The Thorax: Part II—The Thoracic Cavity
external naris
incisor tooth
cervical constriction
7.2 in. (18 cm)
6 in. (15 cm)
bronchoaortic
constriction
11.2 in. (28 cm)
10 in. (25 cm)
tube
diaphragmatic
constriction
17.2 in. (44 cm)
16 in. (41 cm)
duodenum
23.2–27.2 in. (59–69 cm)
22–26 in. (56–66 cm)
FIGURE 3.50 The approximate respective distances from the incisor teeth (blue) and the nostrils (red) to the normal three
constrictions of the esophagus. To assist in the passage of a tube to the duodenum, the distances to the first part of the duo-
denum are also included.
Cross-Sectional Anatomy of the Posteroanterior Radiograph
Thorax A posteroanterior radiograph is taken with the anterior
To assist in the interpretation of CT scans of the thorax, wall of the patient’s chest touching the cassette holder and
study the labeled cross sections of the thorax shown in with the x-rays traversing the thorax from the posterior
Figure 3.51. The sections have been photographed on their to the anterior aspect (Figs. 3.54 and 3.55). First check to
inferior surfaces (see Figs. 3.52 and 3.53 for CT scans). make sure that the radiograph is a true posteroanterior
radiograph and is not slightly oblique. Look at the sternal
ends of both clavicles; they should be equidistant from the
vertebral spines.
Radiographic Anatomy Now examine the following in a systematic order:
1. Superficial soft tissues: The nipples in both sexes and
Only the more important features seen on standard poster- the breasts in the female may be seen superimposed on
oanterior and oblique lateral radiographs of the chest are the lung fields. The pectoralis major may also cast a soft
discussed here. shadow.
Radiographic Anatomy 103
right brachiocephalic left brachiocephalic
vein vein
left common
carotid artery
left subclavian
artery
right lung
(upper lobe) left lung
(upper lobe)
right scapula
left mammary
gland right ventricle
right lung left ventricle
(upper lobe)
left lung
(upper lobe)
right oblique left oblique
fissure fissure
right atrium
left lung
(lower lobe)
left atrium
FIGURE 3.51 Cross sections of the thorax viewed from below. A. At the level of the body of the 3rd thoracic vertebra. B. At
the level of the 8th thoracic vertebra. Note that in the living, the pleural cavity is only a potential space. The large space seen
here is an artifact and results from the embalming process.
104 CHAPTER 3 The Thorax: Part II—The Thoracic Cavity
left common
brachio- clavicle carotid artery
cephalic
artery left brachio-
cephalic vein
left sub-
superior vena clavian
cava artery
upper lobe
right lung first rib
descending
thoracic
trachea aorta
esophagus second
rib
upper lobe
scapula left lung
third thoracic fourth third
vertebra rib rib
FIGURE 3.52 Computed tomography scan of the upper part of the thorax at the level of the 3rd thoracic vertebra. The
section is viewed from below.
2. Bones: The thoracic vertebrae are imperfectly seen. For this reason, the lungs are more translucent on full
The costotransverse joints and each rib should be inspiration than on expiration. The pulmonary blood
examined in order from above downward and com- vessels are seen as a series of shadows radiating from
pared to the fellows of the opposite side (Fig. 3.54). the lung root. When seen end on, they appear as small,
The costal cartilages are not usually seen, but if calci- round, white shadows. The large bronchi, if seen end on,
fied, they will be visible. The clavicles are clearly seen also cast similar round shadows. The smaller bronchi are
crossing the upper part of each lung field. The medial not seen.
borders of the scapulae may overlap the periphery of 6. Mediastinum: The shadow is produced by the various
each lung field. structures within the mediastinum, superimposed one
3. Diaphragm: The diaphragm casts dome-shaped shad- on the other (Figs. 3.48 and 3.54). Note the outline of the
ows on each side; the one on the right is slightly higher heart and great vessels. The transverse diameter of the
than the one on the left. Note the costophrenic angle, heart should not exceed half the width of the thoracic
where the diaphragm meets the thoracic wall (Fig. 3.54). cage. Remember that on deep inspiration, when the dia-
Beneath the right dome is the homogeneous, dense phragm descends, the vertical length of the heart increases
shadow of the liver, and beneath the left dome a gas bub- and the transverse diameter is narrowed. In infants, the
ble may be seen in the fundus of the stomach. heart is always wider and more globular in shape than in
4. Trachea: The radiotranslucent, air-filled shadow of the adults.
trachea is seen in the midline of the neck as a dark area
The right border of the mediastinal shadow from above
(Fig. 3.54). This is superimposed on the lower cervical
downward consists of the right brachiocephalic vein, the
and upper thoracic vertebrae.
superior vena cava, the right atrium, and sometimes the
5. Lungs: Looking first at the lung roots, one sees relatively
inferior vena cava (Figs. 3.54 and 3.55). The left border
dense shadows caused by the presence of the blood-filled
consists of a prominence, the aortic knuckle, caused by the
pulmonary and bronchial vessels, the large bronchi, and
aortic arch; below this are the left margin of the pulmonary
the lymph nodes (Fig. 3.54). The lung fields, by virtue of
trunk, the left auricle, and the left ventricle (Figs. 3.54 and
the air they contain, readily permit the passage of x-rays.
3.55). The inferior border of the mediastinal shadow (lower
Radiographic Anatomy 105
FIGURE 3.53 Computed tomography scan of the middle part of the thorax at the level of the sixth thoracic vertebra. The sec-
tion is viewed from below.
border of the heart) blends with the diaphragm and liver. cassette holder and the x-rays traverse the thorax from pos-
Note the cardiophrenic angles. terior to anterior in an oblique direction. The heart shadow
is largely made up of the right ventricle anteriorly and the
Right Oblique Radiograph left ventricle posteriorly. Above the heart, the aortic arch
and the pulmonary trunk may be seen.
A right oblique radiograph is obtained by rotating the An example of a left lateral radiograph of the chest is
patient so that the right anterior chest wall is touching the shown in Figures 3.58 and 3.59.
cassette holder and the x-rays traverse the thorax from pos-
terior to anterior in an oblique direction (Figs. 3.56 and
3.57). The heart shadow is largely made up by the right Bronchography and Contrast
ventricle. A small part of the posterior border is formed by Visualization of the Esophagus
the right atrium. For further details of structures seen on
this view, see Figures 3.56 and 3.57. Bronchography is a special study of the bronchial tree by
means of the introduction of iodized oil or other con-
Left Oblique Radiograph trast medium into a particular bronchus or bronchi, usu-
ally under fluoroscopic control. The contrast media are
A left oblique radiograph is obtained by rotation of the nonirritating and sufficiently radiopaque to allow good
patient so that the left anterior chest wall is touching the visualization of the bronchi (Fig. 3.60). After the radio-
106 CHAPTER 3 The Thorax: Part II—The Thoracic Cavity
FIGURE 3.54 Posteroanterior radiograph of the chest of a normal adult man.
Radiographic Anatomy 107
arch of aorta
clavicle
right brachiocephalic vein (aortic knuckle)
pulmonar y trunk
superior vena cava
left auricle
cassette
x-rays
right atrium
inferior vena cava
left ventricle
gas in fundus
liver
of stomach
diaphragm
FIGURE 3.55 Main features observable in the posteroanterior radiograph of the chest shown in Figure 3.54. Note the position
of the patient in relation to the x-ray source and the cassette holder.
graphic examination is completed, the patient is asked to control, a long narrow catheter is passed into the ascending
cough and expectorate the contrast medium. aorta via the femoral artery in the leg. The tip of the cath-
Contrast visualization of the esophagus (Figs. 3.56 and eter is carefully guided into the orifice of a coronary artery
3.58) is accomplished by giving the patient a creamy paste and a small amount of radiopaque material is injected to
of barium sulfate and water to swallow. The aortic arch reveal the lumen of the artery and its branches. The infor-
and the left bronchus cause a smooth indentation on the mation can be recorded on radiographs (Fig. 3.61) or by
anterior border of the barium-filled esophagus. This proce- cineradiography. Using this technique, pathologic narrow-
dure can also be used to outline the posterior border of the ing or blockage of a coronary artery can be identified.
left atrium in a right oblique view. An enlarged left atrium
causes a smooth indentation of the anterior border of the CT Scanning of the Thorax
barium-filled esophagus.
CT scanning relies on the same physics as conventional
Coronary Angiography x-rays but combines it with computer technology. A
source of x-rays moves in an arc around the thorax and
The coronary arteries can be visualized by the introduction sends out a beam of x-rays. The beams of x-rays, having
of radiopaque material into their lumen. Under fluoroscopic passed through the thoracic wall and the thoracic viscera,
(continued on p. 112)
108 CHAPTER 3 The Thorax: Part II—The Thoracic Cavity
FIGURE 3.56 Right oblique radiograph of the chest of a normal adult man after a barium swallow.
Radiographic Anatomy 109
trachea left clavicle
right clavicle
barium in
esophagus left principal
bronchus
vertebral
pulmonary
column trunk
left scapula
right root of left
atrium lung
right
ventricle
diaphragm
diaphragm
gas in fundus
liver
45˚
cassette
x-rays
FIGURE 3.57 Main features observable in the right oblique radiograph of the chest shown in Figure 3.56. Note the position of
the patient in relation to the x-ray source and the cassette holder.
110 CHAPTER 3 The Thorax: Part II—The Thoracic Cavity
FIGURE 3.58 Left lateral radiograph of the chest of a normal adult man after a barium swallow.
Radiographic Anatomy 111
trachea
branches of ar ch of aorta
sternal angle
right principal
bronchus
left principal
bronchus
anterior
mediastinum
vertebral root of lung
column
left ventricle
barium in
left atrium
esophagus
posterior
mediastinum
inferior vena cava
liver
gas in fundus
of stomach
diaphragm
cassette
costodiaphragmatic
x-rays
recess
FIGURE 3.59 Main features observable in a left lateral radiograph of the chest shown in Figure 3.58. Note the position of the
patient in relation to the x-ray source and the cassette holder.
112 CHAPTER 3 The Thorax: Part II—The Thoracic Cavity
FIGURE 3.60 Posteroanterior bronchogram of the chest.
A B
FIGURE 3.61 Coronary angiograms. A. An area of extreme narrowing of the circumflex branch of the left coronary artery
(white arrow). B. The same artery after percutaneous transluminal coronary angioplasty. Inflation of the luminal balloon has
dramatically improved the area of stenosis (white arrow).
are converted into electronic impulses that produce read-
ings of the density of the tissue in a 1-cm slice of the body. Clinical Cases and Review Questions
From these readings, the computer assembles a picture of are available online at
the thorax called a CT scan, which can be viewed on a fluo-
rescent screen and then photographed (Figs. 3.52 and 3.53). [Link]/Snell9e.
