Trachea,Oesophagus and

Thoracic Duct
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INTRODUCcTION Relations of the Thoracic Part

Trachea or windpipe is the tube for passage of Anteriorly
air to and from the lungs. In contrast, oesophagus lying 1 Manubrium sterni.
behind the trachea opens only while drinking or eating. 2 Sternothyroid muscles.
Thoracic duct brings the lymph from major part of the 3 Remains of the thymus.
body to the root of the neck. 4 Left brachiocephalic and inferior thyroid veins.
5 Aortic arch, brachiocephalic and left common carotid
TRACHEA arteries.
6 Deep cardiac plexus (see Fig. 19.9).
The trachea (Latin air vessel) is a wide tube lying more 7Some lymph nodes.
or less in the midline, in the lower part of the neck and
in the superior mediastinum.the Its upper The
end trachea
is con
tinuous with the lower end of larynx.
in the neck is covered by the isthmus of the thyroid Thyroid cartilage
gland and acts as a shield for trachea. At its lower end
the trachea ends by dividing into the right and left Cricoid cartilage Thyroid gland
principal bronchi (Fig. 20.1).
The trachea is 10 to 15 cm in length. Its external Trachea Oesophagus
diameter measures about 2 cm in males and about 1.5
cm in females. The lumen is smaller in the living than
in the cadaver. It is about 3 mm at one year of age. Left common
During childhood itofcorresponds to the age in years,
12 mm in adults, i.e. it Brachiocephalic
carotid artery
with a maximum about trunk Left subclavian
increases 1 mm per year up to 12 years.
artery
The upper end of the trachea lies at the lower border
of the cricoid cartilage, opposite the sixth cervical Right principal Arch of aorta
vertebra. In the cadaver its bifurcated lower end lies bronchus
at the lower border the fourth thoracic vertebra,
corresponding in front to the sternal angle. However,
Left principal
in living subjects,, in the erect posture, the bifurcation bronchus
lies at the lower border of the sixth thoracic vertebra
and descends still further during inspiration.
Over most of its length the trachea lies in the median
plane, but near the lower end it deviates slightly to the Oesophagus
right. As it runs downwards, the trachea passes slightly Fig. 20.1: Trachea and its relations
backwards following the curvature of the spine.
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Posteriorly Left recurent

laryngeal nerve
1 Oesophagus. Left subcavian Trachea
2 Vertebral column.
artery
On the Right Side Let common Oesophagus
carotid artery
1 Right lung and pleura. Thoracic duct
Left superior
2 Right vagus. intercostal vein
3 Azygos vein (Fig. 20.2). Arch of aorta
Left vagus
On the Left Side
Left phrenic nenve
1 Arch of aorta, left common carotid and left sub
clavian arteries.
2 Left recurrent laryngeal nerve (ig. 20.3). Pericardium
Thoracic
aorta

Structure
The trachea has a fibroelastic wall supported by a
-Oesophagus
cartilaginous skeleton formed by C-shaped rings. The
rings are about 16 to 20 in number and make the tube
convex anterolaterally. Posteriorly there is a gap which
is closed by a fibroelastic membrane and contains -Diaphragm
transversely arranged smooth muscle known as the
trachealis. The lumen is lined by ciliated columnar Fig. 20.3: Mediastinum as seen from the left side
epithelium and contains many mucous and serous
Lymphatic Drainoge
Arterial Supply To the pretracheal and paratracheal nodes.
Inferior thyroid arteries. Nerve Supply
Venous Drainage 1 Parasynpathetic: Nerves through vagi and recurrent
laryngeal nerves. It is:
Into the left brachiocephalic vein. a. Sensory and secretomotor to the mucous
Morane.
Oesophagus b. to the trachealis muscle.
Right brachiocephalic vein
Trachea.
-Left brachiocephalic vein
2 Sympathetic: Fibres from the middle cervical
Right vagus
ganglion reach it alorng the inferior thyroid arteries
and are vasomotor.
Superior vena cava

Righl phrenic nenve CLINICAL ANATOMY

Azygos vein
Pericardium " In radiographs, the trachea is seern as a vertical
translucent shadow due to the contained air in
-Root of nght lung front of the cervicothoracic spine (Fig. 21.12).
Clinically the trachea is palpated in the supra
sternal notch. Normally it is median in position.
-Diaphragm Shift of the trachea to any side indicates a
mediastinal shift.
During swallowing when the larynx is elevated, Secion
Thorax
2
the trachea elongates by stretching because the
tracheal bifurcation is not permitted to move by
Inferior vena cava the aortic arch. Any downward pull due to sudden
and forced inspiration, or aorticaneurysm will
Oesophagus with produce the physical sign known as'tracheal tug'.
oesophageal plexus " Tracheostomy: It is a surgical procedure which
around it

Fig. 20.2: Mediastinum as seen from the ight side

allows air to enter directly into trachea. It is done
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THbAÁR81260301 03 info@shikshaview.com

and pierces the diaphragm at the level of tenth thoracic

in cases of blockage of air pathway in nose or
larynx. vertebra. It ends by opening into the stomach at its
cardiac end at the level of eleventh thoracic vertebra.
" As the tracheal rings areduring
incomplete
swalry
theeoesophagus can dilate This Curvatures
also allows the diameter of the trachea to be In gene the oesophagus is vertical, but shows slight
controlled by the trachealis muscle. This muscle
narrows the caliber of the tube, compressing the curvatures in the following directions. There are two
side to side curvatures, both towards the left (see
contained air if the vocal cords are closed. This Fig, 17.4). One is at the root of the neck and the other
increases the explosive force of the blast of com near the lower end. It also has anteroposterior
pressed air, as occurs in coughing and sneezing. curvatures that correspond to the curvatures of the
" Mucus secretions help in trapping inhaled foreign cervicothoracic spine.
particles, and the soiled mucus is then expelled
by coughing, The cilia of the mucous membrane
beat upwards, pushing the mucus towards the
Constrictions
Normally the oesophagus shows 4 constrictions at the
pharynx. following levels.
" The trachea may get compressed by pathological 1 Atits beginning, 15 cm/6 inch from the incisor teeth,
enlargements of the thyroid, the thymus, lymph where it is crossed by cricopharyngeus muscle.
nodes and the aortic arch. This causes dyspnoca, 2 Where it is crossed ibby the aortic arch, 22.5 cm/9-inch
irritative cough, and often a husky voice. from the incisor teeth.
3 Where it is crossed by the left bronchus, 27.5 cm/11
inch from the incisor teeth.
OESOPHAGUS 4 Where it the diaphragm 37.5 cm/15-inch from
piercestu
the incisor
DISSECTION The distance from the incisor teeth are important in
Remove the posterior surface of the parietal pericardium passing instruments like endoscope into the
between the right and left pulmonary veins. This
uncovers the anterior surface of the oesophagus in the oesopha
For sake convenience the relations of the
posterior mediastinum. oesophagus may be studied in three partscervical,
Find the azygos vein and its tributaries on the thoracicarnd abdominal. The relations of the cervical
vertebral column to the right of the oesophagus. Find part are described in Volume 3, and those of the
and follow the thoracic duct on the left of azygos vein. abdominal part in Volume 2of this book.
ldentifty the sternal, sternocostal, interchondral and Relations of the Thoracic Pat of the Oesophagus
costochondral joints on the anterior aspect of chest wall Anteriorly
which was reflected downwards.
1 Trachea.
Expose the igaments which unite the heads of the
ribs to the vertebral bodies and intervertebral discs. 2 Right pulmonary artery.
3 Left bronchus.
4 Pericardium with left atrium.
Features 5 The diaphragm (Figs 20.2 and 20.3).
The oesophagus is a narrow muscular tube, forming
the food passage between the pharynx and stomach. It Posteriorly
extends from the lower part of the neck to the upper 1 Vertebral column.
part of the abdomen (Fig. 20.4),. The oesophagus is 2 Right posterior intercostal arteties.
about 25 cm long. The tube is flattened antero 3 Thoracic duct.
posteriorly and the lumen is kept collapsed; it dilates 4 Azygos vein with the terminal parts of the hemi
only during the passage of the food bolus. The azygos veins.
Secion
2Thoraxpharyngo-oesophageal junction is the narrowest part 5 Thoracic aorta.
of the alimentary canal except for the vermiform 6 Right pleural recess.
appendix. 7 Diaphragm (Fig. 20.4),.
The oesophagus begins in the neck at the lower To the Right
border of the cricoid cartilage where it is continuous
with the lower end of the pharynx. 1 Right lung and pleura.
It descends in front of the vertebral column through 2 Azygos vein.
the superior and posterior parts of the mediastinum, 3 The right vagus (Figs 20.5a to c).
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Trachea Oesophagus
Thoracic duct

Arch of aorta

Azygos vein Left pulmonary artery

Left bronchus
Right pulmonary artery
Outline of pericardium and heart
Azygos vein
Oesophagus
Thoracic duct

Descending thoracic aorta Muscular ring formed by right crus

of diaphragm
Stomach

Fig. 20.4: Structures in the posterior mediastinum seen after removal of the heart and pericardium
Left common To the Left
Carotid artery
-Brachiocephalic 1 Aortic arch.
Left vagus
trunk 2 Left subclavian artery.
3 Thoracic duct.
Left
subclavian
Right vagus 4 Left lung and pleura.
artery 5 Left recurrent laryngeal nerve, all in the superior
Trachea and
Oesophagus
and thora mediastinum (see Figs 19.3 and 19.9).
left recurent
duct In the posterior mediastinum, it is related to:
laryngeal nerve
1The descending thoracic aorta.
Loft lung Right lung 2 The left lung and mediastinal pleura (see Fig. 16.3).
Third thoracic vertebra Arterial Supply
(a
Right and
1The cervical part including the segment up to the arch
left principal of aorta is supplied by the inferior thyroid arteries.
Vagus bronchi 2 The thoracic part is supplied by the oesophageal
Oesophagus branches of the aorta.
Vena ayzgos 3 The abdominal part is supplied by the oesophageal
Thoracic duct branches of the left gastric artery.
Venous Drainage
Descending
thoracic aorta Blood from the upper part of the oesophagus drains
Fifth thoracic vertebra into the brachiocephalic veins; from the middle part itit
(b goes to the azygos veins; and from the lower end
Oesophagus Diaphragm goes to the left gastric veinendand
of
venaoesophagusviais
the
and its plexus hemiazygos vein. The lower
one of the sites of portosystemic anastomoses.
Vena azygos Lymphatic Drainage
Descending The cervical part drains to the deep cervical nodes; the
thoracic aorta
Thoracic duct
thoracic part to the posterior mediastinal nodes; and the
Elghth thoracic vertebra
abdominal part to the left gastric nodes.
(c) Nerve Supply
1 Parasympathetic nerves: The upper half of the
Figs 20.5a to c: Outline drawings of three sections through the
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nerves, and the lower half by the oesophageal plexus

formed mainly by the two vagi. Parasympathetic
nerves are sensory, motor and secretomotor to the
oesophagus. Varices
(dilated veins)
For
2
h e e ror upper hat of oesophagus,
the come cervical ganglion and
run with inferior thyroid arteries. For lower half,
the fibres come directly from upper four thoracic
ganglia, to form oesophageal plexus before
supplying the oesophagus. Sympathetic nerves are
vasomotor.
The oesophageal plexus is formed mainly by the
parasympathetic through vagi but sympathetic fibres
are also present. Towards the lower end of the
oesophagus; the vagal fibres form the anterior and
posteriorsgastric nerves which enter the abdomen
through the oesophageal opening of the diaphragm. Fig. 20.6: Oesophageal varices
CLINICAL ANATOMY
-Outline of oesophagus
" In portal hypertension, the communications
between the portal and systemic veins draining
the lower end of the oesophagus dilate. These Indentation caused by aortic arch
dilatations are called oesophageal varices. Rupture
of these varices can cause serious haematemesis Indentation caused by left bronchus
or vomiting of blood. The oesophageal varices can
be visualised radiographically by barium swallow;
they produce worm-like shadows (Fig. 20.6).
Left atrial as in mitral stenosis can
atrial enlargement Shallow indentation caused by left atrium
also be visualised by barium swallow. The
enlarged atrium causes a shallow depression on
the front of the oesophagus. Barium swallow also
helps in the diagnosis of oesophageal strictures,
carcinoma and achalasia cardia. Diaphragm
The normal indentations on the oesophagus
should be kept in mind during oesophagoscopy Fig. 20.7: Normal indentations of oesophagus
(Fig. 20.7).
The lower end of the oesophagus is normally kept
closed. It is opened by the stimulus of a food bolus.
In case of neuromuscular incoordination, the
lower end of the oesophagus fails to dilate with
the arrival of food which, therefore, accumulates
in the oesophagus. This condition of neuro
muscular incoordination characterised by inability No peristalsis
off the oesophagus to dilate is known as 'achalasia
cardia' (Fig. 20.8). It may be due to congenital
Section
Thorax
2 absence of nerve cells in wall of oesophagus. Oesophageal
Improper separation of the trachea from the dilation due to
back-up of food
oesophagus during development gives rise to
tracheo-oesophageal fistula (Fig. 20.9). Lower oesophageal
Compression of the oesophagus in cases of sphincter fails to
relax
mediastinal syndrome causes dysphagia or
difficulty in swallowing. Fig. 20,8: Achalasia cardia
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Course
The thoracic duct begins as a continuation of the upper
end of the cisterna chyli near the lower border of the
twelfth thoracic vertebra and enters the thorax through
the aortic opening of the diaphragm.
It then ascends through the posterior mediastinum
Oesophageal atresia from level of 12th thoracic vertebra to 5th thoracic
vertebra where it crosses from the right side to the left
side. Thern it courses through the superior mediastinum
Lower segment connected along the left edge of the oesophagus and reaches the
to trachea neck.
In the neck, it arches laterally the level of the
transverse process of seventh cervical vertebra. Finally
it descends in front of the first part of the left subclavian
artery and ends by opening into the angle of junction
between the left subclavian and left internal jugular
veins.

Fig. 20.9: Tracheo-oesophageal fistula Relations

At the Aortic Opening of the Diaphragm

THORACIC DUCT
Anteriorly: Diaphragm.
Posteriorly: Vertebral column.
Features To the right: Azygos vein.
The thoracic duct is the largest lymphatic vessel in the To the left: Aorta.
body. It extends from the upper part of the abdomen
to the lower part of the neck,crossing the posterior and In the Posterior Mediastinum
superior parts of the mediastinum. It is about 45 cm/ Anteriorly
18 inch long, It has a beaded appearance because of the 1 Diaphragm (see Figs 19.3 and 19.5).
presence of many valves in its lumen (Fig. 20.10). 2 Oesophagus.
3 Right pleural recess.
Left internal jugular vein Posteriorly
Thoracic duct 1 Vertebral column.
2 Right posterior intercostal arteries.
Oesophagus 3 Terminal parts of the hemiazygos veins (Fig. 20.10).
Let subclavian vein
To the riglt: Azygos vein.
T5 To the left: Descending thoracic aorta.
Descending thoracic aorta
T6 In the Superior Mediastinum
Azygos veln Accessory hemiazygos vein Anteriorly
1 Arch of aorta.
Hemiazygos vein
2 The origin of the left subclavian artery.
Posteriorly: Vertebral column. Sectio
2Thor
To the right: Oesophagus
L1 To the left: Pleura.
Cisterna chyli In the Neck
The thoracic duct forms an arch rising about3-4 cm above
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arch bas he glawjag relations.
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Right lymphatic duct

Left jugular lymph trunk
Right jugular lymph trunk
Left subclavian lymph trunk

Right subclavian lymph trunk -Left bronchomediastinal lymph trunk

Right bronchomediastinal lymph trunk -
Thoracic duct

Intercostal lymph vessels

Descending thoraclc lymph trunk

Cistema chyli
Intestinal lymph trunk

Left lumbar lymph trunk

Internal iliac lymph trunk External iliac lymph trunk

Fig. 20.11: The tributaries of the thoracic duct

Anteriorly FACTS TO REMEMBER

1 Left common carotid artery.
2 Left vagus. " Trachea contains Cshaped hyaline cartilaginous
3 Left internal jugular vein. rings which are deficient posteriorly, so that the
oesophagus situated behind the trachea is not
compressed by trachea.
Posteriorly " Trachea begins at 6th cervical vertebra and ends
Vertebral artery and vein.
2 Sympathetic trunk. at thoracic 4 (in expiration) by dividing into two
3 Thyrocervical trunk and its branches. principal bronchi. Trachea is always patent.
Left phrenic nerve. "Oesophagus is 25 cm long, like duodenum and
ureter. Its maximum part about 20 cm/8" lie in
5 Medial border of the scalenus anterior.
6 Prevertebral fascia covering all the structures thoracic cavity.
mentioned. " There is no digestive activity in the oesophagus.
The first part of the left subclavian artery. Lower part of oesophagus is a site of portocaval
anastomoses.
Tributaries " Thoracic duct drains lymph from both lower
limbs, abdominal cavity, left side of thorax, left
The thoracic duct receives lymph from, roughly, both upper limb and left side of head and neck.
halves of the body below the diaphragm and the left
half above the diaphragm (Fig. 20.11).
Section
Thorax
2 In the thorax, the thoracic duct receives lymph CLINICOANATOMICAL PROBLEM
vessels from the posterior mediastinal nodes and from A young lady during her midpregnancy period
small intercostalnodes. At the root of the neck, efferent of
complained rapid and difficulty in
vessels of the nodes in the neck form the left jugular
trunk, and those from nodes in the axilla form the left
swallowing. She also gave a breatnisy of
with pains in her joints during childhood.
sore throat
subclavian trunk. These trunks end in the thoracic duct. " What is the likely diagnosis?
The left bronchomediastinal trunk drains lymph from the " What is the explanation for her symptoms?
8 left half of the thorax and ends in the thoracic duct.
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Ans: The diagnosis most likely is Rheumatic heart. The enlarged left atrium presses on the oeso
It occurs due to streptococcal infection in the throat. phagus, as it passes behind the heart and peri
Its toxins affect the mitral valve of the heart and cardium. So the patient complains of dysphagia. A
kidney as well. In this case her mitral valve got simple barium swallow can show the enlarged left
affected, leading to mitral stenosis which causes left atrium causing narrowness of the oesophagus.
atrial enlargement due to its incomplete emptying As enough blood is not reaching the lungs, there
into the left ventricle. is anoxia in the body, leading to rapid breathing.

MULTIPLE CHOICE QUESTIONS

1. Indentations in the oesophagus are caused by all 3. Oesophageal varices are seen at:
except: a. Upper end of oesophagus
a. Aortic arch b. Left bronchus b. Middle region of oesophagus
c. Left atrium d. Left ventricle
2. In mitral stenosis, barium swallow is done to see c. Lower end of oesophagus
compression of oesophagus due to enlargement of: d. Whole of oesophagus
a. Right atrium Right side relations of thoracic part of oesophagus
b. Left atrium are all except:
c. Left ventricle a. Right lung and pleura b. Azygos vein
d. Right ventricle c. Right vagus d Left vagus

ANSWERs
1.d 2b 3.c 4. d