Paul Couto - W2015

MED 1 BLOCK 2 - WET LAB NOTES

Note: Do not use this guide as your sole source of information for the wet lab exams. The quantity of
material for Block 2 is much more than Block 1. It will take more time to prepare for the wet lab exam,
as well as the actual block exam. The Color Atlas of Anatomy was very useful for Wet Lab Block 2 for
me. Here is a download link: http://www24.zippyshare.com/v/Ll3qUsIe/file.html

WEEK 1: CARDIOVASCULAR SYSTEM LEARNING OBJECTIVES

1: Inspect the orientation of the middle mediastinum
Identify the Pericardial Sac, SVC, Ascending Aorta, Pulmonary Trunk and pulmonary
arteries, Ligamentum arteriosum, aortic arch and its branches.

Orientation of the Middle Mediastinum

- The middle mediastinum is in the very
middle of the chest cavity. It is posterior
to the anterior mediastinum, inferior to
the superior mediastinum, anterior to
the posterior mediastinum, and superior
to the diaphragm.
- The division between the inferior
mediastinum and superior mediastinum
is at the sternal angle (an imaginary
plane running through the
manubriosternal joint through the chest
cavity to the intervertebral disk at T4-T5).
- The structures located in the middle
mediastinum include: Heart, Ascending
aorta, Lower part of superior vena cava
with azygous vein opening into it, Lateral Chest X-ray
Pulmonary arteries and veins, Primary
bronchi.

Middle Mediastinum
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2: Inspect the pericardial sac

Identify the Pericardium – Fibrous, Serous (Parietal and Visceral). Pericardial sac
Identify Transverse and Oblique pericardial Sinus
Pericardial Layers
- “Peri” = around
- “Cardium” = heart

From Superficial to Deep:

1. Fibrous layer of Pericardium
2. Parietal Pericardium
3. Pericardial Cavity
4. Visceral Pericardium (Epicardium)
5. Myocardium
6. Endocardium

Serous Pericardium = Parietal + Visceral

Some of the cardiac layers are like two

sides of the same coin. For instance, the
Fibrous layer of the Pericardium & the
Parietal Pericardium are completely
adherent. Visceral layer of pericardium is
adherent to the myocardium (the musculature layer of the heart).

Separating the Fibrous+Parietal Pericardium from the Visceral+Myocardium is the Pericardial Cavity.
This cavity can become effused with fluid.

[CLINICAL CORRELATE - BLOCK EXAM RELEVANT MATERIAL] Fluid accumulation in the pericardial cavity
leads to increased intrapericardial pressure which can negatively affect heart function (Cardiac
Tamponade). This can be seen sonographically with Ultrasound and presents with swinging of the heart
in the middle mediastinum (called mediastinal shift). Treatment involves a procedure called a
“pericardial tap” or Pericardiocentesis – in which a needle with a catheter is inserted through the
Fibrous and Parietal Pericardia into the Pericardial cavity to drain the excess fluid.

*Sensory innervation of fibrous and parietal layers of pericardium = Phrenic Nerve (C3 – C5)

Pericardial Sinuses (Posterior to Heart)

- “Sinus” = cavity
Transverse Pericardial Sinus
- A passage/recess posterior to the
great vessels (SVC & Ascending
Aorta).
- The transverse pericardial sinus is
basically through or under the
aortic arch.
Oblique Pericardial Sinus
- A passage inferior to the
pulmonary veins. Note: The heart depicted here has been
lifted out of its normal position, so that
the oblique pericardial sinus can be seen.
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3. Examine the heart in-situ and remove it, and further inspect the pericardial sac
Examine the removed heart
Apex & Base of heart, Superior vena cava, Inferior vena cava, Pulmonary veins, Right
auricle, Left auricle, Atria, Ventricles, Aorta, Pulmonary trunk, Coronary sulcus,
Anterior interventricular sulcus, Posterior interventricular sulcus
*Know every structure on the following pictures*
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4. Identify the borders and surfaces of the Heart

- Right Border: formed by Right Atrium (RA) and is in line with the
Superior Vena Cava (SVC) and Inferior Vena Cava (IVC).
- Inferior/Diaphragmatic Border: nearly horizontal; formed mainly
by the Right Ventricle (RV), and slightly by the Left Ventricle (LV)
near the apex.
- Left Border: formed by the LV and very slightly by the Left Auricle.
- Superior Border: formed by the base of the heart, where the great
vessels enter and leave the heart.
- Anterior Surface: formed mainly by the Right Ventricle.
- Posterior Surface: Left Atrium is found posteriorly.

7. Discuss the radiographic images of the Chest.

Chest X-ray
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CT Section Below Sternal Angle

CT Section Above Sternal Angle

R & L Brachio- Branches of Arch of Aorta

cephalic vein (BC, LCC, LSC)

No Descending Aorta
Trachea

*Note: the reason these two CT scans look different is because different contrast media was used.
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The Sternal Angle (Manubriosternal Junction to the Intervertebral disk at T4-T5) is an Important
Structural Landmark! Many anatomical changes take place at this imaginary plane:
o It denotes the division between superior mediastinum and inferior mediastinum.
o The aortic arch divides into ascending and descending aorta (starts and ends)
o The trachea bifurcates into the L & R primary bronchi at the sternal angle (point of
bifurcation is called Carina)
o Azygous vein empties into SVC

Lateral X-ray

The esophagus runs immediately

posterior to the posterior-most heart
chamber, the Left Atrium. When
there is Left Atrial Hypertrophy, the
LA expands and invades the area
once previously occupied by the
esophagus, compressing it. Clinically ,
this represents as dysphagia
(difficulty swallowing).

Right Ventricle anterior-most chamber

Left ventricle forms left border; has

the most musculature out of all the
chambers (why do you think this is?
Answer found later)

Left Atrium posterior-most chamber

Vertebral body indicates Posterior

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Know the Pathway for the Flow of Blood Through the Heart:
Right Side of the Heart
Blood enters the heart through two large veins, the inferior and superior vena cava, emptying
oxygen-poor blood from the body into the right atrium of the heart.
As the atrium contracts, blood flows from your right atrium into your right ventricle through the
open tricuspid valve.
When the ventricle is full, the tricuspid valve shuts. This prevents blood from flowing backward
into the atria while the ventricle contracts (regurgitation or backward flow clinically manifests as
murmurs).
As the ventricle contracts, blood leaves the heart through the pulmonic valve, into the
pulmonary artery and to the lungs where it is oxygenated.
Left Side of the Heart
The pulmonary vein empties oxygen-rich blood from the lungs into the left atrium of the heart.
As the atrium contracts, blood flows from your left atrium into your left ventricle through the
open mitral valve.
When the ventricle is full, the mitral valve shuts. This prevents blood from flowing backward
into the atrium while the ventricle contracts (again, preventing regurgitation)
As the ventricle contracts, blood leaves the heart through the aortic valve, into the aorta and to
the body.
*Pulmonary arteries carry deoxygenated blood; and Pulmonary veins carry oxygenated blood*
*The left ventricle has greater musculature. Why? Because it must generate enough pressure to force
the blood out of the heart, through the aortic valve, and into systemic circulation to reach all parts of
the body.

The Great Vessels:

Superior Vena Cava
- Enters into RA without valves
- Venous blood draining into SVC from the R & L Brachiocephalic veins
- Each brachiocephalic vein receives venous blood from:
o Internal jugular vein
o External jugular vein
o Subclavian vein

Inferior Vena Cava

- Also deposits venous blood into the RA.
- Is a retroperitoneal structure (more on that next block)

Ascending Aorta
- Comes from left ventricle (aortic valve)
- Aortic leaflets viewed from above create the aortic sinuses
- Within the aortic sinuses begin the L & R coronary arteries

Pulmonary trunk
- Comes from Right ventricle
- Left pulmonary veins (2)
- Right pulmonary veins (2)
- These 4 pulmonary veins return to left atrium from lungs.
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Chambers & Associated Structures

R & L Atria
- *Smooth part of the atrium is an embryological remnant of the sinus venosus.
- Right atrium receives deoxygenated blood from a variety of sources, the most significant being
the SVC and IVC.
- Left atrium receives oxygenated blood from pulmonary veins (remember the exception!).

R & L Ventricles:
- Trabeculae carneae (“meaty ridges”): Rough muscular tissue on the inside of both ventricles
- Valve supporting structures
- Papillary muscles
o 1 for each valve leaflet
o Prevent superior prolapse of valve leaflets upon closure
o Failure to close causes a regurgitant valve
o Blood will go the wrong way when valve should be closed
o Chordae tendineae: Attaches valve leaflet to papillary muscle

Auricles or Atrial Appendages

- Continuous with their respective L or R atrium
- Embryological remnants of the primitive atrium.
- Not very clinically relevant except in the case of atrial fibrillation, it provides a space for blood to
possibly clot.

Moderator band (in R. ventricle) aka “septomarginal trebecula”

- Muscular tissue extending from base of anterior papillary muscle to ventricular septum
- Carries part of right bundle branch to the anterior papillary muscle (useful for conduction of
impulses)

Annulus fibrosus cordis (fibrous skeleton or fibrous rings)

- Fibrous tissue in the atrioventricular septum
- Prevents electrical conduction passing from atrium to ventricles
- Allows there to be a delay mediated by AV node between atrial & ventricular contraction (called
the “AV Delay”).
- This delay allows for an appropriate amount of time for filling of the chambers.
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SAMPLE QUESTIONS FOR WEEK 1

- These are just to help further your understanding of the material and are more similar to Block
exam questions than Wet lab exam questions. The answers to all the sample questions are at
the end of this document.

1. Patient with pulmonary fibrosis has developed Right Ventricular Hypertrophy. The Right
Ventricle is most likely situated:
a. Retro-sternally
b. Inferiorly
c. Posteriorly
d. Superiorly
e. Right Laterally

2. 38 year old male with Hemopericardium. A need was inserted into the pericardial space to drain
the accumulated blood. The needle lies between which layers?
a. Parietal & Visceral
b. Visceral & Epicardium
c. Visceral & Myocardium
d. Parietal & Fibrous

3. Patient presents with pericardial rub due to deficiency of the pericardial fluid. In this case the
patient complains of sharp retrosternal chest pain radiating to his shoulders. Which of the
following nerves are responsible for innervation of the fibrous layer of the heart?
a. Vagus nerve
b. Phrenic nerve
c. Supraclavicular nerve
d. Axillary nerve

4. Which of the following structures are located within the middle mediastinum?
a. Trachea
b. Common Carotid artery
c. Left Subclavian artery
d. Sternum
e. Primary Bronchi
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WEEK 2: CARDIOVASCULAR SYSTEM LEARNING OBJECTIVES

1. BLOOD SUPPLY TO THE HEART
IDENTIFY Right coronary artery & its Branches. IDENTIFY Left coronary artery & its
Branches. IDENTIFY the cardiac veins:

Right Coronary Artery

- Right Coronary Artery (RCA) branches:
o Posterior descending artery (PDA) or Posterior Interventricular artery
o Right Marginal artery
- RCA runs in the Atrioventricular sulcus (ie. The RCA divides the RA from the RV).
- Turns behind and anastomoses with the Circumflex artery (“Anastomosis” = communication)
- Has atrial branches and ventricular branches (run off the main arteries)
- Right Marginal artery – at the Inferior margin (inferior border or diaphragmatic surface)
- Anterior interventricular artery (or LAD) anastomoses with the posterior interventricular artery
(or PDA) along the interventricular sulcus [Sulcuses – on the outside; septa on the inside –
arteries supply both the sulcus and the septum (also septal branches)].
- LAD supplies 2/3 of heart; PDA supplies 1/3 of heart
Left Coronary Artery
- Left Coronary Artery (LCA) branches:
o Circumflex artery (LCX)
o Left Anterior Descending artery (LAD) or Anterior Interventricular artery
- As soon as the left coronary starts, it bifurcates – lateral one is circumflex, medial one is LAD.
- Anterior interventricular artery (or LAD) – biggest branch of the left coronary artery;
anastomoses with the posterior interventricular artery (gives septal branches). Biggest supply of
blood is to left and right ventricles (essentially supplies the entire anterior surface of the heart).
- Circumflex predominantely supplies the left border of the heart.
- Also there are the minor coronary arteries: Left marginal artery & Diagonal artery.
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Coronary Artery Anatomical Variation & Heart Dominance

- Within the patient population there are numerous anatomical variations in the coronary
circulation.
- This coronary artery dominance is determined by the artery that supplies the PDA.
- The majority of individuals, around 85%-90%, are often described as being right dominant. This
means that it is the right coronary artery (RCA), which supplies the posterior descending artery.
- Of the remainder, around 10-15%%, are left dominant, meaning the left circumflex supplies the
PDA.
- Heart dominance becomes extremely relevant when a coronary artery becomes occluded.
- A left dominant heart is depicted below. Notice the difference between the diagraph on the
previous page.

The PDA is branching off of the Circumflex. This is

a left dominant heart. Normally, the PDA would
branch off of the RCA (right dominance).

Cardiac Veins

*Cardiac veins (easy to remember if you know the location of the coronary arteries):
- Great Cardiac Vein runs with LAD
- Middle Cardiac Vein runs with PDA
- Small Cardiac Vein runs with RCA
- Coronary Sinus drains into RA
- What are the inputs into the Right Atrium? SVC, IVC, Coronary sinus, and Small Cardiac Vein
(Anterior Cardiac Veins)
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2. INTERIOR OF THE HEART

Expose and inspect the heart valves
Expose and inspect the chambers of the heart

ICM/Physio/Anatomy Relevant Information

- Valves make sound when they close, not when they open.
- Closure of Atrioventricular valves (tricuspid & mitral) -> generation of the first heart sound (S1,
lub)
- Closure of Semilunar valves (Pulmonary and Aortic) -> generation of the second heart sound (S2,
dub)
- Know where you will auscultate for each of the heart sounds
- 5th intercostal space left parasternally = tricuspid valve (remember RV and valve is
behind sternum – but it is best heard/conducted lateral to the sternum – even though
it’s not physically present at that location) – interventricular line = mitral valve in the 5th
intercostal space (midclavicular line)
- Aortic valve on right side – 2nd intercostal space parasternally
- Pulmonary valve on left side – 2nd intercostal space parasternally.
- How are heart sounds sometimes louder? More volume, more blood flow, more
turbulence, greater sound.
- Right side louder: inspiration; left side louder: expiration.
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Tricuspid valve
- Has anterior cusp
- Septal cusp (only present for tricuspid valve)
- Posterior cusp

- Septal cusp is absent in mitral, only present in tricuspid valve.

- Annulus fibrous ring is what suspends the cusps
- Valvular complex consists of: annulus fibrous ring, cusps, chordae tendinae, and papillary
muscles.
- Tricuspid Valve closes when ventricle contracts. Why? Pull of chordae tendinae and papillary
muscles. If you cut cordae tendinae, you will get regurgitation back into atria Murmur.

3. Inspect the superior mediastinum

Identify Brachiocephalic veins, Aortic Arch, Brachiocephalic trunk, left common
carotid, left subclavian, Ligamentum arteriosum, left recurrent laryngeal nerve, left
Vagus, Trachea and its bifurcation, trachea-bronchial lymph nodes, Esophagus.

*Remember the anatomical changes at the Sternal Angle*

- Above sternal angle (T4-T5 intervertebral disc) = Superior Mediastinum
- Aortic arch and its branches
- Superior vena cava
- Left and Right brachiocephalic veins which divide into internal jugular
vein and subclavian vein),
- Trachea (superior to bifurcation into Primary Bronchii)
- Upper esophagus (*Esophagus runs posterior to the trachea (in the
posterior mediastinum)
- *Vagus nerves are more medial than Phrenic nerves; the left of which
wrap anteriorly over the arch of Aorta.
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4. Inspect the posterior mediastinum anatomy

Identify Esophagus, Descending Aorta,
Posterior Intercostal arteries, Vagus nerve and
Thoracic duct. 5. Inspect the right side of the
Posterior mediastinum
Identify Azygos vein, sympathetic chain and
Intercostal spaces. 6. Inspect the left side of
the Posterior mediastinum
ID: Hemi-azygos vein, accessory hemi-azygos,
sympathetic chain and Intercostal spaces.
Major Structures of the Posterior Mediastinum:
- Esophagus
- Esophageal plexus (Innervated by the vagus
nerve by parasympathetic fibers)
- Posterior Intercostal arteries
- Vagus nerve
- Descending aorta
- Thoracic duct

- Azygous vein drains into SVC at the level of the

Sternal angle.
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- Posterior Intercostal neurovascular bundles run on the inferior groove or notch of each rib.
Diaphragm Openings:
- IVC pierces diaphragm at T8
- Esophagus pierces diaphragm at T10
- Descending aorta pierces diaphragm at T12
Phrenic nerves (Left and Right)
- “Phrenic” = Diaphragm
- C3, C4, C5 keeps the diaphragm alive! This
nerve keeps us alive. Diaphragmatic paralysis
= death without a ventilator.
- The phrenic nerve travels in a neurovascular
bundle with the pericardiophrenic vessels
- The neurovascular bundle runs along the
anterior surface of the pericardium
- The pericardiophrenic vessels supply the
pericardium & diaphragm.

Conductance of the Heart

- SA node -> AV Node -> Bundle of His -> L. & R. Bundle -> Purkinje fibers.
- Right Bundle contains the Moderator Band (also called Septomarginal trabeculae)
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L & R vagus nerves (CNX)

- Provide parasympathetic innervation for nearly all viscera down to the transverse colon
- Gives off recurrents to innervate larynx (recurrent laryngeal nerves)
- Clinical Correlation: Recurrent laryngeal nerves pass through the thyroid gland. Surgeon
performing thyroidectomy must be very careful not to damage them. Unilateral damage
leads to hoarseness of voice. Bilateral damage leaves patient almost completely unable to
breathe & unable to speak.

7. Discuss the radiographic pictures

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8. Major arteries of the Body & Location of

palpable pulses.
- Palpable pulses:
o Temporal
o Facial
o Carotid
o Brachial
o Radial
o Femoral
o Popliteal
o Posterior tibial
o Dorsalis pedis.
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Sample Questions for Week 2

5. Patient has a myocardial infarction leading to ischemic damage to the majority of the anterior
surface of the heart. Which coronary artery has most likely become occluded?
a. PDA
b. RCA
c. LCX
d. LAD
e. LCA

6. A 42-year-old man presents with severe retrosternal pain that radiates to his right shoulder.
Examination reveals pericarditis. Identify the nerve that is most likely responsible for the
radiating pain.
a. Intercostal nerve
b. Phrenic nerve
c. Long thoracic nerve
d. Greater splanchnic nerve
e. Cardiopulmonary nerve

7. A 58-year-old man complains of dysphagia (difficulty swallowing). Imaging reveals that the
anterior wall of his esophagus in the midthorax region is compressed. Identify the structure
most likely responsible for his dysphagia.
a. Left Ventricle
b. Right Atrium
c. Left Atrium
d. Right Ventricle
e. Pulmonary Trunk

8. Which structure is not located in the superior mediastinum?

a. Heart
b. Thymus
c. Esophagus
d. Trachea

9. A 19-year-old presents to the emergency department after having been stabbed. The
penetrating wound is immediately adjacent to the sternum in the left 4th intercostal space.
Identify the structure most likely injured due to this wound.
a. Right Atrium
b. Left Ventricle
c. Left upper lobe of lung
d. Right Ventricle
e. Left Atrium
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WEEK 3: Nasal & Pharyngeal Anatomy

1. Nasal cavity and Paranasal sinuses; Nasal cavity topography; Nasal septum
Lateral wall of the nasal cavity; Paranasal sinuses

- Anterior nares are the openings of the nostrils to the nasal cavity.
- Sinuses of facial skeleton – make skull lighter, adds resonance to voice
o Frontal sinus
o Maxillary sinus
o Sphenoidal sinus
o Ethmoidal sinus (also called Ethmoidal Air Cells; between orbit and nasal cavity)
- Concha are better viewed from a saggital section.
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- Conchae – on lateral wall, increases surface area, temperature, humidity of air

- Order of the Conchae from Inferior to Superior:
o Inferior meatus – contains the naso-lacrimal duct
o Inferior Concha
o Middle meatus – openings of the Maxillary, Frontal, Anterior Ethmoidal, & Middle
Ethmoidal; bulla-ethmoidalis, hiatus semi-lunaris.
o Middle Concha
o Superior meatus – opening of the Posterior Ethmoidal air sinus
o Superior Concha
o Supreme meatus/Spheno-Ethmoidal Recess – opening of the sphenoidal sinus
Medial wall:
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- Nasal septum is partly cartilaginous anteriorly, and partly bony posteriorly (deviated nasal septa
are fairly common in the population, and simply involves displacement of the septum).
o Nasal Septum comprised of: Vomer, Perpendicular plate of Ethmoid, and septal
cartilage.
o Arterial supply: Internal Carotid branch = Ethmoidal artery & External Carotid branches
= Septal, Greater palatine, and spheno-palatine.
Little’s area (Kiesselbach’s plexus): vascular plexus of a group of arteries near
the anterior nares. The majority of nose bleeds (Epistaxis) occur in Little’s area,
as it is exposed to the drying effect of inspiratory air.
- Cribiform plate of Ethmoid (postero-superior nasal cavity bone): porous for olfactory nerves.
- Nasal cavity contains respiratory epithelium (pseudostratified columnar with cilia) – the cilia
are necessary for the removal of dust particles. Goblet cells in this epithelium secrete mucous.
- Naso-lacrimal duct: duct that connects medial canthus of eye to nasal cavity (reason why tears
make you snotty). Opens just below the inferior meatus.

2. Pharynx: Nasopharynx, Oropharynx and Laryngopharynx

- The pharynx is a musculo-membranous tube lined internally by mucus membrane. It extends
from the base of the skull to the level
of the C6, where it is continuous with
the esophagus.
- It is situated behind the nasal and oral
cavities, and behind the larynx. Hence,
the interior of the pharynx is divided
into three parts – Naso-pharynx, oro-
pharynx and laryngo-pharynx.
- The pharynx acts as a common
channel for both deglutition and
respiration.

Nasopharynx
- Begins at the posterior nasal aperture
(internal nares). Ends at the end of
the soft palate.
- Contained within the nasopharynx is the opening of the Eustachian (or Auditory or
Pharyngotympanic) tube, which is used to equalize pressure in an airplane or scuba diving. If
there is an infection of the middle ear (Otitis media) it can spread to the nasopharynx (or vice
versa).
- Around the opening of the Eustachian tube is the Torus
Tuberius, which has the Tubal tonsils.
- On the postero-superior wall of the nasopharynx is the
Pharyngeal tonsil (which, if inflamed, is called Adenoids).

Oropharynx
- Behind the oral cavity, through the oropharyngeal isthmus.
- The lateral walls of the oropharynx contain the Palatine tonsils
(commonly inflamed – Tonsilitis). The palatine tonsils are
contained between the palatoglossal and palatopharyngeal
folds or arches.
Acute Palatine Tonsilitis
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Laryngopharynx
- The epiglottis marks the end of the oropharynx and the beginning of the laryngopharynx. The
inferior border is the cricoid cartilage, where it becomes continuous with the esophagus.
- Piriform fossa – where foreign bodies can become lodged; situated on each site of the inlet of
the larynx (piriform fossa also called “smuggler’s pouch”).

Orientation of the above figure: It is a coronal section of the pharynx, viewed posteriorly (notice how
the trachea is anterior to the esophagus). You can see 3 openings: nasal cavity, oral cavity, and the
laryngeal inlet (airway to the trachea).
- Laryngeal inlet – formed by:
o Ary-epiglotic fold
o Inter-arytenoid fold
o Epiglottis
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3. Larynx - Identify the cartilages of the larynx; Identify the primary extrinsic and
intrinsic muscles of the larynx. Identify the superior, external, internal and recurrent
laryngeal nerves, and trace their course to the larynx. Identify the Vocal and
vestibular fold and the laryngeal sinus
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- Larynx cartilages:
o Epiglottis (Elastic cartilage)
o Thyroid cartilage – laryngeal prominence (Hyaline cartilage)
o Cricoid cartilage (ring shaped; Hyaline cartilage)
o Arytenoid cartilage [Apex (Elastic cartilage); Base (Hyaline cartilage)]
o Corniculate and cuniform cartilage (Elastic cartilage)

Larynx Musculature

Thyro-hyoid membrane
- Superior laryngeal vessels
- Internal laryngeal nerve

Crico-thyroid muscle
- External laryngeal nerve
- Tensor of the vocal fold (relaxer is
thyro-arytenoids and vocalis)

Posterior crico-arytenoid
- Abduction of the vocal fold
- Life-saving muscle of the larynx
- Recurrent laryngeal

Vocalis muscle
- Formed by medial fibers of the thyroaryteroid muscle attached directly to the outer side of the
vocal ligament. It shortens and relaxes portions of vocal cords.
- Nerve supply is recurrent laryngeal.
o Closed vocal cord = adduction (can’t breathe)
o Open vocal cord = abduction (passage is called rema-glotteris) – posterior to the cricoid
cartilage (*crico-arytenoid muscle – the only abductor of the larynx).
- Laryngeal sinus is located between the vestibular fold and the vocal fold.
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Innervation of Larynx:
(note: remember everything is bilateral)
- The vagus (CNX) innervates the entire
larynx
- It gives off the following two branches:
- 1) Superior laryngeal nerve innervates
the superior portion. Injury results in a
change of pitch to the voice.
- Further subdivides into internal &
external
- 2) Internal branch innervates sensory
(afferent fibers)
- Glottis & laryngeal vestibule sensory
- 3) External branch innervates the
cricothyroid muscle (efferent fibers)
- 4) Recurrent laryngeal nerve innervates
the inferior portion (below vocal folds).
If damaged, patient has hoarseness of
voice.

- Nerve in the pharynx: superior laryngeal nerve

o Divides into internal laryngeal nerve –supplies vocal fold and muscles of the larynx
(except the one).
o External laryngeal nerve – supplies the crico-thyroid muscle (exception) – a tensor of
the vocal cord.

4. Discuss the radiographic images (Paranasal sinuses).

Radiograph A (Coronal CT) Radiograph B (Coronal CT)

- Radiograph A: Notice how the sinuses are radiolucent in comparison with the surrounding
tissue – reason being that they are air-filled.

- Radiograph B: Individual with sinusitis – clogged maxillary and ethmoidal sinuses – notice how
they are somewhat filled with hypodense matter (mucus) – it is hypodense in comparison to the
radiopaque bone, and the radiolucent areas of the sinuses that are not mucus-filled.
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Sample Questions
10. You are watching a particularly touching moment in a movie but are embarrassed to cry in front
of your friends. Although you successfully hold back the tears, your nose starts to run. The tears
have passed from your orbit into your nose through the nasolacrimal duct, which opens into the
nasal cavity via the:
a. Superior Nasal Meatus
b. Middle Nasal Meatus
c. Sphenoethmoidal Recess
d. Inferior Nasal Meatus

11. A young man is hit in the eye by a blunt object during a street fight. Imaging reveals an inferior
blowout fracture of the floor of his orbit. Identify the space below the orbit into which the
periorbital fat would most likely protrude.
a. Ethmoidal Air Cells
b. Maxillary Sinus
c. Sphenoid Sinus
d. Frontal Sinus
e. Nasal Cavity

12. A 53-year-old woman recovering from thyroidectomy now has a hoarse voice. Damage is noted
to be below the vocal folds. Damage to which nerve during surgery best explains the new
symptoms?
a. Phrenic nerve
b. Superior laryngeal nerve
c. External laryngeal nerve
d. Recurrent laryngeal nerve
e. Internal laryngeal nerve

13. Patient with sinusitis has dull pain over the eyebrow region. This symptom is caused by
inflammation within which structure?
a. Sphenoid sinus
b. Maxillary sinus
c. Frontal sinus
d. Ethmoid air cells

14. A John Doe in the morgue perished from a knife slice to a muscle in the larynx. This muscle was
crucial for the proper passage of air through the laryngeal inlet and vocal folds and into the
trachea. This muscle is involved in the abduction of the vocal folds in the larynx, and therefore,
once sliced, the man died of asphyxiation. Which muscle was injured?
a. Cricothyroid muscle
b. Thyrohyoid muscle
c. Cricoarytenoid muscle
d. Vocalis muscle
e. Oblique arytenoid muscle
 Paul Couto - W2015

Week 4: Thoracic Wall, Breasts, Lungs & Pleura

Observe the anterior thoracic wall muscles. Identify the pectoralis major & minor
muscle. Identify the External, Internal and Innermost intercostal muscles. Observe
the inner aspect of the anterior thoracic wall. Identify the Internal thoracic vessels.
Identify the phrenic nerve, pericardiacophrenic artery, and pericardiacophrenic vein.

Internal Thoracic Artery

- Paired artery that supplies the anterior chest wall and the breasts.
- One runs along each side of the sternum
- Bifurcates into superior epigastric and musculophrenic arteries.
 Paul Couto - W2015

Anterior Thoracic Wall Muscles:

Outside of the anterior thoracic wall:
- Pectoralis major: adducts & medially rotates humerus
- Pectoralis minor: adducts & medially rotates humerus
- Serratus anterior: maintains scapula against posterior thoracic wall

- External intercostals: inspiratory muscles

o *Fibers run from superolateral to inferomedial
- Internal intercostals: expiratory muscles
o *Fibers run from superomedial to inferolateral
o Note: expiration is mainly passive and powered by elasticity of chest wall and lungs

- Inferior surface of ribs is sharp; superior surface of ribs is blunt

o Costal groove inferior surface of ribs
o Lower border - Vein, artery, nerve (block -> needle at lower border of ribs) – if you
have to drain fluid (from pleura for instance), you go in the middle of the space.

- Posterior intercostal arteries -> contributes to notching of ribs during coarctation of aorta.

Internal thoracic vessels [2 arteries & 2 veins (L & R each)]:

- The internal thoracic arteries arise from the subclavians
- The internal thoracic veins drain into the brachiocephalics
- Run just on either side of midline on the inside of the anterior thoracic well
- They give off branches on the way down to form the anterior intercostal vessels that run
just inferior to each rib & with each respective intercostal nerve
- They split into musculophrenic vessels & superior epigastric vessels (they continue to run
together on both branches)
 Paul Couto - W2015

- The superior epigastric vessels

eventually become inferior
epigastric vessels as they run
inferiorly & eventually merge with
the external iliacs
- This makes the internal
thoracic/epigastric vessels a
collateral circulation system
- This can be important in the case
of a coarctation of the aorta in the
case of the arterial system or
portal hypertension in the case of
liver cirrhosis (usually due to
alcoholism).
- In the case of portal hypertension,
this can lead to a symptom called caput medusa (seen above), which is an enlargement of
the epigastric veins because the body is using them way more than what’s normal and is a
critical sign of hepatic cirrhosis.

Discuss the structure of the breast (female cadaver).

 Paul Couto - W2015

- Suspensory ligaments – connected from

superficial to deep fascia (ligaments of Cooper)
- Nipples normally at T4 and in 4th intercostal
space in the mid-clavicular line
- Lymphatics
o Medial quadrant – parasternal – can
spread to either breast
o Lateral – axillary
- Internal thoracic artery – supplies the
mammary gland

Identify the components of the pleural sacs.

Lungs: Study the fissures, lobes, borders and
surfaces of the right lung and left lung. Discuss the Surface anatomy of lungs,
oblique fissure and horizontal fissure.
Identify the vascular and bronchial structures within the substance of the lungs.
Identify structures impressing the mediastinal surface of right and left lungs.

The pleura (membranes around the lungs)

- Visceral pleura is adherent to the lung tissue
- Upon full expiration the inferior border is as follows:
o mid-clavicular line : rib 6
o mid-axillary line: rib 8
o mid-scapular line: rib 10
- Parietal pleura is adherent to the inner surface of the thoracic
cavity
- Inferior border of parietal pleura:
o mid-clavicular: rib 8
o mid-axillary: rib 10
o mid-scapular: rib 12

- There is some fluid in the pleural cavity (between the parietal

and visceral layers) normally for lubrication.
- Excess fluid in the pleura is called pleural effusion
- Pleuritis is inflammation of the pleura; This is usually caused
by an infection.
- Hemothorax is collapse of the lung due to build-up of blood in
the pleural space. Pneumothorax is collapse of the lung due
to build-up of air in the pleural space; usually due to a
puncture wound. These are life-threatening.
- Treatment is the same for both: drain the pleural space.
o Thoracocentesis (aka pleural tap): insert
aspiration needle at the mid-axillary line between
ribs 8 and 10.
- If there is no external wound, the pneumothorax (or hemothorax) is a tension pneumothorax.
This means there is a communication between the lung and the pleural space but not to the
external air. This cannot be treated with a dressing. It needs a thoracocentesis.
- Chylothorax is a build of up lymph in the pleura space and is rare
 Paul Couto - W2015

BP segment
- Tertiary bronchus also called segmental
bronchus.
- What are the structures in intra-segmental
and inter-segmental?

INTRA-SEGMENTALLY:
- Tertiary bronchus
- Branch of pulmonary artery (carrying deoxy
blood)
- Branch of bronchial artery
- Lymphatics

INTER-SEGMENTALLY:
- Pulmonary veins (present on the boundary of
the BP segment)
 Paul Couto - W2015

*KNOW IMPRESSIONS* - This is testable material

*Remember that they can tag the impressions and ask what structure would be here.
 Paul Couto - W2015

- How do you confirm side of lung on a cadaver if you’re just presented with a single lung?
o Anterior sharp border on left lung
o 3 lobes on right, 2 on left
o Linguala (upper lobe of left lung) – useful
for distinguishing left from right
o 5 openings at hilum on right, 4 on left – due
to early division of primary bronchi on
right.

- Hilum
o 2 pulmonary arteries, 1 on each side
o 4 pulmonary veins, 2 on each side
o 1 principle bronchus
o On right, divides before entering.
o Left enters then divides

The dotted line demarcates where

the bronchi enter the lungs at the
hilum. Notice how there is an early
division on the right bronchus in
comparison with the left.

Discuss the radiological pictures.

Upper Lobe

Tumor of the upper lobe

Middle Lobe

Inferior Lobe

- Notice how the inferior lobe takes up the majority of lung area on the posterior aspect. This is
true for both the left and the right lungs.
- Oblique fissure essentially divides the heart in half from a lateral X-ray.
- Horizontal fissure begins at point along oblique fissure, in the middle of the lungs from a lateral
view.
 Paul Couto - W2015

Sample Questions

15. A 46-year-old man with lung cancer has a tumor in the lingula of his lung. Identify the location of
the lingula of the lung.
a. Inferior lobe of the right lung
b. Inferior lobe of the left lung
c. Superior lobe of the right lung
d. Superior lobe of the left lung

16. During a breast self-exam, a 41-year old-women notices a lump in her breast. Following tests,
the lump is determined to be cancerous. In an effort to determine whether the cancer has
spread, it is important to palpate the armpit region to check for swelling in what structures?
a. Intercostal veins
b. Axillary lymph nodes
c. Medial mammary veins
d. Subareolar lymphatic plexus
e. Subscapular lymph nodes

17. Anesthesia of which of the following intercostal nerves will numb the breast tissue in
preparation for a breast lump biopsy?
a. T2-T3
b. T6-T8
c. T4-T6
d. T6-T10
e. T8-T10

18. A 26-year-old woman gives birth to a baby at 29 weeks. The baby is struggling to breathe
because his immature lungs cannot yet secrete surfactant. Identify the cells that create
surfactant.
a. Dust cells
b. Type I alveolar cells
c. Type II alveolar cells
d. Alveolar macrophages

19. What is the epithelium typically found in the respiratory system (also called respiratory
epithelium)?
a. Stratified squamous
b. Simple cuboidal
c. Simple columnar
d. Ciliated pseudostratified columnar
e. Pseudostratified cuboidal

20. What is the type of epithelium found in the alveoli?

a. Stratified squamous
b. Simple squamous
c. Stratified cuboidal
d. Ciliated pseudostratified columnar
e. Pseudostratified cuboidal
 Paul Couto - W2015

ANSWERS TO SAMPLE QUESTIONS

1. A
2. A
3. B
4. E
5. D
6. B
7. C
8. A
9. D
10. D
11. B
12. D
13. C
14. C
15. D
16. B
17. C
18. C
19. D
20. B