chest pain - الرئيسية...1 chest pain although chest pain can result from pulmonary disease,...

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Chest PainAlthough chest pain can result from pulmonary disease, it is prob-ably the most important symptom of cardiac disease (Swartz, 2002). However, chest pain may also occur in intestinal, gallblad-der, and musculoskeletal disorders. When evaluating a patient with chest pain, the examination is largely concerned with dis-criminating between serious conditions and the many minor caus-es of pain. People who have had a heart attack usually describe the associated pain as a â€œcrushingâ€ sub-sternal pain (deep to the sternum) that does not disappear with rest

Rib FracturesThe short, broad 1st rib, posteroinferior to the clavicle, is rarely fractured because of its protected position (it cannot be palpat-ed). When it is broken, however, injury to the brachial plexus of nerves and subclavian vessels may occur. The middle ribs are most commonly fractured. Rib fractures usually result from blows or from crushing injuries. The weakest part of a rib is just an-terior to its angle; however, direct violence may fracture a rib anywhere, and its broken end may injure internal organs such as a lung and/or the spleen. Lower rib fractures may tear the di-aphragm and result in a diaphragmatic hernia (see Chapter 2). Rib fractures are painful because the broken parts move during respiration, coughing, laughing, and sneezing.

Flail ChestMultiple rib fractures may allow a sizable segment of the anterior and/or lateral thoracic wall to move freely. The loose segment of the wall moves paradoxically (inward on inspiration and outward on expiration). Flail chest (stove-in chest) is an extremely painful injury and impairs ventilation, thereby affecting oxygenation of the blood. During treatment, the loose segment is often fixed by hooks and/or wires so that it cannot move.

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for Medical SciencesAl Andalus Univerity

Thoracotomy, Intercostal Space Incisions, Rib Excision, and Bone GraftingThe surgical creation of an opening through the thoracic wall to enter a pleural cavity is a thoracotomy (Fig. B1.1).

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An anterior thoracotomy may involve making H-shaped cuts through the perichondrium of one or more costal cartilages and then shelling out segments of costal cartilage to gain entrance to the thoracic cavity (Fig 1.16). The posterolateral aspects of the 5thâ€“7th intercostal spaces are important sites for posterior thoracotomy incisions. In general, a lateral approach is most sat-isfactory for entry into the thoracic cage. With the patient lying on the contralateral side, the upper limb is fully abducted, placing the forearm behind the patient’s head. This elevates and laterally rotates the inferior angle of scapula, allowing access as high as the 4th intercostal space. Surgeons use an H-shaped incision to incise the superficial aspect of the periosteum that ensheaths the rib, strip the periosteum from the rib, and then remove a wide segment of the rib to gain better access, as might be required to enter the thoracic cavity and remove a lung (pneumonectomy), for example. In the rib’s absence, entry into the thoracic cavity can be made through the deep aspect of the periosteal sheath, sparing the adjacent intercostal muscles. After the operation, the missing pieces of ribs regenerate from the intact periosteum, although imperfectly. Sometimes surgeons use a piece of rib so removed for autogenous bone grafting in procedures such as re-construction of the mandible (lower jaw) after tumor excision.

Supernumerary RibsPeople usually have 12 ribs on each side, but the number is in-creased by the presence of cervical and/or lumbar ribs, or de-creased by failure of the 12th pair to form (see Chapter 4 for details). Cervical ribs are relatively common (0.5â€“2%), but lumbar ribs are less common. Cervical ribs may interfere with neurovascular structures exiting the superior thoracic aperture (See â€œThoracic Outlet Syndromes,â€ in Chapter 6.) Supernu-merary (extra) ribs also have clinical significance in that they may confuse the identification of vertebral levels in radiographs and other diagnostic images.

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Protective Function and Aging of Costal Car-tilagesCostal cartilages provide resilience to the thoracic cage, prevent-ing many blows from fracturing the sternum and/or ribs. Because of the remarkable elasticity of the ribs and costal cartilages in children, chest compression may produce injury within the tho-rax even in the absence of a rib fracture. In elderly people, the costal cartilages lose some of their elasticity and become brittle; they may undergo calcification, making them radiopaque (e.g., in radiographs).

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Ossified Xiphoid ProcessesMany people in their early 40s suddenly become aware of their partly ossified xiphoid process and consult their physician about the hard lump in the â€œpit of their stomachâ€ (epigastric fossa). Never having been aware of their xiphoid process before, they fear they have developed a tumor, such as â€œstomach cancer.â€

Sternal FracturesDespite the subcutaneous location of the sternum, sternal frac-tures are not common. Crush injuries can occur after traumatic compression of the thoracic wall in automobile accidents when the driver’s chest is forced into the steering column, for exam-ple. The installation and use of air bags in vehicles has reduced the number of sternal fractures. A fracture of the sternal body is usually a comminuted fracture (the sternum is broken into sever-al pieces). Displacement of the bone fragments is uncommon be-

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cause the sternum is invested by deep fascia (fibrous continuities of radiate sternocostal ligaments; Fig. 1.6A) and the sternal at-tachment of the pectoralis major muscles. The most common site of sternal fracture is at the sternal angle, after the manubrios-ternal joint has fused in elderly people, resulting in dislocation of the (re-established) manubriosternal joint.

In sternal injuries, the concern is not primarily for the fracture itself but for the likelihood of heart injury (myocardial contusion, cardiac rupture, tamponade) or pulmonary injury. The mortali-ty (death rate) associated with sternal fractures is reported as 25â€“45%, largely owing to these underlying injuries. All pa-tients with sternal contusion should be evaluated for underlying visceral injury (Rosen, 1998).

Median SternotomyTo gain access to the thoracic cavity for surgical operations in the mediastinumâ€”for example, for coronary artery bypass graft-ingâ€”the sternum is divided (split) in the median plane and retracted. The flexibility of ribs and costal cartilages enables spreading of the halves of the sternum. Sternal splitting also gives good exposure for removal of tumors in the superior lobes of the lungs. After surgery, the halves of the sternum are joined (e.g., with wire sutures).

Sternal BiopsyThe sternal body is often used for bone marrow needle biopsy because of its breadth and subcutaneous position. The needle pierces the thin cortical bone and enters the vascular trabecu-lar (cancellous) bone. Sternal biopsy is commonly used to ob-tain specimens of marrow for transplantation and for detection of metastatic cancer and blood dyscrasias (abnormalities).

Sternal AnomaliesThe cartilaginous halves of the sternum of the fetus (sternal

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plates) may not fuse because of defective ossification. Complete sternal cleft is uncommon. Sternal clefts involving the manubri-um and superior half of the body are V- or U-shaped and can be repaired during infancy by direct apposition and fixation of the cartilaginous sternal halves.

Sometimes there is a perforation (sternal foramen) in the sternal body because of incomplete fusion of the fetal sternal plates. It is not clinically significant; however, one should be aware of its possible presence so that it will not be misinterpreted on a med-ical image of the thorax as a bullet wound. Although the xiphoid process is commonly perforated in elderly persons because of age-related changes, this perforation is not clinically significant. Similarly, a protruding xiphoid process in infants is not unusual; when it occurs, it usually does not require correction

Thoracic Outlet SyndromeAnatomists refer to the superior thoracic aperture as the thoracic inlet because non-circulating substances (air and food) may en-ter the thorax only through this aperture. When clinicians refer to the superior thoracic aperture as the thoracic outlet, they are emphasizing the arteries and T1 spinal nerves that emerge from the thorax through this aperture to enter the lower neck and upper limbs. Hence, various types of thoracic outlet syndrome (TOS) exist in which emerging structures are affected by obstruc-tions of the superior thoracic aperture (Rowland, 2000). Although TOS implies a thoracic location, the obstruction actually occurs outside the aperture in the root of the neck (see Chapter 8), and the manifestations of the syndromes involve the upper limb (see Chapter 6).

Dislocation of RibsA rib dislocation (slipping rib syndrome) is the displacement of a

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costal cartilage from the sternumâ€”dislocation of a sternocostal joint or the displacement of the interchondral joints. Rib dislo-cations are common in body-contact sports; complications may result from pressure on or damage to nearby nerves, vessels, and muscles. Displacement of interchondral joints usually occurs uni-laterally and involves ribs 8, 9, and 10. Trauma sufficient to dis-place these joints often injures underlying structures such as the diaphragm and/or liver, causing severe pain, particularly during deep inspiratory movements. The injury produces a lump-like de-formity at the displacement site.

Separation of RibsRib separation refers to dislocation of a costochondral junction between the rib and its costal cartilage. In separations of the 3rdâ€“10th ribs, tearing of the perichondrium and periosteum usually occurs. As a result, the rib may move superiorly, overrid-ing the rib above and causing pain.

Paralysis of the DiaphragmParalysis of half of the diaphragm (one dome or hemidiaphragm) because of injury to its motor supply from the phrenic nerve does not affect the other half because each dome has a separate nerve supply. One can detect paralysis of the diaphragm radiographical-ly by noting its paradoxical movement. Instead of descending as it normally would during inspiration owing to diaphragmatic con-traction (Fig. B1.2A), the paralyzed dome ascends as it is pushed superiorly by the abdominal viscera that are being compressed by the active contralateral dome (Fig. B1.2B). Instead of ascending during expiration, the paralyzed dome descends in response to the positive pressure in the lungs.

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Figure B1.2

Surface Anatomy of the Thoracic Wall SkeletonThe clavicles (collar bones) lie subcutaneously, forming bony ridges at the junction of the thorax and neck (Fig. SA1.1). They can be palpated easily throughout their length, especially where their medial ends articulate with the manubrium of the sternum. The clavicles demarcate the superior divide between zones of lymphatic drainage: above the clavicles, lymph flows ultimately to inferior jugular lymph nodes; below them, parietal lymph (that from the body wall and upper limb) flows to the axillary lymph nodes.

The sternum lies subcutaneously in the anterior median line and is palpable throughout its length. Between the prominences of the medial ends of the clavicles at the sternoclavicular joints, the jugular notch in the manubrium can be palpated between the prominent medial ends of the clavicles. The notch lies at the level of the inferior border of the body of T2 vertebra and the space between the 1st and 2nd thoracic spinous processes.

The manubrium, approximately 4 cm long, lies at the level of the bodies of T3 and T4 vertebrae (Fig. SA1.2). The sternal angle is

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palpable and often visible in young people because of the slight movement that occurs at the manubriosternal joint during forced respiration. The sternal angle lies at the level of the T4â€“T5 IV disc and the space between the 3rd and 4th thoracic spinous pro-cesses. The sternal angle marks the level of the 2nd pair of costal cartilages. The left side of the manubrium is anterior to the arch of the aorta, and its right side directly overlies the merging of the brachiocephalic veins to form the superior vena cava (SVC). Because it is common clinical practice to insert catheters into the SVC for feeding extremely ill patients and other purposes (Ger et al., 1996), it is essential to know the surface anatomy of this large vein. The SVC passes inferiorly deep to the manubrium and manubriosternal junction but projects as much as a fingerbreadth to the right of the margin of the bony structures. The SVC enters the right atrium of the heart opposite the right 3rd costal carti-lage.

The body of the sternum, approximately 10 cm long, lies anteri-or to the right border of the heart and vertebrae T5â€“T9. The in-termammary cleft (midline depression or cleavage between the mature female breasts) overlies the sternal body. The xiphoid process lies in a slight depression, the epigastric fossa, where the converging costal margins form the infrasternal angle. This angle is used in cardiopulmonary resuscitation (CPR) for locating the proper hand position on the inferior part of the sternal body. You can feel the xiphisternal joint, often seen as a ridge, at the level of the inferior border of T9 vertebra.

The costal margins, formed by the joined costal cartilages of the 7thâ€“10th costal cartilages, are easily palpable because they extend inferolaterally from the xiphisternal joint. The costal margins form the sides of the infrasternal angle.

The ribs and intercostal spaces provide a basis for locating or describing the position of structures or sites of trauma or pathol-ogy on or deep to the thoracic wall, much like lines of latitude are used in navigation. For example, â€œthe beat of the mitral

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valve of the heart may be heard by placing the stethoscope in the intercostal space between the 5th and 6th ribs inferior to the left nipple.â€ Because the 1st rib is not palpable, rib counting in physical examinations starts with the 2nd rib adjacent to the subcutaneous and easily palpated sternal angle.

Figure SA1.1

Dyspnea: Difficult BreathingWhen people with respiratory problems (e.g., asthma) or with heart failure struggle to breathe, they use their accessory respi-ratory muscles to assist the expansion of their thoracic cavity. They lean on their knees or on the arms of a chair to fix their pectoral girdle so these muscles are able to act on their rib at-tachments and expand the thorax.

Dyspnea: Difficult BreathingWhen people with respiratory problems (e.g., asthma) or with heart failure struggle to breathe, they use their accessory respi-ratory muscles to assist the expansion of their thoracic cavity.

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They lean on their knees or on the arms of a chair to fix their pectoral girdle so these muscles are able to act on their rib at-tachments and expand the thorax.

Extrapleural Intrathoracic Surgical Ac-cessFixation makes it difficult to appreciate in the embalmed cadaver, but in surgery the relatively loose nature of the thin endothorac-ic fascia provides a natural cleavage plane, allowing the surgeon to separate the costal parietal pleura lining the lung cavity from the thoracic wall. This allows intrathoracic access to extrapleural structures (e.g., lymph nodes) and instrument placement without opening and perhaps contaminating the potential space (pleural cavity) that surrounds the lungs.

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Figure 1.16. Segmental innervation (der-matomes) of thoracic wall. Spinal nerve C5 sup-plies skin at the level of the clavicles and immediately below. Anteriorly, the dermatome immediately infe-rior to the C5 dermatome is that of spinal nerve T1. Dermatomes C6â€“C7 are located mostly in the upper limbs and are represented on the posterior, but not the anterior, body wall. Since the anterior rami of spi-nal nerves T2â€“T12 are not involved in plexus forma-tion, there is no difference between the dermatomes and the zones of peripheral nerve distribution here. Dermatome T4 includes the nipple; dermatome T10 includes the umbilicus.

Herpes Zoster Infection of the Spinal Gan-gliaA herpes zoster infection causes a classic, dermatomally distrib-uted skin lesionâ€”shinglesâ€”an agonizingly painful condition (Fig. B1.3). Herpes zoster is primarily a viral disease of spinal ganglia, usually a reactivation of the varicella-zoster virus (VZV), or chickenpox virus. After invading a ganglion, the virus produces a sharp burning pain in the dermatome supplied by the involved nerve (Fig. 1.16). The affected skin area becomes red, and ve-sicular eruptions appear. The pain may precede or follow the skin eruptions. Although primarily a sensory neuropathy (pathological change in the nerve) weakness from motor involvement occurs in 0.5â€“5.0% of people, commonly in elderly cancer patients (Rowland, 2000). Muscular weakness usually occurs in the same myotomal distribution, as do the dermatomal pain and vesicular eruptions.

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Figure B1.3

Intercostal Nerve BlockLocal anesthesia of an intercostal space is produced by injecting a local anesthetic agent around the intercostal nerves between the paravertebral line and the area of required anesthesia. This procedure, an intercostal nerve block, involves infiltration of the anesthetic around the intercostal nerve trunk and its collateral branches (Fig. B1.4). The word block indicates that the nerve endings in the skin and the transmission of impulses through the sensory nerves carrying information about pain are interrupted (blocked) before the impulses reach the spinal cord and brain. Because any particular area of skin usually receives innervation from two adjacent nerves, considerable overlapping of contigu-ous dermatomes occurs. Therefore, complete loss of sensation usually does not occur unless two or more intercostal nerves are anesthetized.

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Figure B1.4

Changes in the BreastsChanges, such as branching of the lactiferous ducts, occur in the breast tissues during menstrual periods and pregnancy (Fergu-son et al., 1992). Although mammary glands are prepared for secretion by midpregnancy, they do not produce milk until short-ly after the baby is born. Colostrum, a creamy white to yellow-ish premilk fluid, may secrete from the nipples during the last trimester of pregnancy and during initial episodes of nursing. Colostrum is believed to be especially rich in protein, immune agents, and a growth factor affecting the infant’s intestines. In multiparous women, the breasts often become large and pendu-lous. The breasts in elderly women are usually small because of the decrease in fat and the atrophy of glandular tissue.

Breast QuadrantsFor the anatomical location and description of tumors and cysts, the surface of the breast is divided into four quadrants (Fig. B1.5). For example, a physician’s record might state: â€œA hard irregular mass was felt in the superior medial quadrant of the

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breast at the 2 o’clock position, approximately 2.5 cm from the margin of the areola.â€

Figure B1.5

Carcinoma of the BreastUnderstanding the lymphatic drainage of the breasts is of prac-tical importance in predicting the metastasis of carcinoma of the breast (breast cancer). Carcinomas of the breast are malignant tu-mors, usually adenocarcinomas arising from the epithelial cells of the lactiferous ducts in the mammary gland lobules (Fig. B1.6A). Metastatic cancer cells that enter a lymphatic vessel usually pass through two or three groups of lymph nodes before entering the venous system.

Interference with the lymphatic drainage by cancer may cause lymphedema (edema, excess fluid in the subcutaneous tissue), which in turn may result in deviation of the nipple and a thick-ened, leather-like appearance of the skin. Prominent or â€œpuffyâ€ skin between dimpled pores give it an orange-peel appearance

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(peau d’orange sign). Larger dimples (fingertip size or bigger) re-sult from cancerous invasion of the glandular tissue and fibrosis (fibrous degeneration), which causes shortening or places trac-tion on the suspensory ligaments. Subareolar breast cancer may cause inversion of the nipple by a similar mechanism involving the lactiferous ducts.

Breast cancer typically spreads by means of lymphatic vessels (lymphogenic metastasis), which carry cancer cells from the breast to the lymph nodes, chiefly those in the axilla. The cells lodge in the nodes, producing nests of tumor cells (metastases). Abundant communications among lymphatic pathways and among axillary, cervical, and parasternal nodes may also cause metas-tases from the breast to develop in the supraclavicular lymph nodes, the opposite breast, or the abdomen. Because most of lymphatic drainage of the breast is to the axillary lymph nodes, they are the most common site of metastasis from a breast can-cer. Enlargement of these palpable nodes suggests the possibility of breast cancer and may be key to early detection. However, the absence of enlarged axillary lymph nodes is no guarantee that metastasis from a breast cancer has not occurred because the malignant cells may have passed to other nodes, such as the in-fraclavicular and supraclavicular lymph nodes.

The posterior intercostal veins drain into the azygos/hemiazy-gos system of veins alongside the bodies of the vertebrae (Fig. 1.31B) and communicate with the internal vertebral venous plex-us surrounding the spinal cord. Cancer cells can also spread from the breast by these venous routes to the vertebrae and from there to the cranium and brain. Cancer also spreads by contiguity (invasion of adjacent tissue). When breast cancer cells invade the retromammary space (Fig. 1.20), attach to or invade the deep pectoral fascia overlying the pectoralis major, or metastasize to the interpectoral nodes, the breast elevates when the muscle contracts. This movement is a clinical sign of advanced cancer of the breast. To observe this upward movement, the physician has

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the patient place her hands on her hips and press while pulling her elbows forward to tense her pectoral muscles.

MammographyRadiographic examination of the breasts, or mammography, is one of the techniques used to detect breast masses (Fig. B1.6B). A carcinoma appears as a large, jagged density in the mammo-gram (upper two arrows in Fig. B1.6C).

The skin is thickened over the tumor. The lower arrow points to the depressed nipple. Surgeons use mammography as a guide when removing breast tumors, cysts, and abscesses.

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Surgical Incisions of the BreastIncisions are placed in the inferior breast quadrants when pos-sible because these quadrants are less vascular than the supe-rior ones. The transition between the thoracic wall and breast is most abrupt inferiorly, producing a line, crease, or deep skin foldâ€”the inferior cutaneous crease. Incisions made along this crease will be least evident and may actually be hidden by over-lap of the breast. Incisions that must be made near the areola or on the breast itself are usually directed radially to either side of the nipple (Langer tension lines run transversely here; see the Introduction) or circumferentially.

Mastectomy (breast excision) is not as common as it once was as a treatment for breast cancer. In simple mastectomy, the breast is removed down to the retromammary space. Radical mastecto-my, a more extensive surgical procedure, involves removal of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region. In current practice, often only the tumor and surrounding tissues are removedâ€”a lumpectomy or quadrantectomy (known as breast-conserving surgery, a wide local excision)â€”followed by radiation therapy (Goroll, 2000).

Polymastia, Polythelia, and AmastiaPolymastia (supernumerary breasts) or polythelia (accessory nipples) may occur superior or inferior to the normal pair, occa-sionally developing in the axillary fossa or anterior abdominal wall (Figs. B1.7 and SA1.5). Supernumerary breasts usually consist of only a rudimentary nipple and areola, which may be mistaken for a mole (nevus) until they change pigmentation with the normal nipples during pregnancy. However, glandular tissue may also be present and further develop with lactation. Extra breasts may appear anywhere along a line extending from the axilla to the groinâ€”the location of the embryonic mammary ridge (the milk line) from which the breasts develop (Moore and Persaud, 2003),

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and along which breasts develop in animals with multiple breasts. In either sex, there may be no breast development (amastia), or there may be a nipple and/or areola, but no glandular tissue.

Figure B1.7

Breast Cancer in MenApproximately 1.5% of breast cancers occur in men. As in wom-en, the cancer usually metastasizes to lymph nodes but also to bone, pleura, lung, liver, and skin. Carcinoma of the breast affects approximately 1000 men per year in the United States (Swartz, 2002). A visible and/or palpable subareolar mass or secretion from a nipple may indicate a malignant tumor. Breast cancer in males tends to infiltrate the pectoral fascia, pectoralis major, and apical lymph nodes in the axilla. Although breast cancer is uncommon in men, the consequences are serious because they

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are frequently not detected until extensive metastases have oc-curredâ€”for example, in bone.

GynecomastiaSlight temporary enlargement of the breasts is a normal occur-rence (frequency = 70%) in males at puberty (age 10â€“12 years). Breast hypertrophy in males after puberty (gynecomastia) is relatively rare (< 1%) and may be age related or drug related (e.g., after treatment with diethylstilbestrol for prostate cancer). Gynecomastia may also result from an imbalance between estro-genic and androgenic hormones or from a change in the metabo-lism of sex hormones by the liver. Thus a finding of gynecomastia should be regarded as a symptom, and an evaluation must be ini-tiated to rule out important potential causes, such as suprarenal and testicular cancers or cirrhosis (Goroll, 2000). Approximately 40% of postpubertal males with Klinefelter syndrome (XXY triso-my) have gynecomastia (Moore et al., 2000).

Injuries to the Cervical Pleura and Apex of LungBecause of the inferior slope of the 1st pair of ribs and the su-perior thoracic aperture they form, the cervical pleura and apex of the lung project through this opening into the neck, posteri-or to the inferior attachments of the sternocleidomastoid mus-cles. Consequently, the lungs and pleural sacs may be injured in wounds to the base of the neck resulting in a pneumothorax, the presence of air (G. pneuma) in the pleural cavity. The cervical pleura reaches a relatively higher level in infants and young chil-dren because of the shortness of their necks. Consequently, the cervical pleura is especially vulnerable to injury during the first few years after birth.

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Injury to Other Parts of the PleuraeThe pleurae descend inferior to the costal margin in three re-gions, where an abdominal incision might inadvertently enter a pleural sac: the right part of the infrasternal angle and right and left costovertebral angles. The small areas of pleura exposed in the costovertebral angles inferomedial to the 12th ribs are poste-rior to the superior poles of the kidneys. The pleura is in danger here (i.e., a pneumothorax may occur) from an incision in the posterior abdominal wall when surgical procedures expose a kid-ney, for example.

Pulmonary CollapseThe lungs (more specifically, the air sacs that collectively make up the lung) are comparable to an inflated balloon when they are distended. If the distension is not maintained, their inherent elasticity will cause them to collapse (secondary atelectasis is the collapse of a previously inflated lung; primary atelectasis refers to the failure of a lung to inflate at birth). An inflated balloon re-mains distended only as long as its outlet is closed. Normal lungs in situ remain distended even when their outlet (the airway) is open because their outer surfaces (visceral pleura) adhere to the inner surface of the thoracic walls (parietal pleura) as a result of the surface tension consequent to the pleural fluid between them. The elastic recoil of the lungs causes the pressure in the pleural cavities to be sub-atmospheric. The pressure is usually about -2 mm Hg; during inspiration, it drops to about -8 mm Hg.

If a penetrating wound (hole) opens through the thorax or in the lungs, air will be sucked into the pleural cavity because of the negative pressure (Fig. B1.8). The surface tension adhering vis-ceral to parietal pleura (lung to thoracic wall) will be broken, and the lung will collapse, expelling most of its air because of its in-herent elasticity (elastic recoil). When a lung collapses, the pleu-ral cavity (normally a potential space) becomes a real space. The pleural sacs do not normally communicate; thus one lung may

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be collapsed after surgery, for example, without the other lung collapsing. Laceration or rupture of the surface of a lung (and its visceral pleura) or penetration of the thoracic wall (and its pa-rietal pleura) results in hemorrhage and the entrance of air into the pleural cavity. The amount of blood and air that accumulates determines the extent of pulmonary collapse.

Figure B1.8

When the lung collapses, it occupies less volume within the pul-monary cavity and the pulmonary cavity does not increase in size (in fact, it may decrease in size) during inspiration. This reduction in size will be evident radiographically on the affected side by elevation of the diaphragm above usual levels, intercostal

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space narrowing (ribs closer together), and displacement of the mediastinum (mediastinal shift; most evident via the air-filled trachea within it) toward the affected side. In addition, the col-lapsed lung will probably appear more dense (whiter) surrounded by more radiolucent (blacker) air.

In open-chest surgery, respiration and lung inflation must be maintained by intubating the trachea with a cuffed tube and us-ing a positive-pressure pump, varying the pressure to alternately inflate and deflate the lungs.

Pneumothorax, Hydrothorax, and Hemotho-raxEntry of air into the pleural cavity (pneumothorax), resulting from a penetrating wound of the parietal pleura from a bullet, for example, or from rupture of a pulmonary lesion into the pleu-ral cavity (bronchopulmonary fistula), results in collapse of the lung (Fig. B1.8). Fractured ribs may also tear the visceral pleura and lung, thus producing pneumothorax. The accumulation of a significant amount of fluid in the pleural cavity (hydrothorax) may result from pleural effusion (escape of fluid into the pleu-ral cavity). With a chest wound, blood may also enter the pleu-ral cavity (hemothorax) (Fig. B1.9). Hemothorax results more commonly from injury to a major intercostal or internal thoracic vessel than from laceration of a lung. If both air and fluid (he-mopneumothorax, if the fluid is blood) accumulate in the pleural cavity, an airâ€“fluid level or interface (sharp line, horizontal re-gardless of the patient’s position, indicating the upper surface of the fluid) will be seen on a radiograph.

ThoracentesisSometimes it is necessary to insert a hypodermic needle through an intercostal space into the pleural cavity (thoracentesis) to obtain a sample of fluid or to remove blood or pus (Fig. B1.10).

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To avoid damage to the intercostal nerve and vessels, the needle is inserted superior to the rib, high enough to avoid the collat-eral branches. The needle passes through the intercostal mus-cles and costal parietal pleura into the pleural cavity. When the patient is in the upright position, intrapleural fluid accumulates in the costodiaphragmatic recess. Inserting the needle into the 9th intercostal space in the midaxillary line during expiration will avoid the inferior border of the lung. The needle should be angled upward, to avoid penetrating the deep side of the recess (a thin layer of diaphragmatic parietal pleura and diaphragm overlying the liver).

Figure B1.9. Hemothorax in right lung cavity.

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Figure B1.10. Technique for thoracentesis (in MAL)

Insertion of a Chest TubeMajor amounts of air, blood, serous fluid, pus or any combination of these substances in the pleural cavity are typically removed by placement of a chest tube. A short incision is made in the 5th or 6th intercostal space in the midaxillary line (which is approxi-mately at nipple level). The tube may be directed superiorly (to-ward to the cervical pleura or pleural cupula) for air removal or inferiorly (toward the costodiaphragmatic recess) for fluid drain-age. The extracorporeal end of the tube (i.e., the end that is out-side of the body) is connected to an underwater drainage system, often with controlled suction, to prevent air from being sucked back into the pleural cavity. Removal of air allows reinflation of a collapsed lung. Failure to remove fluid may cause the lung to de-velop a resistant fibrous covering that inhibits expansion unless it is peeled (lung decortication).

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ThoracoscopyThoracoscopy is a diagnostic and sometimes therapeutic proce-dure in which the pleural cavity is examined with a thoracoscope (Fig. B1.11). Small incisions are made into the pleural cavity via an intercostal space. In addition to observation, biopsies can be taken and some thoracic conditions can be treated (e.g., disrupt-ing adhesions or removing plaques).

Pleuritis (Pleurisy)During inspiration and expiration, the sliding of normally smooth, moist pleurae makes no detectable sound during auscultation of the lungs (listening to breath sounds); however, inflammation of the pleura, pleuritis or pleurisy, makes the lung surfaces rough. The resulting friction (pleural rub) is detectable with a stethoscope. It sounds like a clump of hair being rolled between the fingers. The inflamed surfaces of pleura may also cause the parietal and visceral layers of pleura to adhere (pleural adhe-sion). Acute pleuritis is marked by sharp, stabbing pain, especial-ly on exertion, such as climbing stairs, when the rate and depth of respiration may be increased even slightly.

Figure B1.11

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Pleurectomy and PleurodesisObliteration of a pleural cavity by disease such as pleuritis (in-flammation of pleura) or during surgery (pleurectomy, or exci-sion of a part of the pleura, for example (Fig. B1.11) does not cause appreciable functional consequences; however, it may pro-duce pain during exertion. In other procedures, adherence of the parietal and visceral layers of pleura is induced by covering the apposing layers of pleura with an irritating powder or sclerosing agent (pleurodesis). Pleurectomy and pleurodesis are performed to prevent recurring spontaneous secondary atelectasis (sponta-neous lung collapse) caused by chronic pneumothorax or malig-nant effusion resulting from lung disease (Ahya et al., 2001).

Variations in the Lobes of the LungOccasionally, an extra fissure divides a lung or a fissure is ab-sent. For example, the left lung sometimes has three lobes and the right lung only two. The most common â€œaccessoryâ€ lobe is the azygos lobe, which appears in the right lung in approximately 1% of people. In these cases, the azygos vein arches over the apex of the right lung and not over the right hilum, isolating the medial part of the apex as an azygos lobe.

Appearance of the Lungs and Inhalation of Carbon Particles and IrritantsThe lungs are light pink in healthy children and people who are non-smokers and live in a clean environment (e.g., Pacific island-ers). The lungs are commonly dark and mottled in most adults who live in either urban or agricultural areas, especially those who smoke, because of the accumulation of carbon and dust par-ticles in the air and irritants in tobacco that are inhaled. Smoker’s

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cough results from the inhalation of these irritants. However, the lungs are capable of accumulating a considerable amount of car-bon without being adversely affected. Lymph from the lungs car-ries special â€œdust cellsâ€ (phagocytes) that remove carbon from the gas-exchanging surfaces and deposit it in the â€œinactiveâ€ connective tissue, which supports the lung or in lymph nodes re-ceiving lymph from the lungs.

Auscultation of the Lungs and Percussion of the ThoraxAuscultation of the lungs (listening to their sounds with a stethoscope) and percussion of the thorax (tapping the thorax over the lungs with the fingers to detect sounds in the lungs) (Fig. B1.12A) are important techniques of physical examination. Auscultation assesses airflow through the tracheobronchial tree into the lobes of the lung. Percussion helps establish whether the underlying tissues are air filled (resonant sound), fluid filled (dull sound), or solid (flat sound). An awareness of normal anatomy, particularly the projection of the lungs and the portions that are overlapped by bone with associated muscles (e.g., the scapula) enable the examiner to know where flat and resonant sounds should be expected (Fig. B1.12B). Auscultation and percussion should always include the root of the neck where the apices of the lungs are located. When clinicians refer to â€œauscultating the base of the lung,â€ they are not usually referring to its diaphragmat-ic surface or anatomical base. They are usually referring to the inferoposterior part of the inferior lobe. To auscultate this area, the clinician applies a stethoscope to the posterior thoracic wall at the level of the 10th thoracic vertebra.

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Figure B1.12. Percussion of the lungs. A. Bimanual per-cussion is shown. B. Areas of flatness (yellow) and reso-nance are shown.

Lung Cancer and Mediastinal NervesLung cancer involving a phrenic nerve may result in paralysis of the hemidiaphragm. Because of the intimate relationship of the recurrent laryngeal nerve to the apex of the lung (Fig. 1.27B), this nerve may be involved in apical lung cancers. This involve-ment usually results in hoarseness owing to paralysis of a vocal fold (cord) because the recurrent laryngeal nerve supplies all but one of the laryngeal muscles (see Chapter 8).

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Aspiration of Foreign BodiesBecause the right bronchus is wider and shorter and runs more vertically than the left bronchus, foreign material (e.g., a foreign body or food) is more likely to enter and lodge in it or one of its branches. A potential hazard encountered by dentists is an as-pirated foreign body, such as a piece of tooth or filling material, that is likely to enter the right main bronchus. To create a sterile

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environment and avoid aspiration of foreign objects, dentists may insert a thin rubber dam into the oral cavity during procedures.

BronchoscopyAs a bronchoscope proceeds down the trachea to enter a main bronchus, a keel-like ridge, the carina (L. keel of a boat) is ob-served between the orifices of the main bronchi (Fig. B1.13). A cartilaginous projection of the last tracheal ring, the carina nor-mally lies in a sagittal plane and has a fairly definite edge. If the tracheobronchial lymph nodes in the angle between the main bronchi are enlarged because cancer cells have metastasized from a bronchogenic carcinoma, for example, the carina is distorted, widened posteriorly, and immobile. Hence, morphological chang-es in the carina are important diagnostic signs to bronchoscopists in assisting with the differential diagnosis of respiratory disease.

The mucous membrane covering the carina is one of the most sensitive areas of the tracheobronchial tree and is associated with the cough reflex. For example, when children aspirate a pea-nut, they choke and cough. Once the peanut passes the carina, coughing usually stops. If the choking victim is inverted to make use of gravity to expel the foreign body (postural drainage of the lungs), lung secretions passing the carina also cause coughing, which assists the expellation.

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Figure B1.13

Pulmonary EmbolismObstruction of a pulmonary artery by a blood clot (embolus) is a common cause of morbidity (sickness) and mortality (death). An embolus in a pulmonary artery forms when a blood clot, fat globule, or air bubble travels in the blood to the lungs from a leg vein, for example, after a compound fracture. The embolus pass-es through the right side of the heart to a lung through a pul-monary artery. It may block a pulmonary arteryâ€”pulmonary embolism (PE)â€”or one of its branches. The pulmonary arteries carry all of the blood that has been returned to the right heart via the vena caval system. Consequently, the immediate result of PE

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is partial or complete obstruction of blood flow to the lung. The blockage results in a lung or a sector of lung that is ventilated with air but not perfused with blood.

When a large embolus occludes a pulmonary artery, the patient suffers acute respiratory distress because of a major decrease in the oxygenation of blood, owing to blockage of blood flow through the lung. Conversely, the right side of the heart may become acutely dilated because the volume of blood arriving from the systemic circuit cannot be pushed through the pulmonary circuit (acute cor pulmonale). In either case, death may occur in a few minutes. A medium-size embolus may block an artery supplying a bronchopulmonary segment, producing a pulmonary infarct, an area of necrotic (dead) lung tissue.

In physically active people, a collateral circulationâ€”an indirect, accessory blood supplyâ€”often exists and develops further when there is a PE so that infarction is not as likely to occur, or at least not be as devastating. Anastomoses with branches of the bron-chial arteries abound in the region of the terminal bronchioles. In ill people with impaired circulation in the lung, such as chronic congestion, PE commonly results in lung infarction. When an area of visceral pleura is also deprived of blood, it becomes inflamed (pleuritis) and irritates or becomes fused to the sensitive parietal pleura, resulting in pain. Pain from the parietal pleura is referred to the cutaneous distribution of the intercostal nerves to the tho-racic wall, or, in the case of inferior nerves, to the anterior ab-dominal wall.

Lymphatic Drainage after Pleural AdhesionIf the parietal and visceral layers of pleura adhere (pleural adhe-sion), the lymphatic vessels in the lung and visceral pleura may drain into the axillary lymph nodes. The presence of carbon par-ticles in these nodes is presumptive evidence of pleural adhesion.

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Bronchogenic CarcinomaThe term bronchogenic carcinoma once was a specific designation for cancer arising in the bronchusâ€”usually squamous- (oat) or small-cell carcinoma (cancer)â€”but now the term refers to any lung cancer. Lung cancer is mainly caused by cigarette smok-ing; most cancers arise in the mucosa of the large bronchi and produce a persistent, productive cough or hemoptysis (spitting of blood). Malignant (cancer) cells can be detected in the sputum (saliva-borne matter).

The primary tumor, observed radiologically as an enlarging lung mass, metastasizes early to the bronchopulmonary (hilar) lymph nodes and subsequently to other thoracic lymph nodes. Com-mon sites of hematogenous metastases (spreading through the blood) of cancer cells from a bronchogenic carcinoma are the brain, bones, lungs, and suprarenal (adrenal) glands. The tumor cells probably enter the systemic circulation by invading the wall of a sinusoid or venule in a lung and are transported through the pulmonary veins, left heart, and aorta to these structures. Often the lymph nodes superior to the clavicleâ€”the supraclavicular lymph nodesâ€”are enlarged when bronchogenic carcinoma de-velops owing to metastases of cancer cells from the tumor. Con-sequently, the supraclavicular lymph nodes are called sentinel lymph nodes because their enlargement alerts the physician to the possibility of malignant disease in the thoracic and/or abdom-inal organs.

Pleural PainThe visceral pleura is insensitive to pain because it receives no nerves of general sensation. The parietal pleura (particularly the costal part) is extremely sensitive to pain. The parietal pleura is richly supplied by branches of the intercostal and phrenic nerves. Irritation of the parietal pleura may produce local pain or referred

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pain projected to dermatomes supplied by the same spinal (pos-terior root) ganglia and segments of the spinal cord. Irritation of the costal and peripheral parts of the diaphragmatic pleura results in local pain and referred pain to the dermatomes of the thoracic and abdominal walls. Irritation of the mediastinal and central diaphragmatic areas of parietal pleura results in referred pain to the root of the neck and over the shoulder (C3â€“C5 der-matomes).

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Surface Anatomy of the Pleurae and LungsThe cervical pleurae and apices of the lungs pass through the su-perior thoracic aperture into the supraclavicular fossae, which are located posterior and superior to the clavicles and lateral to the tendons of the sternocleidomastoid muscles (Fig. SA1.6). The anterior borders of the lungs lie adjacent to the anterior line of reflection of the parietal pleura between the 2nd and 4th costal cartilages. Here the margin of the left pleural reflection moves laterally and then inferiorly at the cardiac notch to reach the 6th costal cartilage. The anterior border of the left lung is more deep-ly indented by its cardiac notch. On the right side, the pleural reflection continues inferiorly from the 4th to the 6th costal car-tilage, paralleled closely by the anterior border of the right lung. Both pleural reflections and anterior lung borders pass laterally at the 6th costal cartilages. The pleural reflections reach the MCL at the level of the 8th costal cartilage, the 10th rib at the MAL, and the 12th rib at the SL; however, the inferior margins of the lungs reach the MCL at the level of the 6th rib, the MAL at the 8th rib, and the scapular line at the 10th rib, proceeding toward the spinous process of T10 vertebra. They then proceed toward the spinous process of T12 vertebra. Thus the parietal pleura gener-ally extends approximately two ribs inferior to the lung.

The oblique fissure of the lungs extends from the level of the spi-

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nous process of T2 vertebra posteriorly to the 6th costal cartilage anteriorly, which coincides approximately with the medial border of the scapula when the upper limb is elevated above the head (causing the inferior angle to rotate laterally). The horizontal fis-sure of the right lung extends from the oblique fissure along the 4th rib and costal cartilage anteriorly.

Figure SA1.6

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chest pain - الرئيسية...1 chest pain although chest pain can result from pulmonary disease,...

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