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Paul W. Furlow and also Douglas J. Mathisen
Corresponding author.

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Anatomy as the structure of surgical treatment is a principle no far better exemplified than by the history of tracheal surgery. Incremental developments in our expertise of the trachea’s position, structure, blood supply and adjacent organs each enabled for stepwise enhancements in the thoracic surgeon’s capacity to address upper airway disease. Together such, the mastery of tracheal anatomy is basic to those clinicians responsible for dealing with such ailments. In this article, tracheal anatomy is reviewed and points crucial to the thoracic surgeon room highlighted. The structure and also location that the trachea, the blood supply to the trachea, and the trachea’s spatial partnership to vital mediastinal organs room presented. This material gives the groundwork for understanding all facets of tracheal surgical procedure today.


Introduction

The surgeon’s mastery that anatomy is paramount to performing a successful procedure and, thus, to enhancing the life the the patient. This, however, does not just entail the memorization of structures and their location in two-dimensions. The practicing operated doctor must know the relationship between structures in real an are and anticipate typical variations in those structures at the moment of dissection (1). Surgical anatomy likewise respects the biological and duty of structures in the operative field, appreciates the results of transforming the setup of those structures, and also must account because that the distorting result of pathology top top a framework or a bordering structure. For the tracheal surgeon, these principles certainly hold true, together airway complications can be extremely morbid and also quickly fatal.


Structure of the trachea

The trachea is a conduit in between the exterior world and the parenchyma of the lungs. Oxygen from the environment travels to the lungs during inspiration and carbon dioxide is ventilated indigenous the lung to the atmosphere throughout expiration. The trachea is a cartilaginous tubular structure connecting the larynx superiorly and the main bronchi inferiorly (Figure 1) (2). The reduced edge that the cricoid cartilage specifies the beginning of the trachea. The end of the trachea is significant by the carina, the steep-angled take off of the right key bronchus, and the take turn off of the an ext horizontal left main bronchus. The carina is usually uncovered at the level that the T4 vertebral body however its vertical place in the mediastinum changes with the phases of respiration. ~ above average, the size of the trachea is 11.8 cm through a normal variety of 10 come 13 cm in males. The trachea often tends to be shorter in females.



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Figure 1

Structure of the trachea. Anterior view.


In the adult, the trachea sit anteriorly in the neck and also dives posteriorly in the mediastinum as it travels towards the carina. This edge of lower is much more acute in children and also tends come become much more horizontal with age due to kyphotic transforms in the spine and tethering the the left key stem bronchus under the aortic arch. This age-related change needs to be thought about when assessing and positioning a patient because that tracheostomy placement, in elderly patients the size of the trachea in the neck has tendency to remain constant with cervical extension, this contrasts with younger patients because that whom it tends to lengthen.

The scaffolding that the trachea is consisted of of 18 to 22 D-shaped “rings” through anterior and lateral walls made the C-shaped cartilage and a posterior membranous wall surface connecting the arms of the C (Figure 2). The trachealis muscle runs longitudinally ~ above the posterior element of this wall and abuts the anterior esophagus. One intercartilaginous membrane connect the inferior edge the the upper cartilage come the superior edge that the cartilage below. Over there are approximately two ring of cartilage per centimeter the trachea and also each tracheal ring is an typical of 4 mm in height. The wall of the trachea averages around 3 mm in thickness. The average external diameter the the trachea is 2.3 and 1.8 centimeter in the coronal and sagittal dimensions, respectively.



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Figure 2

Relationship in between the trachea and also esophagus highlighting the segmental tracheal blood supply.


At birth, the cross-sectional form of the tracheal lumen is circular. Together a child grows right into an adult, the lumen most commonly takes on one ovoid form, despite a persistent circular form is a regular adult variant. The luminal diameter that the trachea varies v alterations in intraluminal pressure occurring during regular respiration, ventilation and Valsalva maneuvers. Sneeze narrows the lumen by bring about the trachealis muscle that the posterior wall to pull the cartilaginous C-arms together. With age or obstructive airway disease, the lateral diameter that the lumen has tendency to narrow, if the anteroposterior (AP) diameter increases, resulting in the “saber sheath” trachea. The wall surfaces of this tracheal formation may exhibit wall surface calcification. Ring softening in chronic obstructive pulmonary an illness results in AP narrowing the the lumen in the setup of posterior wall thickening. This can reason luminal obstruction during expiration or coughing.

The luminal mucosa the the trachea is inside wall by ciliated pseudostratified columnar epithelium include mucous producing goblet cells. The mucosa likewise harbors ducts that attach mucous glands in the submucosa come the surface of the tracheal lumen. The surface ar mucous and also cilia action in cooperation to trap and also expel particulates or microbe that get in the airway. Airborne irritants deserve to temporarily or permanently damage this mucociliary escalator. Irreversible cigarette smokers, because that example, have actually increased mucous production and defective ciliary function, making castle dependent ~ above an reliable cough to clear their airways.


Blood supply to the trachea

Safe and successful tracheal dissection requirements a in-depth understanding that tracheal blood supply to prevent the sequelae of tracheal ischemia (e.g., tracheal stenosis and anastomotic breakdown). A an essential principle that the airway operated doctor must always bear in mind is that the arteries feeding the trachea method the tracheal wall laterally and also vascularize the trachea in a segmental fashion follow me its longitudinal access (Figure 2). As the various segmental arteries giving the trachea approach the lateral tracheal wall, castle branch superiorly and also inferiorly in a longitudinal fashion forming anastomoses v the segmental arteries over and below. In ~ the intercartilaginous ligaments the tracheal arteries again branch into anterior and posterior branches that travel circumferentially within the tracheal wall surface where they anastomose through the corresponding tracheal arteries from the contralateral side. This segmental arrangement of blood flow limits circumferential tracheal dissection to no an ext than 1–2 centimeter on either side of a tracheal anastomosis due to the danger of devascularization and ischemia with bigger dissections.

The arterial it is provided of the trachea divides it right into the upper (cervical) and lower (thoracic) trachea. The tracheoesophageal branches of the worse thyroid arteries bring blood to the cervical trachea native the right and also left thyrocervical trunks the branch turn off the subclavian arteries (Figure 3). While the configuration of the branches might vary slightly between individuals, in general, the first tracheoesophageal branch supplies the reduced cervical trachea, the 2nd branch offers the center cervical trachea and also the third branch provides the upper cervical trachea. The exceptional thyroid artery walk not directly supply the trachea however forms one anastomosis through the worse thyroid artery wherein fine branches supply the thyroid isthmus and also the adjacent anterior tracheal wall.


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Figure 3

Blood supply to the trachea. (A) Left anterior oblique view; (B) ideal anterior oblique view.


The thoracic trachea and also carina obtain blood native the bronchial arteries occurring directly from the aorta (Figure 3). Most commonly, over there is a superior, middle and inferior bronchial arteries responsible for bringing blood to the trachea and carina. The superior bronchial artery comes off the anteromedial element of the descending thoracic aorta lateral to the carina and also posterior come the left key bronchus. The anterior branch courses over the proximal left main stem bronchus, i beg your pardon it offers on its method to offering blood come the anterior section of the carina. The principal and also posterior branches that the superior bronchial artery happen behind the posterior wall surface of the stomach to supply the proximal right main stem bronchus. Any variety of these branches might arise native an intercostal bronchial trunk. The center bronchial artery comes off the aorta distal to the superior bronchial artery and travels posterior to the medial facet of the left key stem bronchus to supply the carina together it anastomoses v the anterior branch of the exceptional bronchial artery or higher tracheoesophageal branches. The worse bronchial artery arises turn off the right posteromedial ascending thoracic aorta to it is provided the left key stem bronchus. Though the fads of bronchial artery branching are highly varied, approximately 40% of the time the left bronchial tree receive blood from 2 left-sided aortic branches and also the right main stem bronchus is provided by one right-sided aortic branch.


Structural relationships v the trachea

The right and left lobes the the thyroid gland sit anterolateral to the proximal cervical trachea and the isthmus connecting the 2 lobes tends to cross the anterior trachea in ~ the 2nd or 3rd tracheal ring (Figure 4). In enhancement to the proximal trachea, the inferior thyroid artery offers blood to the worse thyroid gland.


Critical mediastinal structures neighboring the trachea. Keep in mind the food of the vagus nerves and also the equivalent recurrent laryngeal nerves.


The esophagus has an intimate relationship with the trachea follow me its food (Figures 2 and also 3B​3B).). The esophagus starts at the level the the cricoid cartilage and also runs towards the gastroesophageal junction along the left posterior border that the trachea. Fibroelastic membranes and rare muscle yarn lie between the longitudinal muscle that the outer esophagus and also the trachealis muscle. The best posterior border the the trachea runs follow me the anterior aspect of the vertebral bodies. Occasionally, the esophagus might be found more laterally ~ above the left next making it vulnerable to injury during mediastinoscopy.

The right and also left vagus nerves travel distally v the neck in a place posterolateral come the corresponding usual carotid arteries (Figure 4). The right and also left recurrent laryngeal nerves room branches that the vagus nerves and role to innervate the true vocal cords. They enter the larynx in between the thyroid and also cricoid cartilages under the worse horn, or cornua, that the thyroid cartilage. The origin of the left recurrent laryngeal nerve occurs distal come the aortic arch when it climate dives and courses posteromedially just lateral to the ligamentum arteriosum, in ~ which suggest it recurs and also ascends toward the cricoid cartilage within the left tracheoesophageal groove. The ideal recurrent laryngeal nerve branches turn off the appropriate vagus nerve just distal come the right subclavian artery as soon as its course then dives posteromedially under the origin of the ideal subclavian where it recurs and also ascends toward the cricoid cartilage in the appropriate tracheoesophageal groove. A non-recurrent laryngeal nerve variant running from the vagus nerve in ~ the level the the thyroid cartilage straight to the larynx is seen in 0.5–0.7% that patients. Injury to the recurrent laryngeal nerves, whether by finish or partial transection, traction, contusion, thermal burn, ischemia or tumor invasion, can cause vocal cord paresis or paralysis bring about hoarseness or finish loss that voice or airway depending upon the extent of injury and the truth of the contralateral nerve. The thoracic surgeon should respect the food of this nerves during dissection of the proximal trachea.

There space a number of large blood ship lying in nearby proximity come the trachea that need to be respected throughout tracheal operations. The brachiocephalic, or innominate, artery is the very first branch the the aortic arch (Figure 4). It originates at the appropriate anterior facet of the trachea and also runs superiorly from left-to-right end the appropriate anterolateral part of the distal and mid trachea. The left usual carotid artery is the next branch the the aorta. The takes off simply to the left the the trachea’s midline and runs superiorly native right-to-left end the left anterolateral trachea. The exceptional vena cava courses towards the best atrium along the right anterior facet of the trachea (Figure 5). The azygous vein, coursing superiorly follow me the appropriate side that the thoracic vertebral column before bending anteriorly, join the remarkable vena cava lateral and also just exceptional to the right tracheobronchial angle. Treatment must be taken during mediastinoscopy to anticipate this landmark so regarding avoid mistaking the azygos vein for a lymph node throughout biopsy.


Large vessels intimately linked with the trachea. Right oblique view. Keep in mind the location and also course of the innominate artery, superior vena cava and azygos vein.


The key pulmonary artery, or pulmonary trunk, lies anterior and to the left that the carina (Figure 6). That branches, the right and also left pulmonary artery, operation laterally and also anterior to their equivalent main stem bronchi before branching right into the lobar arteries that the right and also left lungs. The positioning of the pulmonary arteries in connection to the main stem bronchi must be remembered once mobilization of the subcarinal and tracheobronchial lymph nodes is attempted throughout mediastinoscopy. Additionally, extreme traction top top the right-sided lower paratracheal nodes threats massive blood loss, together these nodes are in near proximity to the first branch that the appropriate pulmonary artery. A review of the local lymph node maps because that lung cancer screening is past the border of this article, but all thoracic operated doctor should know the crucial anatomic relationships and clinical significance of various node stations uncovered along the trachea, carina and also bronchi.


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Figure 6

Relationship in between the pulmonary vessels, the distal trachea and also the carina. Anterior view.

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This write-up provides a solid foundation in the anatomy the the trachea and also its partnership with vital mediastinal structures. A surgeon’s mastery that this product supports safe and effective operative planning and permits for the anticipation of typical anatomical variations, thereby reducing patient morbidity and also mortality in the operating room. In addition, the development of new surgical approaches that promise to enhance patient outcomes is dependent on a deep respect for the human anatomy.