Table of Contents
INTRODUCTION
The suprasternal notch, also known as the jugular notch, is a prominent anatomical feature located at the superior border of the manubrium of the sternum, between the clavicles. This anatomical landmark is crucial for various medical and clinical applications, serving as a reference point for procedures, imaging, and diagnosis. This article delves deeply into the anatomy, clinical significance, and applications of the suprasternal notch, supported by extensive research and studies.
Anatomy of the Suprasternal Notch
Location and Structure
The suprasternal notch is situated at the superior border of the sternum, also known as the manubrium, which is the upper part of the breastbone. It lies between the two clavicles and above the sternoclavicular joints. The notch is a shallow depression that can be easily palpated through the skin. Its anatomical position makes it a vital reference point for identifying other structures in the neck and thorax.
Surrounding Structures
Several important anatomical structures surround the suprasternal notch, including:
- Trachea: The windpipe, or trachea, lies just behind the suprasternal notch, making it an essential landmark for procedures involving the airway.
- Carotid Arteries: These major arteries run on either side of the trachea and can be palpated in the neck, using the suprasternal notch as a reference point.
- Jugular Veins: These veins are located on either side of the trachea and are significant in clinical procedures such as central venous catheterization.
- Thyroid Gland: The thyroid gland is situated in front of the trachea and just below the larynx, with the suprasternal notch acting as a helpful landmark for thyroid examinations.
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Palpation Technique
Palpating the suprasternal notch involves placing two fingers in the depression at the superior border of the sternum. This technique is commonly used in physical examinations to assess the position and integrity of the trachea, identify the presence of any abnormalities, and guide various medical procedures.
Historical Perspective and Anatomical Discovery
The suprasternal notch has been recognized as a significant anatomical landmark for centuries. Early anatomists and physicians identified this notch as a crucial reference point for various medical procedures. Ancient Greek and Roman medical texts often referenced the notch in descriptions of the human anatomy. Over time, its significance has only grown as medical science has advanced.
Evolution of Anatomical Understanding
The understanding of the suprasternal notch has evolved alongside advancements in medical imaging and surgical techniques. Early anatomists relied on dissection and surface anatomy to describe the notch, but modern imaging technologies such as ultrasound and MRI have provided more detailed insights into its structure and surrounding tissues.
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Clinical Significance
The suprasternal notch holds considerable clinical importance due to its strategic location and ease of palpation. It serves as a vital landmark in numerous medical disciplines, including anesthesiology, cardiology, emergency medicine, and pediatrics.
Airway Management
Predicting Difficult Tracheal Intubation
Nasr-Esfahani and Honarmand (2020) introduced the acromio-axillo-suprasternal notch index as a predictive tool for difficult tracheal intubation. This index utilizes the distance between the acromion, the axilla, and the suprasternal notch to assess the likelihood of encountering difficulties during intubation. This method provides a non-invasive, reliable way to anticipate challenges in airway management, particularly in patients with abnormal anatomical features.
| Technique | Description | Reference |
|---|---|---|
| Acromio-Axillo-Suprasternal Notch Index | A method to predict difficult tracheal intubation by measuring distances involving the SSN | Nasr-Esfahani & Honarmand (2020) |
| Endotracheal Tube Placement | Using the SSN as a landmark for confirming the position of the endotracheal tube tip | Murphy & O’Donnell (2017) |
| ProSeal Laryngeal Mask Positioning | Ensuring correct placement of the laryngeal mask by using the SSN test | O’Connor et al. (2002) |
Endotracheal Tube Placement
Accurate placement of the endotracheal tube is critical in ensuring proper ventilation and oxygenation during anesthesia and critical care. Murphy and O’Donnell (2017) explored the utility of the suprasternal notch as a surface landmark for confirming the position of the endotracheal tube tip in newborns. Their findings suggest that the SSN can reliably guide clinicians in ensuring proper tube placement, reducing the risk of complications associated with malposition.
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Cardiac Imaging
Suprasternal Notch Echocardiography
Suprasternal notch echocardiography (SNE) is a technique that uses the SSN as a window to visualize the aortic arch and related structures. Allen et al. (1977) and Snider and Silverman (1981) demonstrated the clinical utility of SNE in pediatric cardiology for diagnosing congenital heart diseases. This imaging technique provides a non-invasive method to assess the aortic arch, identify abnormalities, and monitor conditions over time.
Devauchelle et al. (2018) further highlighted the potential of SNE for measuring respiratory variation in aortic blood flow peak velocity in mechanically ventilated children. This method serves as an alternative to traditional imaging techniques, offering a quick and efficient way to gather critical information in pediatric patients.
Emergency Medicine
Cardiac Ultrasound
Focused cardiac ultrasound from the suprasternal notch view is an effective method for evaluating the aortic arch. Kinnaman et al. (2016) and Kinnaman et al. (2013) validated the accuracy of this approach, emphasizing its utility in emergency settings for rapid and non-invasive assessment of aortic arch dimensions. This technique is particularly valuable in diagnosing and managing conditions such as aortic dissection and aneurysm.
CPR Guidance
Kim et al. (2016) identified the SSN as a reliable landmark for determining the depth of chest compressions during cardiopulmonary resuscitation (CPR). Proper depth of chest compressions is crucial for effective CPR, and using the SSN as a reference point enhances the precision and effectiveness of this life-saving procedure.
Vascular and Thoracic Surgery
Anomalous Pulmonary Vein Connection
Shaikh et al. (2014) described a case where SSN imaging unveiled an anomalous connection of the left upper pulmonary vein to the vertical vein. This diagnostic insight underscores the SSN’s role in detecting vascular anomalies that may otherwise be overlooked. Identifying such anomalies is critical for planning surgical interventions and avoiding potential complications.
Thymectomy
Yoshimatsu et al. (1971) discussed the application of mediastinoscopy via the SSN for thymectomy procedures. This approach offers a less invasive alternative to traditional surgical techniques, facilitating access to the thymus. The SSN serves as a key entry point for the procedure, reducing the need for more extensive incisions and improving patient recovery times.
Comparative Anatomy
Suprasternal Notch in Other Species
The suprasternal notch is not unique to humans; it is also present in various other species, including primates and some mammals. Comparative anatomy studies have shown that while the notch’s size and shape may vary, its functional significance remains similar across species. In primates, for instance, the notch serves as a crucial landmark for respiratory and vascular structures.
Evolutionary Perspective
The presence of the suprasternal notch in different species suggests an evolutionary advantage. Its role in protecting vital structures such as the trachea and major blood vessels may have contributed to its persistence across evolutionary lines. Studying the notch in other species can provide valuable insights into its development and function in humans.
Research and Innovations
Mechano-Acoustic Sensing
Lee et al. (2020) introduced a novel soft wireless device placed at the SSN for mechano-acoustic sensing of physiological processes and body motions. This innovation demonstrates the SSN’s potential in advancing wearable technology for continuous health monitoring. The device can capture vital signs such as heart rate, respiratory rate, and body movements, providing real-time data for medical professionals and patients.
Point-of-Care Ultrasound
Uya et al. (2020) validated the use of point-of-care ultrasound at the sternal notch to confirm the depth of endotracheal tubes in children. This technique enhances the safety and accuracy of airway management in pediatric patients. By using the SSN as a reference point, clinicians can quickly and non-invasively verify tube placement, reducing the risk of complications and improving patient outcomes.
Future Innovations
The potential applications of the suprasternal notch continue to expand with advancements in technology. Future innovations may include more sophisticated wearable devices for health monitoring, improved imaging techniques for early diagnosis of diseases, and enhanced surgical procedures that minimize invasiveness and improve outcomes.
| Innovation | Description | Reference |
|---|---|---|
| Mechano-Acoustic Sensing Device | A soft wireless device placed at the SSN for continuous health monitoring | Lee et al. (2020) |
| Point-of-Care Ultrasound | Confirming the depth of endotracheal tubes in children using ultrasound at the SSN | Uya et al. (2020) |
| Wearable Health Monitoring | Future potential applications of the SSN in developing advanced wearable health monitoring devices | Future Innovations |
Pathological Insights
Tuberculosis
Moseme and Andronikou (2014) utilized point-of-care sonography through the SSN to diagnose tuberculous mediastinal lymphadenopathy in children. This non-invasive method provides a valuable diagnostic tool in regions with high tuberculosis prevalence. Early detection of lymphadenopathy is crucial for timely intervention and management of tuberculosis, particularly in pediatric populations.
Congenital Heart Disease
Enderlein et al. (1986) demonstrated the effectiveness of SSN echocardiography in diagnosing double aortic arch, a complex congenital heart defect. This technique offers a non-invasive means to identify and evaluate such conditions. Accurate diagnosis of congenital heart defects is essential for planning appropriate surgical and medical interventions.
Mediastinal Lesions
Neuberger et al. (2022) reported on isolated lesions of the SSN in pediatric patients, highlighting the importance of this landmark in identifying and managing rare pathologies. These findings emphasize the need for thorough examination of the SSN region in cases of unexplained symptoms or abnormal findings in pediatric patients.
Suprasternal Abscesses
Khalil et al. (2000) reported on cases of suprasternal notch tuberculous abscesses, emphasizing the significance of recognizing and treating this rare condition. The SSN’s location makes it susceptible to certain infections that can lead to abscess formation. Prompt diagnosis and treatment are crucial to prevent complications.
Cosmetic and Reconstructive Surgery
O’Dey et al. (2011) examined the SSN to nipple distance (SSN) as a factor in vascular complications of the nipple areola complex during superior pedicle vertical technique breast surgeries. Understanding this distance helps mitigate risks and improve surgical outcomes. By considering the SSNdistance, surgeons can optimize the placement of incisions and preserve blood supply to the nipple areola complex.
Importance in Plastic Surgery
In plastic and reconstructive surgery, the SSN serves as a key landmark for procedures involving the chest and neck. Accurate measurement and consideration of the SSN can enhance the aesthetic and functional results of surgeries such as breast augmentation, neck lifts, and corrective procedures for congenital deformities.
Summary of Clinical Applications
The table below summarizes the various clinical applications of the suprasternal notch, highlighting its significance across multiple medical disciplines.
| Application | Description | Reference |
|---|---|---|
| Airway Management | Predicting difficult intubation and confirming endotracheal tube placement | Nasr-Esfahani & Honarmand (2020), Murphy & O’Donnell (2017) |
| Cardiac Imaging | Visualizing aortic arch and diagnosing congenital heart disease | Allen et al. (1977), Snider & Silverman (1981), Devauchelle et al. (2018) |
| Emergency Medicine | Evaluating aortic arch with focused cardiac ultrasound and guiding CPR chest compressions | Kinnaman et al. (2016, 2013), Kim et al. (2016) |
| Vascular and Thoracic Surgery | Detecting vascular anomalies and facilitating thymectomy | Shaikh et al. (2014), Yoshimatsu et al. (1971) |
| Research and Innovations | Developing wearable health monitoring devices and confirming endotracheal tube depth | Lee et al. (2020), Uya et al. (2020) |
| Pathological Insights | Diagnosing tuberculosis and congenital heart disease | Moseme & Andronikou (2014), Enderlein et al. (1986) |
| Procedural Techniques | Ensuring correct laryngeal mask placement and avoiding neurosurgical complications | O’Connor et al. (2002), Akram et al. (2015) |
| Cosmetic and Reconstructive Surgery | Mitigating vascular complications in breast surgery | O’Dey et al. (2011) |
Conclusion
The suprasternal notch is a vital anatomical landmark with wide-ranging applications in medicine. Its significance spans from airway management and cardiac imaging to emergency medicine and surgical procedures. Ongoing research and technological advancements continue to uncover new uses for this critical reference point, enhancing patient care and procedural outcomes across various medical fields.
References
- Nasr-Esfahani, M., & Honarmand, A. (2020). How to predict difficult tracheal intubation: The application of acromio-axillo-suprasternal notch index. Advanced Biomedical, 16(7), 19.
- Murphy, M. C., & O’Donnell, C. P. F. (2017).The suprasternal notch: a surface landmark for endotracheal tube tip position in newborns? Archives of Disease in Childhood-Fetal and Neonatal Edition, 102(4), F371-F375.
- Allen, H. D., Goldberg, S. J., Sahn, D. J., & Ovitt, T. W. (1977). Suprasternal notch echocardiography: Assessment of its clinical utility in pediatric cardiology. Circulation, 55(4), 605-611.
- Snider, A. R., & Silverman, N. H. (1981).Suprasternal notch echocardiography: a two-dimensional technique for evaluating congenital heart disease. Circulation, 63(1), 165-170.
- Devauchelle, P., de Queiroz Siqueira, M., & Lilot, M. (2018). Suprasternal notch echocardiography: a potential alternative for the measurement of respiratory variation in aortic blood flow peak velocity in mechanically ventilated children. Journal of Clinical Monitoring and Computing, 32(1), 15-22.
- Kinnaman, K. A., Kimberly, H. H., Pivetta, E., & Platz, E. (2016). Evaluation of the aortic arch from the suprasternal notch view using focused cardiac ultrasound. The Journal of Emergency Medicine, 51(3), 295-303.
- Kinnaman, K. A., Rempell, J. S., Kimberly, H. H., & Platz, E. (2013). Accuracy of suprasternal notch view using focused cardiac ultrasound to evaluate aortic arch measurements. Annals of Emergency Medicine, 61(3), 337-343.
- Kim, T. H., Lee, S. H., Kim, D. H., Lee, R. K., & Kim, S. Y. (2016). The suprasternal notch as a landmark of chest compression depth in CPR. The American Journal of Emergency Medicine, 34(5), 901-906.
- Shaikh, A., Agarwal, A., Treiber, S., & Agarwal, A. (2014).Anomalous connection of the left upper pulmonary vein to the vertical vein: an uncommon diagnosis unveiled by suprasternal notch imaging. European Heart Journal-Cardiovascular Imaging, 15(12), 1385-1387.
- Yoshimatsu, H., Ikeda, T., Tsuchiya, M., & Ikeda, H. (1971).Mediastinoscopy and its application: Thymectomy via the suprasternal notch. The Keio Journal of Medicine, 20(1-2), 29-37.
- Lee, K. H., Ni, X., Lee, J. Y., Arafa, H., Pe, D. J., & Xu, S. (2020). Mechano-acoustic sensing of physiological processes and body motions via a soft wireless device placed at the suprasternal notch. Nature Biomedical Engineering, 4(5), 420-431.
- Uya, A., Gautam, N. K., & Rafique, M. B. (2020). Point-of-care ultrasound in sternal notch confirms depth of endotracheal tube in children. Pediatric Critical Care Medicine, 21(7), 352-358.
- Moseme, T., & Andronikou, S. (2014). Through the eye of the suprasternal notch: point-of-care sonography for tuberculous mediastinal lymphadenopathy in children. Pediatric Radiology, 44(3), 317-324.
- Enderlein, M. A., Silverman, N. H., Stanger, P., & Kovanen, C. (1986).Usefulness of suprasternal notch echocardiography for diagnosis of double aortic arch. The American Journal of Cardiology, 57(4), 462-465.
- Neuberger, I., Tutman, J. J., White, C. J., & Mirsky, D. M. (2022).Isolated lesions of the suprasternal notch in pediatric patients. Pediatric Radiology, 52(5), 762-767.
- O’Connor, C. J. Jr., Borromeo, C. J., & Stix, M. S. (2002).Assessing ProSeal laryngeal mask positioning: the suprasternal notch test. Anesthesia & Analgesia, 94(5), 1390-1392.
- Akram, H., Limousin, P., Hyam, J., & Hariz, M. I. (2015). Aim for the suprasternal notch: technical note to avoid bowstringing after deep brain stimulation. Stereotactic and Functional Neurosurgery, 93(4), 227-230.
- O’Dey, D. M., Baltes, P., Bozkurt, A., & Pallua, N. (2011). Importance of the suprasternal notch to nipple distance (SSN: N) for vascular complications of the nipple areola complex (NAC) in the superior pedicle vertical technique. Journal of Plastic, Reconstructive & Aesthetic Surgery, 64(6), 743-750.
- Khalil, E. A. G., Elsiddig, K. E., Elsafi, M., El-Hag, I. A., & El-Tayeb, O. (2000). Supra-sternal notch tuberculous abscess: a report of three cases. Transactions of the Royal Society of Tropical Medicine and Hygiene, 94(2), 180-182.
