The pleural dome (cupula) is the most superior extent of the pleural cavity, projecting 2-3 cm above the medial end of the first rib and clavicle into the root of the neck. It is protected by Sibson's fascia (suprapleural membrane) and is adjacent to the subclavian vessels, brachial plexus, and the stellate ganglion.
The pleural dome is at risk in supraclavicular approaches to the brachial plexus and during first rib resection for thoracic outlet syndrome, where pneumothorax is a recognised complication. Apical lung tumours (Pancoast tumours) invade the pleural dome to reach the brachial plexus, subclavian vessels, and stellate ganglion, producing Pancoast syndrome. Stellate ganglion block and cervical sympathectomy are performed adjacent to the pleural dome.
Inadvertent entry into the pleural dome during brachial plexus surgery or subclavian vessel repair producing pneumothorax, identified by sudden respiratory distress and confirmed by post-operative chest X-ray.
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