Chest radiology 1__________________________________________________________________________________ Normal Chest Oblique views : retrocardiac area, post. costophernic angles & chest walls. AP view : ribs are projected over different areas of lung from those of PA + post chest wall is shown. Appicogram: A.Apical view : Pt leans back, AP projection & tube angled 50-60 upward (projection of clavicles up). B.Lordotic view : PA view, Pt leans back, (project clavicles,also done in cases of middle lobe collapse. Paired :Insp. & exp. film. 1. Demonstrates air trapping 2. Diaphragm movement. 3. Small pneumothorax. 4. Interstitial shadowing. Penetrated film : 1. To show the hidden areas. 2. Demonstration of rib destruction. 3. Cavitation or calcification. 4. Air bronchogram demonstration. Comment on plain film: I. Posteroanterior view : 1. Criteria of good quality film: Centralization: med ends of clavicles = distance from spine t4 Full inspiration: ant 6th rib, post 10th rib . Penetration: bodies, discs just visible through cord shadow upper 3rd only. 2. Trachea : Examined for (narrowing, displacement, intraluminal lesion). Normally, it is midline in its upper part, then deviates slightly to the right around the aortic knuckle. NB: *Right paratracheal strip: - On the right side, the tracheal margin can be traced down to the right main Chest radiology 2 __________________________________________________________________________________ bronchus. It is present on 60% of films. Normally, it measures less than 5 mm. Widening occurs with (tracheal malignancy, mediastinal tumors, pleur.effusion) Azygus vein : -Lies in the angle between the right main bronchus and trachea. -Enlarged in (supine position, portal hypertension, I.V.C & S.V.C obstruction, constrictive pericarditis). - On erect film, should be < 10mm. Carinal angle on inspiration is 60-75 degree. Pathologically enlarged in a. Enlarged left atrium. b. Enlarged carinal L.N. Subpulmn. pleural effusion : 1. Erect PA : elevation of diaphragm & the apex of effusion has a more lat. position 2. Supine film : - Opaque hemithorax with decrease visualization of pulm vs. - Blunt costophrenic angle. - Apical cap. - Loss of diaphragm out line 3. Decubitus view with horizontal beam : fluid level along the affected side. 3. Heart and mediastinum : comment on size, shape, and displacement. 4. Diaphragm : -Outline, shape, position. -The right hemidiaphragm is higher than left (due to heart pushing on the left side and not due to liver elevating the Rt), a difference greater than 3cm is significant. The right hemidiaphragm can be traced from anterior to posterior on the lateral film, while the left cannot. -Loss of outlines means that the adjacent lung contains no air. -On inspiration, the domes are at level of : * 6th rib anteriorly * below or at 10th rib posteriorly. . 5. Pleura : -Position of horizontal fissure. (The horizontal fissure runs from the hilum to region of 6th rib). -Costophrenic and cardiophrenic angles. On lateral film : The horizontal fissure runs anteriorly. Both oblique fissures, start posteriorly at the level of T4 or T5, passing through hilum. - The left fissure finishes 5cm behind the anterior costophrenic angle, the right ends Chest radiology 3 __________________________________________________________________________________ * Ant junctioned line: is where the lungs meet anterior to the ascending aorta. It is only 1 mm thick (from below suprasternal notch). * Post junctional line : is where the lungs meet posteriorly behind the esophagus. It is 2mm thick (from lung apex to level of knuckle). * Thymus : both borders may be wavy (sign of Mulvey) dt costal cartilage indentation. It is sail shaped, right border more straight male >female. * Main fissures : (tangential x-ray beam) 1. PA : horizontal fissure runs from hilum to 6th rib in axillary lines may be slight down curve. 2. Lat : All fissures : oblique fissures commence post from D4 or D5 passing through ! hilum, ! left is steeper & finishes 5cm behind ! ant costophrenic angle. * Accessory fissures : 1. Azygous fissure : comma shaped, base & nearly always rt sided (failed azygous v. to migrate). Left side hemiazygous vein. 2. Superior accessory fissure : separates !apical from basal segments of lower lobes. 3. Inferior accessory fissure : separates ! medial basal from the other basal segments (from cardio phrenic angle). 4. Left sided horizontal fissure : separates lingula from other upper lobe segments. Hidden areas : 1. Apices: appicogram. 2. Mediastinum and Hila: lateral film (for central lesions). 3. Diaphragms: post.& lat. basal segments of lower lobes & ! post. sulcus are partially observed. 4. Bones: AP, expiratory film & obliques - Tomography. 6. Lung fields : Hidden areas :(apices, diaphragm, mediastinum, hilae and bones). 7. Hilum : Shape, position, density : -Normally the left hilum is 1/2-1cm higher than right (because left pulm.a. lies above the left main bronchus before passing post.) -They should be of equal density and size with concave lateral borders. -Only the pulmonary arteries and upper lobe veins significantly contribute to hilar 2. * Local (bronchiectasis. Do not follow the bronchi. nodes : along main bronchi. appear as multiple small nodules around hilum.near RLN). lie around lower descending aorta & lower oesoph. b. 8. Intrapulmn. drain into. 3. Pulmonary segments & bronchi : Lymph nodes : * Intrapulmn lymphatics drain to bronchopulmn node (1st group involved by spread from a periph. Cause of enlargement : * General (congestive cyanotic heart disease). Less defined and larger. Paratracheal 4. while the veins : a. 5.Chest radiology 4 __________________________________________________________________________________ shadows. . d. lt ht. mediastinal nodes: (drain thymus & Rt heart .in region of aortic arch. -The pulmonary arteries accompanying the bronchi.( They follow (drain via) interlobular septa) * Upper lobe bronchus may appear as a ring shadow adjacent to upper outer hilum. Ant. bronchi. c. -Enlarged bronchial arteries. Carinal c. primary carcinoma). the lower lobe vessels are larger than the upper lobe vessels as the perfusion and areation of the upper zones are reduced. lower trachea & visceral pleura) a. and 9-15mm in females. Bronchopulmn (hilar). b.drain soft tissue & parietal pleura (also intercostal region). Have fewer branches. -The arteries arise from ventral surface of the descending aorta at the level T5-T6. Tracheo bronchial (Rt . -The maximum diameter of normal descending branch of the right pulmonary artery is 10-16mm in males.). -In erect position.adjacent to azygous . tumor). * Mediastinal Lns (may be involved by tumors above or below the diaphragm). 1. Lt . Middle mediastinal nodes (lung. Parietal nodes: (ant & post behind sternum) . Bronchial vessels : -Normally not visualized on film. Post mediastinal nodes : drain post diaphragm & lower oesophag. Poland syndrome (cong absent pectoral ms). Normal bronchi are not visualized in periph lung zones. spines). Others : -Fissures (displacement. the right lies and in front. scapula. 11. -Normally. calcification) -Chialiditis syndrome : Interposition of bowel between liver and diaphragm (often transient). nipple shadows. loculated interlobar effusion). 4. consolidation). -When filled with fluid. 5. Diaphragm outlines : -Loss of the outline (pleural effusion. 13. 12. Pulmonary arteries : -The left pulmonary artery lies above& posterior to end on carina. The canals of lambert exist between bronchioles and alveoli. Para Vertebral mass). thickening. ribs. Bones : (Clavicles. Lateral Film : Comment on the following : 1. 3. 2. retrocardiac). connect the alveoli.Chest radiology 5 __________________________________________________________________________________ 9. segments not separated by pleura. 10. Soft tissue : -Mastectomy. II. . Loss of this translucency (Posterior basal consolidation. -Companion shadows : 2-3 mm thick // to upper clavicles & inf border of ribs. the retrosternal space measures less than 3cm at its widest point. The clear spaces: (retrosternal. it is seen as a 5mm shadow = acinar or alveolar shadowing. -Is that portion of lung which arises from the terminal bronchiole. Acinus : (functioning lung unit). Vertebral translucency : -The vertebral bodies become progressively more translucent caudally. Pulmonary segments and bronchi (see Sutton) -Pulm. Below diaphragm : (Gas shadow. -The pores of Koha. non branching lines radiating from the hilum (2-5cm in length.g. 5. * Obliteration of the aortic knuckle is a feature of disease in apico-posterior . DD: blood vessels).Pulmonary edema.Lymphoma. Blues. the lesion must be either anterior or posterior e. -Formed by thickened interlobular septa (in lat film seen behind ! sternum () = D lines.Interstitial fibrosis.Chest radiology 6 __________________________________________________________________________________ Differential Diagnosis Krley’s Lines : 1. -If air is displaced.Pneumoconiosis. 2. thick deep intercommunicating lymphatics. 3. 6. 7.Mitral valve disease. the adjacent borders are obliterated where the lesion is located. 4.Alveolar cell carcinoma.Lymphangitis carcinomatosa unilateral kerly. -Seen at the base of the lung lying perpendicular to ! pleura (in costophrenic angle). A-lines : Thin. Silhouette Sign : -It permits localization of the lesion on the PA view by studying the mediastinal and diaphragmatic outlines. 8. B-lines : -Transverse. conversely if the border is retained and the abnormality is superimposed. 1. 2.: * Lesions of the middle lobe (rt) and lingula (lt) affect the right and left cardiac border. 3. thin line of 1-3cm. *Causes of visualization : (Lymphatic obst).Sarcoidosis. -These outlines are visualized because the adjacent alveoli are aerated. C-lines : A spider’s web appearance : interlacing lymphatics. Consolidation (Pneumonia. when a homogenous shadow spreads.Chest radiology 7 __________________________________________________________________________________ segment of upper lobe (left). collapse. Alveolar or acinar shadowing : -Fluid filled acinus that forms (4-10) 7mm shadow. rapidly coalesce into fluffy. TB). 2. Cardiomegaly hilum is displaced. 7. infarction.M. NB: *Air bronchogram and silhouette signs are characteristic features. . *Causes : 1. * A well defined mass seen above the clavicle is always posterior. Shadowing: alveolar(acinar). when air is displaced from the surrounding alveoli (parenchyma). H. Pulmonary edema. * It may be present in consolidation distal to a malignancy if the bronchus remains patent. The bronchus if air filled and not fluid filled becomes visible. 3. Alveolar cell carcinoma. 5. N.B: * An air bronchogram does not occur within pleural fluid or solid tumor. The Hilum Overlap sign : Helps to distinguish a larger heart from a mediastinal mass : A mediastinal mass hilum is seen through mass.D = Hyaline membrane disease. Adult respiratory distress syndrome.(peripheral lung field spared. Pulm hge. 6. Sarcoidosis. ill defined cotton wool shadows and homogenous mostly non segmental. Air bronchogram : An important sign.translucent rim. Lymphona.or interstitial. butterfly). 4. *Pulmn. commonly due to cardiac failure and clears quickly after treatment. -A ground glass appearance or a generalized homogenous haze seen with alveolar shadowing may have a bat’s wing distribution. from hilae with a periph. 3. -Good pasture’s syndrome. Causes of Consolidation = Air bronchogram = alveolar shadows : -Consolidation pneumonia. Pneumonia : -Localized : (pneumococcus). . -Infarction. parasites). 2.D -Aspiration pneumonia. hypoalbuminaemia. -Sarcoidosis.Chest radiology 8 __________________________________________________________________________________ Causes : 1.M. -Lymphom -HMD. -Alveolar cell carcinoma.g. Miscellaneous : -Radiation pneumonitis. Neonatal : -H. 6. -Haematogenous metastasis (e. -Generalized (fungi. -Hge -Alveolar cell ca. Pulmonary edema : -Cardiac pulmn edema. Tumors : -Lymphoma. 4. choriocarcinoma) 5. hematoma. Alveolar blood : -Pulmonary infarction. leukemia. -Non cardiac (Uremia. ARDS Interstitial Shadowing : -Thickening of parenchymal perivascular tissue. TB -Pulm edema. fluid overload). Miscellaneous: -Fibrosing alveolitis.Nodosa.L. -Extrinsic allergic alveolitis. 6. -Collagen . E.E. H. of high density : 1. Collagen diseases : S. F. P. B. scleroderma. . parasitic .Histocytosis -fibrosing -cardiac LHF -Asbestosis. silicosis. Rh arthritis. Cardiac : Left heart failure. fungi. 3. Alveolar microlithiasis. viral. IPF == Interstitial shadows -Ext . viral. lymphangitis carcinomatosa.Sarcoidosis. -Kerley’s lines and honeycomb shadowing may be present. haemosiderosis. -Bronchiectasis. thyroid. Tin or barium inhalation.. Pneumoconiosis 5. Mycoplasma. -Neurofibromatosis. TB. Sarcoidosis 4. Infection : TB. Haemosiderosis.A. lymphangitis carcinomatosa Causes of Miliary Shadowing : (multiple opacities (1/2-2mm) A. of soft tissue density : 1. Neoplasm : Lymphoma.Tuberous sclerosis . Honey comb shadowing. -ARDS -infection TB. -Sarcoidosis. Histoplasmosis B. Calcification (TB).D 2.Chest radiology 9 __________________________________________________________________________________ -Radiologically appears as (reticular.Neurofibromatosis. . ground glass shadowing). D. fungal. -Loss of volume may occur as a result of fibrosis. Metastasis (renal.M.Bronchiectasis . 4. reticulonodular.allergic Drugs . C. Honey comb shadowing : 2. leukemia. nodular 2-3mm. trophoblastic).Neoplasm lymphoma. Causes of diffuse interstitial shadowing : A. 3. -Silicosis . -Secondary: (cannon ball metastasis) “very large”. Histocystosis. when these cysts are 5-10 mm = honey comb shadowing./ Sarcoidosis -Histoplasmosis. 3-Granuloma : -TB.Congenital polycystic lung Solitary pulmonary nodule : 1-Malignant tumors : -Bronchial carcinoma.Bronchiectasis + IPF = Honey comb . 4-Infections :: -Pneumonia. NB: Nodular form of Fungus: Histoplasmosis. staph) -Hydatid. Sarcoidosis. 6. -Calcified metastasis (osteo and chondrosarcoma) -Lymphoma.Chest radiology 10 __________________________________________________________________________________ -Interstitial lung disease parenchymal destruction formation of thin wall cysts. Biliary cirrhosis. 1. -Mycetoma : fungal ball. 8. 3. Neurofibromatosis. Extrinsic allergic alveolitis (upper zone). -Abscess( Klebseilla. NB: . Collagen disorders (seleroderma. Causes of honey comb shadowing :(= Causes of interstitial fibrosis + Bronchiectasis). 4. rheumatoid) mostly basal. 7.. 2. Mycetoma . Actinomycosis. 5. -It is associated with increased risk of pneumothorax. Coccidomycosis. Pneumoconiosis . 2-Benign tumors : -Hamartoma (90% peripheral) -Adenoma. -Plasma cytoma. Bronchiectasis (similar appearance). . -Bone lesion -Pleura (encysted effusion. . .Chest radiology 11 __________________________________________________________________________________ (Aspergillosis) 5-Vascular : -Pulmonary infarction.Malignant tumors thick irregular wall with eccentric cavitation. cell carcinoma.Aspiration abscess mostly right side. Arthritis. *Extrapulmonary & mediastinal masses form obtuse angles. -cavitary sq. lower zone. . -Bronchogenic cyst. -simple lung abscess. 9-Non Pulmonary : -Skin lesion (lateral film helps to distinguish extra pulm masses:* Intrapulmonary mass has acute angles with lung edge.Pulmonary infarction commonly lower zones. Intracavitary bodies : -Aspergillesis : mycetoma. 8-Congenital : -Sequestrated segment. 7-Sarcoidosis. -AVM. infraclavicular. clot in cavity. *Comment on wall pattern : . Cavitation : -Radiologically : A cavity is a translucency within the lung parenchyma surrounded by a complete wall (thick : 3mm or more) *Sites of predilection for certain pathologies : -TB mostly upper lung zone.Sequestrated segment left sided. -Lung gangrene bl. 6-Collagen disease -Rh. -Hematoma. . plaque) -Artifacts. *Comment on presence of fluid level.Amoebic abscess always in the right lower zone. -Hydatid : disintegrated. Aspiration abscess D. Chest wall infection. Causes of cavitation : (P77.Irregular masses of blood clots or necrotic tumor may be seen within cavity. Neop. Achalasia) 4. infarction.Lymphomas 5. NB: Cong. H.Acute abscess 2.Carcinoma 7.Traumatic lung cyst 6.Cystic Bronchiectasis 4.Pneumatoceles 3. *Comment on satellite lesions ? : Are common with TB. Mediastinal (infection.. Sarcoidosis.Rheumatoid nodule 3. fractures. bullae A. cell) 4. lung.Hydatid cyst 5. Pulm. Causes of fluid levels on chest Film: 1. Abscesses 2. Malignant : Primary. Lymphoma Thick wall cavity: 1. *Comment on surrounding lung tissue. E. Intrapulmonary cavitation 2. 6. Causes of multiple cavities : 1. Esophageal (pharyngeal pouch. Rheumatd nodules Thin wall cavity: 1. 2ry.Most neoplasma (usually sq. bronchogenic carc. Klebsiella (abscess).Wegener’s grannuloma 6. but cavitation occurred. Vasc. + bronchietasis. inflam/inf/grannuloma. Bullae.TB.thin wall.Bullae 2. sequst.Chest radiology 12 __________________________________________________________________________________ *Comment on content of cavity : . G. Amoebic. others.Most metastases 3. Pneumoconiosis : Caplan’s syndrome. 5.(commonest). Infection: Staph. Hydropneumothorax 3.. Hydatid. esophageal perforation). Fungal (aspergillosis). hematoma. trauma. aspiration).Chronic inactive TB cavity. Lymphoma. pneumatocele . C. Pneumopericardium (trauma. same reasons as solitary nodule. B. Cystic Bronchiectasis. . Metastasis 4. F. b.A. 2ry hyperparathy. c. vascular. Granuloma. Mediastinal : cardiac. 5.Histoplasmosis characterized by focal areas surrounded by small haloes. tumors. eventration.hamartoma (pop corn calcification). Alveolar microlithiasis: tiny sand like densities in mid and lower zone due to calcium phosphate deposits in the alveoli. * Blood clots occur with cavitating neoplasm.imp). histo. chondrosarcoma). Pleural : TB. blood clot & cavernoliths. commonly described with fungus balls such as aspergilloma. D.V. Chronic pulmonary venous hypertension mitral valve disease. Tumors: a. empyema. Chicken pox. 3.Myeloma. 7. * Meniscus sign is when intracavitary body is surrounded by crescent of air. 4. sarcoid. change position. tuberculosis & primary infarcts. asbestosis. * Other intracavitary lesions include inspissated pus. lymphoma after irradiation.Chronic abscess f. * Common in primary tumors. ! ball moves as : pt.Metastasis (osteo. Diaphragm hernia. old haemothorax.Chest radiology 13 __________________________________________________________________________________ 7. talc. foci are in upper zone.Actinomycosis. infections : a. scattered & of variable size. NB: * Ruptured hydatid cysts have daughter cysts floating within!cavity = water lily sign. B. Rare causes as: Sarcoidosis. infarction. rupture.Carcinoid T. Intrapulmonary : 1. d. & irregular masses. * Uncommon in cavitating metastases & TB cavities. e.Hydatid cyst rarely (fine rim of calcification in wall). c. Calcification : (low KVP) A.. Hematoma. .M. C. Silicosis (egg shell calcification). LN : TB.TB (commonest. silicosis. m. M. 6 Metastatic due to hypercalcaemia: Chronic renal failure. b. d. 2. Congenital lobar emphysema. scoliosis. parasites. Chest wall : bone. 4.Peripheral arterial pruning. *Cyst. Pulm A : Aneurysm. *Encysted pneumothorax. *Pneumatocele.. Compensatory emphysema. Rotation : (positional) 1. E. Pulmonary Asthma. thrombus. 3. Poliomyelitis (unilateral pectoral muscle affection). c. D.Large central pulmonary arteries.Bullae. P++. Obstructive emphysema. Acute bronchiolitis. *Emphysema. 2.Chest radiology 14 __________________________________________________________________________________ E. breast. 5. b. Chest wall : 1. Child (1st year of life). cartilage. Causes of unilateral hypertransradiant hemithorax : A. Poland’s syndrome (Unilateral absence of pectoral muscles + rib defect with syndactly) in 10% of patients. Unilateral bullae. Mastectomy. poor technique 2. 3. 2. Lung : 1. B. soft tiss. With over expansion of lungs : 1. . Chronic obstructive emphysema : a. C. 2. Macloed’s syndrome (the late sequalae of childhood bronchiolitis). DD: Localized transradiancy : *Bullae. Causes of bilateral hypertransradiant hemithoraces : A. Pleura : Pheumothorax. F. Pulmonary vessels : Pulmonary embolism of a major pulmonary artery at least lobar in size. 3. . Cong heart disease oligemia e. 3. may represent old pleural thickening. 2. Causes of apical shadows : 1. B.g Right to left shunt. Abscess (Staph. With mediastinal displacement towards dense hemithorax : 1.). Bronchial carcinoma. Pancost tumor. may present in 5% or population. bullae.Chest radiology 15 __________________________________________________________________________________ *Bronchial wall thickening. With mediastinal displacement away from dense hemithorax : 1.. Pleural caps: Unilateral or bilateral. post pneumonectomy 3. 4. 4. 3. Small or moderate pleural effusion. Increased density of a hemithorax : A. 1ry histoplasmosis IMN. 3. 3. Also technical ( Rotation. Consolidation. Pulmonary agenesis and hypoplasia herniation of the other lung across !midline. Lymphangitis carcinomatosa 4. *Collapse or consolidation are common.. 2ry pneumonias tumor Consolidation with bulging of fissures : 1. laryngeal or bilateral bronchial stenosis. 2. Primary pulmonary hypertension. 4. Primary pneumonia (TB. Multiple pulmonary embolism. Viral. Mesothelioma. crescent shaped. pueumothorax. Klebsiella). streptococcus pn. scoliosis) B. With normal or small lungs: 1. Bilharziasis. Large pleural effusion 2. Diaphragmatic hernia. 2. Pulmonary artery stenosis. 2. C. Pneumonia with an enlarged hilum : 1. Infection (klebsiella pn. 5. Collapse 2. With central mediastinum : 1. TB) 2. Mycoplasma. Tracheal. 4. hair). Nodal (lymphoma. Bilateral : 1. 5.Chest radiology 16 __________________________________________________________________________________ 4. peripheral pneumonia ?? I think central). Sarcoidosis.Unilateral : 1. histoplasmosis. carcinoma. 2. 3. sarcoidosis. Pleural fluid. 4. lymphoma. Mcleod. patches of consolidation + air bronchogram (well apparent). sarcoidosis. lobar collapse. amylodosis. Lymph nodes as in bronchial carcinoma. congenital heart disease. Causes of hilar enlargement : A. TB. Lymphoma following radiotherapy. companion shadows. 6. infection as 1ry TB. scleroderma. B. silicosis. cyanotic HD. 5. With no mediastinal shift : a. EGG Shell calcification of lymph nodes : 1. Hyaline memb. Coal miners pneumonia. unilat pul embolism and hypoplastic pulmonary-artery. Expiratory film. central pulm embolus. Normal in young women. scoliosis). Causes of small hilum: Unilateral: normal. mass. Bilateral. Others (mediast. larger opacities. 2. pneumoceniosis. Pulmonary artery (post stenotic dilation. histoplasmosis. embolus. 2. Pulmonary artery: pulmonary hypertension. 3. Radiation. Soft tissue (sternocliedomastoid. histoplasmosis and fungi). Pulmonary causes : 1. aneurysm). Neonatal respiratory distress : A. apparent. Infection (TB) + Apical fibrosis (TB. Silicosis. ankylosing). 3. Histocytosis & Histioplamosis. 4. actinomycosis. Apparent (rotation. Extrinsic allergic alveolitis. disease (ground glass appearance. Aspergillosis. . Transient tachypnea (wet lung disease). Complete collapse. Atelectasis (mostly misplaced endotracheal tube). Bulla : destruction of alveoli resulting in parenchymal air encystment. Hypoglycemia). D. lobar emphysema. a. To evaluate hilum & proximal airways. Value of tomography : 1. 3. To improve visualization of a lesion. 3. d. To localize & confirm an intrapulmonary lesion. drugs). 4. 2. Meconium aspiration syndrome. c. Cavity : Its wall is compressed tissues or fibrous tissue. Congenital. b. a. Cardiac causes. Abnormal thoracic cage osteogenesis imperfecta. With mediastinal shift away from abnormal side. E.M. 5. Cysts : has an epithelial wall and completely closed. Metabolic causes (Acidosis. Pneumonia . B.Chest radiology 17 __________________________________________________________________________________ b. Agenesis. c. Bleb : Air encysted related to pleura & completely closed → pneumothorax. Choanal atresia.g. hair line walled air cavity. Pleural effusion (rare) 3. Partial hyperinflation. f. Bronchocele. b. Pneumatocele : Thin.D e. Abdominal causes (Massive organomegaly e. polycystic kidney). Bronchiectasis. Pneumonitis abscess.Pulmonary hge resemble H. 2. C. With mediastinal shift towards the abnormal side. 2. Diaphragmatic hernia. . edema. Cerebral causes (Hge. Airway obstruction : 1. Chest Wall Comment on : A.g. 5.D. Metabolic Hyperparathyroidism C. Sceleroderma). . heart is displaced to the left & appears enlarged with straight left border. Absence outer end : (Cleidocranial dysostosis). Fractures. 2. Erosion (adjacent mediastianal mass anteriorly.Rheumatoid arthritis.Chest radiology 18 __________________________________________________________________________________ 4.L. Erosion : Outer or medial end : .E.: ant. metastases. 2. S. Ribs: Superior or inferior unilateral or bilateral. ribs are vertical & post ribs are horizontal.Osteogenesis impertecta. prominent lung markings (Rt paracardiac) misdiagnosed as consolidation). Ewing). To search for a suspected lesion e. C. Tumours (chondroma. B. Fracture. Clavical : 1. Developmental abnormality (depressed "pectus excavatum" sternum in cong.H.Neurofibromatosis. 4. . Connective tissue disease (Rh arthritis. To evaluate : mediastinum & chest wall. Miscellaneous : .Infection. . 3. Rib notching (superior surface) : A. . . 3.Hyperparathyroidism. Tumour (aneurysmal bone cyst. chontrosarcoma.Marfans’ syndrome. 4. infection). B. secondaries). Sternum : 1. Poliomyelitis .C. bifid). arises from C7 with the transverse process pointing caudally.Lower ribs not affected unless : lower abd aorta is affected. Rib notching (inferior surface): Occurs due to hypertrophy of the intevesselsor with neutumours. N.B. occlusion -Subclavian : Takayasu disease.Pathological fracture: senile osteoporosis. N. mammary artery 1st part of subclavian. myelofibrosis). DD: Hypoplastic 1st rib (arise from D1). & Post. -Venous : (S. .Chest radiology 19 __________________________________________________________________________________ . Fracture : .Fallot’s tetralogy. metastasis.C. ant.V. 1-2%. I.C. : When aorta is obstructed reversed blood flow : . . neurogenic tumour and idiopathic. cushing disease. Causes : -Aorta: coarctation. . bridging. .Cough fracture (6-9) ribs at axillary line.Preductal coarctation no rib notching. Generalized (osteo-petrosis. Cervical ribs : Rib anomalies (hypoplasia .1st and 2nd I. Localized (Paget disease)..3-12 posteriorly aorta.Old age. myleoma. .Stress fracture 1st rib.V. . Selerosis : A.B: Looser’s zone : areas of uncalcified osteoid tissue (osteomalacia): rib deformity creates . -Reduced pulm flow (oligemia): Pulmonary atresia or stenosis .Coarctation notching of 1st and 2nd ribs : not develop because of its origin from subclavian. obstruction) -Shunts : Pulmonary or intercostal AV fistula.3-12 anterior inter. (Blalock operation = pulm systmic shunt) -Others : Hyperparathyroidism. . B. costo-cervical trunk (2nd part of subclavian artery). Fibrous dysplasia. Thoracic spine : Comment on: 1. 4.Loss of normal thoracic kyphosis strenum parallel to spine compression of mediastinum.Rickets (widening of rib ends). Vascular tumours. destruction in infective process). D.Alignment. chondroma. Generalized : .Paget. paget's and metastasis. ankyloses.Paraspinal lines.Aneurysmal cyst. . Localised .Hurlur’s syndrome (generalized expansion sparing the proximal end). Gross enlargement of left atrium. 2-Sclerosis (single dense vertebra (ivory)= lymphoma. .Chest radiology 20 __________________________________________________________________________________ a bell shaped thorax.Thalassaemia (expansion more marked proximally + abnormal trabeculae) . Causes of anterior erosion of vertebral bodies : 1. . 3-Destruction (pedicle = metastases). Neurofibromatosis. disc spaces (calcification = post-traumatic. 3.prominent atrial appendage . ochronosis.Haemangioma. .In PA view : . Aneurysm of descending aorta. Expansion : a. 4. . 2.heart appears to be enlarged . . Straight back syndrome : .prominent aortic knuckle. b. .Eosinophillic granuloma. axillary folds and masses + Thyroid. .Left hemidiaphragm is elevated with mediastinal shift to the right. . a feature rarely seen with paralysis. C. .: These is no diaphragmatic defect).B. weak diaphragm). Eventration : . Diaphragmatic hump or dromedary diaphragm (severe form may appear as double contour in PA view N.Tumour of diaphragm : Lipomas . Skin lesion: lipoma may appear as pulmonary lesion.Subdiaphragmatic infection.Gastric tumour.. B. Scalloping (short curves of diaphragm.If more than 8mm pathological (may be due to) .Mainly left sided (thin.Subphremic lesion. Thickness of diaphragm : .May be associated with partial gastric volvulus. fibromas & cysts.On left side between fundus gas and left lung (normal average of 8mm) normal diaphragm 2-3 mm. normally the left hemidiaphragm move more than right by 3-6cm Paradoxical movement : (Moves up with inspiration) .. Breast. concave upward). . Diaphragmatic movement : On screen. .Reduced movement (seen under fluoroscopy) paradoxical movement or abscent.Eventration.Diaphragmatic paralysis. 2. lateral film confirms the diagnosis.neurofibrimas. Diaphragm Appearance . .Pleural effusion. convex upward). buttons. . 3. Surgical etmphysema.Chest radiology 21 __________________________________________________________________________________ Soft tissue of chest wall : A. artefacts: hair plaits. Hernia of diaphragm : . . Muscle slips (small curved lines. (normal variants) 1. . B. may be idiopathic.Plain film : 1. 4. idiopathic. surgery. surgical. 3. .Chest radiology 22 __________________________________________________________________________________ . . Subphrenic abscess : . Phrenic nerve palsy (bronchogenic carcinoma. . Pulmonary collapse. colon strangulation.Morgagni Rt side & anterior in cardiophrenic angle. DD : 1. kid. . . 2.More on Rt side easy diagnosed. Causes of unilateral elevated hemidiaphragm : A. 5.Usually congential→lt side→ respiratory distress . 4. Pulmonary infarction. . Upper motor neuron lesion hemiplegia. infection by gas forming org (Horizontal beam film). fat.No movement. Depression of liver edge or gastric fundus. Eventration (intact diaphragm) 2. DM. Causes below diaphragm : .Eventration.Central mediastinum.Hiatus hernia superimposed on cardiac shadow in PA.Trauma. Rupture of diaphragm : . HZ virus) ccc by: . Ipsilateral basal atelectasis & pleural effusion. trauma. 2. 3.Contain spleen.US & CT. TB glands.Smooth hemidiaphragm.Mainly on the left side herniation of stomach. from pleuro periteneal canal . radiotherapy. . Gas beneath diaphragm dt. Diaphragmatic causes of bilateral elevated hemidiaphragm : .Bochdalek → Postero lat. omentum or bowel. Causes above the diaphragm : 1. Elevated diaphragm with paradoxical or movement. Pneumothorax. C. empyema or thoracotomy). Pleural disease (old haemothorax. g. osteopetrosis. . Linear & band shadows : 1. . Subphenic abscess (bilateral). lymphangiona. HSM. . collagen.Chest radiology 23 __________________________________________________________________________________ . 2. Morgagni hernia. c. Ascitis..Notching →Sup → NF. enteric cyst. Pericordial cyst. f. Causes of bilateral elevated diaphragm : 1.Cervical rib & bifid. Plate atalectasis often post operatively. . . Obesity. Rib diseases : . operation.Subphrenic abscess. haemangisms. Kerley's B lines. teratodermoid.Expansion → Dysplasia fibrous Tumours ABC. →Inf.Fracture. hepatic abscess. Poor inspiratory effort. . 3. DD : hump in PA film appears as a shadow in Rt cardiophrenic angle: 1. 4.g. Mucus filled bronchi : gloved finger branching pattern (bronchoceles). 3. Paget. 3. Causes below diaphragm : a. pouches. aneurysm. . lymphona. Iatraobdominal mass. metastasis. DD: 1. Pulmonary infarcts 2.Bilateral basal pulmonary collapse. . NF. Ruptured diaphragm. 2. b. Pneumoperitoneum. pancreatitis. dis thalassemia Nutritional Rickets. 2. → coarctation.Destruction → MM. d. SVC obstruction. Blood. Fat pad. Causes above diaphragm : . HPT. metastasis. e. thymus.Sclerosis → Myelosclerosis.Small lungs e.Thryoid. 4. Superior medistinum mass : . neurogenic tumours. fibrosing alveolitis.N. Subpulmonary effusion. spinal Pott’s. L.Gaseous distension of stomach or splenic flexure. Pregnancy. Lipoma. . Old pleural & pulm. Normal fissures & vessels. sarcoid). malignancy.Chest radiology 24 __________________________________________________________________________________ 5. 9. 8. Curvilinear shadows : bullae. healed TB. Bronchial wall thickening. pulm aspergillosis. Sentinel lines (bronch. pneumatoceles.congenital membrane. benign tumors . scars (infarction. 7. 6. -No wheezes or eosinophillia. extensive air space filling acinar shadowing with coalescence. Damage to lung parenchyma : Extrinsic allergic alveolitis or hypersensitivity pneumonitis: A large variety of organic dust particles & microorganisms are small enough (1-2m. During acute attack : -May be normal. cotton dust inhalation. Between attacks (normal) : -In subacute phase: reticulonodular pattern (fine lines together with small nodules (1-3 mm). Air condition: fungal spores and drugs Clinically : -6 hours after exposure fever.: Disease due to inhalation of particular matters. B. chills. -In severe cases. Byssinosis.g. Damage to the tracheobronchial tree:Occupational asthma : -History of exposure to animal and fungal spores and in chemical industry e. A. -Has the same radiological picture of asthma during attack. Most of allergens are fungal spores and proteins. eg: Farmers lung. Radiologically : A. With repeated attacks : pulmonary fibrosis : Characterized by coarse lines particularly in mid and upper zones. C. cough. -Mainly shows ground glass appearance with loss of definition of pulmon.Chest 24 ____________________________________________________________________________ OCCUPATIONAL LUNG DISORDERS PNEUMOCONIOSIS Def. . dyspnea. 2. together with ring shadows 5-8mm causing honey comb appearance which is predominant in upper zones (DD fibrosing alveolitis). Organic : 1. < 10m) to reach the alveoli (act as allergens) to provoke Ag-Ab reaction within 4-6 hours after exposure. picture resemble pulmonary edema.vessels. Picture of complication (emphysema. Simple forms : As cool workers pn. ischemic necrosis Cavitation). (TB and Bronchial carcinoma). NB: Two important diseases may occur in association with silicosis and coal workers pn. ??TB. *Gives picture of progressive massive fibrosis: a. B. A linear strands from opacity to periphery of lung.Bronchogenic carcinoma. c. d. NB: Miners with rheumatoid disease may develop crops of nodules varying in size 110 cm know as (Caplan’s nodules or syndrome). *Multiple discrete nodular opacities (1-4mm) more condensed in upper zones which is mainly associated with reticular pattern Reticulonodular appearance.Chest 25 ____________________________________________________________________________ B.Usually bilateral. Simple pneumoconiosis : *Causes no respiratory disability. -It exists in 2 forms: A. Coal worker’s pneumoconiosis : -Disorders due to inhalation of coal dust particles.g. sand blasting and pottery. ceramic industries. Inorganic : Damage to lung parenchyma and pleura: 1. 2. Silicosis : Due to exposure to silica particles e. Radiologically : Very similar to cool workers pneumoconiosis which mainly differentiated by eggshell calcification of enlarged hilar lymph nodes. b. with or without hilar lymphadenopathy. Complicated pneumoconiosis : *Causes respiratory disability : progressive dyspnea. Complicated: As cool workers pn.Large irregular opacities (1-10 cm). Haemoptysis. upper zonal and asymmetrical. . where they are engulfed by Macrophages and evoke a fibrotic response. Pulmonary changes : -Predominantly in lower lung zones (DD silicosis upper) -Earliest changes are seen in costophrenic angles. -CT is very sensitive for early detection. b. with fine irregular lines. NB: Fine irregular line Reticular network honey comb. -Appear as (see pleural diseases) nodular pleural thickening / hemorrhagic effusion/ central mid diaphragm dt collapse / Rib involvement may occur. -When fibrosis progress lines become more profuse reticular network pattern. a. Also. they may penetrate visceral pleura. Adjacent to ribs more prevalent in the axillary part of midchest and tend to spare to upper zones and costophrenic angles. when inhaled. (not common to occur) . Malignant Mesothelioma : -The majority of such tumor is related to asbestos exposure and it does not arise from pleural plaques. Pleural plaques : -They are not seen for at least 10 years following exposure. -They are of variable size and have a characteristic distribution on parietal pleura. A. 2. B. Best seen in oblique views.Chest 26 ____________________________________________________________________________ 3. pass to the respiratory bronchioles and acini. which is best seen in lateral and oblique views -Complications : Bronchial carcinoma. 3. Pleural changes: 1. -At first the vessels have indistinct margins & are associat. -With more progression give honey comb pattern. Asbestosis : The asbestos fibers. which is strongly related to cigarette smoking. -They usually do not calcify until a latent period of 20 years. Over central tendon of diaphragm which produce characteristic curvilinear opacities on diaphragmatic pleura. Benign pleural effusion + pleural thickening. causing pleural reaction. . chlorine and oxides of nitrogen) Leads to : 1.Chest 27 ____________________________________________________________________________ Disease due to inhalation of toxic gases and fumes : (Ammonia. 4.Allergic asthma.May produce pulmonary edema (due to alveolar capillary damage) in acute stage and pulmonary fibrosis in late stage. 3.Bronchitis.Bronchiolitis pneumonia. 2. g. Lymphangiomyomatosis. 1. Eventually. Neurofibromatosis. 7.L. -Hamman-Rich syndrome: Idiopathic pulmonary fibrosis & muscular cirrhosis of the lung all are conditions all are included in the causes of such illness. 2. Fibrosing alveolitis (Interstitial Pneumonia): Cryptogenic & Secondary lower zone. Ulcerative colitis. 9. Sarcoidosis. arthritis. 6. Spond. 10. Tuberous sclerosis. Ank.L. Asbestos inhalation). (Rhtoid basal/ SLE/ AS upper/scleroderma/ PAN /Wegner granuloma/Loffler’s.F) Causes : 1. Rh. 11.Chest 28 ____________________________________________________________________________ DIFFUSE PULMONARY FIBROSIS INTERSTITIAL LUNG FIBROSIS (I. there is complete destruction of alveolar architecture. 5. defin. 8. Adult respiratory distress syndrome. NB: *Key (clinically. poisons and toxic fumes. Inorganic dusts: (Silica.. Collagen dis. -Types : 1ry: Cryptogenic. Histocystosis X. 2ry: In association to a variety of systemic conditions e. 3. 4.E. 12. Drugs. S. . Fibrosing Alveolitis Or diffuse interstitial pneumonia : -A group of disorders characterized by an inflammatory reaction in alveolar walls with alveolar exudate and a tendency to progressive fibrosis. Organic dusts: (Extrinsic Allergic Alveolitis). ).. ground glassreticulonodular honey combing *5C : Cough/ cyanosis/ clubbing/ crepitation/ Cor pulmonale. Chronic pulmonary edema. With progression : The pulmonary vessels lose their normal clarity and a fine reticulo nodular pattern develops in the lower zones. basal crepitations. 3.Chest 29 ____________________________________________________________________________ Cryptogenic fibrosing alveolitis : A clinical syndrome of unknown cause (autoimmune). Desquamative interstitial pneumonia. Giant cell interstitial pneumonia. 2. Generalized ground glass haziness of lungs. 5. Ground glass (Haze) in bases …. Usual interstitial pneumonia (most common). 2. Diffuse alveolar damage with Bronchiolitis obliterans. more easily seen in both cardiophrenic angles (mainly unequal with more on right) which extend upward and outward to costophrenic angles forming: 2. dry cough. . -CT is very sensitive in early detection. -Lung functions studies restrictive defect. clubbing of fingers. In earliest stage : -Lungs may look normal. -The earliest minimal changes appear : 1. Lymphocytic interstitial pneumonia. Radiological features : 1. 3. Pathologically : (Five distinct histological entities are described) 1. 4. With more progression : -Give (honeycomb appearance) coarse reticular pattern (at base) and ring shadows (5-10mm). Clinically : -Middle age patients presented with presented with dyspnoea. -Best seen in post-costophrenic angle in lateral view. Hand-Schullar Christian disease. Radiological findings. Kveim test: intradermal injection of extract of sarcoid tissue reaction = +ve. C. Eosinophillic Granuloma : Young adults (male : female = 4.N. -In earliest stage normal.N. Histocystosis X : A disease of unknown etiology. L. 3 varieties : 1. 3.S and bone.Chest 30 ____________________________________________________________________________ 2.. granulomatous disorder of unknown etiology. characterized by presence of non caseating epithelioid cell granolumas with predilection to involve lungs. proliferation of RE cells in (Bm . 2. -Spontaneous pneumothorax in 20% (dt air cysts). 4. 5. bilateral and symmetrical. -Open lung biopsy is best method to confirm diagnosis. Clinical data.LN). Gallium 67 scanning (taken by nodes and parenchymal lesions). -Pleural reaction and hilar lymphadenopathy (rare). Abn.lung . Radiological features : -Wide spread. Broncho alveolar lavage. Eosinophillic Granuloma (mainly affect lungs). Sarcoidosis : Multisystemic. usually affects multiple organs including the lungs. adrenal.1) Pathology : There is histocytic infiltration of the alveolar walls leading to its fibrosis causing disorganization of the pulmonary architecture with formation of air cysts. Histopathology. skin. Incidence : (30-50ys). more common in black races. Diagnosis : 1. uveal tracts. . III. female: male =2:1). Laterer-Siwe disease. -With progression give honey comb appearance. -Reticulonodular pattern diffuse nodular shadowing in mid and upper zones (110mm) associated with fine lines.HSM . 2. 3. Sarcoidosis 2.Chest 31 ____________________________________________________________________________ Radiological findings : The radiographic abnormalities progress through 3 stages : 1. -Appears as bilateral symmetrical lobulated hilar enlargement not common to be asymmetrical (rarely unilateral). 5. amyloidosis). Recurrence of adenopathy is very rare. Sarcoidosis 2. Metastasis 4. Lymphadenopathy only. it is associated with right paratracheal adenopathy in another 1/3 and with bilateral paratracheal in the remainder 1/3. -In 5% of cases. calcification giving a characteristic egg shell fashion. -Even with massive adenopathy. -Hilar adenopathy is an isolated finding in about 1/3 of cases. 6. Sarcoid lymphadenopathy : has the following features : -Nodal enlargement does not develop after parenchymal shadowing. Others (silicosis. Lymphoma 3. 2. Pulmonary lesions only. irrad). Lymphatic leukemia 5. TB (1ry) 6. Amyloidosis. -Hilar enlargement involves both tracheo bronchial and more distal bronchopulm. Causes of Egg shell calcification: 1. lymph nodes involvement of the later is a feature of sarcoidosis where it causes easily visualization of inferomedial border of hilum by adjacent air containing lung. It may persist in 5% of cases. Causes of Bilateral hilar enlargement : 1. histoplasmosis. Histoplasmosis. Lymphoma (post. the clinically significant compression of adjacent air ways is extremely unusual = No compression on airway. 3. Silicosis 4.Coccidioidomycosis 7. -In 90% of cases nodal enlargement is maximal in the first radiograph and usually disappears within 6-12 months. Lymphadenopathy + pulmonary lesions. SIS but not TB . 3. X-ray staging : 0 normal 1 bilat hilar LN 2 adenopathy + pulm infiltrate 3.Elevation of hilae i. -Characteristically. pulm infiltrate alone. 2.Distortion of pulmonary architecture. -2/3 of parenchymal shadowing clear completely and 1/3 progress to : 6. -Condensation and contraction of the fibrous tissue produces:1. 1. NB: LN + fibrosis (widespread) . range from 1 cm to a segment. slightly well defined (miliary) and symmetrical. Fibrosis : -Coarse linear shadows with evidence of volume loss+ ring shadows+honey comb. 4. wide spread many patterns. Homogenous cloudy opacities : -Commonly contains air bronchogram giving features of consolidation. -Mainly it is bilateral.e displacement of landmarks. bilateral mainly uniform in distribution from apex to base. Large nodules: Multiple bilateral 1-4cm in diameter. 5. Reticulonodular: more common.Chest 32 ____________________________________________________________________________ Sarcoid parenchymal changes : -In 20-50% with or without nodes. 2. + pleural effusion & thickening. Reticulation : -A network of fine lines radiating from hilae. Small nodules : 2-3mm rounded or irregular nodules. 3. -Kerley’s B lines may be seen from lymphatic seedlings. -May be single or multiple. usually with ill defined border. rounded or oval in shape. they appear as nodal enlargement is subsiding (DD lymphoma). there is smooth muscle proliferation in bronchi.E. ‘ lymphatics. which occurs due to restricted diaphragmatic movement by pleurisy.L. 4. More common in females. vessels. B1vs and serosal surface. Characterized by widespread inflammatory changes in CT. IV-Tuberous Sclerosis and Lymphangiomyomatosis: In both diseases. b. Collagen vascular diseases : 1. Diffuse interstitial shadowing : as in fibrosing alveolitis (rare). 3. Radiological features : 1.Mostly bilateral. V. Pleural effusion . associated with pleuritic pain. Segmental basal collapse : Thick horizontal band shadows at lung bases. Pulmonary consolidation either due to (2ry infection or lupus pneumonitis). -Bronchiectasis. lymph nodes and alveolar wall. -Cor pulmonale. 2. S. lung. Pleural effusion (chylous) characteristic for lymphangiomata. c. 5. 6.Chest 33 ____________________________________________________________________________ Complications of massive fibrosis : -Bullae formation. small. a. . -pueumothorax. Pulmonary edema : secondary to heart failure. Neurofibromatosis : The same as in Histocystosis X. Mainly in lower lobe. Diminished diaphragmatic excursion: may be due to myopathy of the diaphragmatic muscles. Histoplasmosis. 3. 2. 3. Fibrosing Alveolitis : Appears as basal reticulonodular shadowing which may progress into honey comb lung with loss of lung volume end stage lung.(crops of nodules = Caplan nodulo) 4. 5. 6. -Upper lobar fibrosis with upward retraction of hilae + bullae formation.Chest 34 ____________________________________________________________________________ II. IV. 2. Pleural effusion: (unilateral or bilateral). -Basal patchy consolidation due to aspiration pneumonia. 5. 3. -Air oesophagogram may be evident in lateral film due to absence or diminished peristalsis. disease: 1. 4. *Causes of upper lobe fibrosis: 1. -Apical pleural thickening. AnkvlS: -Unilateral or bilateral. Identical nodules. TB 2. Rheumatoid Disease : Radiographic features of intrathoracic manifestation of Rh. Progressive massive fibrosis. Pulmonary hypertension and cor pulmonale (rare) = complication of fibrosis III. . Eosinophillic granuloma. Asbestosis Cryptogenic Rheumatoid. -High incidence of bronchogenic carcinoma. *Causes of lower lobe fibrosis: 1. Necrobiotic nodules: Vary in size (few mm to few cm) single or multiple. exposed to silica. 8. characteristically appear rapidly in crops which contain silica dust on histological examination. Sarcoidosis. Systemic Sclerosis (scleroderma): -Picture of fibrosing Alveolitis (ground glass appearance/ fine reticulonodular/ honey comb appearance). Post irradiation. Caplan’s syndrome : In patient with rh. Aspergillosis. 7. Ankylosing spondylitis. Wegener’s Granulomatosis : -More common in females. Radiologically : -Transient areas of consolidation which may appear rapidly then disappear (Loeffler’s syndrome).Large nodules (few cm) may cavitate. Vasculitis “necrotising”→ skin-face.) Eosinophillic pulmonary infiltrate + increased eosinophills in peripheral blood. VI. VII.Chest 35 ____________________________________________________________________________ V. arkylostoma. -Vasculitis affecting mainly small arteries and associated with segmental ‘ glomerulonephritis in 85% necrotising granulomas affecting lung. Radiologically : A. -Kidneys most commonly affected. kid. . -Air space shadowing. -Fungi: (Aspergillus fumigatus). Radiologically : -Single or multiple well defined pulmonary masses varying in size from few mm to few cm which frequently cavitate. ill defined non segmental areas of consolidations in periphery of lungs. Causes : -Bilhariziasis. may occur mainly due to pulmonary hge. -Pleural effusion. ascaris. Polyarteritis Nodosa : -Vasculitis of medium sized arteries. Loeffler’s syndrome : diagnostic vertical (short & thick) band // to chest wall separated from pleura : -Transient pulmonary eosinophillia which produces.Accentuation of vascular lung markings. -Polyarteritis Nodosa. -These changes are characteristically short lived (few days) and self limited. -Hilar and mediastinal lymphadenopathy. . -Unknown : Cryptogenic pulm eosinophillia. -Drugs : sulfonamides. lung. Pulmonary eosinphilia (Eosinophillic Pneumonia): (??Loeffler’s $. . migrating opacities with ill defined margins like pulmonary edema ± ill defined nodules (6mm) may be seen. Repeated episodes of hge and the lung return to normal between attacks.Chest 36 ____________________________________________________________________________ B. Chronic pulmonary eosinophillia : -The same radiological picture of Loeffler’s syndrome but much more persistent. VIII. 4. Clinical Picture: Haemoptysis and anemia : Causes of Pulmonary Haemosiderosis : 1. Miscellaneous: As in heart disease (M. Wegener’s granuloma. Repeated attacks fibrosis. 2. Idiopathic : Children. Radiological features : 1. Of Pulmonary hge : a. b. 2. Pulmn V. congestion. -Classically occur in atopic middle aged females.ill defined micronodular opacities (miliary) with air bronchogram. NB: Pulmonary hge : Acinar shadow Haemosiderosis: Miliary . . Part of widespread Vasculitis e. Pulmonary Hemorrhage & Haemosiderosis : Multifocal bleeding at acinar level distal to terminal bronchioles with exclusion of bleeding states as leukemia and anticoagulant. Of Haemosiderosis: -may be normal. Associated with renal disease : Good pasture syndrome = Antiglomerular basement membrane antibody. 3. Fleeting. Drugs : Penicillamine. 5. Airbronchogram.S).g. both lungs can be almost totally opacified but may be normal in acute attack. NB: In severe cases. c. Cardiac failure. infarction. hepatic C. -caused by : 1. Subphrenic infection. Filariasis. Haemothorax: -Caused by : 1. 4. Pancreatitis. -Caused by obstruction or destruction of the thoracic lymphatics. thin and watery fluid. Meig’s $. 1. lymphoma. Exudate : -Cloudy amber yellow thick and sticky fluid. can not be detected by PA and lateral films but detected by decubitus view. Chylothoras : -Milky fluid high in fatty acids and neutral fat. 2. sac (trauma.Chest 37 ____________________________________________________________________________ DISEASES OF THE PLEURA I. -Caused by : 1. pulmonary TB. -Protein > 3 gm/dl. Frank blood in pl. Small effusion: -< 100 cc. 5.) 2. Pulmonary infarction.. Hypoproteinaemia (nephrotic$. Free effusion (in the absence of pleural adhesions). -Protein < 3gm/dl. Bacterial pneumonia. Pleural fluid (effusion): types and causes : a. Blood stained effusion (pulm. Pulmonary malignancy (1ry or metastatic). Anemia). U/S and CT. Transudate : -Clear. Radiological appearance : A. 3. The commonest cause is : 1. Chest-trauma. . 2. c. bronchial carcinoma). 3. blood dis. 3. d. Malignant invasion. b. 2. -100-200 cc: Can fill the posterior costophrenic recess and appear in lateral film.. -> 200 cc: Effusion can be detected in PA view blunting of costophrenic angle. 2. Massive effusion : -Complete or partial radio opacity of the hemithorax. -Tracking of the fluid in the pulmonary fissures (best seen in the lateral views). Loculated or Encysted effusion : It is due to partial obliteration of the pleural space between visceral and parietal pleura due to pleural disease or between visceral pleural at lung fissures. . devoid of all lung markings. B. a large effusion may collect in the azygo-esophageal recess and mimic a retro-cardiac mass. the fluid will move in free pleural space (diagnostic). -A shallow collection between the chest wall and lung surface. spreading upwards. with well defined concave upper edge. -On the right side. rising laterally more than medially (rising to the axilla). which sometimes spares the costophrenic recess. Sub-pulmonary effusion: -An effusion accumulate between the diaphragm and under surface of the lung false impression of elevated hemi-diaphragm. Costal encysted pleural effusion : -Site : Along the chest wall (usually posterior and laterally). -Shift of the mediastinum toward the opposite side. Moderate effusion : -A homogenous opacity in the lower lung zone. obliterating the costophrenic recess and obscuring the diaphragmatic shadow. -With change in posture. -Retraction of the underlying lung toward the hilum. Lamellar effusion : -Common in children and patient with heart dis. in decubitus and supine films. -± Blunted costophrenic recess or tracking of fluid into fissures. suggesting underlying lung collapse mostly due to bronchial carcinoma. 2. -On the left side increased distance between gastric air bubble and lung base. 3. NB: Massive effusion + lack of mediastinal shift. Radiological appearance : A. Atypical distribution of pleural fluid: 1.Chest 38 ____________________________________________________________________________ while not detected in PA view. B. *If air fluid level is seen it will be either due to therapeutic aspiration. In both frontal and lateral views. oval or rounded shadow with well demarcated edge. -Best determined by fluoroscopy: *Profile: well circumscribed. or development of bronchopleural fistula. markings. * compensatory emphysema. -Parenchymal lung dis from interlobar type. -mediastinal mass from mediastinal type. in profile or obliquely. of encysted effusion : -Extrapleural opacity from costal type. * Obscuration of right cardiac order is common. 1. . -Lateral : Appears as a typical lenticular well defined shadow along fissure (diagnostic). biconvex opacity with the peripheral border adjacent to the chest wall and the inner border is convex and well defined. Middle lobe consolidation * Air bronchogram. * Interlobar effusion disappears rapidly after ttt. Interlobar encysted pleural effusion : Common to occur in patients with heart failure. * Obliteration of right cardiac border is not common. DD. -Free effusion DD by gravitational method. -The remaining part of the fissure to be thickened due to extension of fluid in the fissure.A: Their radiological appearance depends on whether they are viewed en face. * distorted bronchovasc. phantom tumor Encysted effusion * lenticular shape with extension into the fissure in lateral film. Encysted effusion within horizontal fissure : -Appears as lenticular. Encysted effusion within the oblique fissure: -PA view : Appears as rounded or oval shadow mainly well defined lower border and ill defined upper margin. *En-face: Radio-opacity of relatively low density. 2.Chest 39 ____________________________________________________________________________ -R. and may recur in subsequent episodes of heart failure so known as pseudo or vanishing tumors. / subpulmonary). interlobar. mediastinal. diagnosis by CT. * Encysted mediastinal pleural effusion : mimic a mediastinal mass.Chest 40 ____________________________________________________________________________ * Subpulmn encysted effusion : same as free effusion but the fluid doesn’t move into pleural space with changing posture. subpulmonary . Encysted (costal encysted. Effusion : Free/ atypically ( lamellar. P catheters introduction. A small pneumothorax : -In the erect position. -C. . fracture rib. small pneumothorax collects at the apex and appears as a small radiolucency in the pleural space which is devoid of lung markings. B. cystic fibrosis Sarcoidosis. -Children staph. Spontaneous pneumothorax : -Is the commonest type. closed chest trauma.V. -Expiratory films diagnostic. *Conditions associated with interstitial pulmonary fibrosis. pleural bleb (usually in lung apex). Large pneumothorax : -A large radiolucency. -In young adults cong. -Mediastinal shift toward the normal side which increase with expiration.Chest 41 ____________________________________________________________________________ II. 2. pneumonia. *Rupture of subpleural cyst in bronchial carcinoma or rupture of cavitating metastasis. PNEUMOTHORAX Definition : Air within the pleural cavity due to defect in parietal or visceral pleura. the lung volume is at its smallest while volume of pleural air is unchanged. which is devoid of lung markings. -Other causes : *Rupture of subpleural TB focus. -Pleural or lung biopsy. -Old age Emphysema or chronic bronchitis. Etiology : 1. -Lung retraction. since on full expiration. Radiological appearance : A. The apex of lung retracts towards the hilum. -Bronchoscopy and oesophagoscopy. The sharp white line of visceral pleura will be visible. Traumatic pneumothorax : -Chest trauma due to : penetrating wound. Pleural adhesion: R. especially during inspiration. 2. adhesion. D. 2. R. -N. radiolucency adjacent to the chest wall. *Mediastinal shift.D. *Closed pneumothorax: No movement of air occurs. Tension valve like tear air in not out !! increased pleural pr. Lobar collapse or consolidation: 4.Chest 42 ____________________________________________________________________________ C. Appears as a line shadow between the two pleural layers preventing relaxation of the underlying lung. *Depressed ipsilateral diaphragm. 3.. fluid collection. Complications of pneumothorax : 1.: *From large pneumothorax with mediastinal shift on fluoroscopy more mediastinal shift to contralateral side in inspiration with tension pneumothorax (?? encystment. 5. open air in pleura communicate with atmosphere. Pleural thickening : -In chronic cases. * Cardiac Tamponade NB: 1.: *Open pneumothorax: air moves freely during respiration. Pleural fluid collection : -Small amount fluid level at costophrenic angle.: Subpleural cyst and bulla. -Radiological appearance : *The ipsilateral lung may be squashed against the mediastinum. Tension pneumothorax (valvular type): -Mechanism : Air moves in but not out during respiration.D. -Thickening of the visceral pleura may prevent re-expansion of the lung which needs decortication. thickening. -Large amount hydropneumothorax “ horizontal air fluid level”. Encystment pneumothorax: due to pleural adhesion. -D.A. .: Ovoid.A:. closedeg: ruptured bleb(So not open).B. collapse/consolidation) . increase pleural pr.. Rupture of this adhesion may produce hydropneumothorax. thickening of visceral or parietal pleura may occur. but still -ve 3. Unilateral apical thickening or asymmetrical : .Not due to TB.Ischaemia is a probable factor.Decortication of the visceral pleura is needed. .Common with asbestosis. Diffuse pleural thickening : . secondary to lung infection or infarction. PLEURAL THICKENING Causes : 1.Pancost tumor. Old age. .Usually. Following radiotherapy of the chest. .Always of pathological significance. 4. 2. . . 3. 2.Uncertain etiology. the end result of previous thoracotomy.TB + Ank.(unilateral or bilateral) Fibrothorax. . End of pleural fissures. or haemothorax. haemothorax. Pleurisy : primary.Chest 43 ____________________________________________________________________________ III.Elderly patients. 6.This may cause reduced ventilation of the surrounding lung decrease in the volume of that hemithorax. Malignancy Common sites : 1. Extensive pleural thickening : . . empyema. Whole pleura (diffuse pleural thickening). . End result of empyema. 5. . 3. 7. Apices of the lung. Radiological appearance : Bilateral apical thickening or symmetrical : . Previous low grade TB infection apical. spondylitis. After asbestosis exposure diffuse pleural plaques. -When viewed en face bizarre form of calcification. irregular shadows. Contrast study : -Injection of lipidol or hydrast into pleural space (sinography or passes into the bronchial tree. BP fistula should be considered). 2. Radiological appearance : Plain : Picture similar to hydro or pyopneumothorax (if persists or enlarges after surgery.characteristically parallel to the chest wall. 3.usually producing dense. Penetrating chest trauma. Carcinoma of nearby bronchus.Chest 44 ____________________________________________________________________________ IV. PLEURAL CALCIFICATION Causes : The same as pleural thickening : Radiological appearance : -Continuous sheet or discrete plaques . Rupture of lung abscess or empyema. which may cast an ill defined shadow mimic to pulmonary infiltrate. V. BRONCHOPlEURAL FISTULA Communication between the air way and pleural space : Causes : 1. 4. -Injection into bronchial tree passes to pleural space. . coarse. Complication of pneumonectomy. -When viewed tangentially . .CT is the best method for assessing the extent of malignant mesothelioma. PLEURAL TUMOURS -Benign (Lipoma) and (fibroma) = Benign mesothelioma. *Bronchial ??/ stasis by tumor compression. Malignant mesothelioma : Usually due to prolonged exposure to asbestdust.Percutaneous or U/S needle biopsy is diagnostic. diaphragmatic. .Site : Costal. mediastinal or at pleural fissures. -Malignant secondary = commonest sites is breast.Size : Small or occupy most of hemithorax. ..Chest 45 ____________________________________________________________________________ VI. Radiological appearance : Well defined lobulated mass : . Subpleural lipoma : .Rib involvement may occur not common as in metastasis. bronchogenic. .May change their shape with respiration (fluoroscopy). pl. .Nodular pleural thickening around all or part of a lung. Pleural fibroma : Usually associated with hypertrophic osteoarthropathy joint pain and clubbing.Well defined rounded masses. Radiological Appearance : . which may obscure ! mass. ..Other asbestosis changes (pleural thickening. .Mediastinum is mainly central despite of the presence of a large effusion due to underlying collapse of the lung by: *Ventilation restriction by the tumor. calcification) . -Malignant Primary = Malignant mesothelioma.Hemorrhagic pleural effusion may be present. . Radiological appearance : *In between acute attacks: Normal chest. . Extrinsic or atopic asthma : Associated with history of allergy eg. patchy infiltrates of Aspergillosis. Hilar vessels enlargement (enlarged central pulmonary artery) with normal pulmonary vessels distal to hilae. Lobar atalectasis: dt: obstruction of a lobar bronchus by plugs of sticky mucus or mycelia of Aspergillus. Manifestations of lower respiratory tract infection. Intrinsic or non atopic: Precipitated by a variety of factors as exercise. Pneumothorax and pneumomediastinum: due to rupture of the alveoli by high expiratory pressure. Recurrent infections especially in children. *Radiographic picture of complications : 1. *Radiographic picture of associated conditions: 1. Types : 1. *During acute attacks : 1. which is paroxysmal and reversible. Flitting. 2.Chest 46 ____________________________________________________________________________ CHRONIC OBSTRUCTIVE AIRWAY DISEASE I-Bronchial asthma : Definition : Widespread narrowing of the bronchi. Aspergillosis (↑ IgE). 2. *Profile tubular tram-line shadows. Evidences of hyper inflation “see later”. infections. dyspnea. 3. Prominent bronchovascular markings. Pathogenesis : Hyper-reactivity of the larger air ways to a variety of stimuli narrowing of bronchi. causing bronchial wall thickening “peri-bronchial cuffing”. wheezing. 2. 3. Appear *End-on ring shadows. Most common in Rt middle lobe. 2. mainly due to reversible pulmonary hypertension. T. *Picture of complications : .B. NB:.Cor-pulmonale.Abrupt termination of bronchial division after 5-8 generations = Prune tree.*Trachea. ♂. Radiographic picture : . *Alveoli are purely respiratory function. Bronchography : .Pneumothorax. perivascular and peribronchial edema. . Pollution) Pathology :Hypertrophy of mucous secreting glands interference with mucociliary function dt: viscous sputum production with plugging of distal air ways.Emphysema. evidence of hypertrophy of mucous secreting glands in larger air ways. bronchioles.Chest 47 ____________________________________________________________________________ II-Chronic bronchitis : Definition : Production of cough on most of day. bronchi & bronchioles are strictly conducting airways. *Bulla : emphysematous space with diameter > 1 cm in the distended state & its walls are made up of compressed surrounding lung or pleura. . DD: IPF & bronchiectasis . Peribronchial cuffing : rounded. Emphysema : Definition : Enlargement of airways beyond (distal) to the terminal bronchioles with dilation and destruction of their walls.Irregular wall of proximal bronchi.Shows.Accentuated bronchovascular marking with small. ill defined opacities which may represent small focal areas of atalectasis. .50% of patients normal chest. during at least 3 consecutive months for more than 2 years. alveolar ducts & alveolar sacs-conducting & respiratory structures.Signs of over inflation. .Bronchial wall thickening “As before”. (> in smokers. .An appearance which is characteristic for chronic bronchitis: Dirty chest:. *Resp. . . without apparent cause. . tram like. fibrosis.Bronchogenic carcinoma. .Unnecessary but pathogneumonic for diagnosis of chronic bronchitis. . 5. separated by septa = 3-5 acini Respiratory acinus = lung distal to a terminal bronchiole. . in such a way that air enters the lung on inspiration but is trapped on expiration. Composed of all respiratory structures distal to a terminal bronchiole = primary lobule (Respiratory bronchiole.Non selective process.) Types of emphysema : A. distal airway is not necessarily destroyed). the involved distal air ways are ventilated by collateral air drift air trapping of pan-acinar type.It may be localized or generalized. Obstruction to a lobar bronchus by an extrinsic mass or anomalous vessels.( hypertransradiant hemithorax dt decrease perfusion. Deficiency of a bronchial wall cartilage. 3.Chest 48 ____________________________________________________________________________ Secondary pulmonary lobule : Areas supplied by 3-5 terminal conducting bronchioles. Obstructive emphysema : misnomer : obstructive hyperinflation (bec. alveolar duct and sac.(FB or peribronchial tumor). Para-cicatricial emphysema: -Distention & destruction of terminal air spaces adjacent to fibrotic lesions eg TB. Congenital lobar emphysema : .Panacinar : Panlobular : .Refers to an overinflated lobe which compresses adjacent normal lung producing respiratory distress mainly in the neonatal period.It occurs. 4. ??Alpha-1-anti-trypsin deficiency. characterized by destruction of all the lung distal to the terminal bronchiole.Causes : 1. .) Causes of unilateral lung transradiancy : . 2. .It is probably the result of a childhood viral infection causing bronchiolitis and obliteration of the small airways. when a larger bronchus is partially occluded by an intra-luminal mass ball valve effect of this mass. Unilateral or lobar emphysema (Macleod’s syndrome): . Air trapping present at the respiratory bronchiole “symptomatic”: 1. Alveolar abnormality *Polyalveolar lobe increased number of alveoli in a lobe *Rigid alveoli with surrounding stroma. 2. 3. No air trapping “asymptomatic”: 1. 2. Compensatory emphysema (hyperinflation): .Dilatation of the alveolar ducts due to the aging process. bronchogenic cyst.Intra-bronchial obstruction: (All obstructive except 4 is paracicatricial) 1. edema.Abnormal bronchial wall (cartilage deficiency.B.Non significant. II. Pulmonary embolism. . where the alveolar ducts.Selective process. 4. sacs and alveoli are spared. NB: *Type I resp failure: diffusion defect (hypoxic. Polyalveolar lobe. 5.Chest 49 ____________________________________________________________________________ 1. Para-septal emphysema: . Senile emphysema : . .Extensive bronchial compression. 4. Causes of lobar emphysema : I-Bronchial obstruction: .It is frequently found in chronic bronchitis.Mediastinal mass e.Hyperinflation of the unaffected or remaining lung due to collapse of a part or all of the lung. 2. 4.Similar to centri-acinar emphysema.Usually involves the periphery of the secondary lobules at the lung periphery occasionally causes bullae formation. Thoracic cage abnormalities. 3. Centri-acinar : centrilobular. Technical radiographic factors. . F. 2. 2.Vascular anomalies vascular ring or sling. . characterized by destruction and dilatation of respiratory bronchioles. Parenchymal abnormalities: (congenital) 1. Rigid alveoli. but in association with cool dust exposure. 3. 2. Focal dust emphysema : . normo or hypocapnic eg pul. Mucous plugs. B. bronchial stenosis)}Panacinar . Tumors. Compensatory or obstructive emphysema. 3. “Peanut”. pure .}Panacinar 1.g. Endo-bronchial TB. The midfield and peripheral pulmonary vessels are attenuated in both size and number. and 10-11 posterior rib. ARDS. Panacinar : 1. expiratory films. . vascular damage. associated with flattening of the diaphragmatic dome.Limited diaphragmatic movement with emphysema by fluoroscopy and inspiratory. Vascular changes : A. & transverse ribs.The hilar vessels being larger than normal with abrupt tapering. 2.Normally at end of deep inspiration the diaphragm is at the level of 6th-7th anterior rib in frontal view. (Oxygen as much as you want) *Type II : ventilation defect (hypoxic. Over inflation : manifested by low flat diaphragm . . in emphysema it is < 3cm. generalized emphysema: .Increased AP diameter of chest (barrel chest) due to bowing of the sternum and increase thoracic kyphosis. there is low position of the diaphragm below these levels at end of inspiration. restrictive lung dis (differentiated by FEV1). where the normal smooth gradation in size of vessels from the hilum outwards is lost. . Localized emphysema : .. should be 4cm or greater to be considered abnormal.The low flat diaphragm results in an apparently small heart. B. Best seen in lateral view. . “elongated” and decreased cardio-thoracic ratio < 40%.Enlargement of retrosternal translucent zone on the lateral radiograph measured from the back of the sternum to the anterior aspect of lower ascending aorta . ( Care with oxygen therapy) Radiological appearance : The classical radiographic appearance of advanced emphysema consists of a triad of findings (overinflation. In widespread. I. . .In emphysema. bullae). Where diaphragmatic excursion is about 5-10cm.Chest 50 ____________________________________________________________________________ emphysema. hypercapneic) GOAD. May be single or multiple. . 3. Causing distortion or displacement of pulmonary vessels. High pulmonary venous pressure as in left heart failure. The heart may appear normal or enlarged. DD of upper lobe blood diversion : 1. Smooth. as the perfusion of emphysematous lung is less than normal and the pulmonary blood flow is diverted to less affected areas of lung. curved. termed marker vessels which is used as a touchstone for normality and allow one to identify emphysematous area. this is due to pulmonary edema decrease of the hung volume.Emphysema. .When. The level of diaphragm will rise. . Rounded or oval translucency.. Giant bullae : .Vessels of occasionally increased caliber are present in unaffected areas of lung . e. the radio graphic picture of emphysema will alter where : a.) c. b. c. it is mainly associated with “upper lobe blood diversion”. hair line wall (compressed lung parenchyma. . Severe lower lobe disease.With development of cor pulmonale or left heart failure.Fibrosing Alveolitis. d..The vessels are smaller and more deficient in the emphysematous areas. also may be seen independently of emphysema. more than > 1cm in size. .Chest 51 ____________________________________________________________________________ There is uneven distribution of pulmonary vessels where : . 2. emphysema is predominantly basal (lower lobe emphysema) which is common in panacinar type. Radiological appearance: a. Usually peripheral. . The signs of hyperinflation may be decreased. .Bronchiectasis. Bullae : Can be identified in about 1/3 of patients of emphysema.Pulmonary embolism. b. Pneumatocele tomography may be needed. .May cause mediastinal shift or extends across the midline or retro-sternal space. II.It occupies most of the hemithorax. Infection : . 2. DD: of localized transradiancy : 1. 3.Curvilinear margin.Expiratory films. Pneumothorax : Rare if rupture.The bullae shows . .CT scanning. III. Vascular changes as before. When lobar : *Displacement of fissures. Bullae.Has lung tissue peripherally. (air trapping within the bullae). outer aspect of which makes an acute angle with the chest wall. 3. Macloed’s syndrome : . Complications of bullae formation : 1. 2. . 2. Localized emphysema. Air trapping picture by fluoroscopy and expiratory films.Compression of adjacent lung. *Transradiancy of affected lobe or segment. *Compressed lung tissue around. Obstructive emphysema : 1.Displacement of fissure and depression of hemi-diaphragm. Cyst.Where a fluid may partially fill it forming fluid level or completely filling it and appears as a well-defined homogenous opacity. 4. Hemorrhage : Forming fluid level. . . . 5.Chest 52 ____________________________________________________________________________ .The surrounding lung shows inflammatory changes. *Deviation of mediastinum to normal side. 3. *Low flat ipsilateral diaphragm with restricted movement. Encysted pneumothorax. . NB:*Many bullae may be invisible on chest radiograph and can be demonstrated by : . -Air trapping effect of the affected lung. . but shows a characteristic app. .Arterial : 1.Congenital Lobar Emphysema: . Pulmonary angio: .Irregular dilatation of peripheral bronchi till. 3. Plain : -Hyperlucency of the affected lung due to attenuation of vessels within it. of unilateral emphysema : =Other causes of hypertransradiant hemithorax : A.Pneumothorax.Bronchial. Pleural : . Bronchography : Not usually indicated. but no over inflation as above. . .Poland’s syndrome (congenital absence of pectoral muscles). 1.Mastectomy.Contra-lateral pleural effusion with patient supine.Main and segmental bronchi are normal. . Chest wall deficiency : .Technical. .Ventilation scan air trapping DD. Unilateral bollus emphysema.Not commonly used. 2. 2. Congenital absence of one of pulm. D.: .Chest 53 ____________________________________________________________________________ 1. Obstructive emphysema.perfusion scan shows decrease flow. nearby carcinoma) IV. Isotope : . 6th order division. B. Rotation : . reveals: attenuation of pulmonary vasculature of the affected side. .Scoliosis :hypertansradiant hemithorax is the side to which the patient is turned.Lack of bronchial filling distal to the 6th order division (bronchiolitis obliterans) giving pruned tree appearance. C. A. . Pulm. 2. Macloed’s syndrome. 4. 3.Lobar collapse compensatory emphysema. Parenchymal : . a. (occlusion embolism. Signs of hyperinflation is not severe... 2. Obstructive hyperinflation . Compresses remaining lung 2. 3..L. Compensatory hyperinflation (no evidence of expiratory air trapping)..E….Manifestation of hyperinflation. mainly due to mucous inspissation and plugging of a bronchus which may give identical picture of C. .Variable degree of overinflation of one lobe mostly the upper & middle lobes → show hyperlucency with few visible lung markings.Chest 54 ____________________________________________________________________________ . Emphysema with chronic bronchitis : (centriacinar/ no air trapping) Clinically emphysema of two type (Pink Buffer. possibly with cardiac enlargement.. Congenital cyst : evidence of other cysts..Increased bronchovascular marking .. Complications of emphysema : .. May herniate across the midline to opposite side. .Enlarged central pulmonary arteries . More common with centri-acinar emphysema : . More common with pan acinar emphysema..I. Blue Blotter) Pink Buffer :( Pt... increased markings pattern of emphysema..E. Mediastinal shift towards opposite side. Lobar Emphysema: 1. dirty chest.. “Where we call arterial deficiency pattern of emphysema” Blue Bloater : (Chronically retains Co2 dt poor alveolar ventilation). . by major effort ventilates sufficient to maintain normal bl.. Tension pneumothorax : . (+ Cor pulmonale → edema) . DD of Cong. Flattens or inverts ipsilateral lung 3.. .The over expanded lobe leads to 1. 4.Entire ipsilateral lung is collapsed.Patient with chronic bronchitis shows features between these two extremes (panacinar + centri-lobular). V. . Gases).No vascular markings within it. ... This is called ..so bronchoscopy is essential before surgical resection of lobe in C. 4.Peripheral vascular attenuation. Pneumonia : produces.. Asthma: during acute attacks. there is no evidence of hyper inflation. patchy.Chest 55 ____________________________________________________________________________ 1. Cor-pulmonal. Pulmonary edema: of left heart failure with upper lobar in distribution. nodular shadowing. 5. DD of Emphysema: 1.. Primary pulmonary arterial hypertension . Respiratory failure. 2. 3. 2.. . ill defined. Pneumothorax. 6. High incidence of bronchial carcinoma. 4. Chest 56 ____________________________________________________________________________ LARGE AIR WAY OBSTRUCTION Causes of bronchial obstruction: A. In the lumen: 1. Foreign body. - Air trapping > atalectasis. - Lower lobe is most frequently affected. 2. Mucus plug. - Post operative, asthma. 3. Misplaced endo-tracheal tube. 4. Broncho -pulmonary aspergillosis. B. In the wall (mural): 1. Carcinoma of bronchus Tapered narrowing ± irregularity. 2. Bronchial adenoma Smooth, rounded filling defect. 3. Inflammatory stricture (TB). 4. Bronchial atresia. 5. Sarcoid granuloma. 6. Fracture bronchus. C. Outside the wall: 1. Adenopathy. 2. Mediastinal tumor. 3. Enlarged left atrium. 4. Aortic aneurysm, vascular ring. 5. Cong., vascular anomalies. Manifestations of partial or complete major air way obstruction: 1. Collapse or atalectasis. (if complete ob.) 2. Obstructive hyperinflation if partial ob (valve). 3. Obstructive pneumonitis abscess. 4. Bronchocele. 5. Bronchiectasis. Chest 57 ____________________________________________________________________________ COLLAPSE (ATELECTASIS) Collapse means partial or complete loss of volume of a lung. Mechanisms of collapse (types): 1. Relaxation or passive collapse. Air or fluid in the pleural sac passively causes the lung to retract towards its hilum. 2. Cicatrization collapse : The lung can not normally expand (decrease lung compliance) decrease it volume. Occur in pulmonary fibrosis. 3. Adhesive collapse : Normally the surface tension of the alveoli is decreased by surfactant disturbance of such mechanism leads to alveolar collapse with patent major airway. e.g. respiratory distress syndrome in premature. 4. Resorption collapse (obstructive): (causes : outside - inside - lumen) Acute bronchial obstruction leads to absorption of gases within the alveoli by the blood of pulmonary capillaries leads to alveolar collapse no air bronchogram. Radiological appearance of collapse: (direct - indirect). A. Direct signs (Lobar signs) of collapse : - Displacement of the interlobar fissures. The most reliable sign. The degree of displacement depend on extent of collapse. - Loss of aeration or increased density of the collapsed area. The collapsed area adjacent to mediastinum or the diaphragm will obscure their defined border “silhouette sign”. - Vascular and bronchial signs: Crowding of vessels in the collapsed area. Crowding of bronchi if there is air bronchogram. B. Indirect signs (extra-labor): Chest 58 ____________________________________________________________________________ 1. Elevation of the hemidiaphragm: especially in lower lobes collapse. 2. Mediastinal shift: - Tracheal shift to the same side in upper lobe collapse. - Shift of the heart to the same side in lower lobe collapse. 3. Hilar displacement: - Elevated in upper lobe collapse. - Depressed in lower lobe collapse. 4. Compensatory hyperinflation of the normal parts of the lung: - In total lung collapse compensatory hyperinflation of the contralateral lung ? explain. 5. Rib approximation. PATTERNS OF COLLAPSE A. Entire lung collapse “complete collapse”: Acute obstruction to one of the main bronchi lung collapse and causes 1. Opacification of the hemithorax. 2. Displacement of the mediastinum to the affected side. 3. Elevation of the diaphragm. 4. Rib approximation. 5. Compensatory hyperinflation of contralateral lung. a. Hyperlucency with accentuation of its vascular marking. b. Widening of rib spaces. c. Herniation across mediastinum, mainly occur in the retrosternal space or in azygo-ocsophageal recess posteriorly or across the midline. B. Lobar collapse: 1. Right upper lobe collapse : PA view : -The outer aspect of minor fissure moves upward with concavity inferior. - Tracheal shift to the right. - Loss of definition of shape of right border of superior mediastinum (Silhouette sign), In severe collapse band shadow extends downward and forward from hilum.The area of opacity. or superior mediastinal widening. no oblit. . mainly not seen but usually sufficient to blur the sharp right heart border (Silhouette sign) best sign.Elevation of right hilum with more horizontal course. the collapsed area comes to lie against the apex and mediastinum simulating (apical pleural thickening. Right middle lobe collapse: PA view : . .B: In marked collapse. DD.The minor fissure and upper part of the oblique fissure move towards each other. Lingular collapse : Mainly involved in left upper lobe collapse : PA view : Loss of definition of the left cardiac border.Increased density of middle lobe.Compensatory hyperinflation of the lower lobes. 2.Effacement of the anterior margin of the aorta. Lateral view : . . displacement of lower part of oblique fissure and increased opacity anterior to it. .The collapsed middle lobe appears as triangular shadow with its apex pointing laterally from which. lat view → lenticular.Chest 59 ____________________________________________________________________________ . view : . Lat.The minor fissure and lower half of oblique fissure move towards each other with bowing of one of them or both.: Encysted interlobar effusion of lower part of major fissure (no air bronchogram. Lordotic view: . . the fissure line usually extend to chest wall.Wedge like opacity with its base towards apex of the lung and its apex towards the hilum. 3. . .Lateral part of minor fissure moves downward. view : Ant. Lat. N. of cardiac silhouette. . c.As collapse progress. forming an elongated opacity extending from the apex.Hyperinflation of the left lower lobe.. Diaphragmatic and mediastinal shift.Chest 60 ____________________________________________________________________________ 4. .III defined border of aortic knuckle. . d. view : . Silhouette sign: on left side (obscuration of the margin of hemidiaphragm and descending aorta). . anterior to ! hilum and lined posterior by oblique fissure. Hyperinflation of the ipsilateral upper lobe.The lower part of oblique fissure mainly bowed convex backwards & sometimes its upper posterior aspect is depressed by compensatory hyperinflation of upper lobe.With marked volume loss increased radio opacity in the posterior costophrenic angle and loss of lucency of the lower dorsal spines.With minor volume loss no increase in radio-opacity. there is increase in radio-opacity forming a triangular shadow with its apex in hilar region and its base on diaphragm. Left upper lobe collapse : PA view : . On right side : The border mainly remains sharp.Elevated hilum. 5. hilum and the left cardiac border it lingula is involved (Silhouette sign +ve. mid and sometimes lower zones.Ill defined hazy opacity present in upper. On the left side it lies behind the heart and penetrated film may be needed . b. .Anterior displacement of the oblique fissure.With increased collapse. Lat. Collapse of the right or left lower lobe : PA view : . In this situation. the upper lobe retracts posteriorly. indirect signs are important such as: a.) .Shift of trachea to the left. More dense at hilum. Lateral view : . Hilar depression with medial shift of its inferior component. . . . Lat view : Radio opacity of a well defined upper border extending downward and forward from back to front which obliterates the whole hemidiaphragm. always pleural based and associated with chronic pleural thickening DD: pulmonary mass.This type of collapse occurs.A triangular shadow. Atypical forms of collapse : 1.A homogenous opacity. Fleischner’s plate atalectasis : .. with ill defined edges.This distinguish it from isolated lower lobe collapse. DD: subpulmonary effusion or elevated right diaphragm.Chest 61 ____________________________________________________________________________ C. . Rounded atalectasis or folded lung: . . .Obliteration of diaphragm and right cardiac border.Linear densities appear in the lower lung fields soon after abdominal surgery. with its apex at hilum and its base on diaphragm extending laterally to costophrenic angle. D. Multilobar collapse : Right middle and lower lobe collapse dt to obstruction of bronchus intermedius. . 2. when pleural effusion causes fold of the adjacent lung mainly lower lobe and the folding failed to resolve when effusions subsides (with asbestosis). PA view : .A vascular shadow may be seen to radiate from part of opacity mimicking a comet’s tail comet sign. Chest 62 ____________________________________________________________________________ CONSOLIDATION Definition: Means replacement of air in one or more acini by fluid or solid material. The smallest unit of consolidation is a single acinus which casts a shadow approximately 7mm in diameter. Causes of consolidation: - The most common cause is acute inflammatory exudation associate with pneumonia.(TB, infarction, collapse), (same as causes of alveolar and acinar shadows) - Other causes: - Pulmonary edema. - Hemorrhage, aspiration. - Alveolar carcinoma, lymphoma. Consolidation is either : patchy, segmental, or lobar Consolidation : - When associated with patent air way air bronchogram is seen with to change in volume . - When it occurs secondary to bronchial obstruction no air bronchogram seen and there is decrease in lung volume = consolidation collapse. Air in alveoli is displaced by: Fluid Pneumonia, TB, IPF, bronciectasis Pulmn. edema Pulmn. hge Pulmn infection Soft tissue Alveolar cell carcinoma lymphoma Chest 63 ____________________________________________________________________________ OBSTRUCTIVE PNEUMONITIS Pneumonic consolidation distal to an obstructive lesion : The presence of underlying airway obstruction with consolid. can be suspected from : 1. Segmental or lobar distribution. 2. Atalectasis : Marked volume loss, which does not occur with simple pneumonia. Tomography and bronchoscopy can exclude br. obstruction. 3. Drowned lung: When fluid and exudate fill the lung distal to an obstruction appears as dense homogenous consolidation with absent air bronchogram. 4. Slow resolution : Generally if pneumonic consolidation persists more than > 8 weeks after appropriate therapy in a patient who does not have any systemic disease→ suspect underlying obstruction 5. Recurrence : Repeated pneumonia to same segment or lobe is highly suggestive of obstructing bronch. lesion, or local parenchymal abnormality as bronchiectasis. OBSTRUCTIVE HYPERINFLATION See emphysema BRONCHOCELE (MUCOID IMPACTION) Definition: Accumulation of mucus, pus or caseous materials within distended bronchi distal to a segmental bronchus but without collapse. Radiological features : - Oval or finger like branding homogenous opacities along the axis of bronchial tree usually upper lobe. - Tomography (this low density is clearly seen)> - Bronchography shows obstruction as sharp cut off in the contrast column. - With increasing distension, bronchocele assumes a round shape DD from bronchogenic cyst. - Infection bronchiectatic changes. DD: Arteriovenous malformation by: *Multiplicity in AVM with presence of feeding and draining vessels. *Absence of obstructive hyperinflation in AVM. Chest 64 ____________________________________________________________________________ BRONCHIECTASIS Irreversible dilatation of a bronchus (persistant dilataion of ! bronchi ass. with suppurative infla. Etiology : Commonly due to a severe, recurrent or persistent infection which leads to dilation of large airways and obstruction with destructive process of smaller ones bronchiolitis obliterans. NB: Inflammation & destruction: large bronchi dilated (yield under pr.) * Small obstructed (bronchiolitis obliterans). Predisposing factors (infection) : 1. TB 2. Severe childhood pneumonia especially (pertussis, measles). 3. Those associated with bronchial obstruction.(luminal, extraluminal, intraluminal ). 4. Those associated with either inborn immunological defect or with inborn structural abnormalities of bronchial wall e.g. Kartagner’s syndrome. *Non infective bronchial wall damage : occurs following inhalation of toxic gases and allergic damage of aspergillosis. Site : - May be localized, multifocal or generalized. - It is commonly basal but it may be confined to upper zone e.g. TB. CP: See internal medicine (Chest: cough,expectoration, positional- toxemia,clubbing, complict) Types of bronchiectasis : (features of bronchography) 1. Cylindrical bronchiectasis : = tubular. - Bronchial dilation is generally mild with more or less parallel walls, “squared of” ends and some preservation of the side branches. - DD : a. Chronic bronchitis mild and more widespread. b. Collapsed lobe mechanical dilation of collapsed lobe. 4. Fusiform bronchiectasis : . CT : Can identify the degree of bronchiectatic changes and underlying disease (before surgery. Peribronchial thickening and retained secretions. 3.The side branches are permanently occluded and only a handful of bronchial generations distal to the lobar bronchi remain patent. Varicose and cystic or saccular type : .Chest 65 ____________________________________________________________________________ 2. typically at segmental or subsegmental level is highly suggestive of allergic aspergillosis. .This appearance. Coarse honeycomb pattern in very severe disease.e loss of volume. Cystic spaces = air fluid levels. 3. Bronchography : as types of bronchiectasis. 5.Much more dilatation and irregularity with a beaded or saccular outline to airway which end in a bulbous fashion.) . Radiological features : 1.Varicose bronchiectasis with preserved side branches. . It may be normal in 7% 2. Crowded vessels i. early complain 66% . or central.Central: tumor arising at bronchus . Radiological pictures. hilaer LN.Peripheral: tumor arise from lung tissue late complain 33% Diagnosis of bronchogenic carcinoma depends on : 1. Biopsy (U/S.. carcinoma. Squamous cell carcinoma 50%. Tomography : Better definition of lesion but does not differentiate benign from malignant. d. Undifferentiated carcinoma. pulmonary tumors (hamartoma. or at bronchoscopy). c. Peripheral: WHO III: Adenocarcinoma pancost. carc. including alveolar c. Predisposing factors : Cigarette smoking and asbestosis (pneumocon). malig. (APUD. horner. ( periph. massive hilar LN) . . 2. pancost. Age : peak at 6th decade.Large cell type 10%. Clinical picture. apical. CT guided. (central. small . others. b. lymphoma. Plain. peripheral. Adenocarcinoma. never cavitates. small.. WHO II: oat small all anaplastic central. Computed tomography (the best) + MRI. a. 20% (bronchioloalveolar cell/ periph. BRONCHIAL OR BRONCHOGENIC CARCINOMA Incidence: Male:female 5:1.Chest 66 ____________________________________________________________________________ PULMONARY NEOPLASM Benign : Intrabronchial tumors (adenoma). large cavitates). angioma) Malignant : Bronchial. large. cavitates. NB: Central : WHO I: sq-cell car central. never cavitates.) Types : . WHO IV: Large cell carcinoma. 3. 2. (carcinoid.Small cells (Oat cell type) 20%. Pathological types : 1. metastasis. . cylindroma). until it is 1cm in size or more. may be oval or dumbbell shaped. Cavitation : (better seen by CT or tomography).Appear as peripheral tubular density which may branch &occur distal to the mass. notched (umblicated) or irregular ill-defined. Frequently eccentric.Chest 67 ____________________________________________________________________________ Radiological features : A. c. 3. Peripheral tumors: A mass in lung having the following features : 1. Shape : Mainly spherical. Border (edge): . Tumor nodules may be visible.An air fluid level (when communicates with air way). Size : variability is unusual to identify a nodule. . 2.May be seen between a peripherally located mass lesion and pleura.Bronchocele. .The peripheral lung mass may cavitate. *NB:-Squamous cell carcinoma cavitates more frequently than the other types while Oat cell carcinoma never cavitates. Mass effect: . 7. 4. A peripheral line shadow (Tail): . b. *The cavity : a. . rarely smooth. due to obstruction to the segmental or subsegmental bronchus. irregular wall. Calcification : Lack of calcification is the basis and when it is present it is mainly due to engulfment of the tumor to pre-existing calcified granulomata (TB. . 6. -DD : from other cavitary lung lesions.Lobulated. which may break off and lie within the cavity simulating to a mycetoma. revealing central air lucency.Corona radiata: Numerous fine strands may be seen radiating into lung from mass with more transradiant lung parenchyma than normal between these strands which is highly suggestive for carcinoma. Thick. fungal) 5. . Pneumonia confined to one lobe with loss of volume. Central tumors : Identified by (mass. Persistence of localized pneumonia on appropriate antibiotic therapy for more than 8 weeks. Consolidation due to : . An associated hilar mass is rare to occur with simple pneumonia.Encroachment of ! tumor on bronchial lumen causes irregular narrowing or even complete obstruction of a major bronchus leading to : a.Inability to evacuate secretion.This phenomenon can occur in both benign and malignant lesion. 2. signs of air way obstruction). Pneumonia that remains confined to one segment for more than 2 weeks without clearing or spreading into other segments as in simple pneumonia. . . Central bronchial mass. 1.2ry infection (pneumonia). * The more lobular ! shape. NB: Features suggestive of pneumonia secondary to a bronchial carcinoma : 1. 2. 3.Chest 68 ____________________________________________________________________________ .It is mainly due to plate like atalectasis. Unilateral hilar enlargement which is either due to: a. B. the more ! wide spread more suggestive for adenopathy. Atalectasis (+ its signs). Consolidation-collapse. b. Differentiated by shape & extent of lesion. Enlargement of lymph nodes (hilar). . Signs of air-way obstruction (+ SVC) . c. 4. b. Signs of central carcinoma : 1. .Bronchoscopy should be done. secondary to bronchial obstruction or septal edema due to lymphatic obstruction.(No) air bronchogram mainly absent. * Increased density of hilum at one side without significant enlargement may occur to super imposition of the mass on hilum. . * < 1 cm in diameter much suggestive to normal. .CT is the most sensitive method for detecting mediastinal adenopathy.) . Hilar and mediastinal lymph node metastasis : .Phrenic nerve paralysis high hemidiaphragm on chest X-ray. .The peripheral lung carcinoma may cross the pleura and invade the chest wall causing rib or spinal destruction (+ Horners syndrome.Chest 69 ____________________________________________________________________________ C. * > 2cm more suggestive of metastatic neoplasm.Can not be evident on plain film. .Lower lobe collapse.CT can provide evidence of mediastinal invasion.The size of ! L. Mediastinal invasion : .Subpulmonary effusion. . b. Chest wall invasion : . . 2ry to lymphatic obstruction. .Phrenic nerve paralysis. c. * 1-2 cm in diameter considered abnormal but not necessarily neoplastic.N.Pleural invasion:……. 4. Invasion of the pleura by tumor.Central adenopathy may be difficult to be recognized by plain film and can be only recognized by CT or tomography. . 2.Liver enlargement (2ry to metastasis). pleural effusion *Causes of pleural effusion in bronchial carcinoma : a.May be present at the time of initial diagnosis particularly with adenocarcinoma and Oat cell carcinoma. *Cause of high hemidiaphragm in Br.. 3. 2ry to associated pneumonia. unless phrenic nerve is invaded. Spread of tumor : 1. . detected is of great importance in suggestion of metastasis. . carc. 4. cell carcinoma : . . .A common central tumor giving rise to atalectasis. .Cavitation unusual .Blood metastasis : To : . Lymphangitis carcinomatosa. 5. 3. .Either peripheral or central. .Often have visible rib or spine invasion at presentation. . ribs and spine. N. Differences in radiographic patterns according to cell type : 1. .B. Sq. .Ipsilateral lung.mostly adenocarcinoma : . 7.Chest 70 ____________________________________________________________________________ *Superior sulcus tumors (Pancost’s tumor).Clinically may present with shoulder and arm pain due to chest wall invasion + Horner’s syndrome due to invasion of the stellate ganglion (sympathetic).Often give rise to massive hilar or mediastinal adenopathy with a small or no primary tumor could be detected.: Rib destruction is the only sign that differentiates Pancost’s tumor from other benign pleural cap lesion.Usually presents as an ill defined peripheral mass 4cm in diameter.Suprarenal gland (common) or by “lymph spread”. Pulmonary osteoarthropathy. Adenocarcinoma : (20%) .1/3 of tumors arise peripherally. mainly attain a large size before being symptomatic and often cavitate. 6.Large mass cavitation is rare.Atalectasis and or consolidation are common association with hilar mass. .Bronchus obstruction is second common presentation.More common in upper lobes (pancost) . Small cell carcinoma (Oat cell): . 2. Large cell carcinoma : . .Chest 71 ____________________________________________________________________________ ALVEOLAR CELL CARCINOMA (Bronchiolar or bronchio-alveolar carcinoma 5%) It is a subtype of adenocarcinoma. .Septal lines (A. Pulmonary edema. because the cells line the alveoli.: C/P : Cough with production of mucoid sputum (mucus is produced by malignant cells.Lymphoma. DD: 1. Widespread broncho pneumonia. . but do not compress air ways. .Pseudo lymphoma.B Kerley’s lines) and pleural effusion may be seen. 2.The lungs show widespread air space shadowing Unhomogenous consolidation which may contain air bronchogram. N. Diffuse form: (rare) . B.B: Lung carcinomas which show air bronchogram: . .Air bronchogram may be seen within a nodule.Alveolar cell carcinoma. Local form: -Often presents as a peripheral pulmonary nodule which is usually indistinguishable from other cell types . Radiologically : two forms A. medist. * T2 collapsed lung has higher signal > tumor (high signal effusion. Central bronchogenic.Central mass + collapse + pneumonia DD LN . chest wall. ms. bronchocele. . Vascular eg increase Pulmon. 4. adrenal invasion ie local & distal spread. vascular. small & close to hilum) with intermediate intensity on T1 & high on T2. ie.Alveolar cell (local. Tomography. TB.Detects effects (LN++. Lymph node: Met. cavitation. . close to hilar Vs * T1 intermediate signal of tumor high signal intensity of surrounding fat. shape.Chest 72 ____________________________________________________________________________ CT : . pleura. tail . Collapse 2.Lymphoma NB: Increased size of the hilum: 1. . adrenals. edge. diffuse).Differentiates between it (?? The tumor) & lung collapse . medist invasion. lymphangitis + Pulmn osteoarthropathy. liver). Lymphoma. *Summary . .Spread: Hilum. MRI : * Size of tumor esp.Peripheral size.) * Chest wall. blood. or aortic root 3.Metastotic lung . calcification.Detects small nodules. : Mass (esp. .Wide spread.Are due to haematogenous spread from breast. . breast. pancreas and prostate.Cavitation may be seen particularly in metastasis. one or more discrete pulmonary nodules. GIT. colon. .Bronchial carcinoma is ! commonest cause of unilateral lymphangitis carcinomatosis. Hilar and mediastinal node metastasis (see mediastinum) C. tests and from a variety of bone and soft tissue sarcomas.It may be unilateral or bilateral. composed of squamous cell carcinoma risk of pneumothorax. . .Chest radiology 73 __________________________________________________________________________________ METASTATIC TUMOURS A. radiating from tumor in hilar lymph nodes.The fissures may be thickened by subpulmonary edema. .Signs of associated lesion as bronchial carc. which are usually spherical and well defined but it may take any shape and may be irregular.The commonest causes are bronchial carcinoma.Calcification (rare) except in osteosarcoma and chondrosarcoma.Pleural effusion common but small. ill defined 2-3 mm nodular pattern together with wide spread thickening of the pulmonary septa. . . . 2. . Radiologically : .Solitary large cannon ball metastasis usually with renal cell carcinoma (hyper nephroma). . Mechanism : 1. . Or it is probable that initial dissemination is via blood stream and invasion of intrapulmonary lymphatics takes place with permeation of tumor towards hilae and with no initial involvement of hilar lymph nodes. .A solitary metastasis may be a presenting feature without a known primary tumor. Lymphatic permeation. Pulmonary metastasis : . slow: thyroid malignancy.Rate of growth is variable: Very rapid: osteosarcoma.It is a from of metastatic carcinoma in which the pulmonary lymphatics are invaded and blocked by cords of malignant cells. B. Lymphangitis carcinomatosis : . stomach.Appear as. . kidney. Chest radiology 74 __________________________________________________________________________________ Lymphangitis carcinomatosis: - Miliary Metastases. Pulmonary hypertension : .Picture of pulmonary hypertension. Military metastasis : . . - Interstitial fibrosis. trophoblastic carcinomas). . are ! commonest primary tumor to give rise to endobronchial metastasis. DD : Pulmonary edema. . . Unusual pattern of metastasis : Endobronchial metastasis : .Radiologically : Effect of air way obstruction is the dominant feature.Renal and colonic carc.Tumor emboli may block small pulmonary arterioles.The commonest causes are : (Thyroid.It is a particular feature of choriocarcinoma. - Lymphatic permeation. . .Miliary pattern with no evidence of lung masses or associated lymphatic obstr.Unusual. renal. . b. Bone.Mainly occurs with lymphocytic lymphoma. 2.May occur subpleural. . Rib deposits: . Radiological features: 1. Ataxia (telengectasia). . . Pulmonary masses : .May occur and indistinguishable from infection. PDF to develop malig lymphoma : 1. 4. Radiation pneumonitis. Pericardial effusion. 3.(mixture of linear streaks. Lobar atalectasis : results from occlusion by endobronchial dis. Pleural effusion. Consolidation : resembling pneumonia. 8.Rapid increase in size of lymphomatous deposits mainly occurs with histocytic lymphoma. Miliary nodulation : . 2.Common with histocytic lymphoma. (Extension from hilar LN to lung by interlobular. Wiskott Aldrich Synd (cong immune deficiency). small node). Phenytoin. 5. + mediastinal adenopathy. .Usually multiple with irregular smooth border + cavitation. 4. Diffuse lymphangitic form : (Kerley’s A and B lines) . Autoimmune dis (Rhtoid. Occupational exposure: benzene. Associated features : a.Chest radiology 75 __________________________________________________________________________________ MALIGNANT LYMPHOMA Primary pulmonary involvement by malignant lymphoma is usually accompanied by mediastinal adenopathy. perivascular & peribronchial lymphatic channels deposits in intrapulmn.It may radiate from hilum without confining to a segmental anatomy resembling pulmonary edema. SLE. bands and clusters of small nodules).Air bronchogram may be seen.May be segmental or lobar in shape. . 6. . 5. Organ transplantation. 6. 3. Myasthenia). 7. spherical or lobulated endobronchial mass and unlike br. .Central (bronchial obstruction – Extrabronchial mass). solitary. where this extrabronchial component may be visible as a hilar mass.Chest radiology 76 __________________________________________________________________________________ Non-Hodgkin: * rarely starts in thorax. .Have slow rate of growth. infarction.They are not related to smoking. lesions without hilar lymphadenopathy. with well defined smooth edge.Microscopic infiltration of leuk cells around bronch & vessels & alvealor will. . usually seen by tomography as. Sjogern synd. Peripheral lesion (10%).Arise from trachea. Central lesion (90%): . 1. hge. the adjacent bronchial wall is smooth and there is no bronchial narrowing above the lesion. 1.Mediastinal & hilar LN. . . Radiologically : A.The endobronchial part. . .It is locally invasive and spreading to regional hilar LNS.Mainly affect young age. carcinoma. Other primary malignant tumors of the lung : Compared to bronchogenic care : . Lymphocytic interstitial pneumonia. 2. carina or main stem bronchus. Average diameter 4cm and almost never calcify. spherical or lobular nodule. ADENOID CYSTIC CARCINOMA (Cylindroma) . Carcinoid tumors : . pseudolymphoma. 2. . pulmn. . Extranodal mucosa associated lymphoma . B. * Common pulm. .Arise from APUD system (argentaffin cells).Presented as.Infection. Leukemia : .The tumor arising from larger bronchi often have a larger mass lying outside the bronchus than inside it.Diagnosis is confirmed by bronchoscopy. The density may be heterogeneous due to the presence of central lucencies which is probably due to fat content .Popcorn calcification (characteristic). frequently multiple (papillomatosis).True adenomas are rare. Adenoma :. . . .It may be central or peripheral. Bronchocele (Obstruction at segmental or subsegmental level). . . Primary sarcoma of lung : (Rare) . . which may be. 2.Mainly appears as a solitary pulmonary nodule (90 peripheral. spotty. Papilloma : Warty tumors. 10% central. or mucoepidermoids). linear or coarse irregular granularity .Affect young age. Fibroma and lipoma : B. Chondroma : Arise from bronchial cartilage. 3. very well defined nodule . Atalectasis ± pneumonia or lung abscess.It is seen as a spherical or slightly lobulated. Intrabronchial tumors : 1. .Nodal metastasis unusual and distal metastases is late. 2.This type does not include carcinoid or cylindroma. Pulmonary tumors : 1.) . 3. 4.It is either (mucous gland adenoma. . usually < 4cm in size with normal surrounding lung. . Repeated infection bronchiectasis. BENIGN TUMOURS A. 3. Hamartomas : It is composed of a mixture of tissues normally present in the lung.In central lesions (manifestations of major airway obstruction).Chest radiology 77 __________________________________________________________________________________ Signs of bronchial obstruction : 1.Radiologically : Large regular well defined mass. including (cartilage and epithelial elements).Calcification of the cartilage element is common. Radiographic features : . 4. 3. 4. 3.Chest radiology 78 __________________________________________________________________________________ 2. Sequestrated lobe. Outside : Psendopulmonary mass (cutaneous mass. Histoplasmosis. Mycetoma (fungal ball). . 2. pleural “encysted effusion.Spontaneous rupture (pulmonary haematoma).imp) 1. c. Chronic abscess. 3. AVM. . . 3. 3. 2. Others : 1. fungball. Cavernous haemangiomas. Pulmonary haematoma. . Pulmonary infarction. bony lesion. Granuloma: TB. Vascular : 1.Often reveals multiple lesions. Bronchogenic cyst. tumor plaque). lymphoma) 2. Parasitic (Hydatid cyst). Neurofibroma. Inflammatory: 1. 2. Capillary haemangiomas. Malignant : (1ry. Angioma : a. metastasis. b. Rheumatoid 5.Draining vein + feeding artery. Benign : (Hamartomas. neurofibroma) 2. CAUSES OF SOLITARY PULMONARY MASS (v. AV malformation. Neoplastic : 1. Laterally: Parietal pleura.2ry infection (of a non septic infarction).TB. Granuloma . Hydatid. (squamous) . 2.Chest radiology 79 __________________________________________________________________________________ Causes of intracavitary lesion in lungs :(same cavitation + cystic bronchiectasis + emphysematous bullae A. MEDIASTINUM Is situated between the lungs in the center of the thorax. Posteriorly : Thoracic spine. E. B. Anteriorly : Sternum.Bronchogenic carcinoma.Aspergillosis. . C. amoebic. Rheumatic nodule. Vascular : Infarction due to : . . Bronchogenic cyst. Haematoma. aureus and klebsiella. . 3.1ry infection (septic emboli) = pyemia. 2. . Sequestrated lung. as solitary nodule but with . Abnormal lung : (cong) 1. Boundaries : Superiorly : Thoracic inlet. Inferiorly: Central tendon of the diaphragm. 1. Sarcoidosis.(Pneumoconiosis) F. Progressive massive fibrosis. Traumatic : 1.Staph. Infective (Abscess) . D. 4. Neoplastic : .Lymphoma.Metastasis. Infective emphysematous bullae. Cystic bronchiectasis. 3. myeloma. CT is the best method. primary “chondrosarcoma. Fine needle aspiration biopsy either under fluoroscopic or CT guided control. Morgagni hernia. 4. 2. Thymic tumors. giant cell tumors”) Region III : 1. Thymic tumors. 3. 10. Region II: 1. ANTERIOR MEDIASTINAL MASSES Located anterior to the pericardium and trachea : Region I: 1. Tortuous innominate artery. 3. 4. 4. MRI. 3.Chest radiology 80 __________________________________________________________________________________ Radiological methods of investigation : 1. 8. lymphoma. 7. Isotope scanning. 5. Arteriography and venography. 2. Sternal tumors (2ries. Lymphangioma. 2. Myelography. Standard high KV chest radiography. Diaphragmatic hump. Teratodermoid tumors (germinal cell neoplasms). Barium studies. Fat deposition and pericardiac pad of fat./young adult-doesn’t displace trach. Conventional mediastinal tomography. mediastinal or paravertebral mass) 3. 5. Pleuropericardial cysts. . Aneurysm of ascending aorta. 5. 2. Ultrasound. (for evaluation of hilar . 6. 9. Lipoma. Retrosternal goiter. . Clinically : . CT: confirms the diagnosis : Isotope scanning : Shows an area of increased activity extending below ! sternal notch (diagnostic). . .Chest radiology 81 __________________________________________________________________________________ THYROID TUMORS Less than < 5% of enlarged thyroid glands in the neck extend into the mediastinum to produce a retrosternal goiter. stridor and superior vena cava compression syndrome in malignancy.In 20%. linear or crescentic patterns of calcification (not a sure sign). . which extends downward from the neck. the goiters are retrotracheal posterior displacement of the esophagus and the trachea.The mass commonly projects to the right side of mediastinum with displacement and compression of the trachea to the left. US: (Cystic / Solid) Biopsy.The outline is well defined in the mediastinum but fades off in the neck due to its anterior location.The mass may contain central nodular.Dysphagia.Soft tissue swelling that moves on swallowing. Radiographic features : Plain : . .An oval soft tissue mass in the superior part of the anterior mediastinum. . Malignant thymoma pleural metastasis.. Radiographic features : Plain : . SLE. Thymic cyst. Rhtoid. Presentation : .Myasthenia gravis in 10% of cases. projects to one side of the anterior mediastinum. CT guided biopsy can confirm the diagnosis. hyper PTH. Benign and malignant (30%) thymoma. Hyperplasia of the gland: associates thyrotoxicosis. Lateral tomography : Can show the outline of such a mass. 3./ Absence in D’George’s synd : T lymphocyte immune deficiency disease). addison. Thymic tumors include . It may disappear radiologically in the presence of severe neonatal pulmonary infection. 2. 2. . CT : 1. 6. . . Carcinoid tumors cushing synd.Chest radiology 82 __________________________________________________________________________________ THYMIC TUMOURS The normal thymus gland is the commonest cause of a mediastinal abnormality in infants.Anterior mediastinal mass in non symptomatic adult patient. Thymic enlargement after radiotherapy for Hodgkin.( More prominent in expiratory or slightly rotated film.It may contain a peripheral rim or central nodules of calcification. 4. 1. It produces a triangular soft tissue mass which projects to one side often the right of the anterior mediastinum sail sign. arcomegally. .Thymolipoma : a very large soft tissue mass with less radiographic density which changes its shape with respiration. 5. Demonstrates the signs of invasion in malignant thymomas. Thymolipomas. . Shows a soft tissue mass in the anterior mediastinum which occasionally contains calcium or cyst fluid. 3.A round or oval soft tissue mass. .The outline is well defined but becomes irregular in very large tumors due to peripheral atalectasis in surrounding compressed lung. Benign dermoid cyst : . usually project to one side of anterior mediastinum. meso.Appears as round or oval soft tissue mass. cough and chest pain.Appears as a lobulated soft tissue mass which projects on both sides of the anterior mediastinum. .Choriocarcinoma. Radiographic features : Plain : A.Chest radiology 83 __________________________________________________________________________________ TERATODERMOID TUMOURS Germ cell tumors include : . B.All are thought to arise from primitive germ cell rests in the urogenital ridge. Origin : . Presentation : . cyst fluid.Embryonal cell carcinomas . . calcium. a fat fluid level or a rudimentary tooth which is a diagnostic sign. Computed tomography : Solid mass of variable attenuation densities which contains soft tissue. bone or fat.Seminomas.Dyspnea. . .The mass may contain a peripheral rim or central nodules of calcification.Dermoid cyst (ectoderm). endo) . .Benign or malignant teratoma (ecto. .Anterior mediastinal mass in an asymptomatic young adult patient.About 70% of teratodermoid tumors are benign. Malignant teratoma : . About 75% of pleuropericardial cysts occur in right anterior cardiophrenic angle.Excessive deposition of fat in the mediastinum usually presents with widening of the superior part of mediastinum and large epicardial pad of fat in asymptomatic obese patient + Cushing.U.Thin walled cyst containing fluid of low attenuation (0-10 H. . Radiographic features : 1.Cystic swelling.(DD: goitre) 2. Plain : .DD : 1. CT : . PLEUROPERICARDIAL CYST Presentation : An anterior or middle mediastinal mass in asymptomatic adult patient.Fluid density. . Mediastinal lymphadenopathy. Radiological features : 1.It can alter in shape on respiration. .) = Spring water cysts. CT confirms the diagnosis : . FAT DEPOSITION .Chest radiology 84 __________________________________________________________________________________ LYMPHANGIOMA (CYSTIC HYGROMA) Presentation : . Dissecting aortic aneurysm. oval or triangular soft tissue mass in the anterior or middle mediastinum which alters its shape on respiration. .Appears as an oval soft tissue mass in the superior part of the anterior mediastinum which extends up into the neck. Plain : . 2. .A round. but does not displace the trachea. 2.Diagnosis is confirmed by CT : .Soft tissue swelling that transilluminates in the root of the neck in children. 3.An anterior mediastinal mass in an asymptomatic adult patient. Partial eventration of the right hemidiaphragm. epigastric pain and dyspnea. 3.Contains omentum. Morgagni hernia (may contain gas). Thymolipoma. 2. Epicardial fat pad. .Contain small or large bowel or stomach. NB: Masses that alter their shape with respiration 1.The foramen of morgagni is a persistent developmental defect in the diaphragm anteriorly between the septum transversum and the costal origin of the diaphragm.Chest radiology 85 __________________________________________________________________________________ DD from masses in the right cardiophrenic angle : 1. 6. 2. hernias are situated in the right anterior cardiophrenic angle due to the protective affect of the pericardium on the left.Barium studies (meal. 4. Presentation : .More than 90% of morg. Direct needle puncture and aspiration under CT or US guidance. Small hernias : .The hernia can produce retrosternal chest pain. . Large hernias : . 4. Pleuropericardial cyst. MORGAGNI HERNIA Anatomy : . Lymphangioma. Achalasia. 5. . Right middle lobe opleural pathology. . (Hiatus hernia. Lipoma. a loop of transverse colon above the diaphragm and within the chest. Epiphrenic diverticulum). which appears as a rounded soft tissue mass. 3. Right atrial or pericardial tumors. .g. follow through and enema) confirm the diagnosis e.Appear as soft tissue mass containing either gas or gas fluid levels. Bronchogenic cyst. 5.100 H. Tracheal tumors. tracheobronchial. Tuberculosis.Plain chest normal.Histoplasmosis + coccidioidomycosis 2. . bronchopulmonary (hilar) and subcarinal groups. MEDIASTINAL LYMPH NODE ENLARGEMENT Enlargement of the paratracheal. Aortic aneurysm. Lymph node enlargement. 7. Coarctation) 6.Usually presents with hypercalcaemia in an adult patient with hyperparathyroidism. Causes : 1.(RT. Radiological features : . 2. Dilatation of mediastinal veins. 3. CT : Solid mass of fatty attenuation (-50 to . .Abdomen nephrocalinosis or renal calculi. Other infections and granulomas silicosis + amyloidosis .An ectopic parathyroid gland in the chest. . Lymphoma 5. Bronchogenic cyst. 4. 6.) MIDDLE MEDIASTINAL MASSES 1. Tracheomalacia. Metastatic deposits 4. Vascular anomalies. The diagnosis is confirmed by isotope scan.U. Leukemia.Chest radiology 86 __________________________________________________________________________________ PARATHYROID ADENOMA (rare) Presentation : .Skeletal changes of hyperparathyroidism. LIPOMA Plain : A round or oval soft tissue mass with radiographic density and can alter in shape on respiration. Sided Aortic Arch. Dilated main pulm. 3. Sarcoidosis 7. . Measles. Testicular tumors : Paratracheal L.It produces either: * Unilateral hilar mass with an irregular lobulated outline.Such as Histoplasmosis and coccidioidomycosis. Pyogenic lung. adrenal. thyroid).Can metastasize to the right hilar LNs. renal.May involve the posterior mediastinal lymph nodes.Peripheral calcification occasionally occurs in the lymph nodes egg shell calcification. Fungal infections : .Produces an area of consolidation in one of the lobes and a unilateral hilar enlargement.Actinomycosis is ! only fungus causing unilateral hilar lymphadenopathy : USA.Calcification may develop in both primary Ghon’s focus and mediastinal lymph nodes as healing occurs..N. Adenoviruses.May produce enlargement of the hilar or paratracheal lymph nodes. laryngeal.Intrathoracic (bronchial carc. Lymphoma : . Bronchial carcinoma : .Usually involves the paratracheal and tracheobronchial lymph nodes producing asymmetrical bilateral widening of the superior part of the middle mediastinum. Mycoplasma .Chest radiology 87 __________________________________________________________________________________ Metastatic diseases : . Renal and adrenal tumors : .Extrathoracic (breast. . * Widening of superior part of middle mediastinum due to a superior vena caval compression syndrome. . testicular.Calcification may occur in healing stage. pharyngeal. cancer oesoph). whooping cough. ??Also :Infections mononucleosis. Primary TB : . . . .Is the commonest primary tumor to metastasize in mediastinal LN.Involvement of subcarinal lymph nodes splaying of the carina. Esophageal carcinoma : . . . Chest radiology 88 __________________________________________________________________________________ ANEURYSM OF THORACIC AORTA Causes in cardiovascular : Presentation : . Computed tomography : . TORTUOUS INNOMINATE ARTERY Produces widening of the superior part of ! mediastinum on the right side without displacement of the aorta . Radiological features : Plain : a. A round or oval soft tissue mass in any part of mediastinum with a well defined outline. Anterior scalloping of one or two vertebral bodies.) due to enhancement of the blood pool with water soluble contrast medium (true). c. The subintimal flap and false lumen of a dissecting aneurysm can be demonstrated by CT. Pressure erosion of the sternum. Fluoroscopy : .Hoarseness of voice due to traction on Recurrent laryngeal Nerve. b.Confirm the diagnosis except if the aneurysm is thrombosed.Chest pain radiating to back (dissecting).Pulsatile masses are not a sure sign. 2. May also involve adjacent bones producing : 1. Sometimes a peripheral rim of calcification. . Widening of the mediastinum.U. MRI ) .A peripheral layer of clot of lower attenuation which may contain calcification (false lumen). . because any mass adjacent to aorta transmits its pulsation. d. .Dysphagia.Shows a dilated aorta containing a central lumen of blood of high attenuation (80-100 H. Thoracic aortography (& DSA. Causes : 1. Same cause of increased CVP. through which the hilar vessels can be seen. DILATATION OF MEDIASTINAL VEINS Dilatation of superior vena cava produces widening of the superior part of the mediastinum on the right. 4. Rt atrial tumors.C dilatation : = Causes of increased central venous pressure: 1. Cardiomyopathy.V. Congestive H. 3. . DD : LN enlargement: although azygous vein alters in size with change in position or during valsalva. RIGHT SIDED AORTIC ARCH Fallot’s in cardiovascular system. Obst. 2. Constrictive pericarditis. Causes of S. Portal hypertension. failure. 4. Cong azygous continuation of IVC. 2. 5. Mediastinal masses (compress the SVC) Dilatation of azygous vein: produces an oval soft tissues mass in right tracheobronchial angle.Chest radiology 89 __________________________________________________________________________________ DILATATION OF THE MAIN PULMONARY ARTERY Can produce an apparent left hilar mass. Tricuspid valve disease 3. of SVC or IVC. Diagnosis : is confirmed by venacavography & CT. 6. . Bochdalek hernia.Narrowing of the tracheal lumen by a soft tissue mass.Rapid increase in its size indicates internal hemorrhage. O: Pseudopancreatic cyst. . 2. subcarinal regions.A mass of soft tissue attenuation (10-15 H. Anterior thoracic meningocele. Aorta unfolded. dyspnea. POSTERIOR MEDIASTINAL MASS Region I (Paravertebral): 1. Dilated esophagus. 4. 2. paratracheal. CT : . Radiological Features: Plain : . Region III : 1. dilated or aneurysmal.A round or oval soft tissue mass in the middle mediastinum frequently on the right side near ! carina. Enteric cyst : is an intestinal duplication cyst related to oesoph. Tracheobronchial (hilar). The majority of bronchogenic cysts occur around the carina. stridor in children. Neuroenteric cyst. Young adults.The diagnosis is confirmed by tomography and CT. 3. extra medullary haemopoietic system . cough. C/O : Asymptomatic. chest pain.Chest radiology 90 __________________________________________________________________________________ BRONCHOGENIC CYST Age : Children. 3. Region II : 1. .) Tracheal tumors: (rare) Radiologically : .U. Hiatus hernia.An air fluid level is present after rupture of an infected cyst into the bronchial tree. 3. Other paravertebral masses. 2. Neurogenic tumors. .Pleural effusion . Neuroblastoma : . Presentation : . The benign N. The malignant N. . Neuroblastoma) arise in the thoracic sympathetic ganglia. neurilemmoma “Schwannoma”) arise from peripheral inter costal nerves.Enlargement of the intervertebral foramen = dumbbell shaped tumor. Plain x-ray : Neurofibroma : .B. . NB: Neurogenic tumors may involve the posterior ribs or adjacent thoracic vertebra. tumors can produce : . . N.Splaying of several posterior ribs. . Pheochromocytoma). Ganglioneuroma : . (paravertebral gutter) Child : (Ganglioneuroma. . Occurs in the paraganglionic nerve tissue.Bony destruction.A rather elongated soft tissue mass in comparison to the more circular shape of Neurofibroma.Posterior mediastinal mass in asymptomatic child or young adult.Back pain.A localized pressure erosion defect of one or two vertebral bodies.May be part of multiple neurofibromatosis = Von Reklenhousen disease.Rib notching. Others : (Neurofibrosarcoma.Chest radiology 91 __________________________________________________________________________________ NEUROGENIC TUMORS Adult : (Neurofibroma. Radiological features : 1. tumors can produce : .Neurogenic tumor appears as a round or oval soft tissue mass with well defined outline in the paravertebral gutter which project to one side of posterior mediastinum. About 30% of neurogenic tumors are malignant. . .Rapid increase in size of the mass.It may extend through an intervertebral foramen into the spinal canal (hence their name “dumbbell tumors) spinal canal compression syndrome.May contain central spicules or a peripheral rim of calcification. . usually projects on both sides of the posterior mediastinum. bone destruction).Can demonstrate intraspinal extension.Dyspnea. 4. . 2. . 3. Penetrated P film. 5. Myelography : . Radiological features : . Disseminated lymphoma and metastatic carcinoma with paraspinal extension. 6.Chest radiology 92 __________________________________________________________________________________ 2.Involvement of adjacent thoracic vertebrae or intervertebral disc spaces. 2. Conventional tomography. retrosternal chest pain and epigastric discomfort. A traumatic wedge compression fracture of a vertebral body with heamatoma formation. The diagnosis can be confirmed by : 1. Lateral film. . 2. Inflammatory lesion (narrow disc space. 4. Extramedullary haemopoietic tissue. CT + CT guided biopsy. Multiple myelomas. PARAVERTEBRAL LESIONS Common causes of paravertebral mass : 1. A pyogenic or tuberculous paraspinal abscess.Posterior mediastinal mass in asymptomatic elderly patient. Neurogenic tumors. HIATUS HERNIA Presentation : . DD : 1. NB: MRI is superior > CT (better soft T contrast). Computed tomography : . 3. Neoplastic lesion (only bone destruction). 3.An elougated or lobulated soft tissue shadow with a well defined outline.A solid mass of soft tissue attenuation. which may contain calcification and may involve the adjacent bones. Shows the stomach above the diaphragm and within chest. 2.No air in the fundus of stomach. Presby esophagus.Round soft tissue mass in sup part of post mediastinum containing air fluid level. . . . 5. Benign esophageal stricture.A round soft tissue mass containing an air fluid level directed behind ! heart. Cancer esophagus : 3. 4. Pharyngoesophageal pouch (Zenker’s diverticulum) Plain : .Forward displacement of trachea. Achalasia of the cardia. .Chest radiology 93 __________________________________________________________________________________ Radiological features : 1. Mega esophagus : 1. Plain : .An air fluid level in the superior part of the posterior mediastinum with non homogenous mottled appearance of food particles mixed with air. Radiological features : - *Plain : . 3. Barium meal : . *Barium swallow : Confirms the diagnosis. Cancer esophagus. OESOPHAGEAL LESIONS 1.Widening of the posterior mediastinum behind ! heart on the right extending from the thoracic inlet to the diaphragm.In 70% it lies to the left of midline in the posterior mediastinum. . 2. 2. Systemic sclerosis. Radiological features : .Partial or complete persistence of neuroenteric canal + vert anomalies. hernia. * Ipsilateral lung is invariably hypoplastic. NB: Enteric cyst: Intestinal duplication cyst related to ! esophagus + no vertebral anomalies. . N.I. Presentation : . U/S 4. . 2. .B: 13 pairs of ribs may occur in association with a Bochdalek. kidney or spleen.Posterior mediastinal mass in asymptomatic adult patient.Acute respiratory distress in neonatal period.Large hernia: * contains small or large bowel * appears as multiple ring shadows in the chest due to air filled loops of bowel. 1. Urography : Can also confirm diagnosis by showing liver. .About 90% of Bochdalek hernia occur in the left hemidiaphragm due to ! protective effect of liver on ! right . spleen or kidney above diaphragm.V. appears as a soft tissue mass posterior costophrenic angle.T. . NEUROENTERIC CYSTS Etiology : .Chest radiology 94 __________________________________________________________________________________ BOCHDALEK HERNIA Anatomy : The foramen of Bochdalek is a persistent developmental defect in the diaphragm posteriorly produced by a failure of the pleuro-peritoneal canal membrane to fuse with the dorsal esophageal mesentery medially and the body wall laterally. I. Barium: 3.The cysts are often connected to the spinal meninges and to ! G.Small hernia: usually contain retroperitoneal fat. * Displacement of the ! heart and mediastinum to the contralateral side.Incomplete separation of foregut from the notocord in the embryonic life. Plain : . dysphagia. . Plain : . .A mass of soft tissue attenuation.Respiratory distress or feeding difficulties in infants. Radiological features : 1.) extending from abdomen into chest through aortic hiatus behind the diaphragmatic crura. 3. .A round or oval soft tissue mass behind ! heart. EXTRAMEDULARY HAEMOPOIETIC SYSTEM Causes : Chronic hemolytic anemia (Thalassaemia major) Radiological features : . .It appears as a lobulated paravertebral soft tissue mass behind ! heart. Diagnosis is confirmed by myelogarphy in prone position. Computed tomography : . Computed tomography : .Abdomen film: hepatosplenomegaly. .Chest pain in young adult.Typically abnormal skeletal survey (see bone). A well defined mass anterior to spine and projects into lung field.A round or oval soft tissue mass in the posterior mediastinum between the esophagus and the spine causing forward displacement of the esophagus. Plain : . In patients with Neurofibromatosis PSEUDO PANCREATIC CYST Presentation : .Thin walled cystic mass containing fluid (0-20 H. if peptic ulceration occurs within it. 2. 4. The spine show hemivertebra. 2. ANTERIOR THORACIC MENINGOCELE 1.An air fluid level is present after rupture of an infected cyst in ! esophagus. Radiological features : 1.Chest radiology 95 __________________________________________________________________________________ Presentation : . 2.The cyst extending through the esophageal or aortic hiatus into the chest dyspnea.U.Left basal pleural effusion or atalectasis. . DSA: retrograde filling of dilated veins such as ! jugular. Pneumoperitoneum. Reidles thyroditis.Chest radiology 96 __________________________________________________________________________________ PNEUMOMEDIASTINUM Incidental. azygous & internal mammary veins.Vs & other structures with displacement of the parietal layer of the pleura laterally. Perforation of esophagus osophoscopy or Mallory-Weiss.Pleural effusion. Chronic mediastinitis (mediastinal fibrosis) .Common with radiotherapy. Causes : 1. 5. . idiopathic retroperitoneal fibrosis . Mediastinal hemorrhage : .SVC cavography . Air tracks up to neck surgical emphysema.Leaking aortic aneurysm. Whooping cough. IPPV. spinal fracture. .Lateral film air behind sternum or heart. 3.Presents with SVC compression. 4. .Occasionally abscess.Chest pain + fever. . pneumo or hydrothorax.Mediastinum is widened & edematous houtline. . Radiologically : Plain : . Acute mediastinitis : . TB.Plain: wide medistinum . . 2.Plain: widened medistinum. asymptomatic or chest pain which worsens by breathing . . Asthma.Trauma . Rupture of trachea bronchoscopy or trauma.Translucent streaks of gas outlining bl. II. Bronchopneumonia : Multifocal (bronchocentric) infection based on the pulmonary lobule & spreads along the bronchial axis. 3. Homogenous non segmented consolidation. so there is no volume loss & air bronchogram is common. Alveolitis on interstitial pneumonitis: Inflammatory process mainly affecting the alveolar wall. Multi focal. Volume loss is common. Air bronchogram is usually absent.Bronchogenic pneumonia : 1. 3. Centered on air ways. . Affected by bronchiolitis so initially patchy &distributed in course of air ways so it is segmental. Centered on distal air spaces (alveoli). Unifocal. Air way obst. (Pathogenic organism) Pneumonitis : General term= inflammatory reaction of the lung ± consolidation. Rapid spread across the pores of khon uniform consolidation. 2. As airways are not involved & remain patent. 4. Radiologically : 1. May become uniform with confluence later. Spare distal airway.Lobar pneumonia : Pathology : 1. 4. atalectasis & pneumatoceles. Radiologically : 1. 2. Spread along bronchial axis. 5. DIFFERENCE BETWEEN LOBAR AND BRONCHOPNEUMONIA: I. Non homogenous segmental consolidation.Chest radiology 97 __________________________________________________________________________________ PNEUMONIAS Pneumonia: Infective consolidation of the lung (replacement of alveolar air by exudate). 2. 2. 4. 3. Chlamydial pneumonia. 3.No volume loss of the affected lobe.Air bronchogram is commonly present (characteristic).Chest radiology 98 __________________________________________________________________________________ ACUTE PNEUMONIA Etiology : A. . Legionella pneumophilia. but it may occur any where and also may be multifocal.Viral eg influenza & varicella.Kerley’s B lines may appear in affected area from temporary over loading of lymphatics and edema of the interlobar septa. aureus.Commonly basal and solitary. c. NB: All cause bronchopneumonia except Pneumococi (basal) & Klebseilla (apical) cause lobar Pneumococcal (Strept. Non bacterial causes : .Consolidation may not be obvious and suspected by silhouette sign of boundary effacement. alcoholism.Ricketsial pneumonia. a. b. most common 2.Cavitation (lung abscess) rare. . . Bacterial causes : 1. B.) Pneumonia : Age : Extreme of age (occurs at any age). Klebseilla Freidlenders. .Gram -ve organisms. . . Pneumococci (streptococcus pn). effusion / 2.Anaerobic organisms.Staph. e.Initially peripheral. . Loss common : . E coli & proteus.) 1. Predisposing factors: (Chronic illness. Complications : (not common unless treatment is delayed./ 3. d. homogenous consolidation limited by fissure. Haemophlus influenza. . . Delayed resolution. splenectomy). Radiological features : . Empyema. non segmental.Mycoplasma pneumonia : most common. . Pseudomonas. Upper lobes. Rupture of cavity in pleura empyema. .Consolidation is classically segmental & patchy at least initially but later confluent & homogenous. which mainly persists for months or disappear leaving no trace. 4. Septicaemic staph pneumonia multifocal. .Air bronchogram is unusual. Features of complication : 1. Radiologically : . Debilitated hospitalized patients.Has no characteristic radiographic pattern. .volume loss is common.Pulmonary infections follow mechanical ventilation or inhalation therapy . Aspiration from URTI (common). .Middle aged & elderly debilitated persons.Homogenous well demarcated unifocal consolidation.Chest radiology 99 __________________________________________________________________________________ STAPHYLOCOCCUS PNEUMONA: PDF : 1. nodular consolidation. Pneumatocele formation: Occurs when consolidation and fluid content of the abscess cavity are resolved leaving thin hair-line walled air cavities.(Lobar) . Collapse. .Mainly affects the lower lobes and its radiological pattern is similar to staph aureus infection. INFLUENZA: . KLEBSIELLA OR FRIEDLANDER’S PN: . consolidation cavitation and abscess formation.Often. 3.Similar to strept pneumonia. PSEUDOMONAS AERUGINOSA: . Due to strong tendency for necrosis that occur in the center of staph. H. 5. 2. . 2.Mainly associated with chronic lung disease is chronic bronchitis or secondary invader in influenza virus infection. . Multifocal & bilateral. 2. Results commonly from aspiration of infected oral contents. Toxoplasma. LEGIONNAIRES DISEASE (Legionella pneumophilia) .Empyema is common bronchopleural fistula. Adenovirus. . resolution tends to be slow over several weeks but usually complete. Mycoplasma 3.Common in ♂.Chest radiology 100 __________________________________________________________________________________ . .Homogenous. Radiologically : . Q fever = Rickettsial.Consolidation is voluminous by inflammatory exudation.Initially there is a unilateral peripheral lower zone consolidation rapid progression with confluence and or spread of consolidation to other lobes of same or opposite side.Characteristically.Effusion 50%. . . more on the RT side.Rapid cavitation. . Clinically : . septicemia. Often clinically subacute or chronic with prominent systemic symptoms. 2.Cavitation.Similar to bacterial pneumonia and sometimes associated with G. MYCOPLASMA PNEUMONIA: Mycoplasma pneumoniae is an organism intermediate between bacteria and virus. Complications: . 4.Consolidation is uni or multifocal & tends to occupy segments favored by aspiration eg (posterior upper / Apical lower/ postero basal). mainly occurs in epidemic & associated with contaminated water. . Psittacosis . It is one of organisms produce primary atypical pneumonia which are: Causes of primary atypical pneumonia : 1. intestinal and neurological features. abscess and pneumatocele. ANAEROBIC PNEUMONIA Differs from other bacterial pneumonia in that : 1.Chlamydial 5. Radiologically : . so the affected lobe may be swollen & fissures may bulge. but usually cavitation lung abscess. which may simultaneously come and go in different areas. INFLUENZAE Predisposing Factors: old age. Radiologically: .Radiologically: wide spread nodules. . VIRAL PNEUMONIA: . mediastinal & hilar adenopathy. Predisposing f: Lymphoma. VARICELLA Typically affecting young adults. Other possible patterns : .On resolution. the process is reversed. .Massive bilateral bronchopneumonia with abscess formation.Characteristically. .Initially. interstitial streaks from hila. usually resolve in a week but it may persist. .Chest radiology 101 __________________________________________________________________________________ PRIMARY ATYPICAL PNEUMONIA : Radiologically of changing pattern : .Multiple irregular patches with ill defined margins. fine reticulation due to interstitial inflammation followed by consolidation of involved area.Nodules. . or as a part of generalized viral illness in varicella.Common in infants and children. widespread 5-10 mm nodules.20% of the opacities calcify. .Multiple small well defined nodules.Fulminating fibrosing alveolitis.Resolution tends to be slower than bacterial pneumonia. may be be followed by fibrosis. viral pneumonia may be primary as in influenza. .In adult. debilitated persons.It begins a few days after the onset of symptoms. usually segmental or lobar. pregnancy. . Radiologically : .Extensive bilateral confluent consolidation which if patient survives. . . . .. delayed in app. which is caused by coxiella burnetti. Infection by specific material. CHLAMYDIAL PNEUMONIA: The commonest lung infection is ornilhosis caused by chlamydia Psittaci. Abscess formation : . Hydropneumothorax: Iatrogenic or rupture of pneumotocele or abscess or br.Causes: A. . . Fistula.pl. Aspiration of infected material. (staph.One or more rounded segmental consolidations in the lower zone. Effusion: most common with anaerobes .Factors in favor : 1. B. staph & strept.Linear areas of collapse (common). communicates with airway & contents are discharged with resultant air fluid level formation. & C & pneumatoceles.. unusual dist. gram-ve) D. Radiologically : . strept. or when associated with fluid level abscess. Empyema: staph aureus. Tuberculosis.Chest radiology 102 __________________________________________________________________________________ RICKETSIAL PNEUMONIA: The most common ricketsial lung infection is Q fever. * Associated with A. which is mainly acquired from sheep and cattle. B. anaerobes Rad: indistinguishable from effusion. which is acquired from sick birds. patchy or miliary consolidation. 3. Radiologically : .Variable pattern: lobar. .Abscess is within area of consolidation.Resolution mainly slow. Infection by anaerobic organisms. Localized transradiancies: 1. gam-ve ligonella. B. . ASSOCIATED FEATURES AND LOCAL COMPLICATIONS OF PNEUMONIA: A. suspected when large. . * No lobar predilection * Thick walled with raged inner lining.Slow resolution. Staph aureus : * Usually multiple. 2. C. Pneumonia thrombosis of intrapulmn Vs gangrene to pulmn.t partial obst.full of fluid. Pneumatocele : Def. containing an irregular intracavitary body. : pneumonia + empyaema. . & strept. 2. .Most common with Klebseilla pn. Site : in area of consolidation Size : variable. Shape : hair line wall . G.Septicemic staph pneumonia multifocal. * More common in upper lobe. . Course : resolve. F.Occurs when consolidation & fluid content of an abscess cavity are resolved.. hydatid. of small branches. . cavitary neoplasm.With agents that initially bronchitis or bronchiolitis eg staph aureus. DD : hernia Emphysematous bullae ( its wall is made of surrounding compressed lung tissue) .Underlying disease eg sequestrated segment. Number : multiple or solitary. Lobar expansion : . bronchiectasis. rickettsia. bronchogenic cyst. fungal. nodular consolidation. Pulmonary gangrene : .Suspected when a large irreg.: cyst in lung during course of pneumonia (staph aureus).Mainly with Klebseilla pneumonia. leaving thin hair-line walled air cavities which mainly persist for months or disappears leaving no trace. Klebsiella :* Usually single.Chest radiology 103 __________________________________________________________________________________ C. cavity develops. area supplied by these Vs. Pneumatocele : . Residual scarring : .Parenchymal & pleural scarring “fibroses” with volume loss. Cause : tension cyst d. . E. Compl. amebiasis D.May be seen in resolution phase (esp children) . Gram-ve. * Thick walled. 3. Collapse : . Homogenous non seg Non homogenous. achalasia or hiatus hernia. Khon consolidation 3.B. Presence of predisposing local cause e.C. Pn. septicemia. Pn. When changes persist beyond two months delayed resolution. + necrosis & cavitation + pneumatoceles++. systemic disease. TB. Pneumonias (KEY): PDF/AGE/Complications A.g. prep & basal Staph Br. + lower lobes+ in pt with mechanical ventilation H.No volume loss volume loss (atalectasis) . N. 3.B: * Mendelson’s syndrome : Chemical pneumonia./Path & Rad. Repeated aspiration: chronic sinusitis. 3. Inappropriate therapy e. * Young’s syndrome : Obstructive azospermia / Sinusitis / Chr. influenza Br. Spare distal air ways 4. Causes of delayed resolution : 1.D. Centered on air spaces 2. mycosis. Legionella male epidemic. Airway obst.G & resolution. streaks & LN. caused by aspiration of acid gastric contents during anesthesia producing intense bronchospasm which is rapidly followed by pulmonary edema.g.+ associated chronic lung dis viral Klebseilla (fredlender) lobar+ upper lobe + voluminous inflm exudate. 4. empyema or atalectasis. Spread along bronchial 4. Lobar BronchoPneumonia 1. Centered on airways. ↓ ↓ .F. 5. Pn. Anaerobic Br.E. Very extensive consolidation or complicated with cavitation. bronchiectasis. Mycoplasma Atypical pneumonia : also: Q Ricketsial & chlamydial Viral viral symptoms + Bilat fibrosis + nodules.Chest radiology 104 __________________________________________________________________________________ RESOLUTION 90% of bacterial (except TB) and non bacterial pneumonias resolve within one month. Unifocal 1. segmental (late confluece) .. occupy segments favored by aspiration. bronchiectasis or air way obstruction. The commonest : old age. pulmonary infecting eg. Pseudomonas Br. water + GIT & CNS features + preph lower zones. Multifocal 2. .Air bronchogram no air bronchogram Strept lobar + kerly’s b dt fissure edema. 2.Pn. 3. focus is not identified & main sign is hilar or mediastinal lymphadenopathy. Pulmonary Histoplasmosis : Caused by histoplasma capsulatum (soil dust) 1. Histoplasma granuloma : . B. . .Indistinguishable from fibrocavitary TB.Vs .Rounded nodule < 2cm.Widespread small consolidations us may calcify chch pattern of innumerable small calcifications distributed throughout ! lungs. . .Nodules (multiple or single) up to 3cm. II. 2. Chronic pulmonary form : A.Rare : Miliary pattern due to blood dissemination. . Coccidioidomycosis : Caused by coccidia fungus : I.Initially. .presence of central calcification is diagnostic. pulmn. . / mediastinal LN. .Calcified LN may extend into! bronchi.Chest radiology 105 __________________________________________________________________________________ FUNGAL INFECTION A. B. .Cavitation thin wall cavities (grape skin).Mainly lower lobes. Chronic fibrocavitary form : . where they are known as broncholiths bronchial obst. .Mainly upper lobes. Pleural effusion. . Calcify.Cavitation thin wall cavities (resembles TB) DD: miliary TB. .Usually well defined edges .With healing calcification of initial pulmn focus/ lymph nodes.Nodular form : .Inhalation & soil dust contaminated by bird droppings.In few cases: mediastinal fibrosis constriction of major Vs: SVC & pulmn. . Patchy consolidation : .Irregular: difficult to distinguish from primary carcinoma. Acute inhalation histoplasmosis : . Benign primary form : . Blood clot in a cavity.. 4. and +ve skin reaction to aspergillus. cavitary bronchogenic carcinoma). rib osteomylitis . 3. .. * Organizing lobar pneumonia. . The difference is that it develops in an apparently previously normal lung tissue. cong.Mycetoma mainly doesn’t appear in CXR dt high opacity of fungus ball with thickening of the adjacent pleura. empyema. cell C. DD : 1. Cavitary sq.A hypersensitivity reaction. 3. bronchopulmonary. .Chest radiology 106 __________________________________________________________________________________ C. increased serum IgE.No characteristic radiological pattern : * Necrotizing bronchopneumonia with abscess formation.Commensal in oropharynx (normally): Aspiration lower lobe pneumonia (dependant) abscess formation. 2. Allergic. Actinomycosis : . * Single or multiple nodules (1-5cm) which may cavitate. Aspergillosis : Aspergillus fumigatus fungus. * It can mimic with an aspergilloma .. .. 2. lung cyst.Common in upper lobe. Simple lung abscess.Sinuses open on skin yellow sulfur granules. Pulmonary mycetoma (Aspergilloma) . . Disintegrated hydatid cyst.Diagnosis is established by (CT.Pneumonia in immunocompromised pt.It is associated with blood eosinophillia. D. which occurs in ! major airways of some asthmatics. Sarcoidosis. aspergillosis : . histoplasmosis. Three forms : 1. Invasive aspergillosis : .Here ! fungus is present as a saprophyte where ! fungal hyphae are matted together in ! form of a ball in a pre existing lung cavity (eg TB. tomography) that reveales the fungus ball delineated by a crescent of air (halo sign). . reticulations. . B. E. Chronic changes : . .Asymptomatic nodule. allergic response (eosinophillic interstitial infiltration / intraalveolar exudate). . . . . . Moniliasis (candidiasis) : (rare) Caused by candida albicans (normal month community).Small ill defined migrating nodules (0.Linear shadows indicative of fibrosis.Ring formation indicative of bronchiectasis . . . .5cm) : scattered.Streaks radiating from hila & peripheral. . Radiologically: .Node enlargement. . F.The pulmonary lesion is a chronic pneumonia which breaks down with abscess formation.Mycetoma may develop in abscess cavity indistinguishable from aspergilloma.Potential for re-activation. Tropical pulmonary eosinophillia (Filariasis) : Pulmn. common upper lobe (loffler $). opacities of a predominately eosinophillic histology associated with blood eosinophillia.Chest radiology 107 __________________________________________________________________________________ Radiologically : A.Consists of non segmental areas of consolidation. .Branching thick tubular opacities due to distended bronchi with mucus and fungus (bronchocele).Consists of bronchial wall thickening with tram line shadows.Chronic pneumonia.Severe snow storm picture.Lobar collapse. Acute changes : . Blastomycosis : .Subtle bilateral midzonal haze. N.B: Loffler’s synd = applied to almost any transient pulmn. PARASITIC PULMONARY INFECTIONS A. . homogenous with air bronchogram.Chest radiology 108 __________________________________________________________________________________ B. young adult male . .If lodge in large arteries irritation vas. Arteries (100 m) small granulomas like TB.Basal band shadow (discoid atalectasis). . . Radiologically: .Diffuse bilateral pulmonary opacification like pulmonary edema. US liver. Pneumocystitis carinii infection : Only expressed in immunocompromised patients.Diffuse interstitial fibrosis.Elevation of hemidiaphragm.Presented as primary atypical pneumonia and mediastinal lymphadenopathy.Eggs lodge in small pulmn. 2.Blood spread consolidation or abscess in part away from ! diaphragm. Pleuropulmonary amoebiasis : Usually secondary to liver amaebiasis. 3.When liver abscess erodes ! diaphragm basal non segmental consolidation cavitates & fistulae develops between air way & pericardium. . Toxoplasmosis : .Human acquisition is from cats. Radiologically : . Also aspiration biopsy guided by U/S is valuable. Protozoa : 1. . 3. Schistosomiazis : . C. . Serological test. Diagnosis : 1. necrosis fibrotic occlusion pulmn. which may complicate with pneumothorax and pneumomediastinum. . 2. where multiple air cysts with air fluid level may be seen.Focal emphysema may occur. hypertension (Ayerza dis). pleural effusion / or thickening. Bronchography: * ?? c. Angiography: * derives its bl. Radiological appearance: Plain: * Soft tissue mass in posterior part of lower lobe close to the diaphragm (> on lt. Radiologically : The cyst is unilocular.Infection .Chest radiology 109 __________________________________________________________________________________ D. .) * Rupture of a liver cyst into ! right lung produces a basal opacity from lobar infection or atalectasis-pleural effusion.m. Complication : . TC99m labelled IDA hepatic defect. lower lobe is the next most common site. CONGENITAL PULMONARY SEQUESTRATION Definition: a portion of the lung is separated from the normal bronchial tree & blood supply.side). *Bronchial tree is spread around the mass & is typically complete with no of its divisions. * venous drainage is via the pulmonary system or IVC. smoothly spherical and of homogenous density. Rt. Hydatid Disease : Infection with the tape warm Echinococcus granuloses. Divisions : 1. though retaining some characteristics of lung tissue.Rupture: * into ! pleural cavity or a bronchus. * Partial replacement of fluid by air (fluid level. calcification is rare. Intralobar : lying within the lung. rarely enters the lesion. usually posteriorly in left lower lobe. supply from ! descending thoracic aorta. * if connected to ! bronchial tree air containing cystic masses ± air fluid levels (infection). Amoebic lung abscess e. * venous drainage is via IVC. c. tree coughing of liquid center. candida. It is much less common than intralobar sequestration & is interposed between inferior surface of lt lower lobe & diaphragm + other congenital anomalies (found at autopsy).Chronic abscess : inner margin smoothens (fibrosis) & surrounding inflammatory reaction subsides. d.Chest radiology 110 __________________________________________________________________________________ II./ Klebs.Acute cavitation : irregular wall & surrounded by excessive inflammatory reaction. Thick wall. 4.Rupture: Central necrosis. commonest. . Actinomycosis. Extension : From amebic liver abscess. 5.Pneumonic : patch of consolidation surrounded by congestion. Inhalation : (primary). Embolic (Blood-born): Part of systemic pyemia or septicemia (staph). Miscellaneous : a. Destruction of affected areas with breaking down & cavitation 3. usually in base of Rt lung Stages . thin shaggy wall. cavity or cyst esp at left lung base. scattered in both lungs. small. Angiography: * arterial supply is frequently from abdominal aorta. Infected hydatid cyst. . pneumonic) TB/staph. Extra lobar : The non-functioning portion of the lung (sequestrated portion) develops enclosed in its own pleura. Malignant lung abscess: eccentric. LUNG ABSCESS (Localized suppurative inflammation of lung) Types (modes of infection) 1. thick irreg wall. C/P : Recurrent infection in part of a lung with unusual abscess. azygous or portal venous system. 2. Multiple. communicate with br. Infected pulmonary infarction. Aspergillus) b. . Pneumonic : complication of pneumonia (met or syn. empyema or mediastinitis (lymphatics). . Abscess on a preexisting solid lesion : 1. Peripheral bronchogenic Carcinoma: eccentric cavity with irreg. Abscess on a preexisting abnormality : - . Site : uncommon above clavicles. inner wall. Leak from cyst crumpled float within space originally occupied by cyst. Moist gangrene. 3. obst). 4. . . Hodgkin node. or Secondary Pn. sequestrated segment.Chest radiology 111 __________________________________________________________________________________ Complications : I-Local: 1. Chronicity amyloidosis. Toxemia 3. 4. 2. . Local extension 2.Evidence of the disease may be present elsewhere in the lungs III.Infected cyst. coal miner. Systemic pyemia septicemia 2.Inner lining : Shaggy smooth . bronchiectasis.Wall : thick thin 5. Consolidation : Primary Pn. Wegener’s granuloma. 2. Radiological features : I.Air fluid level within lumen . General: 1. Massive fibrosis in pneumoconiosis silicosis. Myocarditis. Fibrosis & bronchiectasis 4. 6. Hemoptysis 3. Hydatid cyst intracavitary body fluid level : water Lilly sign).↑ lobe containing abscess→ bulging of fissures. Corpulmonale II. 5. Abscess arising on cavitation of consolidation : 1. Metastases (sq-cell). 4. Surrounding lung tissue : . 3. 3. Size : Rapid increase indicates air trapping tension cavity. Fate : Resolution or lung damage (fibrosis & or bronchiectasis) II. Shape: . (br. 5.↑ markings & patchy consolidation (inflam). Brain abscess. Fate of tubercle 1. Macrophage phagocytose bacilli epithelioid cells. Granulomas: Wegener’s granulomatosis /Rheumatoid nodules caplan / Progressive massive fibrosis pneumoconiosis / Sarcoidosis. serous membranes & meninges of a sensitized individual esp. Proliferative reaction Tubercle made of : 1. Fusion of several epithelioid cells Langhan’s giant cells * Caseation of tubercle center occurs by lymphokines 4. DD: Lung cavities 1.Chest radiology 112 __________________________________________________________________________________ 6.B bacilli reach the lung.e Abscess Staph / Klebsiella / TB /Aspiration / Gram-ve / Fungi / Hydatid 2. Vascular: Infarction 4. blood. High immunity: complete fibrosis / fibrous capsule & central calcification. Neoplastic: Carcinomas of bronchus / Metastases / Hodgkin 3. Lymphocytes & fibroblasts usually surround epitheloid cells. or natural passages). Abnormal lung: Cystic bronchiectasis / sequestrated segment / bronchogenic cyst 5. of low resistance. Exudative reaction : Occurs when T. Traumatic Haematoma / Traumatic lung cyst Tuberculosis Body reactions : I. 3. II. Release of tuberculoprotein (cell mediated immune response) sensitized Tlymphocytes. 6. Low immunity: fuse to form bigger tuberculous patch / spread (local. lymphatic. 2. rapid caseation of the lesion occurs. 2. Caplan nodule. Infective i. . Ill defined roughly circular shadows 0. Disappears completely after healing. II. Shape of consolidation : 1. Primary pulmonary TB: Ghon’s. 2. Pneumonic consolidation (= pul focus = Gohn’s focus) Usually single. 3. It doesn’t cavitate but caseation is common producing calcified nodule on healing. Mottling (common): individual shadows 1-5mm in diameter with no tendency to coalesce. Encapsulation & Reactivation. II. Chronic active opacities + strands + cavities. III. hematogenous or bronchial. 2. segments of upper lobe & apical segments of lower lobes (upper post. Old healed fibrosis + calcification. Large homogenous areas up to lobar involvement. Slow resolution leaving only the calcification (no fibrosis in few cases). Post primary pulmonary TB: (reactivation or reinfection) 1. Spread : Direct. II. Glandular enlargement: (mediastinal / hilar) May obstruct bronchi collapse / consolidation. Radiological features of Primary Pulmonary TB : Affects children (& adults exposed for 1st lime) I. 3. It is differentiated from . homogenous. chest portions) Commonly bilateral (both apices / one apex & opposite mid zone). in mid or upper zones. Chronic fibrocaseous TB. Small pleural effusion : Course : I. Site : Apical & post. II. 2.Chest radiology 113 __________________________________________________________________________________ Classification of TB: I. variable in size.5-2 cm in diameter. Early fluffy opacities. III. Acute (Miliary TB of the lung / tuberculous bronchopneumonia) Post Primary TB : 1. Radiological features of Post Primary TB: (chronic) X-ray findings are basically those of consolidation (pneumonia) differentiated from other pneumonias by : I. IV. 2. & Lung damage. Emphysema: localized (bullae) / compensatory (fibrosed or collapsed lobe). 4. 5. Infiltrations : small discrete aceas (1-3mm) / Homogenous shadows (1-3cm).: Lymphadenopathy is rare in post primary TB. Less common forms of TB : I.B. Site: upper post chest positions (DM basal TB) when bilateral: both apices / one apex & opposite mid zone. Cavitation : very common : . Bronchiectasis : upper lobe. 2. Collapse of part or whole of ! lung: sputum block / LN compression / Endobronchial TB. Cavitation is common. Combination of events.Indicates active disease : 1.Usually rounded. A cavity surrounded by aerated lung (2mm thick). . Combination of events : Simultaneous spread & healing: areas of infiltration & Cavitation (active disease) together with fibrosis & calcification (healing). Calcifcation : In healing lesion irregular calcified foci in clusters. 3. Fibrosis: (Lung Damage / may cause fibrothorax): 1. Calcification in healing parts. All these consolidations: Increased Vascular markings reaching them Evidence of fibrosis III.Oval or spherical 1-3 cm in diameter. Tuberculoma : (chronic) . VI. well defined regular outline . 2.Usually located near pleural surface.Chest radiology 114 __________________________________________________________________________________ other pneumonias by site & infiltration in adjacent lung or other lung. N. Fibrous strands shift of normal land marks they persist after clearance of consolidation. seldom contain more than a trace of fluid. single . usually peripheral & lung around it invariably shows evidence of infiltration & fibrosis V. 3. Typical radiological features of chronic pulmonary TB : 1. 4. Breaking down in an area of homogenous consolidation. TB. FB Miliary TB : (Hematogenous interstitial nodules. Infections mononucleosis (brucellosis). Bronchogenic. ?? 2ry to bronchogenic carcinoma . 3. Segmental lesions . DD.Individual shadows are 1-2mm in diameter with indistinct margins. Blood bone.DD : (from neoplasm): calcification / LNS not enlarged / satellite shadows.g.Wide spread mottling evenly distributed in all zones. 4. TB heart & ribs Pulmonary hypertension HF.May cavitate (eccentric). DD : 1. 3. Pneumonias with LN enlargement : 1. 2. suppurative bronchitis. tongue entritis. Sarcoidosis .No lung changes except those due to the original Illness e. Complications : 1.Chest radiology 115 __________________________________________________________________________________ .Collapse consolidation of a single segment (endobronchial TB). Haemoptysis. Haemosiderosis . Amyloidosis. II. 2. Pleura pleurisy. . . . Pneumoconiosis 2. brain. TB. . TB bronchopneumonia. laryngitis . . 6.The commonest causes of segmental lesions in children : 1. 2. empyema.Initially discrete but coalesce into patchy consolidation in the terminal stage. Extrinsic allergic alveolitis 4.Carcinoma.) . male & female genital 5.collapse due to bronchial obst . Viral pneumonia 3. . evidence of pulm TB or lymphadenopathy (1ry TB).May calcify (flecks. pneumothorax. Massive solid lesions : Whole lobe (usually UL): dense consolidation . eccentric). II.