Radiological presentation of chest diseases gamal agmy

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<ul><li>1.Gamal Rabie Agmy, MD, FCCPProfessor of Chest Diseases, Assiut UniversityERS National Delegate of Egypt</li></ul><p>2. L:LungR:RibT:TracheaAK:Aortic knobA:Ascending aortaH:HeartV: VertebraP: PulmonaryarteryS:Spleen 3. Missing Right Breast"Hyperlucent" right base secondaryto missing breast.Silicone Breast Implantation 4. Cancer BreastLarger right breastInverted nippleRadiation Fibrosis ofLungRight lung smallerRight hemithorax smallerParamediastinal fibrosis 5. Cervical Rib 6. Pleural Effusion / Lytic Lesions in Clavicle and Scapula 7. Cervical rib 8. Kyphoscoliosis 9. Rib Fracture / Hematoma 10. Extra Pleural SignCancer LungDensity in peripherySharp inner marginIndistinct outer marginAngle of contact with chest wallExpanding destructive rib lesionParatracheal wideningThis is an example of an RUL lesion 11. Neurofibromatosis 12. Sprengels DeformityHigh set scapulaVertebral anomalyRib anomaly 13. Subcutaneous EmphysemaAir outlining pectoral musclesAir along chest wallPneumomediastinum 14. Lateral ChestThere is valuable information that can be obtained by a chestlateral view. A few of them are listed below:SternumVertebral columnRetrosternal spaceLocalization of lung lesionsLobes of lungsOblique fissuresPulmonary arteryHeartAortaMediastinal massesDiaphragmVolume measurementsSPNRadiologic TLCTracheoesophageal stripe 15. Tuberculosis of SpineLoss of intervertebral spaceVertebral collapseCold abscess is not present in this case. PA view is not diagnostic. 16. Mediastinal Lymph NodesExtrapleuralPolycyclic marginAnterior mediastinum 17. RML AtelectasisVague density in right lower lung field, almost normalRML atelectasis in lateral view, not evident in PA view 18. Atelectasis Left UpperLobeHazy density over leftupper lung fieldLoss of left heartsilhouetteTracheal shift to leftA: Forward movement of obliquefissureC: Atelectatic LULB: Herniated right lung 19. LocalizationWhen a lesion is not contiguous to asilhouette, it is not possible to localize itwithout a lateral view. This is a case of asolitary pulmonary nodule with popcorncalcification: Hamartoma. 20. Air Bronchogram In a normal chest x-ray, the tracheobronchial tree is notvisible beyond the 4th order. As the bronchial treebranches, the cartilaginous rings become thinner, andeventually disappear in respiratory bronchioles. Thelumen of the bronchus contains air and the surroundingalveoli contain air. Thus, there is no contrast to visualizethe bronchi. The air column in the bronchi beyond the 4th orderbecomes recognizable if the surrounding alveoli is filled,providing a contrast or if the bronchi get thickened The term air bronchogram is used for the former stateand signifies alveolar disease. 21. Silhouette SignAdjacent Lobe/SegmentSilhouetteRLL/Basal segmentsRight diaphragmRML/Medial segmentRight heart marginRUL/Anterior segmentAscending aortaLUL/Posterior segmentAortic knobLingula/Inferior segmentLeft heart marginLLL/Superior and basal segmentsDescending aortaLLL/Basal segmentsLeft diaphragmCardiac margins are clearly seen because there is contrast between the fluiddensity of the heart and the adjacent air filled alveoli. Both being of fluid density,you cannot visualize the partition of the right and left ventricle because there is nocontrast between them. If the adjacent lung is devoid of air, the clarity of thesilhouette will be lost. The silhouette sign is extremely useful in localizing lunglesions. 22. Atelectasis Right LungHomogenous density right hemithoraxMediastinal shift to rightRight hemithorax smallerRight heart and diaphragmatic silhouette are not identifiable 23. Atelectasis Left LungHomogenous density left hemithoraxMediastinal shift to leftLeft hemithorax smallerDiaphragm and heart silhouette are not identifiable 24. LateralMovement of oblique and transversefissuresAtelectasis Right Upper LobeHomogenous density right upper lungfieldMediastinal shift to rightLoss of silhouette of ascending aorta 25. Atelectasis Left UpperLobeHazy density over leftupper lung fieldLoss of left heartsilhouetteTracheal shift to leftLateralA: Forward movement ofoblique fissureB: Herniated right lungC: Atelectatic LUL 26. Consolidation RightUpper Lobe /Density in right upper lungfieldLobar densityLoss of ascending aortasilhouetteNo shift of mediastinumTransverse fissure notsignificantly shiftedAir bronchogram 27. Consolidation Left Lower LobeDensity in left lower lung fieldLeft heart silhouette intactLoss of diaphragmatic silhouetteNo shift of mediastinumPneumatoceleOne diaphragm only visibleLobar densityOblique fissure not significantlyshifted 28. Left Upper Lobe ConsolidationDensity in the left upper lung fieldLoss of silhouette of left heart marginDensity in the projection of LUL in lateral viewAir bronchogram in PA viewNo significant loss of lung volume 29. Vague density right lower lung fieldIndistinct right cardiac silhouetteIntact diaphragmatic silhouetteDensity corresponding to RMLNo loss of lung volumeRML pneumonia 30. S Curve of GoldenWhen there is a massadjacent to a fissure, thefissure takes the shapeof an "S". The proximalconvexity is due to a mass,and the distal concavity isdue to atelectasis. Note theshape of the transversefissure.This example represents aRUL mass with atelectasis 31. Tracheal ShiftTrachea is index of upper mediastinal position. The pleural pressures on eitherside determine the position of the mediastinum. The mediastinum will shifttowards the side with relatively higher negative pressure compared to theopposite side. Tracheal deviation can occur under the following conditions: Deviated towards diseased side Atelectasis Agenesis of lung Pneumonectomy Pleural fibrosis Deviated away from diseased side Pneumothorax Pleural effusion Large mass Mediastinal masses Tracheal masses Kyphoscoliosis 32. Atelectasis Right Lung Homogenous densityright hemithorax Mediastinal shift to right Right hemithorax smaller Right heart anddiaphragmatic silhouetteare not identifiable 33. Pleural Effusion Massive Unilateral homogenousdensity Mediastinal shift to right Left diaphragmatic andleft heart silhouettes lost Left hemithorax larger 34. Pneumonectomy Opacity lefthemithorax Tracheal shift to left Cardiac and leftdiaphragmaticsilhouettes missing Crowding of ribs 35. Air Bronchogram In a normal chest x-ray, the tracheobronchial tree is notvisible beyond the 4th order. As the bronchial treebranches, the cartilaginous rings become thinner, andeventually disappear in respiratory bronchioles. Thelumen of the bronchus contains air and the surroundingalveoli contain air. Thus, there is no contrast to visualizethe bronchi. The air column in the bronchi beyond the 4th orderbecomes recognizable if the surrounding alveoli is filled,providing a contrast or if the bronchi get thickened The term air bronchogram is used for the former stateand signifies alveolar disease. 36. Bowing Sign In LUL atelectasis orfollowing resection, as inthis case, the obliquefissure bows forwards(lateral view). Bowingsign refers to this feature.The arrow points to theforward movement of theleft oblique fissure. 37. Doubling Time Time to double in volume (not diameter) Useful in determining the etiology of solitarypulmonary nodule Utility Less than 30 days: Inflammatory process Greater than 450 days: Benign tumor Malignancy falls in between 38. Eccentric Location of Cavity in aMass Thick wall and irregular lumen can beseen in both malignancy andinflammatory lesions. However eccentric location of cavity isdiagnostic of malignancy. 39. This is an example ofsquamous cellcarcinoma lung. LUL mass Thick walled cavity Eccentric location ofcavity Fluid level This is diagnostic ofmalignancy. 40. Cortical Distribution Mirror image of pulmonary edema Alveolar disease of outer portion of lung Encountered in: Eosinophilic pneumonia Bronchiolitis obliterans with pneumonia 41. Medullary Distribution It is also called "butterfly pattern" Note the sparing of lung periphery both inthe CT, PA and lateral views This is one of the radiologic signsindicative of diffuse alveolar disease This is an example of alveolar proteinosis. 42. Note the sparing of lung periphery both in the CT, and PA viewThis is one of the radiologic signs indicative of diffuse alveolar diseaseThis is an example of alveolar proteinosis. 43. Diffuse Alveolar DiseaseRadiological Signs Butterfly distribution / Medullary distribution Lobar or segmental distribution Air bronchogram Alveologram Confluent shadows Soft fluffy edges Acinar nodules Rapid changes No significant loss of lung volume Ground glass appearance on HRCT 44. Distribution Cortical Eosinophilic pneumonia BOOP Lower lobes / Mineral oil aspiration Medullary 45. Acute Diffuse Alveolar Disease Water Pulmonary edema, Cardiogenic, Neurogenic pulmonary edema Blood SLE Goodpastures syndrome Idiopathic pulmonary hemosiderosis Wegeners granulomatosis Inflammatory Cytomegalovirus pneumonia Pneumocystis carinii pneumonia Influenza Chicken pox pneumonia Fat embolism Amniotic fluid embolism Adult respiratory distress syndrome 46. Acinar NodulesInterstitialAcinarSame sizeSharp edgessmallerVarying in sizeIndistinct edgesLarger than interstitial nodulesAcinar nodules are difficult to distinguish from interstitialnodules. Some distinguishing characteristics are as follows: 47. Cut Off Sign When you see an abrupt ending of visualizedbronchus, it is called a "cut off sign". It indicatesan intrabronchial lesion. This is useful to identifythe etiology of atelectasis . Be careful as thetracheobronchial tree is three dimensional andthe finding need to be confirmed with tomogram.In the modern era, a CT scan will take care ofthis. 48. Air Fluid LevelCauses Cavities Pleural space: Hydropneumothorax Bowel: Hiatal hernia Esophagus: Obstruction Mediastinum: Abscess Chest wall Normal stomach Dilated biliary tract Sub diaphragmatic abscess 49. Wedge Shaped DensityThe wedges base is pleuraland the apex is towards thehilum, giving a triangularshape. You can encountereither of the following:Vascular wedges :InfarctInvasive aspergillosisBronchial wedges :ConsolidationAtelectasis 50. Polycyclic MarginThe wavy shape ofthe mediastinal massmargin indicates thatit is made up ofmultiple masses,usually lymph nodes.This is a case oflymphoma. 51. Open Bronchus Sign / Alveolar AtelectasisThe right lung is atelectatic. You can see air bronchogram, which indicatesthat the airways are patent .This case is an example of adhesive alveolaratelectasis. 52. Pulmonary Artery OverlaySignThis is the same concept asa silhouette sign. If you canrecognize the interlobarpulmonary artery, it meansthat the mass seen is eitherin front of or behind it.This is an example of adissecting aneurysm. 53. S Curve of GoldenWhen there is a massadjacent to a fissure, thefissure takes the shapeof an "S". The proximalconvexity is due to a mass,and the distal concavity isdue to atelectasis. Note theshape of the transversefissure.This example represents aRUL mass with atelectasis 54. Tracheoesophageal StripeThe posterior wall of the trachea (T)and the anterior wall of the esophagus(E) are in close contact and form thetracheoesophageal stripe in the lateralview (arrow).It is considered abnormal when it iswider than __ mm.Common causes for thickening oftracheoesophageal stripe are:Esophageal diseaseNodal enlargement 55. AV FistulaOsler-Weber-RenduSyndrome"Pulmonary nodule"Multiple lesionsFeeding vesselCardiomegalyPatient presented withsevere congestive heartfailure and severe irondeficiency anemia. Hadmultiple telangiectasia oftongue, lips andconjunctivae. 56. PneumonectomyDiffuse hazinessSmaller right hemithoraxMediastinal shift to rightSurgical clips 57. The definition of atelectasis is loss of air in the alveoli;alveoli devoid of air (not replaced).A diagnosis of atelectasis requires the following:1-A density, representing lung devoid of air2-Signs indicating loss of lung volumeAtelectasis 58. 1-Absorption AtelectasisWhen airways are obstructed there is no furtherventilation to the lungs and beyond. In the earlystages, blood flow continues and gradually theoxygen and nitrogen get absorbed, resulting inatelectasis.Types of Atelectasis: 59. 2-Relaxation AtelectasisThe lung is held close to the chest wall because of thenegative pressure in the pleural space. Once thenegative pressure is lost the lung tends to recoil dueto elastic properties and becomes atelectatic. Thisoccurs in patients with pneumothorax and pleuraleffusion. In this instance, the loss of negativepressure in the pleura permits the lung to relax, dueto elastic recoil. There is common misconception thatatelectasis is due to compression.Types of Atelectasis: 60. 3-Adhesive Atelectasis :Surfactant reduces surface tension and keeps thealveoli open. In conditions where there is loss ofsurfactant, the alveoli collapse and becomeatelectatic. In ARDS this occurs diffusely to bothlungs. In pulmonary embolism due to loss of bloodflow and lack of CO2, the integrity of surfactantgets impaired.Types of Atelectasis: 61. Types of Atelectasis:4-Cicatricial AtelectasisAlveoli gets trapped in scar andbecomes atelectatic in fibroticdisorders 62. .5-Round AtelectasisAn instance where the lung gets trapped bypleural disease and is devoid of air.Classically encountered in asbestosis.Types of Atelectasis: 63. Generalized1-Shift of mediastinum: The trachea and heart gets shiftedtowards the atelectatic lung.2-Elevation of diaphragm: The diaphragm moves up andthe normal relationship between left and right side getsaltered.3-Drooping of shoulder.4-Crowding of ribs: The interspace between the ribs isnarrower compared to the opposite side.Signs of Loss of Lung Volume: 64. Movement of FissuresYou need a lateral view to appreciate the movement ofoblique fissures. Forward movement of oblique fissure inLUL atelectasis. Backward movement in lower lobeatelectasis.Movement of transverse fissure can be recognized in thePA film.Signs of Loss of Lung Volume: 65. Movement of HilumThe right hilum is normally slightly lower than the left.This relationship will change with lobar atelectasis.Signs of Loss of Lung Volume: 66. Compensatory HyperinflationCompensatory hyperinflation as evidenced by increasedradiolucency and splaying of vessels can be seen with thenormal lobe or opposite lung.Signs of Loss of Lung Volume: 67. Alterations in Proportion of Left andRight LungThe right lung is approximately 55% and left lung 45%. Inatelectasis this apportionment will change and can be aclue to recognition of atelectasis. .Signs of Loss of Lung Volume: 68. Hemithorax AsymmetryIn normals, the right and left hemithorax are equal in size.The size of the hemithorax will be asymmetrical andsmaller on the side of atelectasisSigns of Loss of Lung Volume: 69. Signs of Loss of Lung Volume:GeneralizedShift of mediastinum: The trachea and heart gets shifted towards the atelectatic lung.Elevation of diaphragm: The diaphragm moves up and the normal relationship between leftand right side gets altered.Drooping of shoulder.Crowding of ribs: The interspace between the ribs is n...</p>