Plain CXR. Fluoroscopy. CT scan. MRI. Ultrasound Angiography. Radionuclide studies.
Computed tomography *CT indications: Clinical suspicion of intrathoracic pathology with normal CXR, Detection of small lesion 2-3mm in diam at any part of lung Characterize nature of pulmonary mass ( fluid, fat, blood content, any calcification , and vascularity ) Pre-operative staging of primary tumour, Presence, extent & nature of mediastinal pathology ex.(mediastinal . LN enlargement in Ca & Lynphoma, differentiating vascular from non vascular pathology, causes of wide mediastinum). Evaluation of broncial tree down to segmental bronchi ex. Bronchiectasis (presence, extent and severity) Assessment of Pulmonary vessels (Ct pulm. Angiography) ex. Congenital anomalies, pulmonary embolism. Diffuse pul. Disease (Diagnosis and extent) CT guided biopsy.Technical factors: → 5-10 mm. → ± IVCM. → lung, medias. And bone window & normal interpretation (Blood vessels, pleura and bronchi)
MRI → limited role in (lung, pleura and media). →Ht and aorta →helpful in: → Sup. Sulcus T. (chest wall, spinal extension) →neural t. (intraspinal extent.) *US: →Peripheral pleural lesion (effusion, pneumothorax,mass) → Dx biopsy →any mass in contact with chest wall.
Most commonly requested radiological investigation of chest , it can diagnosis up to 80% of chest pathology.Standered view of chest are.Postero-anterior view(x-ray beam entre patient back, ,use 80-120kvp,focus film distance about 6feet) . . Additional view s:- these view not requested routinely , only done with some diagnostic problemsLateral view aiding in localization of lesion, (normally there is ↑ lucency downward dorsal spine) Anterioposterior view for patient stand to stand like infants , very tired patient cannot take PA view. ex. ICU patients.Oblique view. For ribs, chest wall. & retrocardiac areaApical lordotic view. For close visualization of apical segments of lung Decuitus view to diagnosis small (5cc) and subpulonaay pleural effusion
Reduces magnification of heart therefore preventing appearance of cardiomegalyReduces radiation dose to radiation sensitive organs such as thyroid,eyes,breastsVisualised maximum areas of lungMoves scapula away from the lung fieldsMore stable positioning for the patient as they can hold onto the unit – this reduces patient movement.Compression of breast tissue against the film cassette reduces the density of tissue therefore visualizing them more clearly
In PA view Clavicles don’t project too high into the apices or thrown above the apices (more horizontal)Heart wont be magnified over the mediastinum therefore preventing the appearance of cardiomegalyScapula are away from the lung fieldsRibs are obliquely oriented in PA viewSpine and posterior ends of ribs are clearly seen
P.A VIEW
AP VIEWWhat are the acceptable CXR criteria?
Is the Patient name and age ,sex, and date of examination are mentioned? Is it labelled?( Lt. or RT) Is it at good inspiration? Is I well centred? Is it of good exposure? Are al the lung fields , costphrenic angles are completely visualized
Inspiration: The volume of air in the hemithorax will affect the configuration of the heart in relation to cardiac size. The vascular pattern in the lung fields will be accentuated with a shallow inspiration. The level of inspiration can be estimated by counting ribs. Visualization of nine-ten posterior ribs, or six anterior ribs on an upright PA radiograph projecting above the diaphragm would indicate a satisfactory inspiration
Inspiration
ExpirationRotation . Rotation of the radiograph is assessed by judging the position of the clavicle heads and the thoracic spinous process.
1- general consideration : Patient name , age , sex, date to examination & position of the marker.2.thoracic cage; →Bone (ribs, spine, clavicle and shoulder joint) →soft tissue Soft tissues cast shadow on plain radiographs which have less dense radio-opacity.Breast shadow result in increased opacity over the lower thorax bilaterally.Nipple shadow may appear as round opacities in the 4th-5th or lower ant. Intercostal space.Breast and nipple shadow are usually bilateral and symmetrical.don’t mistake breast, nipple (5th ant. Rib space) for pulmary . shadow”3-Diaphragm → upper surface should clearly visualized from one costophrenic angle to another , except at Heart and mediastinum. → Rt. hemidiaphragm is 2.5 cm higher than Lt.A difference greater than 3 cm in the level of two hemi diaphragms is significantBoth costophrenic angles should be acute angle
NIPPLE SHADOWS
3-mediastinum → border sharp and distinct rt mediastinal border form by SVC superiorly and RT atrium inferiorly. Lt mediastinal border form by from above down ( aotic knucckles, Lt pul.A., Lt.atrial appendages &Lt ventricle)Tracheal position (midline from medial ends of clavicle), tracheal bifurcation ( carina ) seen at level of T5 vertebrae → Thymus seen in young children. Heart → position 1/3 to the Rt. → size (C/T ratio < 50%. Except in infant and atheltes patient may reach 60%) →shape4-Hilar region: →pul. A. , pul. V., main bronchi & hilar LN (LN normally too small to cast shadow). → Lt. hilum is slightly higher than Rt. by up to 1cm. →check size and density ( both hilum should be equal) .5- lung : compare two lungs zone by zone( the lung divided imaginary into three zones:Upper zone from apices to lower border of 2nd rib anteriorly.Mid zone from lower border of 2nd rib anteriorly -4th rib.Lower 4th- lung bases. → only marking seen (Blood vessel, large bronchus Wall ; seen end on & inter lobar fissure (two layers of pleura): →Azygous fissure seen in 1% of PA CXR seen at upper zone of RT lung. →horizontal Fissure only seen in frontal CXR, form Rt.6th rib. →oblique fissure seen only in lat. View.
OBLIQUE FISSURE major
HORIZONTAL FISSURE minor
OBLIQUE FISSURE (major)
CARINA
RT. MAIN BRONCHUS
LT. MAIN BRONCHUS
6TH RIB
Silhouette sign Air bronchiogram abnormal intrapulmonary shadow
The silhouette sign is extremely useful in localizing lung lesions. It means loss of cardiac, mediastinal and diaphragmatic border clarity when intra-thoracic lesion touching that border. Normally Cardiac margins are clearly seen because there is contrast between the density of the heart and the adjacent air filled alveoli., If the adjacent lung is devoid of air, the clarity of the silhouette will be lost. It has two important applications: * Localization of lesion. * Give Dx (consolidation, collapse),.Right diaphragm (RLL/Basal segments) Right heart margin (RML/Medial segment) Ascending aorta (RUL/Anterior segment) Aortic knob (LUL/Posterior segment) Left heart margin( Lingula/Inferior segment) Descending aorta (LLL/Superior and basal segments) Left diaphragm( LLL/Basal segments)
•Haziness in the right mid lung field. •Right heart margin slightly hazy with intact silhouette of right diaphragm •Middle lobe density in lateral •No significant loss of lung volume in lateral •Air bronchogram in lateral
•Haziness in the left lower lung field •Blunting of left costophrenic angle •Loss of silhouette of left heart margin •Density in the projection of lingula in lateral view •Air bronchogram in lateral •No significant loss of lung volume
Air filled bronchi( dark) made visible by opacified alveoli(white) . Its almost always caused by pathlogic airspace/alevolar process in which air are replaced by other material examples: Pulmonary oedema Blood Gastric aspirate Inflammatory exudates Causes : Pulmonary consolidation Pulmonary edema. Non obstructive atelectasisa Alveolar cell carcinoma Pulmonary lymphoma Pulmonary infarct
refers to non-specific air-space opacification on a chest radiograph or chest CT. Many things can fill the alveolar spaces, including fluid (heart failure), pus (pneumonia), blood (pulmonary haemorrhage) and cells (lung cancer). A.Lobar consolidation ( strep. Pneumonia) which is virtually dx of bacterial pneumonia: Lung opacity opacity. air bronchogram . Silhouette sign. No volume loss.
B. Patchy consolidation (Bronchopneumonia , lobular pneumonia) :One or more of ill defined shadows :causes Pneumonia Infarction Contusion Immunological disorders.
Cavitations ( abscess formation ) within consolidation occur due to bacterial or fungal infection. This only recognized by communication with the bronchial tree ( air fluid level).
Categorize any abnormal intrapulmonary shadow in to one of the following: 1-alevoar shadow. 2-Interstaial shadows 3-atealctasis
1- Air space alveolar shadow : refers to opacity on chest X-ray associated with fluid (transudative or exudative )Filling the acini, It is 4-8mm nodular shadowing , may coalesces to form ill define cotton wall shadows Causes of Alveolar Opacity pneumonitis pulmonary contusion pulmonary oedema Aspiration Neoplasm: alveolar cell carcinoma ,lymphoma
Pulmonary edema.
2- interstitial shadow: Pulmonary septa are connective tissue planes containing lymph vessels ,normally invisible . only thickened septa are visible the interstitial lung shadows result from thickening of any of the interstitial compartments by blood, water, tumour cells, fibrous disease or any combination .Anatomy of lung interstitial tissueCan be : Linear Reticular: fine or coarse linear shadowsReticulonodularNodular—small (2 to 3 mm), medium, large, or masses (>3 cm)Reticulonodular A reticulonodular interstitial pattern is produced by the presence of reticular shadowing and pulmonary nodules. While this is a relatively common appearance on a chest radiograph, very few diseases are confirmed to show this pattern pathologically. Examples include: silicosis pulmonary sarcoidosis lymphangitis carcinomatosis )
Miliary pattern — 2 to 3 mm well-defined nodules (“micronodular pattern”), causes: Infection: Tuberculosis, Fungal, Nocardia, VaricellaSilicosis, Coal Worker’s lung, Sarcoidosis, Eosinophilic granulomaNeoplastic (adenocarcinoma, thyroid CA.)5mm-3cm medium size nodular shadowingInfectionHyaline membrane disease AspirationAlevolar cell carcinoma sarcoidiosisamyloidiosisRadiation pneuomnitisDrugs >3cm lung nodule or mass
Small noduar shadow
Causes : Bronchial CA \ bronchial carcinoid . Benign tumours of the lung ; hamartoma (most common) . Infective granuloma ; tuberculoma & fungal granuloma . Metastasis . Lung abscess . Rarely rounded pneumonia .Metastasis . Hydatid cysts. Abscess . Fungal granuloma or tuberculomas . Collagen vascular disease .
3.Linear (plate, discoid, subsegmental) atelectasis .appear as relatively thin, linear densities in the lung bases oriented parallel to the diaphragm (known as Fleischner's lines Associated with signs of volume loss Common cause Postoperative obesity
Diseases of the airways Asthma : CXR is usually normal Chronic Obstructive Airway Disease (COPD) Include chronic bronchitis,emphysema and bronchiectasis the most common plain film appearance of asthma &COPD is "normal" and the role of chest radiography is to eliminate other causes of lung symptoms such as infection, bronchiectasis , cor pulmonale or cancer
is characterised by a triad of airway inflammation, reversible airway obstruction, and hyper-reactivity of the airways to a variety of stimuli. Radiological features Early in the disease the radiology may be entirely normal, anterior and posterior ribs are visible; lungs are otherwise clear. Chronic asthma is associated with a number of distinct radiographic changes. CXR lungs are hyperinflated bilateral diaphragmatic flatteningThere is bronchial wall thickening (>1 mm). This is a more marked finding in children and in adults with infection. There is also hilar enlargement due to a combination of lymphadenopathy and pulmonary hypertension. . CT :may confirm thickened bronchi, but also areas of mosaic perfusion on ‘lung windows’. These represent variable alternate areas of air trapping set against normally perfused and aerated lung. Always look for complications of asthma: Pneumothorax or rarely pneumomediastinum. Consolidation secondary to pulmonary infection. Mucus plugging and subsequent lobar or segmental lung collapse. In 2% allergic bronchopulmonary aspergillosis (ABPA) ASTHMA : is characterised by a triad of airway inflammation, reversible airway obstruction, and hyper-reactivity of the airways to a variety of stimuli. Radiological features Early in the disease the radiology may be entirely normal, bilateral low flat diaphragm,; lungs are otherwise clear. Chronic asthma is associated with a number of distinct radiographic changes. CXR lungs are hyper inflated, bilateral diaphragmatic flatteningThere is bronchial wall thickening (>1 mm). This is a more marked finding in children and in adults with infection. There is also hilar enlargement due to a combination of lymphadenopathy and pulmonary hypertension. CT : thickened bronchi, areas of mosaic perfusion on ‘lung windows’. (expiratory air trapping)Always look for complications of asthma: Pneumothorax or rarely pneumomediastinum. Consolidation secondary to pulmonary infection. Mucus plugging and subsequent lobar or segmental lung collapse. In 2% allergic bronchopulmonary aspergillosis (ABPAa
Mucous plug
The signet ring sign corresponds to a dilated bronchus immediately adjacent to a smaller companion pulmonary artery Tubular opacities caused by dilated, fluid-filled bronchi - These may occur as "finger-in-glove" opacities, which radiate from the pulmonary hilum 5. Increased size and loss of definition of the pulmonary vessels in the affected areas as a result of peribronchial fibrosis 6. Crowding of pulmonary vascular markings from the associated loss of volume, usually caused by mucous obstruction of the peripheral bronchi 7. Oligemia as a result of reduction in pulmonary artery perfusion (severe disease) 8. Signs of compensatory hyperinflation of the unaffected lung CT: Non-tapering bronchi with irregular thickened wall Multiple ring shadows with signet ring sign
BRONCHIAL MUCOCELE
.1- increased density (opacity) of the atelectatic portion of lung 2- displacement of the fissures toward the area of atelectasis ,upward displacement of hemidiaphragm ipsilateral to the side of atelectasis & Displacement of compensatory overinflation of unaffected lung 3-crowding of pulmonary vessels and bronchi in region of atelectasis 4--Silhutte sign ; it helps to Dx collapse & which lobe is collapsed . Anteriorly located lobes (upper & middle ) , causing obliteration of the portions of the mediastinal & heart outline . * Lower lobes collapse , will obscure the outline of the adjacent diaphragm & descending aorta
5. Indirect signs: Compensatory emphysema i.e. compensatory expansion of the un obstructed lobe(s) on the side of collapse. Collapse of the whole lung opaque hemithorax + substancial mediastinal & tracheal shift. CT shows lobar collapse very well, but rarely necessary simply to dx collapse
Hamartoma: Pulmonary hamartomas, the most common benign tumors of the lung( 75%), are the third most common cause of solitary pulmonary nodules hamartomas are composed of tissues that are normally present in the lung, including fat, epithelial tissue, fibrous tissue, and cartilage. However, they exhibit disorganized growth It is, The tumors are usually solitary, although multiple tumors have been reported Pulmonary hamartomas are usually asymptomatic and are typically discovered as an incidental coin lesion on a routine chest radiograph. On chest radiographs, it characteristically appear as well-defined, solitary; slowly grow pulmonary nodules, most of them are smaller than 4 cm, although they may reach 10 cm in diameter they may show varying patterns of calcification, including an irregular popcorn, stippled, or curvilinear pattern, or even a combination of all 3 patterns. Calcification that is detectable on plain radiography is reported to occur in 10-15% of patients. Popcorn calcification is virtually diagnostic CT SCAN The fundamental appearances of hamartomas on CT scans are similar to those on chest radiographs. However, thin sections also allow for more detailed evaluation of the internal architecture and morphology of lesions.[In particular, calcium and fat are better visualized with CT scanning than with radiography
carcinoid
Role of radiology : To making diagnosis Staging . Treatment follow up 1. hilaer enlargement : common non specific manifestation of lung cancer . It may represent central tumor mass Metastasis to hilar LN from peripheral tumor. 2. airway obstruction due to tumor growth, large LAP, occasionally due to mucous impaction lung infection with consolidation ( but with absence of air bronchogram) , lung collapse 3-Pleural involvements by direct spread or lymphatic obstruction 4. Peripheral mass difficult to differentiate between benign & malignant lung mass.bengin
MalignantSize
variable
Usually large
margins
Well define smooth
Ill define Lobulated or spiculated
Satellite opacities
frequent
Less frequent
calcification
Very suggestive
Rarely seen
Doubling time
Not changes over 2years
1-18 months
Cavitations
Thin wall, smooth margins
Thick ,irregular wall
Aggressive behavior
-
bone destruction , soft tissue invading, brachial plexus involvements.
Alveolar cell carcinoma Account for 2-5% of all lung tumor Not associated with smoking It called bronchio-aleveolar or bronchiolar. Its type of lung cancer with special feature : It arise within alveoli producing area of consolidation with air bronchogram. Multiple acinar shadow.
Loculated pleural effusion
CXR (supine) Large amounts of fluid can be present on supine films with minimal imaging changes, as the fluid is dependant and collects posteriorly. There is no meniscus and only a veil-like increased density of the hemithorax may be visible. It is therefore especially difficult to identify similar sized bilateral effusions as the density of the lungs will be similar.A lateral decubitus film is most sensitive, able to identify even a small amount above 10-25 ml of liquid. At the other extreme, supine films can mask large quantities of fluid.
White out hemithorax
Early pleural effusion seen by U/S Ultrasound allows the detection of small amounts of pleural locular fluid, with positive identification of amounts as small as 15 to 20 ml, that cannot be identified by x-rays, also US can differentiate between pleural thickening & small effusion & used to guide fluid aspiration , The typical appearance of the pleural effusion is an anechoic layer between the visceral pleura and the parietal pleura.Pleural thickening ( fibrosis ) Types focal pleural thickening pleural plaques calcify pleural plaques hairy pleural plaques diffuse pleural thickening circumferential pleural thickening nodular pleural thickening blunting of the costo phrenic angle , due to infection or hemorrhage . N.B. small pleural effusion difficult to differentiate from pleural thickening by CXR U\S or CT .
Bacterial pneumonia Chemotherapy Drugs Infection Injury to the ribs Lung contusions Lupus Pleural effusion Pulmonary embolisms Radiation therapy Rheumatoid lung disease Tuberculosis Tumours (benign and malignant)
Along lateral chest walls + calcification asbestos exposure .
Pleural tumours 2nddeposits most common primary mesothelioma relatively uncommon .
CXR lobulated mass , based on pleural. pleural effusion that obscure the tumor
Pleural irregular plaques of calcification &\ or pleural thickening . old haematoma . pleural calcification old empyma usually T.B. Bilateral pleural calcification with thickening often caused by asbestos exposure .
DX by CXR :Pleural line forming the lung edge separated from the chest wall , mediastinum or diaphragm by air .absence of vessels shadows outside this line this alone is insufficient evidence to DX as in emphysematous bulla .Small Pneumothorax ,may be dx on expiratory film .After DX of Pneumothorax if it’s tension or not & this by mediastinal shift . flat or inversion of the diaphragm .
causes of Pneumothorax : Majority occur in young people due to rupture of small blebs or bullae at the lung periphery. Emphysema . Truma . Pul. Fibrosis . Pneumocystis carinii pneumonia . Metastases (rarely ). Hydropneumothrax or Haemopneumothrax .
for descriptive purpose ; the mediastinum is divided in to anterior , middle & post. Division .If mediastinal mass is dx on frontal CXR should be followed with lateral CXR .The value of CT & MRI over CXR Cross sectional image differentiate fat , various soft tissue & B.V. In chest CT is superior to MRI except in:Aneurysms & vascular anomalies , which needs no CM. Posterior mediastinum mass , it’s relation to spinal canal .
Intrathorax thyroid goitres the most common cause of superior med. Widening . CXR Dx mass extended from sup. Med. To neck . almost invariably compress or displace trachea . enlarged LN ; the next common or frequent cause of med. Widening ; could occur in any one of three compartments. .
DX CXR lobulated outline . multiple location . Neurogenic T. : the most common cause of posterior med. Masses . DX ; pressure erosion or deformity of adjacent ribs & thoracic spine . Thymoma & dermoid cysts Ant. Med. Calcification occur in many conditions but not in malignant lymphadenopathy . Calcification may have characteristics app. Aneurysm of aorta . egg shell.
H.H. ; usually easy to dx on plain x-ray due to air or fluid level ( best on lateral CXR ). Rt cardiophrenic angle ; nearly all benign Fat pad pericardial cyst hernia through formen of morgagn .
: Tracking in to mediastinum from neck root adjacent chest wall or retro peritoneum Tear esophagus Tear bronchi. Tear lung. Spontaneous or truma Endoscopy or FB
Sources of air Intrathoracic Trachea and major bronchi Esophagus Lung Pleural space Extrathoracic Head and neck Intraperitoneum and retroperitoneum
Subcutaneous emphysema Thymic sail sign Pneumopericardium Ring around the artery sign Tubular artery sign Double bronchial wall sign Continuous diaphragm sign Extrapleural sign Air in the pulmonary ligament
Air outlining left subclavian & left carotid
e.g. pleura peeled off diaphragmEnlarged pulmonary arteries : Branching pattern . Usually bilateral + Herat size + enlarged pul.A . Enlarged hilar LN .: Lobulated outline . Unilateral or bilateral . Adjacent bronchi are normal or slightly narrowed .
Unilateral enlargement of hilar LN Metastasis; CA bronchus. Malignant lymphoma . Infection : TB (commonest cause of unilateral hilar LN enlargement \ child ) or histoplasmosis.
bilateral enlargement of hilar LN : sarcoidosis (Commonest symmetrical , enlarged LN , Rt. Paratrachel ). Malignant lymphoma . Infection TB & fungal . CA bronchus : hilar mass + lober collapse \ consolidation or narrowing of adjacent bronchus is visible DX of CA bronchus is virtual .
Homogenous spherical shadow .Central lucency within shadow (air) .Fluid level within shadow .DDx : cavitary CA , cavitation with wegener’s granuloma .
Pulmonary T.B. : 95% caused by mycobacterium tuberclosis 5% caused by atypical mycobateruim. Primary 1st infection with mycobacterium tuberculosis usually in child . Post primary : re infection in adult after developing relative immunity following the primary infection .
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3.Pleural effusion ; more often is the only abnormally. Pleural effusion as a manifestation of primary TB occurs more often in adults than children (seen in 30-40% of cases, whereas they are only present in 5-10% of paediatric cases ) It usually unilateral & usually resolve with out complication. 4.Miliary tuberculosis seen both primary T.B( usually children) & post primary T.B (usually elderly , debilitating & immune compromised patients) is a consequence of hematogenous spread of organisms to the pulmonary parenchyma. Radiographically, miliary spread can be recognized by circumscribed nodules less than 1-2 mm in diameter located diffusely throughout both lungs, occasionally may calcified ...
Tuberculomas: tuberculosis granuloma They may be present in primary or postprimary tuberculosisare Multiple small areas of consolidation appear as spherical masses , < 5 cm with sharp defined margin , & partly calcified. are often bilateral , most of them are inactive but viable bacilli may present even in calcified lesion Airway involvement in primary pulmonary tuberculosis Airway involvement is frequently present in primary tuberculosis and may take any of the following forms: Airway compression by adjacent lymphadenopathy with resultant atelectasis Mucosal infection with resultant ulceration and long-term stricture formation Broncholithiasis, ie, extrinsic erosion of a bronchus by adjacent lymphadenopathy, with extrusion of calcified material into the bronchus Endobronchial spread of infection Bronchiectasis
The findings of reactivation or re infection tuberculosis typically become radiographically apparent within 2 years of the initial infection.] apical & posterior segments of upper lobes & the apical segment of lower lobes . Patchy or confluent airspace opacities that involve the apical and posterior segments of the upper lobes and the superior segments of the lower lobes , these tended to coalesces caseating and caviating Cavity are commonly within the upper lung zones. It demonstrate a thick outer wall with a smooth inner contour. Air-fluid levels may be present. Superinfection by Aspergillus organisms may occur, leading to a mycetoma.
3. Pleural involvement is seen more commonly in post-primary tuberculosis than in primary infection. * Pleural effusions may occur and may progress to empyema. Healing usually causing pleural thickening & often calcification. An empyema may require emergent surgical intervention because the infection is maintained within a closed space and because it may result in rapid destruction of surrounding structures (eg, lung parenchyma, osseous structures of the thorax) * pleural thickening over lung apex often accompany lung fibrosis & healing of apical T.B *pneumothorax may complicate sub-pleural cavity. .
Is the disease is active ? by comparison of serial films over prolonged period are available . Valuable dx signs of activity :Development of new lesions on serial films .Cavitation . N.B. : present of calcification dosn’t exclude activity the better defined the shadow & the greater the calcification less likely to be active while ill defined shadows active .