L3 - IM - Correlated Lecture (Sept0922)
L3 - IM - Correlated Lecture (Sept0922)
Outline Page
Anatomy - Bones
Systematic Approach and Anatomy 1
ABCDEF System 1
Airways 2
Bone Abnormalities 3
Cardiac Silhouette 5
Mediastinum and Hila 6
Diaphragm 7
Pleural Effusions 7
Hyperinflation 10
Alveolar (a.k.a. airspace) opacities 10
Interstitial opacities 11
Cardiogenic Pulmonary Edema 12
Anatomy - Airways
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Airways, Bones and Soft Tissues
• To be able to assess the airways, bones and soft tissues
• To know the common etiologies of abnormalities seen in the
airways, bones, and soft tissue
AIRWAYS
Abnormalities deviating Abnormalities deviating
• Abnormalities of the Airways
trachea away from affected trachea towards the affected
o On chest X-ray, airways can either be:
▪ Narrowed side side
▪ Deviated Pneumothorax Marked atelectasis/ collapsed
▪ Contain foreign objects lung
Pleural effusion Lobectomy/ Pneumonotomy
Airway Narrowing Large Mass Pleural fibrosis
• Subglottic airway narrowing is an important radiographic finding Pulmonary fibrosis (rarely
in croup and tracheal stenosis unilateral)
• However, narrowing of trachea is easy to over-call in
asymptomatic adults due to overlying shadows from mediastinal Pleural Effusion
structures
Airway Deviation
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Airway deviation • Old rib fracture is suggested by focal thickening of the rib
consistent with callous formation
Other Fractures
BONE ABNORMALITIES
On chest X- ray, bones can be:
• Fractured (recent vs old)
• Deformed (Kyphosis, scoliosis)
• Sclerosed (solitary vs multiple vs diffuse) Barrel Chest
• Lytic (solitary vs Multiple) • Refers to specific thoracic deformity that occurs in advanced
• Osteopenic COPD:
• Notched (ribs) o Kyphosis
o Increased AP diameter
Rib fracture
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Sclerosis Cervical Ribs
• Sclerosis- high density of bone • Anatomic variant
• Can be focal or diffuse • Prevalence ~ 0.5—1%
• Etiologies include: • Can be unilateral or bilateral
o Osteoblastic metastasis • Usually, an incidental finding
o Primary bone tumor • Can cause thoracic outlet syndrome
o Various benign tumor-like bone lesions
o Paget’s disease
o Chronic osteomyelitis
SOFT TISSUES
Lytic Lesions
• Lytic lesions– low density of bone
• Can be solitary or multiple
• Etiologies include:
o Osteolytic metastasis
o Multiple myeloma
o Various benign cyst-like bone lesions
o Paget’s disease
o Acute osteomyelitis Subcutaneous Emphysema
Air within the subcutaneous tissue can occur due to:
• Air introduced internally
o Pneumothorax
o Pneumomediastinum
o Pulmonary interstitial emphysema
• Air introduced externally
o Penetrating chest wall trauma
o Post-surgical
o Complications from chest tube
• Air produced locally
o Necrotizing infection with gas producing organism
Rib Notching otherwise known as gas gangrene
• Rib notching is focal deformation of one or more ribs
• Etiologies depend upon whether the superior or inferior surface Shrapnel Injuries
is affected:
Superior surface Inferior surface
Osteogenesis imperfecta Coarctation of the aorta
Connective tissue diseases Subclavian or SVC
obstruction
Local pressure s/p Blalock Taussig shunt
(only 2 upper ribs)
Hyperparathyroidism
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CARDIAC SILHOUETTE AND MEDIASTINUM o Mitral valve disease
PA vs. AP films
Chest X-ray quality – Projection
AP projection:
• AP projection image is of lower quality than PA image • Findings include
• The scapulae are not retracted laterally, and they remain o Filling of retrosternal space (on lateral view)
projected over each lung. • Right ventricular enlargement
• Heart size is exaggerated o Pulmonary hypertension (any cause)
o Pulmonary valve disease (e.g., pulmonic stenosis,
Abnormalities of the Cardiac Silhouette pulmonary regurgitation)
• Cardiomegaly
Cardiothoracic Ratio = Maximum horizontal cardiac width
Maximum horizontal thoracic width
(inner surface of rib cage)
*Cardiomegaly is considered to be present if the cardiothoracic ratio
is > 50% on PA film
PERICARDIAL EFFUSION
• not all clinically relevant pericardial effusions are visible on X-
ray, particularly if they developed acutely.
• Primary finding is an enlarged cardiac silhouette
• Other findings include:
o Water bottle morphology of silhouette
Etiologies of Cardiomegaly o Oreo cookie sign
• any cause of left or right sided heart failure
• pericardial effusion can be mistaken for cardiomegaly
• Findings include:
o Splaying of the carinal angle >90 degrees
o Double density sign
• Left atrial enlargement
o Left sided heart failure (any cause)
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• Posterior Chocolate Layer = Pericardial Fat
• Middle Cream Layer = Pericardial Effusion
• Anterior Chocolate Layer = Epicardial Fat Mediastinal Masses
Sub-acute to Chronic
• Malignancy (e.g. lymphoma, breast, lung)
• Renal failure
• Collagen Vascular Disease
• Hypothyroidism
• Tuberculosis Hilar Enlargement
Malignancy Infection Other
DEXTROCARDIA - Primary lung - Tuberculosis - Sarcoidosis
• Congenital anomaly cancer - Viruses (e.g. EBV) - Silicosis
• Incidence= 1/12,000 pregnancies - lymphoma - Histoplasmosis - Pulmonary
- Metastatic - Coccidioidomycosis Hypertension
• May be isolated and discovered incidentally, or associated with
disease (e.g. - Tularemia - Pulmonary artery
life-threatening additional congenital malformations
Lung, breast, aneurysm
head/neck, - Bronchogenic
melanoma) cyst
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DIAPHRAGM AND PLEURA • Visceral pleural line -
necessary to make a definitive
diagnosis
• Visceral pleural line parallels
the curvature of the chest wall
(ie. Convex outwards)
o Pneumothorax mimic
conditions do not
maintain this spatial
relationship Eg. bullae,
artifacts.
• Usually there is absence of
lung markings peripheral to
ABNORMALITIES OF THE DIAPHRAGM AND PLEURA pleural line.
Learning objectives o Pleural adhesions - lung
• To be able to identify and list the common etiologies of common markings may be visible beyond the pleural line
radiographic abnormalities of the pleura and diaphragm
(including abnormal air under the diaphragm)
PNEUMOTHORAX
• Size of a pneumothorax is based on the thickness of the rim of
air around the lung at the level of the hilum on a PA film
• <2cm -”small” pneumothorax
• >2cm -”Large” pneumothorax
• Radiologic findings:
o Contralateral mediastinal shift
o Depression of ipsilateral hemi-diaphragm
o Compressive atelectasis of adjacent normal lung
• Presence of significant increased intrathoracic pressure
• Role of imaging in patients with pneumothorax:
1. Confirm the clinical diagnosis PNEUMOTHORAX
2. Assess extent of pneumothorax Primary pneumothorax
3. Detect signs of tension ● A.k.a spontaneous pneumothorax
4. Follow-up examination to monitor resolution of
pneumothorax after drainage Secondary pneumothorax
● Iatrogenic
● (e.g., Thoracentesis, lung biopsy, central line placement)
● COPD
● Cystic fibrosis
PLEURAL EFFUSIONS
Characteristics of effusions visible on chest X-ray:
● Unilateral vs. Bilateral
● Size
● Free flowing vs. Loculated
● Associated findings that may suggested the etiology of the
Bilateral tension pneumothorax due to barotrauma from positive
effusion
pressure ventilation. Note the flattening of the diaphragm. The
presence of bilateral abnormality results in no mediastinal shift. Note
the collapsed lungs (arrows) and bilateral hyperlucency.
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LOCATED PLEURAL EFFUSION Etiologies of Pleural Effusions
● Homogeneous density Transudative Exudative
● Loculated (Secondary to imbalance (Secondary to pleural
● Loss of cardiophrenic angle between hydrostatic and inflammation or lymphatic
● Loss of lateral portion of diaphragmatic silhouette oncotic pressures within obstruction)
pleural space)
Heart failure Pneumonia/ Empyema
Hepatic hydrothorax Malignancy
(pleural effusions due to
cirrhosis/ascites)
Hypoalbuminemia Pleural Tuberculosis
Nephrotic Syndrome Pancreatitis
Sarcoidosis
Various rheumatological
Free flowing vs Loculated (lateral decubitus view)
diseases
(e.g. Lupus, rheumatoid
arthritis, etc.)
Pseudotumor
● Term most commonly used to refer to a fluid collection trapped
within a fissure, which can give the appearance of a lung mass.
● Suspicion for trapped fluid based on:
○ Location at a fissure (most occur in the horizontal fissure)
○ Smooth lenticular contour
Pleural-based malignancy
Pleural Malignancies
Metastatic disease
(can be from hematogenous dissemination or direct invasion)
Mesothelioma
(strongly associated with asbestos exposure)
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Pneumomediastinum
Trauma
Esophageal rupture
Vomiting
Asthma
Post-neck or chest surgery
Barotrauma (e.g. Diving, positive pressure ventilation)
Elevated Hemidiaphragm
Elevated Hemidiaphragm
Diminished lung volume (e.g. Atelectasis)
Phrenic nerve paralysis
Eventration of the diaphragm
Subphrenic abcess
Hepatomegaly or splenomegaly
PNEUMOPERICARDIUM
• Trauma
• Bacterial pericarditis secondary to gas-producing organism
• Post-cardiac surgery or pericardial drain
• Fistula between pericardium and either lung, stomach, or
esophagus
Diaphragmatic Hernias
LEARNING OBJECTIVES
• To be able to identify and know the differential diagnosis of how
lung volumes, and hyperinflation
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• To be able to identify pulmonary edema, as well as specific DIFFERENTIATING CARDIOGENIC FROM NON-CARDIOGENIC
features that can help distinguish cardiogenic from non- EDEMA
cardiogenic etiologies • Air Bronchograms
• To be able to classify interstitial processes based on their • Peribronchial Cuffing
radiographic features • Kerley Lines
• To be able to compare typical findings in alveolar and interstitial • Cephalization
processes • Bat’s Wing Pattern
HYPERINFLATION AIR BRONCHOGRAMS
• Subjective impression that the total lung capacity is likely • Bronchi are usually not visible on X-ray
increased, based upon: • Opacification of alveoli adjacent to bronchi results in the dark,
o Number of ribs seen air-filled bronchi becoming identifiable
o Flattening of the diaphragm
o Diffusely increased lucency of the lungs
• Hyperinflation
o COPD
o Asthma (during an exacerbation only)
Peribronchial Cuffing
• Bronchi are usually not visible on X-ray
• Interstitial edema can accumulate around bronchi, making the
bronchi walls thick
• Appears like a ring when seen in cross section, and like tram
RADIOGRAPHIC CATEGORIES OF DIFFUSE LUNG OPACITIES tracks when seen longitudinally
• Alveolar (a.k.a. airspace) opacities
• Interstitial opacities
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Diffuse Alveolar Opacities Not due to Pulmonary Edema
Alveolar Opacities without Edema
Multilobar Pneumonia
Diffuse Alveolar Hemorrhage
INTERSTITIAL OPACITIES
- Subtypes Interstitial Opacities
o The appearance of interstitial opacities can be further
described based on pattern:
▪ Reticular (too many lines)
Cephalization ▪ Nodular (too many dots)
• Increased visibility of pulmonary vessels at the lung apices as ▪ Reticulonodular (too many line and dots)
compared to the bases
• Suggestive of increased left atrial pressure
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May contain air bronchograms Usually devoid air
(if Edema is non-cardiogenic) bronchograms
Rapidly changing over time Changes more slowly over time
Described in highly subjective Described in semi-objective
terms: “fluffy”, “cotton wool-like”, terms: reticular, nodular,
“cloud-like” reticulonodular
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