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Respiratory > Causes of Mediastinal Shift > Flashcards

Causes of Mediastinal Shift Flashcards

1
Q

How much of the heart is normally right of the midline?

A

A third

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2
Q

What is the mediastinum?

A

Consists of blood vesselsm trachea, oesphagus, thoracic duct, phrenic nerves and the thymus

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3
Q

How can you tell if the mediastinum has moved?

A

The heart may also move, so that a third is no longer on the right hand side of the midline

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4
Q

What parts of the lung that can normally be seen on X-Ray can be obliterated by disease?

A

Fissures - major and minor
Hila - left is higher than the right
Junction lines
Paraspinal lines should be less than 10mm

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5
Q

Which hila is higher?

A

Left - superior to the heart

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6
Q

Name some causes of bilateral adenopathy.

A

Sarcoidosis
Lymphoma
TB
Malignancy - most likely

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7
Q

What is the distinctive feature of mediastinal adenopathy?

A

Mediastinal nodal masses

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8
Q

Does lobar collapse normally cause mediastinal shift?

A

No

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9
Q

Name a cause of upper lobe collapse.

A

Tumour presence - should be the primary suspect

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10
Q

How can right upper lobe collapse be identified on an X-Ray?

A

Opacification of the right upper zone
Displacement of the horizontal fissure superiorly
Bulging of fissures medially - Golden’s reverse sign
Trachea deviated towards the affected side (the right)

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11
Q

When a lobe collapse (upper or lower) is identified, what further investigation should be done?

A 
History
Examination
Blood tests
CT
Bronchoscopy
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12
Q

How can left upper lobe collapse be identified on an X-Ray?

A

Opacification in the left upper zone
Displacement of the oblique fissure superiorly
Bulging of fissures medially - Golden’s
reverse sign
Trachea deviated towards the affected side (the left)
May see a veil like opacification of the left hemithorax and aerated left apex due to expanded left lower lobe
- may see elevated left hemidiaphragm

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13
Q

What is the most important cause of lower lobe collapse?

A

Tumour - although other causes are possible

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14
Q

How can left lower lobe collapse be identified on an X-Ray?

A

Wedge shaped, triangular opacification behind the left heart border (sailing boat sign)
Displacement of the left hilum inferiorly
Obliteration of the left hemidiaphragm
Hyperlucent remaining left lung

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15
Q

What are the causes of a hyperlucent lung?

A 
Technical causes (rotation)
Chest wall/pleural abnormalities 
Vascular problems (PTE)
Surrounded by ring shadows (bullae)
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16
Q

If you see a hyperlucent lung with mediastinal shift, what is the diagnosis?

A

Tension pneumothorax

17
Q

How can a pnuemothorax be diagnosed on X-Ray?

A

Identification of the pleural line (visceral) - it will be folded into the lung area
Bullea
Most easily seen on an expiratory film
Deep costophrenic angle
Increased clarity of the mediastinal border
Depression of the diaphragm and visualisation of the undersurface of the heart

18
Q

How can a left tension pneumothorax be identified on a chest X-Ray?

A

Depression of the left hemidiaphgram (increased pressure in chest cavity)
Tracheal displacement to the right
Hyperlucency of the left hemithorax
Small left basal pleural effusion (loss of the costophrenic angle)
Displacement of the heart to the right (more than a third is visible to the right of the midline)
Pleural line can be seen

19
Q

What are the possible complications of a pneumothorax?

A

Haemothorax
Tension
Adhesions - slow re-expansion or bleeding if they tear
Delayed expansion adhesions lead to airway obstruction
Re-expansion oedema

20
Q

What is a pleural effusion?

A

Fluid in the pleural space

- fluid is normally generated by the parietal layer and absorbed by the visceral layer

21
Q

What are the types of fluid that can cause pleural effusion?

A 
Transudate
Exudate 
Blood - haemothorax
Chyle - chylothorax
Mixed
22
Q

How can a pleural effusion be recognised on an X-Ray?

A

Blunting of the costophrenic angle
Some of the lung has become white
Massive effusion
- there is mediastinal shift away from the white lung
- diaphragmatic inversion (more common on the left)

23
Q

What are the possible causes of a pleural effusion?

A

Hypoproteinaemia - cirrhosis, nephrotic syndrome
Cardiovascular - CCF, constrictive pericarditis or SVCO
Neoplasm - bronchial, metastases, lymphoma or mesothelioma
Infection - bacterial, fungal or viral
Trauma
Thromboembolism
Inhalation - asbestos
Collagen vascular disease - SLE, rheumatoid arthritis
Subdiaphragmatic disease - pancreatitis, subphrenic abscess

24
Q

What is the most common cause of a massive pleural effusion?

A 
Malignant disease
Heart failure
Cirrhosis 
TB
Empyema 
Trauma
25
Q

What are the most common causes of opacification of the hemithorax?

A 
Pleural effusion
Consolidation
Collapse
Massive tumour
Fibrothorax
Combination
Pneumonectomy 
Lung agenesis
26
Q

How does mediatstinal shift occur after a pneumonectomy?

A

The heart moves into the space where the lung was, taking the mediastinum with it.
The heart can’t be seen as it is oscured by the opacification of the pneumonectomy

27
Q

How can a subpulmonary effusion be recognised on a chest X-Ray?

A

Free fluid collects under the lung
- becomes generalised around 250mls
Hemidiaphragm is high and appears opaque
Best seen on a lateral decubitas film

28
Q

How can fluid accumulation in the fissures of the lung be caused and identified on X-Ray?

A

Most commonly caused by heart failure or a phantom
tumour
The lung will have sharp margins, with a biconvex tail along the fissure

29
Q

What are the causes of a white lung with mediastinal shift towards the dense side?

A

Collapse
Post pneumonectomy
Lymphangitis carcinomatosa
Pulmonary agensis and hypoplasia

30
Q

What are the causes of a white lung with a central mediastinum?

A

Consolidation
Pleural effusion - small
Mesothelioma

31
Q

What are the causes of a white lung with mediastinal shift away from the dense side?

A

Pleural effusion - large

Diaphragmatic hernia

Respiratory (12 decks)

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