DI 3 Midterm Flashcards
Describe the appearance of the major and minor fissures on PA and lateral chest films.
Right lung: 2 fissures
( 3 lobes- upper, middle, and lower) Begins @ T5 Oblique fissure (major): Superior and middle lobes above fissure Inferior lobe below fissure Visible on LATERAL film ( not seen on PA)
Right horizontal ( minor ) fissure:
Absent or incomplete in 25%
Seen in 54% of PA
Describe the appearance of the major and minor fissures on PA and lateral chest films.
Left lung: (2 lobes)
Left upper lobe
Left lower lobe
Separated by oblique fissure
Begins @ T5
Locate the lingular lobules.
Located in the LUL
What anatomical parts are responsible for the cardiac contours on the PA and lateral chest films?
Anterior (heart) structures
Right heart border (Right atrium), left heart border (Left atrium and ventricle), ascending aorta Aortic Arch Pulmonary trunk Brachiocephalic vessels Superior Vena Cava Inferior Vena Cava
What anatomical parts are responsible for the cardiac contours on the PA and lateral chest films?
Posterior heart structures
Descending thoracic aorta, aortic knob (posterior portion of aortic arch) Ascending Aorta Left Atrium and Ventricle Right Atrium (looks anterior) Inferior Vena Cava
Which views are included in routine plain film examination of the chest?
PA and left lateral……..full inspiration
How does a thoracic spine plain film study differ from a chest study?
- Technique
- Collimation
- Positioning
Technique
72” FFD, high kVp, low mA and short time, full inspiration
Collimation
Chest films must include all air spaces of the lungs vs tightly collimated thoracic spine films
Positioning
PA chest vs. AP thoracic
Left lateral chest vs. either lateral thoracic
What condition or anatomical region is best demonstrated by the apical lordotic view?
See apices of the lung, can dx a pancoast tumor ( or anything in the apices of the lung)
Is the routine chest x-ray taken with inspiration or expiration?
Full inspiration
- Breath held on inspiration
- Expands lung fields
- depresses diaphragm
- Provides contrast (air vs. tissue)
Describe the difference in appearance between inspiration and expiration.
Need good inspiration, should see first 10 ribs posteriorly, lowers the diaphragm
On expiration -
What condition is better demonstrated upon expiration than inspiration?
Pneumothorax: upright expiration more sensitive
What is the appearance of interstitial disease?
- Thickened alveolar septa, alveolar walls; interstitial lymph, veins, cells
- Usu diffuse pattern, mb combined with consolidation
- A) Pattern: reticular, nodular, honeycomb, or any combo/ combo—acing shadow
- *B) Ground glass: hazy inc density, vasculature clearly visible (usu acute, some chronic fibrosis)
- **C) Linear ( reticular): thickened septa, fibrosis, Kerley B lines
- ***ID tends to produce opacities that can be characterized at reticular (delicate lines of opacity), nodular, reticulonodular, or ground glass (hazy inc in density) It represents the accumulation of fluid or tissue in the pulmonary intersitium, which includes not only the potential space between the alveoli but the lymphatics and veins as well.
*Infectious dz of the interstitium: viruses, mycoplasma, TB, Pneumocystis carinii, collagen vascular dz (RA), pneumoconioses.
What is the appearance of alveolar/air space disease?
Silhouette sign, air bronchogram, pattern—diffuse, lobar/localized, solitary nodule/mass, multiple nodule/mass, atelectasis
A) Represents filling of the pulmonary acini, the 8mm respiratory units composed of respiratory bronchioles, alveolar ducts, and alveoli
B) Opacities appear fluffy and ill-defined and often become confluent to form larger regions of opacity.
C) Other findings are air-bronchograms (lucent tubular and branching structures representing aerated bronchi surrounded by opaque acini), absence of volume loss (the acini remain filled, with replacement of air by fluid or tissue), and a non-segmental distribution.
Pneumococcal pneumonia, TB, fungal pneumonia, bronchoalveolar carcinoma, lymphoma, ARDS, pulmonary edema ( including cariogenic)
5 substances fill air space:
pus, tumor, water, protein, blood
Alveolar/air space disease? (7)
Pneumococcal pneumonia, TB, fungal pneumonia, bronchoalveolar carcinoma, lymphyoma, ARDS, pulmonary edema ( including cardiogenic)
List the 4 patterns of “white lung” disease (lung opacification on chest films)
1) Diffuse - consolidation
2) Localized / Lobar
3) Solitary mass / nodule
4) Condition: neoplasm
Differential list for “white lung” disease (lung opacification on chest films)
1) Diffuse - consolidation
Usu b/l
Condition: CHF (pulm edema), systemic/ widespread dz – sarcoidosis, histoplasmosis
Mb acing shadow, air bronchogram, mult silhouette signs, suggests more systemic / widespread dz
Differential list for “white lung” disease (lung opacification on chest films)
2) Localized / Lobar
Usu only a portion of one lung
Condition: bacterial info, pneumonia
Differential list for “white lung” disease (lung opacification on chest films)
3) Solitary mass / nodule
Usu u/l; Small, well defined area
Differential list for “white lung” disease (lung opacification on chest films)
4) Condition: neoplasm
Multiple masses / nodules
Usu b/l; multiple well defined areas
Condition: metastasis
What is the silhouette sign?
Obliteration of an anatomical shadow dt a water density (structure or lesion) in anatomic contact with that structure (can’t see structure any longer)
Water densities that may cause a silhouette sign include:
Pneumonia, Tumors, Pleural Effusion
Structures that may show silhouette sign:
Mediastinal structures: Heart, Aorta
Diaphragms dt effusion/fluid
Chest Wall – tumors, etc.
What is the significance (which bronchopulmonary segments involved) when obliteration of the following is observed?
Aortic knob:
apical posterior segment of LUL
What is the significance (which bronchopulmonary segments involved) when obliteration of the following is observed?
Ascending aorta:
in anatomic contact with anterior segment of RUL (as is uppermost portion of R heart border)
What is the significance (which bronchopulmonary segments involved) when obliteration of the following is observed?
Right heart border:
To have silhouette sign of R heart border, the R side of the heart must extend beyond R edge of the spine. Most of R heart border is silhouetted by RML (except the uppermost portion which is silhouetted by the anterior segment of the RUL)
What is the significance (which bronchopulmonary segments involved) when obliteration of the following is observed?
left heart border:
contacts the lingual on L side; upper portion of L heart border is in contact w/ anterior segment of LUL
What is the significance (which bronchopulmonary segments involved) when obliteration of the following is observed?
right diaphragm:
basal segment RLL
What is the significance (which bronchopulmonary segments involved) when obliteration of the following is observed?
left diaphragm:
anterior portion usually obliterated by the bottom of the heart ( physiological silhouette)
basal segment of LLL lie in anatomic contact with L hemidiaphram
What are the causes of atelectasis?
Resorptive ( OBSTRUCTIVE):
Resorptive ( OBSTRUCTIVE):
Central: bronchogenic carcinoma, bronchial adenoma, foreign body, bronchial TB, lymphadenopathy, mediastinal mass, aneurysm
Peripheral: pneumonia, mucous plugging, POST-OPERATIVE
What are the causes of atelectasis?
Passive ( compressive):
Passive ( compressive):
Interthoracis space occupying process
Pneumothorax, hemothorax, hydrothorax, any mass essentially; few actually show signs of atelectasis
Which is the most common cause of atelectasis?
Resorptive ( obstructive)
What are the signs of atelectasis?
Resorptive:
Resorptive:
- Displaced fissures
- Elevated hemidiaphram
- Displaced hilus
- Mediastinal shift-> everything shifts towards it
- Increased density-> everything is compressed in that area
- Approximation of the ribs-> spaces ben ribs closer on that side
- Vascular bronchial crowding
- Compensatory emphysema-> other lung may shift towards that side too
- Lung herniation
What are the signs of atelectasis?
Passive:
Passive:
- Collapsed lung-> hard to appreciate collapsed lung look for
- Lack of lung margins and blood vessels in the periphery
- Edge of visceral pleura on outer margin of lung
What is the direction of the collapse in the different types of atelectasis?
Resorptive-> Structures shift TOWARD collapsed lung
Passive-> Structures shift AWAY form collapsed lung
What is an air bronchogram sign and what does it indicate?
- Most bronchi/bronchioles are not visible on normal chest x-ray
- **Air filled, surrounded by air, thin walls
- When air spaces are filled with water density, air filled bronchi are visible = air bronchogram
- **If have pneumonia then alveoli filled with fluid and sometimes the little bronchioles still have air in them so you can see them
Which condition commonly demonstrates as a mass in the pulmonary apex or hilar area and may cavitate?
- Bronchogenic carcinoma
- **Solitary mass, mediastinal, apical, mb atelectasis, u/l hilar enlargement, mb cavitation, pleural effusion
*Secondary Tuberculosis can also show up in the pulmonary apex and cavitates in 40%. Usu b/l
Which condition commonly demonstrates pleural plaques in the lung bases?
Asbestosis
What are the radiographic signs of pulmonary emphysema?
- Flattened, depressed hemidiaphragms
- Hyperlucency
- Increased retrosternal clear space
- Inc AP chest diameter
- Dec peripheral vascular markings
What is an air filled bulla?
*AbN air filled spaces w/i lung
mb dt Emphysema (destruction of alveolar walls)
*focal round/oval radiolucencies surrounded by thin wall.
Describe the appearance of pleural effusion and name some causes.
- Free fluid at costophrenic angle
- Radiographic findings: meniscus sign, blunted costophrenic angle, effusion ( transudate/ exudates), blood, pus, lymph (chylothorax)
- Causes ( ddx): CHF, pneumonia, neoplasm, infection ( empyema), trauma, embolism, CT Dz, TB, abdominal dz ( pancreas, cirrhosis)
What are the different types of pneumothorax?
*Spontaneous
1° : tall thin males
2°: underlying lung dz, bullae, blebs, air trapping
- Traumatic Or iatrogenic
- Tension – Valve effect with progressive accumulation of air, shift of mediastinum away from collapsed lung, leads to vascular compromise, medical emergency ( chest tube)
What is the appearance of pneumothorax with pleural effusion?
Shrunken lung, pleural space larger – no BVs seen where they shld be, heart is shifted away from lung, may see a meniscus sign from pleural effusion
What is the difference in appearance between spontaneous and tension pneumothorax?
- Tension extensive collapse… spontaneous/traumatic pneumothorax progressively shrinks down to the hillum
- Spontaneous small amt of collapse
What is pancoast tumor?
- Superior sulcus tumor; apical; extension into adjacent chest wall; usually Sq Cell
- Clinical presentation: horner synd—miosis, ptosis, andhydrosis, pain radiating to arm, apical mass: look for rib or vertebral dysfunction, plural extension
- Sq cell or adenocarcinoma
Are multiple pulmonary masses of varying sizes suggestive of bronchogenic or metastatic carcinoma?
Metastatic carcinoma ( bronchogenic is solitary)
Is calcification common in a malignant pulmonary mass?
NO…..most of the calcifications are benign and two are questionable
List 4 conditions that demonstrate “elevation” of the hemidiaphragm.
Unilaterally
Unilateral: atelectasis, phrenic nerve palsy, splinting, eventration, subphrenic inflammation
List 4 conditions that demonstrate “elevation” of the hemidiaphragm.
Bilaterally
Bilateral: poor inspiration, obesity, pregnancy, ascites, hepato-splenomegaly
What is the butterfly/bat wing appearance?
Pulmonary edema w/ perihilar distribution = bat-wing consolidation
What is the normal relation between the transverse diameter of the heart and the thoracic cage on the PA chest film?
- Located in the middle mediastinum, 1/3 to right of midline, 2/3 to left of midline
- Cardiothoracic ratio: on PA upright full inspiration chest film—widest coronal diameter of heart ≤ ½ thoracic cavity ( no minimum)
- **( not the best evaluation for cardiomyopathy)
List causes of left ventricle hypertrophy
Aortic stenosis,
Chronic HTN
List causes of right atrium enlargement.
CHF
Describe the divisions and boundaries of the mediastinum, their contents, and possible pathologic processes.
ANTERIOR
ANTERIOR –masses above clavicle
Sternum to anterior cardiac silhouette = anterior (retrosternal) clear space
Contents:
Thymus Gland
Lymph Nodes
Pathologies – 3T’s and an H:
- Thyroid Retrosternal goiTer – m/c (Sup mediastinum continuous with Thyroid gland)
- Hodgkin’s lymphoma
- Thymic mass - Thymoma
- Teratoma - Germ cell tumor
Describe the divisions and boundaries of the mediastinum, their contents, and possible pathologic processes.
MIDDLE
MIDDLE:
Anterior to posterior cardiac silhouette
Contents: Pericardium Heart Great and pulmonary vessels Phrenic nerve Upper vagus nerves Trachea, primary bronchi Lymph nodes
Pathologies – masses below clavicle
- Lymphadenopathy – enlarge LN
- Bronchogenic carcinoma – in primary bronchi
- Aortic Aneurysm
- Bronchogenic cyst
- Congestive heart failure
- CVD – cardiovascular Dz à hardening of the arteries
Describe the divisions and boundaries of the mediastinum, their contents, and possible pathologic processes.
POSTERIOR
POSTERIOR - Posterior cardiac silhouette to posterior border of lung field
Contents: Descending thoracic aorta Esophagus Thoracic duct Azygous, hemiazygous veins Sympathetic ganglia Lower vagus nerves Lymph nodes
Pathologies:
- M/C=> Hiatal hernia – see magenblasse – gastric bubble
- Neurogenic tumors
- Paravertebral masses – something growing of vertebral body
- Meningocele – opening of spinal canal can be towards the chest
- Esophageal masses
- Aneurysm
What is the most common retrocardiac mass?
Hiatal Hernia
What is Black Lung Dz?
Trapped air – obstruction
Pneuomothorax, Emphysema, Cystic dz,
What is Apical Lordotic view
Pt leaning back and looks like xray beam angled on pt – fuzzier film
used to view pancoast tumor, Reactivated TB
Why would you get a Loss of costophrenic angle
water from pleural effusion
Accessory fissure in lungs on upper R side
azygos fissure
Nodules – bright white
usually means calcification – older nodule and more likely B9
Multiple discrete masses mb mets
Complete diffuse pattern (whitening) seen throughout both lungs meaning?
could be interstitial fibrosis, interstitial disease, sarcoidosis, etc.
