DI midterm 3 Flashcards
Describe the appearance Right lung on chest films
Right lung: ( 3 lobes- upper, middle, and lower) Oblique fissure:
- Superior and middle lobes above fissure
- Inferior lobe below fissure
- Visible on LATERAL film ( not seen on PA)
- Identify side O.F. by which diaphragm it intersects with
- Horizontal fissure will run into O.F. but will not cross it
Right horizontal ( minor ) fissure:
- Anterior portion of superior lobe above fissure
- Middle lobe below fissure
- Separates right anterior segment of right upper lobe from right middle lobe
- Begins at right oblique fissure at mid-axillary line
- Runs horizontally anterior to sternal end of 4th costal cartilage
- Absent or incomplete in 25%
- Seen in 54% of PA
Describe the appearance of oblique ( minor) fissures on chest films
Left oblique fissure:
- Separates left upper lobe from left lower lobe
- Begins @ T5
- Extends obliquely down and forward
- Ends at anterior plural gutter of diaphragm
Right oblique fissure:
- Separates right upper and middle lobes from right lower lobe
- Begins @ T5
- Extends down and forward
- Ends at anterior pleural gutter of diaphragm
Less vertical than left oblique fissure
Describe the appearance of horizontal ( minor) fissures on chest films
Right horizontal fissure:
- Separates anterior segment of the RUL from the RML
- Begins at the oblique fissure at mid-axillary line
- Runs horizontally anterior to the sternal end of 4th costal cartilage
Locate the lobes of the left and right lungs.
- RUL: apical, anterior, & posterior
- RML: lateral & medial
- RLL: superior, medial basal, anterior basal, lateral basal, & posterior basal
- LUL: apical-posterior, anterior, superior lingular, & inferior lingular
- corresponds to RML
- LUL is analogous to RUL and RML combined
- LLL: superior, medial basal, anterior basal, lateral basal, posterior basal
- LLL is the same as LRL
What anatomical parts are responsible for the cardiac contours on the PA and lateral chest films? - anterior
- Right heart border, left heart border, ascending aorta
- Right medial segment of right medial lobe lies in anatomic contact with all but the uppermost portion of the right heart border
- Uppermost portion of the heart border and ascending aorta are in anatomic contact with the anterior segment of the RUL
- Lingual ( left side) is in contact with the left heart border
- Anterior segment of LUL-upper portion of left heart border
- Anterior part of left hemidiaphram is usually obliterated by the bottom of the heart bec they are in anatomic contact ( physiological silhouette)
- Anterior mediastinal tissue and plural fluid
What anatomical parts are responsible for the cardiac contours on the PA and lateral chest films? - posterior
- Descending thoracic aorta, aortic knob (posterior portion of aortic arch)
- Apical posterior segment of the LUL lies in contact w/ aortic knob
- RLL and LLL are not in contact with the heart borders. Therefore, disease in the RLL and LLL will NOT obliterate heart borders
- LLL and RLL overlaps middle portion of the heart border, but will not obliterate borders ( if it lies behind the aortic knob is could be in LLL but would still see the knob)
- Posterior pleural cavity
- Posterior mediastinum
- Basal segments of the RLL and LLL lies in anatomic contact with the hemidiaphragms
What anatomical parts are responsible for the cardiac contours on the PA and lateral chest films?
- basal segments
- All basal segments contact the diaphragm
- water density in the basal segments can cause a silhouette sign of a portion of the diaphragm
Which views are included in routine plain film examination of the chest?
PA and left lateral……..full inspiration
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
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
- Usually a diffuse pattern of involvement
- Often combined with consolidation
- Pattern: reticular, nodular, honeycomb, or any combo/ combo—acinar shadow
- Ground glass: hazy inc density, vasculature clearly visible ( use acute, some chronic fibrosis)
- Linear ( reticular): thickened septa, fibrosis, Kerley B lines
What is the appearance of alveolar disease?
- Silhouette sign, air bronchogram, pattern—diffuse, lobar/localized, solitary nodule/mass, multiple nodule/mass, atelectasis
- Represents filling of the pulmonary acini, the 8mm respiratory units composed of respiratory bronchioles, alveolar ducts, and alveoli
- Opacities appear fluffy and ill-defined and often become confluent to form larger regions of opacity. 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.
- 5 substances fill air space: pus, tumor, water, protein, blood
- Pneumococcal pneumonia, TB, fungal pneumonia, bronchoalveolar carcinoma, lymphyoma, ARDS, pulmonary edema ( including cardiogenic) ( essential radiology p. 117)
What are the x-ray findings of lobar consolidation?
- Lobar density
- Air bronchogram
- No significant loss of lung volume
White arrows are pointing to transverse fissure which is in normal location
List the 4 patterns of “white lung” disease (lung opacification on chest films) and a differential list for each?
• Diffuse Usually bilaterally symmetric Suggest more systemic/widespread disease DDX: Pulmonary Edema (CHF) Unusual infections pneumocysitis carinii, opportunistic, immune compromised Sarcoidosis Histopasmosis, TB Bronchiolaveolar carcinoma Idiopathic pulmonary hemorrhage • Localized Lobar Usually only a portion of one lung Most common presentation of infection DDX: Acute bacterial pneumonia Pulmonary TB Pulmonary infarct Bronchopulmonary sequestration Pancoast Tumor Atypical pneumonia (viral, mycoplasma) • Solitary mass/nodule Smaller, fairly well defined area Common presentation of neoplasm • DDX: Bronchogenic carcinoma Hematogenous metastasis Hamartoma Tuberculoma Lung abscess Hydatid cyst Hematoma Bronchopulmonary sequestration • Multiple masses/nodules Multiple fairly well defined areas Common presentation of metastasis DDX: Pulmonary metastasis Lymphoma Granulamatous infection (TB, histoplasmosis, coccidioidomycosis) Rheumatoid nodules Wegener’s granulomatosis
What is the silhouette sign?
- When 2 structure of the same radiographic density ( water) are in anatomic contact, the margins of those structures will be obliterated
- Normal site: heart on left hemidiaphram
- Abnormal: indicates water density material in air spaces; can localize by structure silhouetted
What is the significance (which bronchopulmonary segments involved) when obliteration of the following is observed?
- aortic knob : apical posterior segment of LUL
- ascending aorta:
in anatomic contact with anterior segment of RUL ( as is the uppermost portion of the of the right heart border) - right heart border:
To have silhouette sign of the right heart border, the right side of the heart must extend beyond the right edge of the spine. Most of the right heart border is silhouetted by the RML ( except the uppermost portion which is silhouetted by the anterior segment of the RUL) - left heart border:
- contacts the lingual on the left side
- upper portion of the left heart border is in contact w/ anterior segment of LUL - right diaphragm:
- basal segments of RLL lie in anatomic contact with hemidiaphram - left diaphragm:
- anterior portion of the left hemidiaphram is usually obliterated by the bottom of the heart ( physiological silhouette)
- basal segment of the LLL lie in anatomic contact with hemidiaphram
What are the causes of atelectasis?
- Resorptive ( OBSTRUCTIVE)
- Central: bronchogenic carcinoma, bronchial adenoma, foreign body, bronchial TB, lymphadenopathy, mediastinal mass, aneurysm
- Peripheral: pneumonia, mucous plugging, POST-OPERATIVE - Passive ( compressive): interthoracis space occupying process
- Pneumothorax, hemothorax, hydrothorax, any mass essentially; few actually show signs of atelectasis - Cicatrisation( contraction): local of generalized fibrosis
- TB ( especially in apices), interstitial pulmonary fibrosis, silicosis, radiation tx - Adhesive (surfactant abnormality): surfactant abnormality
- Respiratory distress syndrome, acute radiation pneumonitis
Which is the most common cause of atelectasis?
Resorptive ( obstructive)
What are the signs of atelectasis?
- ( resorptive??): displaced fissure
- Elevated hemidiaphram
- Displaced hilus
- Mediastinal shift
- Increased density
- Approximation of the ribs
- Vascular bronchial crowding
- Compensatory emphysema
- Lung herniation
What is the direction of the collapse in the -different types of atelectasis?
- Structures shift TOWARD collapsed lung Resorptive - Cicatrization - Adhesive - Structures shift AWAY form collapsed lung - Passive
What is an air bronchogram sign?
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
Which condition commonly demonstrates as a mass in the pulmonary apex or hilar area and may cavitate?
Bronchogenic carcinoma:
- Solitary mass, medistinal, apical, lung field, atelectasis possible, hilar enlargement possible, cavitation possible, pleural effusion possible
Which condition commonly demonstrates pleural plaques in the lung bases?
- Asbestoses related disease
- Calcifications of plaques are pathoneumonic of asbestoses exposure
What are the radiographic signs of pulmonary emphysema?
- Flattened, depressed hemidiaphragms
- Hyperlucency
- ncreased retrosternal clear space
- Inc AP chest diameter
- Dec peripheral vascular markings
What is an air filled bulla?
- Abnormal air filled spaces within the lung may result from confluent destruction of alveolar walls due to emphysema (bulla),
- Bulla are localized regions of panacinar emphysema which exceed one centimeter in diameter and are marginated by a uniformly thin wall
- Radiographically, bulla are recognized as focal round or oval radiolucencies surrounded by a thin wall. Large lesions can compress adjacent normal lung, producing curvilinear bands of passive atelectasis. The recognition of the limiting wall of the bulla helps distinguish this from a pneumothorax. Occasionally, CT may prove useful in this distinction, by demonstrating fibrous septa traversing large bullae.
Describe the appearance of pleural effusion and name some causes.
- Free fluid at costophrenic angle
- Radiographic findings: meniscus sign, blunted costophrenic angle, posterior costophrenic angle deeper that lateral, effusion ( transudate/ exudates), blood, pus, lymph (chylothorax)
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, may see a meniscus sign form pleural effusion
What is the difference in appearance between spontaneous and tension pneumothorax?
- Tension pushes away from side of collapse… shrunken down to the hillum
- Spontaneous towards the side 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 adenocarcin
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.
- Unilateral: atelectasis, phrenic nerve palsy, splinting, eventration, subphrenic inflammation
- Bilateral: poor inspiration, obesity, pregnancy, ascites, hepato-splenomegaly
What is the butterfly/bat wing appearance?
- Pulmonary edema w/ perihilar distribution = bat-wing consolidation
- Mechanism: capillary permeability, increased hydrostatic capillary pressure, blocked by lymph channels
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 and right atrium enlargement.
- left dt aortic stenosis, right dt CHF
Describe the divisions and boundaries of the mediastinum, their contents, and possible pathologic processes.
• Superior Mediastinum
• Ant border manubrium
• Post border T1-4
• Inf border line drawn from sternal angel to the inferior body margin of T4
• Contents: thymus, aortic arch, brachiocephalic, subclavian, and common carotid, upper ½ of superior VC, trachea, esophagus
• Inferior Mediastinum
• 3 divisions: anterior—middle—inferior
• Anterior Inferior Mediastinum
• Defined by anterior pericardium
• Contents: no major structures, some lymph nodes & BV, Thymus gland (esp in children), transverse thoracic mm
• Middle Inferior Mediastinum
• Between anterior pericardium and posterior pericardium
• Contents: heart, ascending aorta, lower ½ superior VC, tracheal bifurcation, pulmonary arteries and veins, phrenic nerves
• Posterior Inferior Mediastinum
• Well defined by posterior pericardium, tracheal bifurcation, and pulmonary vessels
• Contents: descending aorta, vagus, splanchnic, azygos, and hemiazygos nerves, esophagus, thoracic duct, posterior mediastinal lymph nodes
- What is the significance of the retrosternal and retrocardiac clear spaces?
- The “4 Ts”: ddx for dec in retrosternal clear space (ant mediastimum)-> thyroid mass, thymic lesion, teratoma, “ terrible” lymphoma
• Thymoma, thyroid goiter, teratoma and hodgkins lymphoma - The “ H”: Hypertension ( pulmonary atrial HTN) R-ventricular enlargement is evidenced by impingement of anteriorly situated R-ventricular silhouette in the retrosternal clear space in lateral CRX
What is the most common retrocardiac mass?
Hiatal Hernia
Radiographic Findings: Poster mediastinal mass
Located posterior to left heart on PA & lateral films
May see air-fluid level of stomach contents