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Head, neck and thorax > Lecture 2- mediastinum p2 > Flashcards

Lecture 2- mediastinum p2 Flashcards

1
Q

what is a chilaiditi sign

A

*Is the anterior interposition of the colon to the liver reaching the under surface of the right hemi-diaphragm
*One of the cause of pseudopneumoperitonuem
*Can have Chilaiditi syndrome where patients experience pain
*often looks like air below the diaphragm

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2
Q

Breast implants

A

Breast implants can often mimic a chest infection.
-always read patients history beforehand

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3
Q

what is dextrocardia?

A

Heart on the right side.

  • Dextrocardia is a congenital cardiac malposition in which the heart is situated on the right side of the body (dextroversion) with the cardiac apex pointing to the right.

Doesn’t cause any major problems, but does make you prone to certain defects.

ECG and defibs need to be switched the other way when being used.

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4
Q

what is dextrocardia of embryonic arrest (also known as isolated dextrocardia)

A
  • the heart is simply placed further right in the thorax than is normal
  • commonly associated with severe defects of the heart, including abnormalities such as pulmonary hypoplasia 1
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5
Q

What is dextrocardia with situs inversus

A
  • dextrocardia situs inversus refers to the heart being a mirror image situated on the right side
  • although persons with dextrocardia situs inversus tend not have any medical problems from the disorder, some are prone to a number of bowel, oesophageal, bronchial and cardiac problems where some of these conditions can be life-threatening if uncorrected
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6
Q

describe hiatus hernia, and what is its main causes?

A

Occurs when there is a herniation of the abdominal contents through the oesophageal hiatus of the diaphragm. Circular mass and air fluid level

causes: Increases with age and slight female predilection, obesity

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7
Q

What are the symptoms of hiatus hernia

A

May be symptomatic
Chest / abdominal pain
Nausea and vomiting
Sometimes GORD (gastro-oesophagel reflux disease)

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8
Q

what modality is used to diagnose hiatus hernia?

A

plain film- retrocardiac opacity with air fluid level
CT- fat collection in middle mediastinum, may see hernia or widened oesophageal hiatus.

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9
Q

what are the complications associated with hiatus hernia

A

volvulus of stomach- twists.
Gastric volvulus is a specific type of volvulus that occurs when the stomach twists on its mesentery. It should be at least 180° and cause bowel obstruction to be called gastric volvulus. Merely gastric rotation on its root is not considered gastric volvulus.

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10
Q

What treatment method is used for hiatus hernia, and what is the differential diagnosis?

A

surgery in severe cases

differential diagnosis: Can make the heart difficult to assess or look like a collection or abscess / mass behind the heart

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11
Q

what is pulmonary embolic disease?

A

Most commonly a blood clot (which oftenstarts in the leg), which travels through the circulatory system and then causes a blockage in the pulmonary artery – can be partial or complete

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12
Q

what are the causes of pulmonary embolic disease?

A

Recent surgery
Immobility
Diseases with a risk of thrombus formation e.g. lupus, HIV, Covid
Drugs such as the contraceptive pill,
Pregnancy
Malignancy

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13
Q

what are the symptoms of pulmonary embolic disease?

A

History fitting any of the causes above
Tachycardia (fast heart rate) , dyspnea (difficulty breathing), chest pain, hemoptysis (coughing up blood).
Signs of a DVT

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14
Q

how do doctors diagnose pulmonary embolic disease

A

Elevated d dimer
Positive scoring on Wells or other scoring system

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15
Q

what complications are associated with pulmonary embolic disease?

A

PEA in the case of a cardiac arrest
Right ventricular strain
Pulmonary infarction
Pulmonary hypertension
Damage heart

Part of lung can die off- Stopping blood getting out of the lungs.
Get a dead space where there is ventilation.
Not getting enough oxygenated blood around the body.
Alveolar collapse because there’s no diffusion

PBA

Get increased pulmonary artery pressure which leads to right heart strain which can lead cardiac arrest or instant death.

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16
Q

what treatment is used for pulmonary embolic disease, and what is the differential diagnosis?

A

Anticoagulation
CPR if necessary- can lead to cardiac arrest
IBC filter if someone is prone to clots.

differential diagnosis:
Movement
Slow flow contrast – poor opacification

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17
Q

which imaging is best used for pulmonary embolic disease?

A

Which imaging?
CXR
Nonspecific, not suggested. Is used to see if the patient has an infection.

CT
CTPA immediately if possible depending on Wells score.
If wells is <4 D-dimer – if high = CTPA

VQ
Looks for that mismatch from ventilation and perfusion
Have to have a CXR first
Replaced by SPECT and no longer recommended

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18
Q

what is a pulmonary oedema?

A

Accumulation of fluid in the interstitial and alveolar spaces- very broad term!
it manifests in 2 types: alveolar and interstitial.

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19
Q

what causes pulmonary oedema.

A

cariogenic:
Congestive heart failure
Cardiomyopathy
Arrythmias
Mitral regurgitation

non cariogenic:
Near drowning
O2 (post intubation)
Trauma
CNS
Alveolitis (hypersensitivity pneumonitis)
Renal failure
Drugs
Inhaled toxins
Altitude
Contusion

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20
Q

what are the symptoms of pulmonary oedema?

A

Breathlessness, distress, high heart rate because they have fluid in their lungs.

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21
Q

How do we diagnose a pulmonary oedema?

A

-CXR- increased cardio/thoracci rati, upper lobe pulmonary venous diversion, alveolar signs (batwing shadowing, airspace shadowing, consolidation), interstitial signs (Kelley B lines, thickening of fissures), pleural effusion.

-CT- Ground glass opacification, septal thickening,

-US- B lines.

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22
Q

what complications are associated with pulmonary oedema?

A

Depends on underlying cause, but can result in large pleural effusions. Also leads to impaired gas exchange and can result in respiratory failure.

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23
Q

what treatment is used for pulmonary oedema, and what is the differential diagnosis ?

A

depends on underlying cause

differential diagnosis:
-pulmonary haemorrhage
-Pneumonia

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24
Q

what is aortic dissection (type A)

A

Separation in the aortic wall intima (tear), allowing blood to flow between the layers of the aortic wall (inner and outer walls of the media). Type A – ascending aorta with or without the aortic arch and descending aorta. Type B – mainly descending aorta and / or abdominal aorta.

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25
Q

what are the causes of aortic dissection?

A

Risk factors include:
Hypertension- high blood pressure
Marfan syndrome
Ehlors-Danlos syndrome- both connective tissue disorders

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26
Q

what are the symptoms of aortic dissection?

A

Acute severe chest pain- struggling to breathe
Left right blood pressure differential- not getting enough pressure to pump the blood properly around the body.
Pulse deficit- –end up with no pulse in the wrist or other extremities.
Dyspnoea- shortness of breath

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27
Q

how do we diagnose aortic dissection?

A

CXR - _not specific and may appear normal. However, you may see:
-Widened mediastinum
-Irregular aortic contour
-Deviation of the mediastinum and / or trachea

CT - _Investigation of choice. Sensitivity and specificity of nearly 100%. Needs to be a contrast scan, preferably a CT angiogram. Will see
-Dilation of the aorta due to aortic insufficency
-Double lumen

MRI - _mainly used in follow ups, but useful in patients with poor renal function. Issues with an acutely unwel patient. Similar snesitivity to CTA

US- _not often used due to availability of CT but can perform transoesophageal echocardioraphy.

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28
Q

what complications are associated with aortic dissection

A

Organ ischaemia
Stroke
Paraplegia
Aortic rupture
Mortality of 10-35% in hospital

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29
Q

what is the treatment method for aortic dissection, and what is the differential diagnosis?

A

Aggressive blood pressure control with beta blockers to reduce blood pressure and heart rate
Immediate surgical repair

differential diagnosis
-CXR- any cause of mediastinal widening.
-CT- Pseudo dissection - motion artefact, adjacent infection.
-Symptons- PE, pneumonia, acute coronary syndrome

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30
Q

what is pneumonia, and what is its main causes?

A

Broad term to describe acute infection on the lung parenchyma (functional tissue e.g. alveoli).

causes:
- infections e.g. COVID 19, bacterial, viral or fungal.

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31
Q

symptoms of pneumonia?

A

-productive cough/ breathlessness / chest pain.
-high temperature (pyrexia) sometimes associated with tachycardia
-malaise- (general feeling of discomfort, uneasiness, or lack of well-being).

32
Q

how do we diagnose pneumonia

A

-CXR- air space opacification
-CT- not generally used as the initial diagnostic tool, but useful in cases with complications or for follow up.

33
Q

what are the complications with pneumonia

A

-empyema (collection of pus in the pleural cavity, gram-positive, or culture from the pleural fluid)
-pulmonary abscess
-bronchopleural fistula- tract between lung and pleura.

34
Q

treatment for pneumonia, and differential diagnosis

A

-antibiotics
-potentially follow up imaging

differential diagnosis:
-consolidation
-mass

35
Q

what is primary lung cancer, and its main causes?

A

primary lung malignancy or bronchogenic.

causes:
-tobacco smoking
-asbestos
-COPD

36
Q

what are the symptoms of primary lung cancer?

A

Patients may be asymptomatic in up to 50% of cases
Hemoptysis- coughing gup blood
Cough and dyspnoea
Pleural effusion
Pneumonia

37
Q

how do we diagnose lung cancer?

A

CXR – may see a lung nodule – rounded or irregular area of increased attenuation. May also see a widened mediastinum, pleural effusion or consolidation
CT – nodule or mass with spiculated or irregular margins. May see cavitation. Or metastases.
PET-CT – assists with staging and assessment of nodal and distant metastatic spread.

38
Q

complications associated with primary lung cancer?

A

-Metastatic spread
-Pleural effusions and infections leading to difficulty in breathing

39
Q

what is the treatment used for primary lung cancer, and the differential diagnosis?

A

-Surgery, chemotherapy, radiotherapy depending on status of tumour

-Molecular / genetic testing can help with targeted treatments

differential diagnosis:

-consolidation
-TB

40
Q

what is a pleural effusion, and its main causes?

A

any accumulation of fluid in the pleural cavity- this could be simple fluid, blood, pus etc. Results from many pathological processes which overwhelm the pleural ability to reabsorb fluid.

causes:
most common are cardiac failure and malignancy- where you are blocking the drainage channels.

41
Q

symptoms of pleural effusion?

A

-small amount may have no symptoms
-as volume increases symptoms include breathlessness especially when active.
-causes are generally split into transduate and exudate.

42
Q

what is transudate and exudate- pleural effusion

A

-2 types of fluid.

transudate:
Lower protein content (<30g/L)
Occurs when there is an increase in hydrostatic pressure
Cardiac failure
Cirrhosis
Trauma
Post coronary surgery

exudate:
Higher protein content (>30 g/L)
Occurs due to an alteration in the pleural space drainage to lymph nodes
Bronchial cancer
Lung metastases
PE
Pneumonia
TB
Mesothelioma

43
Q

how do we diagnose pleural effusion?

A

US- allows detection of small amounts (3-5ml)- helps guide for pleural taps or drainage.

CT- excellent in detecting small amounts.

CXR- most commonly used imaging method. BUT needs as much as 250mls- 600mls of fluid to see.

Will see blunting of the cost and cardiophrenic angles, fluid within the horizontal fissure, fluid level may see some mediastinal shift if large.

44
Q

what are the complications associated with pleural effusion?

A

-Lung collapse
-Fibrotic changes- scarring. Scarring can cause the lungs to not expand.

45
Q

how do we treat pleural effusion, and what is the differential diagnosis ?

A

-targeted to underlying cause
-May drain- if it is large

differential diagnosis:
-elevated hemi diaphragm
-collapse or consolidation
-pleural thickening.

46
Q

what might we see is an x ray for pleural effusion was taken AP or PA erect?

A

Erect films are insensitive to small amounts of fluid
May see blunting of the costophrenic angle
Blunting of the cardiophrenic angle
Fluid within the horizontal or oblique fissure
Eventually a meniscus will be seen, (not with a hydropneumothorax)
Lateral images can identify a smaller amount of fluid

47
Q

what might we see if an x-ray for pleural effusion is taken supine?

A

-large amounts of fluid can be present on supine image with minimal imaging changes, as the fluid is dependent and collects posteriorly.
-There is no meniscus and only a veil like increased density of the hemithorax may be visible
-can be very difficult to identify bilateral effusions as the density will be similar.

48
Q

what is a pneumothorax?

A

Air in the pleural space

49
Q

what are the main causes of a pneumothorax

A

-Primary generally in younger patients, secondary in older/
Primary spontaneous – no underlying lung disease- tends to be younger patients, tall young men.
Secondary spontaneous – underlying lung disease is present e.g COPD. – older patients
Iatrogenic / traumatic- caused by a medical device e.g biopsy, or trauma such as fractured ribs.

50
Q

what are the main causes of pneumothorax through the chest wall and visceral pleura?

A

air entry through the chest wall:
-trauma
-latrogenic

air entry though the visceral pleura:
-many pulmonary diseases predispose you to pneumothorax including

-cystic lung disease
-bullae
-emphysema, asthma
-end stage interstitial lung disease
-cystic fibrosis
-lung abscess- necrotic pneumonia, TB.

51
Q

what are the main symptoms of pneumothorax?

A

pain
breathlessness

52
Q

how do we diagnose pneumothorax?

A

CT – considered the gold standard.
Point of care US is more accurate than a supine CXR

53
Q

what complications are there regarding a pneumothorax?

A

-tension pneumothorax- so big it puts pressure on the heart and can lead to death

54
Q

how do we treat a pneumothorax

A

Observation- only if its small, resolves by itself.
Aspiration-
Chest drain
Surgery- stitch top of lungs to pleura so it doesn’t happen again.

55
Q

differential diagnosis for pneumothorax?

A

Artifacts and monitoring leads
Overlapping breast margin
Pulmonary bullae- alveolar have become over expanded.
Calcified pleural plaques
Pneumomediastinum or pneumopericardium- air around mediastinum or heart, can often mimic pneumothorax.

56
Q

imaging appearances for an AP/PA erect CXR for pneumothorax

A

-Visible visceral pleural edge seen as a very thin sharp white line
-No lung markings seen peripheral to this line
-Peripheral space is radiolucent compared to adjacent lung
-Lung may completely collapse
-Mediastinum should not shift unless there is a tension pneumothorax
-May also see subcutaneous emphysema or a pneumomediastinum

57
Q

imaging appearances for a supine CXR for a pneumothorax

A

It is much harder to see on a supine chest x ray

Does not display classical signs when a patient is supine. May see:

Relative lucency of the involved hemithorax
Deep sulcus sign
Increased sharpness of the adjacent mediastinal margin and diaphragm
Increased sharpness of the cardiac borders
Double diaphragm sign
Depression of the ipsilateral hemidiaphragm

58
Q

pneumothorax- what is a deep sculls sign that is often seen in a supine CXR

A

The costophrenic angle is abnormally deepened when the pleural air collects laterally, compared to the other side

59
Q

pneumothorax- what is a double diaphragm sign that is often seen on a supine CXR

A

With apneumothorax air outlines the anterior portions of the hemidiaphragm outlining the anterior costophrenic sulcus – you see the diaphragmatic dome and the anterior portion of the diaphragm

60
Q

what is pneumoperitoneum?

A

Gas within the peritoneal cavity
Generally, from a perforated hollow viscus, post operative, from peritoneal dialysis, due to mechanical ventilation, pneumothorax or pneumomediastinum, and many diseases
Patient will often be very ill
On CXR (most sensitive):
Sub diaphragmatic free gas
Continuous diaphragm sign

61
Q

what is COPD (chronic obstructive pulmonary disease), and its causes, and symptoms ?

A

is a general term with 2 key disease features- chronic bronchitis and emphysema.

Causes:
smoking- most common
-cystic fibrosis
-industrial exposure- e.g. mining.

symptoms:
-dyspnoea on exertion
-wheezing
-productive cough

62
Q

How do we diagnose COPD?

A

CT- may be as for CXR and also fibrotic changes and bronchial wall thickening for bronchitis and for emphysema- airspace enlargement and possible bulla.

CXR- bronchitis predominant- increased bronchovascular markings and enlarged heart.
-emphysema predominant- hyperinflation of the lungs with flattening of the hemidiaphragms and small heart.

63
Q

what complications are associated with COPD?

A

-exacerbation- infection and acute breathlessness
-pulmonary hypertension

64
Q

how do we treat COPD and what is the differential diagnosis?

A
  • condition is irreversible, but can manage symptoms and delay progression

differential diagnosis:
pneumothorax if bulla are seen.

65
Q

What is COPD emphysema predominant

A

Hyperinflated lung fields- see many ribs.
Diaphragm flattens.
Small heart as they are increasing lung volume capacity

clinical phenotype of COPD where emphysema is the primary feature

Emphysema is a chronic lung disease that damages the air sacs in your lungs, making it difficult to breathe:

66
Q

what is COPD bronchitis predominant

A

chronic bronchitis produces a frequent cough with mucus

67
Q

what are rib fractures, and its main causes?

A

Most commonly due to trauma. when a rib is fractured twice it is termed a floating rib. When there are 3 or more, this is a flail chest which indicates severe chest trauma- causes risk to pneumothorax.

causes:
-trauma
-osteoporosis
-pathological fracture

68
Q

What are the symptoms of rib fractures?

A

-relevant clinical history
-pain on inspiration or movement.

69
Q

how do we diagnose rib fractures, and what are the common complications?

A

CXR- fracture and displacement seen.
-CT- better at diagnosing a flail chest

common complication: Fracture of 1st rib is an indicator for severe chest trauma as this is protected by the clavicle and scapula.

70
Q

how do we treat rib fractures, and what is the differential diagnosis?

A

-O2 therapy as infection is a common complication
-Surgery is rare.

differential diagnosis:
confusion between pathological and traumatic fracture.

71
Q

what is goitre and its main causes?

A

enlargement of the thyroid gland, it can be caused by multiple conditions including- iodine deficiency, thyroid cancer, hashimotos.

-causes- it can be caused by multiple conditions including- iodine deficiency, thyroid cancer and hashimotos.

72
Q

what are the symptoms of goitre and its possible complications?

A

Visible swelling
Tight feeling in throat
Coughing
Difficulty in swallowing or breathing

complications:
-difficulty in swallowing and breathing
-may need thyroid surgery.

73
Q

how do we diagnose goitre?

A

US- can give accurate measurements
CXR- may see deviation of the mediastinum and a soft tissue mass in the upper mediastinum.
CT- as for chest, also mixed density mass.

74
Q

what treatment is used for goitre and what’s the differential diagnosis?

A

-may need surgery if large

-enlarged lymph nodes

75
Q

what is mesothelioma, and its cause and symptoms?

A

Raremalignancy that mostly arises from the pleura

Causes​
Asbestos exposure

Symptoms​
Vague
Dyspnoea- shortness of breath.
Back pain
Pleural effusion

-

76
Q

how do we diagnose mesothelioma and what are some of tis complications?

A

Diagnosis ​
PET CT is often used for staging as metastases are common
CXR – non specific. Will see pleural thickening with / without a pleural effusion. May see rib destruction.
CT – most commonly used for diagnosis. Will see a pleural, nodular mass. May see invasion into chest wall lung or bones. May see metastases in lung and lymphadenopathy
MRI – not commonly used but may provide more accurate staging

Complications ​
From metastases
Pleural effusion- harder to breathe

77
Q

how do we treat mesothelioma and what’s the differential diagnosis?

A

Treatment​
Long term survival is poor. Surgery, chemotherapy and radiotherapy can be used.

Differential diagnosis
Pleural effusion
Pleural mass

Head, neck and thorax (5 decks)

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