Midterm Flashcards
Which lobes does the right oblique fissure (major) divide?
superior & middle lobes are above fissure and inferior lobe is below fissure
*begins at T5 and extends down & fwd to end at anterior pleural gutter of diaphragm
On what type of view is oblique fissure seen?
only on lateral film
not seen on PA
Which lobes does the right horizontal fissure (minor) divide?
anterior portion of superior lobe is above fissure and middle lobes is below fissure
*begins at the oblique fissure at mid-axillary line and runs horizontally to the sternal end of 4th costal cartilage
On what type of view is right horizontal fissure seen?
lateral film
seen in 54% of PA
(absent or incomplete in 25% of individuals)
What lobes does the left oblique fissure (major) separate?
left upper lobe from left lower lobe
*begins at T5 and extends obliquely down and fwd to end at anterior plural gutter of diaphragm
In lungs, LUL is analogous to _________
RUL & RML combined
LLL = LRL
What are the lingula?
there are two lingular bronchopulmonary segments of the left upper lobe (inferior & superior lingular segment)
What is the radiographic significance of lingula?
the abut the left heart border causing a silhouette sign when there is lingular collapse or consolidation
What anatomical parts are responsible for the cardiac contours on the PA film?
right atrium (R heart border), left atrium & ventricle (L heart border), ascending aorta, aortic arch, pulmonary trunk, brachiocephalic vessels, SVC, IVC
(all of these are retrosternal)
What anatomical parts are responsible for the cardiac contours on a lateral film?
Right ventricle, ascending aorta, aortic arch, descending aorta, left atrium & ventricle, IVC
(all of these are in the posterior mediastinum)
Which views are included in a routine plain film examination of the chest?
Minimum = PA and left lateral done during full inspiration
put area of interest closest to the film
apical/lordodic view to look at apices in addition to PA (gets clavicle out of the way)
How does positioning of chest study differ from thoracic spine plain film?
chest study - PA chest and left lateral chest
thoracic study - AP thoracic & either lateral view
What is the technique for chest study plain film?
72” FFD, high kVp, low mA and short time, full inspiration
how does collimation differ on chest vs. thoracic plain film study?
chest films must include all air spaces of the lungs vs. tightly collimated thoracic spine films
What condition or anatomical region is best demonstrated by the apical lordotic view?
see apices of lung, can dx a pancoast tumor (or anything in the apices of the lung)
Is routine chest xray taken with inspiration or expiration?
Full inspiration so there is no crowding and you can see all the vessels
breath held in inspiration expands the lung fields, depresses diaphragm, and provides contrast (air vs. tissue)
Describe the difference in appearance between inspiration and expiration
during a good inspiration you should see the first 10 ribs posteriorly, lowers diaphragm
diaphragm crosses T12 vertebral body on lateral film during full inspiration & is at level of posterior R10-11 on PA
What condition is better demonstrated upon expiration than inspiration?
pneumothorax - upper right expiration is more sensitive; look for mediastinum displacement
on expiration consolidation appears more bright
What is the appearance of interstitial dz?
thickened alveolar septa, alveolar walls; interstitial lymph, veins, cells
usu. a diffuse pattern, mb combined with consolidation
What dz has the pattern of reticular, nodular, honeycomb, or any combo
interstitial disease
What do you see with a combination of air space dz and interstitial dz (both types of lung opacification)?
acinar shadow
What is the appearance air space disease?
silhouette sign, air bronchogram, atelectasisi
pattern = diffuse, lobar/localized, solitary nodule/masses, multiple nodule or masses
What dz has pattern of diffuse, lobar/localized, solitary nodule/masses, multiple nodule or masses?
air space disease
air-bronchograms
lucent tubular and branching structures representing aerated bronchi surrounded by opaque acini
What are the four patterns of “white lung” disease?
Diffuse - consolidation
Localized/Lobar
Solitary mass/Nodule
Multiple masses/Nodule
DDx for diffuse-consolidation pattern of “white lung” disease
pulmonary edema (MC) d/t CHF, stroke, trauma, drugs; systemic/widespread dz such as sarcoidosis, histoplasmosis, TB; unusual infx (pneumocysitis carnii, opportunistic, immune compromised); bronchioalveolar carcinoma; idopathic hemorrhage
usu. see bilateral sx; implies involvement of all lobes
DDx for localized/lobar pattern of “white lung” disease
bacterial infx or pneumonia (MC); pancoast tumor; pulmonary TB; pulmonary infarct; bronchopulmonary sequestration; atypical pneumonia (viral, mycoplasma)
MC presentation for infx
usu. only a portion of one lung
primary TB is usu. seen with consolidation in _______, while secondary TB is usu. seen with patchy consolidation in ________
1' = lower lobe 2' = upper lobe
DDx for solitary mass/nodule pattern of “white lung” disease
primary neoplasm (bronchogenic carcinoma - is most alarming); hematogenous metastasis; hamartoma; tuberculoma; lung abscess; hydatid cyst; hematoma; bronchopulmonary sequestration
smaller, well-defined area
Is there calcification? usu. a good finding, but depends on the pattern
DDx for multiple masses/nodules pattern of “white lung” disease
MC indicates pulmonary metastesis; lymphoma; granulomatous infx (TB, histoplasmosis, coccidioidomycosis); Rheumatoid nodules; Wegener’s granulomatosis
usu. bilateral, see multiple well-defined areas
What is the silhouette sign?
obliteration/burring of an anatomical shadow d/t a water density (structure or lesion) in anatomic contact with that structure (can’t see structure any longer)
*indicates water density materia in air spaces; can localize by structure silhouetted
Examples of water densities that may cause a silhouette sign
pneumonia, tumors, pleural effusion
Structures that may show a silhouette sign
1) Mediastinal structure - heart, aorta
2) Diaphragms d/t effusion/fluid
3) Chest wall - tumors, etc.
4) Posterior heart structures - descending aorta, aortic knob
Where do you normally see a silhouette sign?
heart on left of hemidiaphragm
If most of the right heart border is obliterated, it indicates involvement of
right middle lobe
If uppermost portion of the right heart border is obliterated, it indicates involvement of
anterior segment of the right upper lobe
If most of the left hear border is obliterated, it indicates involvement of
lingular portion of the left upper lobe
If uppermost portion of the left heart border is obliterated, it indicates involvement of
anterior segment of the left upper lobe
If the aortic knob is obliterated, it indicates involvement of
apical segment of the left upper lobe
If the diaphragm is obliterated, it indicates involvement of
appropriate basal segment (determine anterior or posterior)
Two water densities ________________ will dim the borders of each but will NOT obliterate them
superimposed but not in contact
Water densities that may cause a silhouette sign include
pneumonia, tumors, pleural effusion, etc.
With pneumothorax, you see mediastinal push ______ from the area of air/concern
away
What main types of atelectasis?
1) Resorptive (obstructive)
2) Passive (compressive)
Causes of central resorptive (obstructive) atelectasis
bronchogenic carcinoma, bronchial adenoma, foreign body, bronchial TB, lymphadenopathy, mediastinal mass, aneurysm
Causes of peripheral resorptive (obstructive) atelectasis
pneumonia, mucous plugging, POST-OPERATIVE
Causes of passive (compressive) atelectasis
interthoracic space occupying process - pneumothorax (MC), hemothorax, hydrothorax, any mass essentially
few actually show signs of atelectasis
What is the MC cause of atelectasis?
resorptive (obstructive) - think tumor
Signs of resorptive atelectasis
displaced fissures, elevated hemidiaphram, displace hilus, mediastinal shift (everything shifts twd it)
Also see increased density, approximation of the ribs, vascular bronchial crowing, compensatory emphysema (other lung shifts twd that side), lung herniation
Signs of passive atelectasis
collapsed lung –> look for lack of lung margins and b.v. in periphery & edge of visceral pleura on outer margin of lung
What is direction of collapse if different types of atelectasis?
Resorptive = toward collapsed lung
Passive = away from collapsed lung
What is the air bronchogram sign?
when air spaces are filled with water density –> air filled bronchi are visible
*bronchi/bronchioles are normally not visible on chest xray
What does air bronchogram indicate?
pneumonia
*this sign is likely with diffuse consolidation and possible w/ lobar/localized consolidation; it is unlikely with masses
Which condition commonly demonstrates as a mass in the pulmonary apex or hilar area and may cavitate?
bronchogenic carcinoma
(2’ TB can also show up in pulmonary apex and cavitates in 40%, but it is usu. bilateral, whereas bronchogenic carcinoma is usu. unilateral)
Which condition commonly demonstrates pleural plaques in the lung bases (calcified)?
this is the MC change in asbestos related dz
15% visible on chest x-ray
What is pathognomonic for asbestos exposure?
calcified pleural plaques - this may take up to 20 yrs after exposure
Radiographic signs of pulmonary emphysema?
flattened, depressed hemidiaphragms; hyperlucency; increased retrosternal clear space; increased AP chest diameter; decreased peripheral vascular markings; > 10 ribs visible (hyperinflated); may present with pneumothroax
What is an air filled bulla?
abn air filled spaces within lung - mb d/t confluent destruction of alveolar walls 2’ to emphysema
radiographic image of focal round or oval radiolucencies surrounded by a thin wall
air filled bulla
indicates emphysema
radiographic findings of meniscus sign, blunted costophrenic angle, effusion (transudate/exudate), blood, pus, lymph (chylothorax)
pleural effusion
causes of pleural effusion
CHF, pneumonia, neoplasm, infection (empyema), trauma, embolism, CT dz, TB, abdominal dz (pancreas, cirrhosis)
Types of pneumothorax
Spontaneous, traumatic/iatrogenic, tension
_________ pneumothorax is seen in tall, thin males and ____________ pneumothorax is seen with underlying lung dz, bullae, blebs, air trapping
primary spontaneous
secondary spontaneous
valve effect with progressive accumulation of air, shift of mediastinum away from collapsed lung, leads to vascular compromise (MEDICAL EMERGENCY)
tension pneumothorax
need a chest tube
what is the appearance of pneumothorax with pleural effusion?
shrunken lung, pleural space larger, no b.v. seen where they should be, heart shifted away from lung, may see meniscus sign from pleural effusion
What is the difference btwn tension and spontaneous pneumothorax?
Tension = extreme collapse Spontaneous = small amount of collapse
What is a pancoast tumor?
superior sulcus tumor; apical; extension into adjacent chest wall; usu. squamous cell (can also be adenocarcinoma)
clinical presentation of pancoast tumor
Horner syndrome - ptosis, anhydrosis, myosis
Pain radiating to arm, apical mass (look for rib or vertebral dysfn), pleural extension
What are multiple pulmonary masses of varying sizes suggestive of?
metastatic cancer
bronchogenic is solitary
Is calcification common in a malignant pulmonary mass?
NO - most calcifications are benign
MC calcification is granuloma (TB, histoplasmosis, cocsidiomycosis)
Conditions that demonstrate unilateral elevation of hemidiaphragm
atelectasis phrenic nerve palsy splinting eventration subphrenic inflammation
Conditions that demonstrate bilateral elevation of hemidiaphragm
poor inspiration obesity pregnancy ascites hepato-splenomegally
Normal relation btwn transverse diameter of heart and thoracic cage on PA chest fil,?
located in middle mediastinum, 1/3 to right of midline & 2/3 to left of midline
cardiothoracic ratio on PA upright w/ full inspiration
widest coronal diameter of heart is less than or equal to thoracic cavity (no minimum)
**not the best evaluation for cardiomyopathy
Causes of left ventricle hypertrophy
aortic stenosis, chronic HTN
Causes of right atrium enlargement
CHF
In lateral view of chest x-ray, heart should be _______ the width of the heart cavity
less than half
anterior mediastinum from lateral view
sternum to anterior cardiac silhouette = anterior (retrosternal) clear space
middle mediastinum from lateral view
anterior to posterior cardiac silhouette
posterior mediastinum from lateral view
posterior cardiac silhouette to posterior border of lung field
Contents of anterior mediastinum
thymus gland & lymph nodes
Pathologies of anterior mediastinum
3T’s and an H
Thyroid retrosternal goiter (MC)
Hodgkin’s Lymphoma
Thymic mass - thymoma
Teratoma - germ cell tumor
contents of middle mediastinum
pericardium, heart, great and pulmonary vessels, phrenic nerve, upper vagus nerves, trachea - primary bronchi, lymph nodes
masses above clavicle are in ____________ and masses below clavicle are in ____________
anterior mediastinum
middle mediastinum
pathologies of middle mediastinum
lymphadenopathy (enlarge LN), bronchogenic carcinoma (in primary bronchi), aortic aneurysm, bronchogenic cyst, CHF, CVD (hardening of aa)
contents of posterior mediastinum
descending thoracic aorta, esophagus, thoracic duct, azygous vv., hemizygous vv., sympathetic ganglia, lower vagus nn., lymph nodes
pathologies of posterior mediastinum
Hiatal hernia (MC), neurogenic tumors, paravertebral masses, meningocele, esophageal masses, aneurysm
increased retrosternal clear space
emphysema
what is the MC retrocardiac mass?
hiatal hernia
apical lordotic view
pt. learning back and looks like xray beam angled on pt. - fuzzier film
* used to view pancoast tumor, reactivated TB
loss of costophrenic angle
water from pleural effusion
accessory fissure in lungs on upper R side
azygous fissure
extrapleural sign
xs bone seen in lung xray –> usu. d/t rib bone metastasis or rib fx with hematoma
Black lung dz
pneumothorax, emphysema, cystic dz, trapped air - obstruction
