Pediatric Flashcards
Bandlike lucencies on chest radiograph
Pulmonary interstitial emphysema
Ropy opacities on chest radiograph
Meconium aspiration
Granular opacities on premature chest radiograph
Surfactant deficiency disease
VACTERL
V: vertebral anomalies A: imperforate anus C: cardiac anomalies TE: tracheoesophageal fistula or esophageal atresia R: renal anomalies L: limb and ray anomalies
Infarcted spleen
Sickle cell anemia
Weigert-Meyer Rule
Duplicated collecting systems.
Upper moiety inserts inferomedially into the bladder, and is prone to obstruction and ureterocele formation.
Lower moiety inserts superolaterally into the bladder, and is prone to reflux.
Cobra head sign
Suggests ureterocele on ultrasound or intravenous pyelogram
Keyhole sign
Posterior urethral valves
Tibia vara
Blounts disease
Neuroblastoma Stage 4S
Less than 1 year old
Distal metastases confined to skin, liver, bone marrow (not bone cortex)
Excellent prognosis
Neuroblastoma appearance
Age: less than 2 years old
Calcifies 90%
Encases vessels (doesn’t invade)
Poorly marginated
Metastasizes to bone
Wilm’s appearance
Usually around 4 years old (never before 2 months)
Rarely calcifies (<10%)
Invades vessels (doesn’t encase)
Well-circumscribed
Doesn’t usually metastasize to bone
Croup
Barky “croupy” cough
Parainfluenza virus
Steeple sign on radiograph
Steeple sign on radiograph
Croup
Thumb sign
Epiglottitis
Exudative tracheitis radiograph findings
Linear soft tissue filling defect in airway
6-10 years old
Staphylococcus aureus
PHACES Syndrome
P: posterior fossa (Dandy Walker) H: hemangiomas A: arterial anomalies C: coarctation of aorta, cardiac defects E: eye abnormalities S: subglottic hemangioma
Subglottic hemangioma radiograph findings
Asymmetric subglottic narrowing
in contradistinction to steeple sign, which is bilateral
Retropharyngeal abscess radiograph findings
Massive retropharyngeal soft tissue thickening
Meconium aspiration radiograph findings
Ropy appearance
Hyperinflation with areas of alternating atelectasis
Pneumothorax in 20 to 40% of cases
Transient tachypnea of the newborn
Clinical history: C-section, maternal sedation, maternal diabetes
Findings: coarse interstitial markings and fluid in fissures. Lung volume is normal to increased.
“Post term baby”
Meconium aspiration
“C-section”
Transient tachypnea of the newborn
“Maternal sedation”
Transient tachypnea of the newborn
Premature infant
Surfactant deficiency disease
Neonatal pneumonia (beta-hemolytic strep) radiograph findings
Low long volumes, granular opacities often will have pleural effusion
Neonatal pneumonia (non-beta hemolytic strep) radiograph findings
Patchy, asymmetric perihilar densities
Hyperinflation
Full-term baby
“Bandlike opacities”
Bronchopulmonary dysplasia (chronic lung disease)
Croup: Age
6 months - 3 years (peak 1 year)
Croup: Main Radiologic Features
Steeple Sign: loss of the normal shoulders (lateral convexities) of the subglottic trachea
Croup: Cause
Viral (Most common parainfluenza)
Most common cause of acute airway obstruction in young kids.
Croup
Epiglottitis: Age
3.5 years (now also seen in teenagers)
Epiglottitis: Main radiologic features
Thumb Sign (lateral X-ray): marked enlargement of epiglottis
When looking for Thumb Sign of epiglottitis, what “fake out” do you need to watch for, and how would you tell the difference?
Omega Esophagus: caused by oblique imaging. Look for thickened aryepiglottic folds to distinguish.
Epiglottitis: Cause
H. influenza
Epiglottitis: prognosis
Can kill! Death by asphyxiation from aryepiglottic folds (NOT epiglottis!)
Croup: Prognosis
Usually self-limiting.
Exudative Tracheitis: Age
6-10 years
Exudative Tracheitis: main radiologic features
Linear soft tissue filling defect (a membrane) seen within airway
Exudative Tracheitis: cause
Staph A
Exudative Tracheitis: prognosis
Serious, possibly deadly (although uncommon condition)
Retropharyngeal Cellulitis and Abscess: age
6 months- 12 months
Retropharyngeal Cellulitis and Abscess: main radiologic features
Lateral X-ray: massive retropharyngeal soft tissue thickening.
Retropharyngeal Cellulitis and Abscess: When looking for characteristic retropharyngeal soft tissue thickening, what is a possible fake out on X-ray? And how would you differentiate from the real thing?
Real world: can get pseudothickening when neck not truly lateral. To differentiate, repeat with an extended neck.
Retropharyngeal Cellulitis and Abscess: what is the possible fake out on CT?
More lateral, low density suppurative node.
Subglottic Hemangioma: main radiologic feature
Loss of ONE of the shoulders of the subglottic trachea (compared to Steeple Sign of croup, which has loss of both shoulders)
Most common soft tissue mass in the trachea
Hemangioma
Most common location of tracheal hemangioma
Subglottic
Subglottic Hemangioma: which side favored?
Left
Subglottic Hemangioma: associated with what other mass? (And what %?)
Cutaneous hemangioma (50%)
Subglottic Hemangioma: associated with what syndrome? (And what %?)
PHACES syndrome (7%)
What is PHACES syndrome?
Posterior fossa (Dandy Walker) Hemangiomas Arterial anomalies Coarctation of the aorta, cardiac defects Eye abnormalities Subglottic hemangiomas
What 2 conditions are you looking for on frontal neck radiographs & how do you tell them apart?
Croup: Steeple Sign (loss of both shoulders)
Subglottic Hemangioma: loss of ONE shoulder
**If you can’t tell, look at the history. Cough, fever–think croup.
What 4 conditions are you looking for on lateral neck radiographs?
Epiglottitis,
Retropharyngeal Abscess,
Tonsils (adenoids),
Exudative Tracheitis
True or False: If the ordering Dr. suspects epiglottitis, you should have them bring the kid to x-ray for a lateral view.
False. Do not bring the kid to you. Have them do a portable.
Retropharyngeal Abscess: main radiographical feature
Retropharyngeal soft tissue too thick:
>6 mm at C2 or
>22 mm at C6
Retropharyngeal Abscess: Next step after lateral X-ray
CT
Retropharyngeal Abscess: Aside from the thickened retropharyngeal tissue, what else must be assessed on CT?
Mediastinum for “Danger Zone” extension.
Tonsils: Age they are first seen
About 3-6 months
Tonsils: Age they get big (not when first seen)
About 1-2 years
Tonsils: how big is too big?
Too big when encroach on the airway
Meconium Aspiration: Cause
Usually secondary to stress (hypoxia)
Meconium Aspiration: preterm, term, or post-term?
Term or POST term
Meconium Aspiration: 3 main radiologic features
- “Ropy appearance” of asymmetric lung densities
- Hyperinflation (aka increased lung volume) w/areas of atelectasis
- Pneumothorax (20-40% of cases)
Transient Tachypnea of the Newborn: 3 classic histories
C-section,
Maternal sedation,
Maternal Diabetes
Transient Tachypnea of the Newborn: Timing of findings (onset, peak, resolution)
Onset: 6 hours
Peak: day 1
Resolved by: day 3
Transient Tachypnea of the Newborn: lung volumes
Normal to Increased
Transient Tachypnea of the Newborn: radiologic features
Coarse interstitial marking & fluid in fissures
Surfactant Deficient Disease (SDD, RDS, Hyaline membrane disease): preterm, term, or post-term?
Pre-term
Surfactant Deficient Disease (SDD, RDS, Hyaline membrane disease): lung volumes
Low lung volumes
Most common cause of death in premature newborns.
Surfactant Deficient Disease (SDD, RDS, Hyaline membrane disease)
Surfactant Deficient Disease (SDD, RDS, Hyaline membrane disease): main radiologic features
Low lung volumes & granular opacities. NO PLEURAL EFFUSION! (that’s B-hemolytic pneumonia)
True or False: A normal plain film at 6 hours excludes SDD (RDS).
True.
Surfactant Replacement Therapy: radiographic features post treatment
Lung volumes get better, opacities clear centrally. Bleb-like lucencies (can mimic PIE)
Surfactant Replacement Therapy: increases risk of what? (2 things)
Pulmonary hemorrhage, PDA
Neonatal Pneumonia (NOT B-hemolytic Strep): main radiographic findings
Patchy, asymmetric perihilar densities; hyperinflation.
Neonatal Pneumonia (not B-hemolytic Strep): preterm, term, or post-term?
Term
Neonatal Pneumonia (B-hemolytic Strep): more common in preterm, term, or post-term?
More common in preterm than full term (but not exclusive).
Most common type of Pneumonia in newborns.
Neonatal Pneumonia (B-hemolytic Strep)
Neonatal Pneumonia (B-hemolytic Strep): main radiographic features
- LOW lung volumes (other pneumonias are high),
- Granular opacities (also in SDD)
- Pleural Effusion often (NOT in SDD)
Persistent Pulmonary Hypertension (persistent fetal circulation): causes
Primary (it just is), or secondary from hypoxia (meconium aspiration, Pneumonia, etc)
True or False: You can see persistent pulmonary hypertension on a CXR.
False. You can see the cause, but not the actual hypertension. That’s just ridiculous. 😝
Chest Buzzword: “Post term baby”
Meconium aspiration
Chest Buzzword: “c-section”
Transient tachypnea
Chest Buzzword: “maternal sedation”
Transient tachypnea
Chest Buzzword: premature
SDD/RDS
Conditions with HIGH lung volumes
Meconium Aspiration,
Transient Tachypnea,
Neonatal Pneumonia (not B-hemolytic strep)
Conditions with LOW lung volumes
SDD, Neonatal Pneumonia (B-hemolytic Strep)
(note: other pneumonias have high lung volumes)
Two conditions caused by ventilation in the NICU
Pulmonary Interstitial Emphysema, Bronchopulmonary Dysplasia (chronic lung disease)
Pulmonary Interstitial Emphysema (PIE): cause
Ventilation (air escapes alveoli, ends up in interstitium & lymphatics)
Pulmonary Interstitial Emphysema (PIE): age of occurrence
FIRST week of life
Note: BPD > 2 weeks
Pulmonary Interstitial Emphysema (PIE): CXR appearance
“Linear lucencies” (buzzword)
“Linear lucencies” on CXR
Pulmonary Interstitial Emphysema (PIE)
Pulmonary Interstitial Emphysema (PIE) is a warning sign for what condition?
Impending pneumothorax
Pulmonary Interstitial Emphysema (PIE): what can mimic appearance?
Surfactant therapy
Pulmonary Interstitial Emphysema (PIE): treatment
Put them affected side down &/or switch ventilation methods
Pulmonary Interstitial Emphysema (PIE): rare-but-possible progression
Can progress to large cystic mass. Can even cause mediastinal mass effect. (Zebra!!)
Chronic Lung Disease (Bronchopulmonary Dysplasia): classic history
Tiny (<1000g),
Premature (<32 weeks),
Prolonged ventilation
Chronic Lung Disease (Bronchopulmonary Dysplasia): Age
> 2 weeks old
Note: PIE in 1st week
Chronic Lung Disease (Bronchopulmonary Dysplasia): radiographic features
“BAND LIKE OPACITIES” (buzzword)
After 2 weeks old, get hazy lungs.
After few months, coarseness & give bubble-like lucencies.
Pulmonary Hypoplasia: secondary causes (3 major categories)
- Decreased hemilaminectomy-thoracic volume.
- Decreased vascular supply.
- Decreased fluid.
Pulmonary Hypoplasia: of the 3 major categories of secondary causes, which is the most common?
Decreased hemi-thoracic volume
Primary differentials for decreased hemi-thoracic volume leading to secondary Pulmonary Hypoplasia.
Congenital diaphragmatic hernia (w/bowel in the chest) or other space occupying mass—most common.
Also can be neuroblastoma or sequestration.
Potter Sequence
Causes secondary pulmonary hypoplasia due to decreased fluid. Refers to no kidneys-> no pee-> no fluid -> hypoplastic lungs.
True or False: Radiographs are a passable way to differentiate between intralobar and extralobar bronchopulmonary sequestration.
False. You cannot tell the difference between these radiographically.
(Note: age of presentation is best practical way to differentiate.)
Bronchopulmonary Sequestration: which is more common, intralobar or extralobar (give percentages)?
Intralobar more common (75%)
Extralobar (25%)
Bronchopulmonary Sequestration, Intralobar: age of presentation
Adolescent or adult
Note: extralobar in infants
Bronchopulmonary Sequestration, Intralobar: chief presenting complaint
Recurrent Pneumonia in adolescent or adult (bacteria migrates in from pores of Kohn)
Bronchopulmonary Sequestration, Intralobar: site most commonly affected (radiographic findings)
Left lower lobe, posterior segment (2/3s).
Uncommon in upper lobes & rarely associated w/other developmental anomalies.
Bronchopulmonary Sequestration: which has a pleural cover, intralobar or extralobar? (And can you see it radiographically?)
Extralobar. (No, it cannot be seen radiographically.)
Bronchopulmonary Sequestration, Exralobar: age of presentation
Infant
Note:intralobar adolescent or adult
Bronchopulmonary Sequestration, Exralobar: clinical history
Infant with respiratory compromise due to associated anomalies
Bronchopulmonary Sequestration, Exralobar: does it usually get infected?
No. Rarely gets infected because it has its own pleural covering.
Bronchopulmonary Sequestration, Extralobar: can rarely have a patent channel to where?
Stomach or distal esophagus (sometimes described as part of a bronchopulmonary foregut malformation.)
Bronchogenic Cysts: radiographic features
Solitary, unilocular, NO GAS (if you see gas, think infection).
Typically incidental.
Congenital Cystic Adenomatoid Malformation (CCAM/CPAM): region typically affected
Usually only one lobe (no lobar preference).
Congenital Cystic Adenomatoid Malformation (CCAM/CPAM): name the types
Type 1: cystic
Type 2: in the middle
Type 3: solid.
Congenital Cystic Adenomatoid Malformation (CCAM/CPAM): communicate with the airway?
Yes. They fill with air.
Congenital Cystic Adenomatoid Malformation (CCAM/CPAM): prognosis and treatment
Most (like 90%) spontaneously decrease in size in 3rd trimester, but tiny risk of malignant transformation, so recommend surgical excision.
Congenital Cystic Adenomatoid Malformation (CCAM/CPAM): what if you see a systemic arterial feeder (one off the aorta) going to the CCAM?
Then it’s not a CCAM. It’s a sequestration. :)
Congenital Lobar Emphysema (Congenital Lobar Overinflation): radiographic findings
Lucent, hyper-expanded lobe on CXR
Congenital Lobar Emphysema (Congenital Lobar Overinflation): site preference
Left Upper Lobe (40%)
Congenital Lobar Emphysema (Congenital Lobar Overinflation): treatment
Lobectomy
Congenital Lobar Emphysema (Congenital Lobar Overinflation): The name says “Emphysema,” but it’s not. Why?
Actually just air-trapping secondary to a bronchial anomaly.
You are shown a series of CXRs. First has opacity in left upper lung. Second shows opacity resolved. Following X-ray shows lobe getting more and more lucent until it’s actually pushing the heart over. Diagnosis?
Congenital Lobar Emphysema (Congenital Lobar Overinflation).
Congenital Diaphragmatic Hernia: most common type (and location)
Bochdalek type, typically back/posterior and left.
B–Bochdalek, Back
Congenital Diaphragmatic Hernia: usually left posterior. If on right, what is it associated with?
GBS Pneumonia
Congenital Diaphragmatic Hernia: prognosis most closely related to what factor?
Mortality rate related to Degree of pulmonary hypoplasia
Congenital Diaphragmatic Hernia: common associated condition
Most have congenital heart disease
True or False: malrotation is rare with congenital diaphragmatic hernias.
False. Essentially all are malrotated.
You are shown a study with the NG tube curving into the chest. Diagnosis?
Congenital Diaphragmatic Hernia
You are shown a study with Left Upper Lung Lobe affected. Top differentials?
Congenital Lobar Emphysema (1st).
CCAM (no lobar preference, so possible)
You are shown a study with Left Lower Lung Lobe affected. Top differentials?
Sequestration (first).
Congenital Diaphragmatic Hernia (favors that side, too).
Newborn w/congenital heart disease. Lesion left lower lobe. Diagnosis?
Extralobar Sequestration
10 year old with recurrent Pneumonia. Lesion left lower lung lobe. Diagnosis?
Intralobar Sequestration
Peds chest, viral infection: radiographic findings
“Peribronchial edema” (buzzword),
Dirty/busy hilum,
Hyperinflation,
Subsegmental atelectasis.
Peds chest: which is more common (regardless of age), bacterial or viral infection?
Viral. By far.
Round Pneumonia: primary differential/fake out
Mass. Sneaky fuckers try to trick you into thinking kid has a mass. Don’t get a CT to exclude cancer if it fits criteria for around Pneumonia. Just get a follow-up X-ray.
Round Pneumonia: age
Younger than 8 years old. (“They love to show this and try to trick you into thinking it’s a mass. Younger than 8, think round Pneumonia, round pneumonia, round pneumonia…”)
Round Pneumonia: most common agent
S. pneumonia
Round Pneumonia: why does it happen?
Don’t have good collateral ventilation pathways
Round Pneumonia: radiographic features
Solitary, posterior lower lobes
6 year old boy. CXR shows solitary mass in posterior lower left lobe. Next step?
Follow-up X-ray. Don’t get CT to exclude cancer because probably round Pneumonia. (Younger than 8)
Swyer James: radiographic features
Unilateral lucent lung. Affected lobe smaller than normal (NOT hyper-expanded).
Swyer-James: usually occurs after what event?
Viral lung infection in childhood resulting in post-infectious obliterative bronchiolitis.
Peds chest, Papillomatosis: radiographic findings
Multiple lung nodules which demonstrate cavitation. (Can look like LCH, but trachea is also involved.)
Peds chest, Papillomatosis: cause
Perinatal HPV
Peds chest, Papillomatosis: cancer risk?
2% chance of squamous cell cancer
Peds chest, Papillomatosis: true or False–manipulation can lead to dissemination.
True.
Sickle Cell/Acute Chest: age
2-4 years usually (can be any age)
Leading cause of death in sickle cell patients
Acute Chest
Sickle Cell/Acute Chest: radiographic features
Opacities in the CXR of kid with sickle cell
(Sickle cell findings:
big heart,
bone infarcts–esp humoral head,
H-shaped vertebra–look on lateral.)
Radiographic findings of patient with sickle cell.
big heart,
bone infarcts–esp humoral head,
H-shaped vertebra–look on lateral.
Bronchial Foreign Body: radiographic findings (and why)
Air trapping (key concept)!!
Lung looks more lucent.
Remains lucent when put affected side down.
Fluoro: mediastinum shifts AWAY from affected side on expiration.
Cystic Fibrosis: pathophysiology
Sodium pump doesn’t work. Thick secretions. Poor pulmonary clearance. Recurrent infections.
Cystic fibrosis: radiographic findings pertaining to chest
Bronchiectasis (starts cylindrical and progresses to varicoid.)
UPPER LOBE predominance (less in lower lobes).
Hyperinflation.
Pulmonary Arterial Hypertension.
Mucus plugging (finger in glove sign).
(Note: Primary Ciliary Dyskinesia has LOWER LOBE bronchiectasis.)
Cystic fibrosis: site predominance in chest
Upper Lobe predominance (less in lower lobes)
Cystic fibrosis: what is Finger in Glove Sign?
Mucus plugging in chest
Cystic fibrosis: effect on fertility
Men are infertile. Missing vas deferens.
Note: Primary Ciliary Dyskinesia men are infertile because tails don’t work.
What condition could these indicate?
- Fatty replaced pancreas on CT.
- Abdominal Films with constipation.
- Biliary cirrhosis (blockage of intrahepatoc bike ducts) and resulting portal hypertension.
Cystic fibrosis.
Primary Ciliary Dyskinesia: pathophysiology
Cilia don’t work. Can’t clear lungs. Recurrent infections.
Primary Ciliary Dyskinesia: radiographic findings
Bronchiectasis.
LOWER LOBES.
Kartageners (situs inversus) in 50%.
(NOTE: CF has bronchiectasis of UPPER lobes)
Primary Ciliary Dyskinesia: effect on fertility
Men infertile (tails broken). Women subfertile (cilia needed to transport egg)
Pleuropulmonary Blastoma: age
1-2 year old
Pleuropulmonary Blastoma: radiographic features
Right-sided BFM, pleural based, NO CHEST WALL/RIB INVASION! No calcifications.
(Note: Askin tumors often have rib invasion)
Pleuropulmonary Blastoma: types
Cystic, mixed, solid
Pleuropulmonary Blastoma: prognosis/behavior by type
Cystic: more in <1 year old & more benign.
Solid: can have mets in bone & brain.
(Mixed: no data provided)
Pleuropulmonary Blastoma: preferred site
Right side
Pleuropulmonary Blastoma: common concurrent lesion
Multilocular cystic nephroma (10% of the time)
Pleuropulmonary Blastoma: top look-alike differential
CCAM
Umbilical Venous Catheter: describe pathway
Umbilical v, L portal v, ductus venosus, hepatic v, IVC
Umbilical Venous Catheter: ideal spot
IVC-Right Atrium junction
Umbilical Venous Catheter: where do you NOT want it to end up
Don’t lodge it in the portal vein. Can infarct the liver!
Umbilical Artery Catheter: pathway
Umbilicus,
Umbilical artery,
Iliac artery,
Aorta
Umbilical Artery Catheter: major risk factor and how to avoid it
Renal Arterial thrombosis .
Avoid renal arteries by going high (T8-10) or low (L3-5)
Between Umbilical Venous Catheter and Umbilical Artery Catheter, which goes straight up, and which goes down and then up?
UVC: straight up.
UAC: down then up
Anterior mediastinal mass: 6 major differentials
Normal thymus, Thymic rebound, Lymphoma, Germ cell tumor: teratoma, seminoma, NSGCT
Things that make you think thymus is a cancer?
Abnormal size for patient age.
Heterogenous.
Calcification.
Compression of airway or vessels.
“Sail sign”
Triangular shape of thymus
Note: not same as spinnaker sail sign–when pneumomediastinum lifts up the thymus
Normal thymus: ages when it is pretty big
Pretty big in kids Less than 5 years, and especially infants.
What is thymic rebound
In times of acute stress (Pneumonia, radiation, chemo, burns), thymus shrinks. In recovery phase, rebounds to normal and sometimes LARGER than before. Can be PET avid during rebound.
During Thymic rebound, is thymus PET avid or not?
Can be PET avid during rebound
Most common abnormal mediastinal mass in children (older children and teenagers)
Lymphoma
Best way to decide thymus vs lymphoma
Age.
Under 10- usually thymus.
Over 10-usually lymphoma.
Approx 10- look for cervical lymph nodes to make you think lymphoma
In deciding thymus vs lymphoma, what is the age cutoff and which differential applies to which age group?
Under 10- usually thymus.
Over 10-usually lymphoma.
Approx 10- look for cervical lymph nodes to make you think lymphoma
Is calcification common or uncommon in lymphoma?
Calcification is UNCOMMON in untreated lymphoma.
If see calcification in untreated lesion, think teratoma.
Complications of mediastinal lymphoma (4 answers).
Compression of SVC,
Compression of pulmonary veins,
Compression of airway,
Pericardial effusion
3 types of germ cell tumors in differentials for anterior mediastinal mass.
Teratoma,
Seminoma,
NSGCT
Mediastinal teratoma: radiographic features
Large mass from/next to thymus.
Mostly cystic,
With Fat and Calcium
Mediastinal seminoma : radiographic features
Large mass from/next to thymus.
Bulky, lobulated.
“Straddles the midline”
Mediastinal NSGCT: radiographic features
Large mass from/next to thymus.
Big and ugly!
Hemorrhage and necrosis!
Can get crazy and invade lung.
Risk factor for extra-gonadal germ cell tumors
Klinefelter’s Syndrome (300x risk of getting a GCT)
Middle mediastinal mass: differentials (3)
Lymphadenopathy,
Bronchogenic duplication cyst,
Enteric duplication cyst.
(Note: neuroenteric duplication cyst is posterior mediastinum!!)
Middle mediastinal mass: lymphadenopathy–most common causes
Granulomatous disease (TB or fungal) or lymphoma
Mediastinal mass: duplication cysts–3 types and their locations
Bronchogenic: middle,
Enteric: middle,
Neuroenteric: posterior
Expected attenuation for each type of duplication cyst.
All are water attenuation.
Bronchogenic duplication cyst: Specific location
Middle mediastinum, close to trachea or bronchus
Enteric duplication cyst: Specific location
Middle mediastinum (but lower than bronchogenic), close to the esophagus
Posterior mediastinal mass: 5 major differentials (plus 1 bonus differential)
Neuroblastoma, Ewing Sarcoma, Askin Tumor, Neuroenteric (duplication) cyst, Extramedullary Hematopoiesis
(Also Wilms, which mets to lungs more than neuroblastoma)
Most common posterior mediastinal mass in child under 2.
Neuroblastoma
Thoracic vs abdominal neuroblastoma: which has better prognosis?
Thoracic neuroblastoma has a better outcome.
True or False: neuroblastoma may involve ribs and vertebral bodies.
True.
Askin tumor is now considered part of the _______ spectrum.
Ewing sarcoma
Sometimes called a Ewing sarcoma of the chest wall.
Askin tumor: tendency to displace or invade adjacent structures? (Pick one)
Tends to displace early on. Can invade when get big, but higher tendency to displace.
Askin tumor: radiographic appearance
Heterogenous, solid parts will enhance, displace adjacent structures rather than invade (until big, then may invade).
Neuroenteric cyst: associated with what condition(s)
Vertebral anomalies (Scoliosis!)
Neuroenteric cyst: does it communicate with CSF?
NO! It does NOT communicate with CSF.
Neuroenteric cyst: radiographic features
Associated with vertebral anomalies (scoliosis),
Does NOT communicate with CSF,
Well demarcated,
Water density
Extramedullary hematopoiesis: who gets it?
Patients with myeloproliferatove disorders or bone marrow infiltration (including sickle cell)
Extramedullary hematopoiesis: most common manifestation
Big spleen and liver
Extramedullary hematopoiesis: big spleen and liver is most common manifestation, but what is the less common appearance?
Paraspinal masses: bilateral, smooth, sharply delineated, soft tissue density
A kid with anterior mediastinal mass suspected to be lymphoma. Assume Hodgkin’s or NHL?
Assume hodgkin’s because it’s 4x more common than NHL.
Hodgkins involves thymus 90% of the time.
Does Hodgkin’s lymphoma involve the thymus?
Hodgkins involves thymus 90% of the time.
Thymic rebound: what history might make you start thinking this?
Got off chemo,” or “got off corticosteroids,” or other stressor.
Strategy, Anterior mediastinal mass w/soft tissue density and kinda homogenous. Differentials?
Lymphoma or hyperplasia
Strategy, Anterior mediastinal mass w/fat density. Differentials?
Germ cell tumor
Strategy, Anterior mediastinal mass w/water density. Differentials?
Congenital things, lymphangiomas
Strategy, Posterior mediastinal mass: first and most important piece of information to narrow the list
Age!
Under 10-think malignant
Over 10-think benign
Strategy, Posterior mediastinal mass: over 10 years old, round mass. Differentials?
Ganglioneuromas, neurofibromas
Strategy, Posterior mediastinal mass: kid over 10, cystic mass and scoliosis.
Neuroenteric cyst
Strategy, Posterior mediastinal mass: kid over 10, coarse bone trabeculation with adjacent mass (or history of anemia). Differential?
Extramedullary hematopoiesis
Stately: BFM in chest of a kid. 2 differentials and how to most rapidly distinguish.
Askin tumor (AGE 10+!! Eaten up rib)
Pleuropulmonary Blastoma (AGE <2)
Esophageal atresia/TE fistula: 2 classic ways of showing it
- Frontal CXR, NG tube stopped in upper neck.
2. Fluoro lateral, blind-ending sac or communication with tracheal tree.
Esophageal atresia/TE fistula: 3 subtypes described in the book (there are 5, but 3 high yield) and approx frequency
N-type Fistula (85%),
Esophageal Atresia w/o fistula (10%),
H-type Atresia (1%)
Esophageal atresia/TE fistula: most common subtype
N-type fistula (blind-end esophagus, distal esophagus hooks up to trachea.)
Esophageal atresia/TE fistula: excessive air in stomach. Which type?
H-type Atresia (but can also be N type)
Esophageal atresia/TE fistula: NO air in stomach. Which type?
Esophageal Atresia
Esophageal atresia/TE fistula: what specific non-airway finding must be described prior to surgery?
Presence of a right arch (4%) must be described prior to surgery. Changes the approach!
How many of the defined anomalies are required to diagnose VACTERL association?
Three. (So keep looking if you find 1 or 2.)
What is VACTERL? (General terms, not what it stands for)
List of associated anomalies that often occur together. When you find one, look for more on this list.
What are the anomalies in VACTERL and each one’s frequency?
Vertebral anomalies (37%), Anal (imperforate anus) (63%), Cardiac (77%), TE-Tracheoesophageal fistula or Esophageal Atresia (40%), Renal (72%), Limb (radial ray) (58%)
Which organs most commonly affected by VACTERL association?
Heart (77%) and kidneys (72%)
VACTERL: true or False. If both limbs involved, then both kidneys involved. If one limb, then usually one kidney.
True.
