Jaypee Gold Standard Mini Atlas Series® CHEST RADIOLOGY Jaypee Gold Standard Mini Atlas Series® CHEST RADIOLOGY Editor Hariqbal Singh MD DMRD Professor and Head Department of Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • London • Philadelphia • Panama ® Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: +507-301-0496 Fax: 507-301-0499 Email: cservice@jphmedical.com Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh 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incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the editors Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device Jaypee Gold Standard Mini Atlas Series®: Chest Radiology First Edition: 2013 ISBN : 978-93-5090-463-3 Printed at Dedicated to My son Hamitesh Singh on joining Indian Armed Forces Buoyancy Low knowledge, bestows high confidence Less one knows, more sure he is as One fails to know what he does not know —Hariqbal Singh Contributors Abhijit Pawar DNB (Radiology) Parvez Sheik MBBS DMRE Aditi Dongre MD (Radiology) Roshan Lodha DMRD Amol Nade DMRE Santosh Konde MD (Radiology) Assistant Professor Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Assistant Professor Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Consultant Radiology Nidam Imaging Centre Pune, Maharashtra, India Amol Sasane MD (Radiology) Lecturer Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Hariqbal Singh MD DMRD Professor and Head Department of Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Consultant Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Consultant Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Assistant Professor Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Shishir Zargad DMRE Consultant Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Sikandar Sheikh MD (Radiology) DMR Consultant (Radiology and PET-CT) Apollo Health City Hyderabad, Andhra Pradesh India viii Chest Radiology Sushil Kachewar MD (Radiology) Associate Professor Rural Medical College Loni, Maharashtra India Varsha Rangankar MD (Radiology) Associate Professor Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Vikash Ojha MD (Radiology) Consultant Radiology Department of Radio-Diagnosis Apollo Jehangir Hospital Pune, Maharashtra, India Preface Chest X-ray is the most commonly requisitioned film in any medical establishment and continues to be the most informative film due to availability of tissue contrast provided by air in the lungs; consequently, the approach to understanding chest X-ray is important In routine, reporting practice often the technical quality is below perfect, such films have also been included in this collection to expose the reader to actual life situation Contrast studies, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography in many cases complement the plain film to provide perfect diagnosis This book is steal a look into chest imaging in an easy and understandable manner This assemblage of images will be useful to all residents entering the domain of any medical specialization and to any general practitioner or specialist in the field of medicine Hariqbal Singh Miscellaneous Cluster Fig 14.16 Calcified guinea worm (Dracunculiasis medinencis) Fig 14.17 Left plural calcification 191 192 Chest Radiology Fig 14.18 Multiple consolidated fractures, 3rd to 8th ribs on right side Fig 14.19 X-ray chest shows bilateral basal bronchiectasis Few ecstatic cavities show air-fluid level Bronchiectasis is also seen behind the cardiac shadow Miscellaneous Cluster Fig 14.20 Pathological fracture surgical neck humerus left with overriding of fracture fragments, metastatic lesion is seen in lateral end of left clavicle Fig 14.21 Consolidation right upper lobe 193 194 Chest Radiology Fig 14.22 Consolidation anterior segment of right upper lobe Fig 14.23 Left sided pneumothorax with underlying partial lung collapse with resultant push of trachea and mediastinum towards right Miscellaneous Cluster Fig 14.24 Situs inversus, in this there is complete reversal of visceroatrial situs Fig 14.25 Fungal ball shows mobile lesion seen in thick walled cavity in left upper lobe with crescent of air 195 196 Chest Radiology Fig 14.26 Bronchial carcinoma on CT seen as left hilar mass with adjacent consolidation, left pleural effusion, left pneumothorax and mediastinal adenopathy and few metastatic lesions in right lung Fig 14.27 Fallot’s tetralogy Miscellaneous Cluster Fig 14.28 Mastectomy right side with raised right dome of dia phragm secon dary to radi ation-induced fibrosis right upper zone Picture Archiving and Communications System Picture archiving and communications system (PACS), is based on universal DICOM (Digital imaging and communications in medicine) format DICOM solutions are capable of storing and retrieving multimodality images in a proficient and secure manner in assisting and improving hospital workflow and patient diagnosis (Fig 14.29) PACS helps in eliminating paper requisition forms and radiology reports The aim of PACS is to replace conventional radiographs and reports with a completely electronic network, these digital images can be viewed on monitors in the radiology department, emergency rooms, inpatient and outpatient departments, thus saving time, improving efficiency of hospital and avoid incurring the cost of hard copy images in a busy hospital The three basic means of rendering plain radiographs images to digital are computed radiography (CR) using photostimulable phosphor plate technology; direct digital radiography (DDR) 197 198 Chest Radiology Fig 14.29 PACS flow chart and digitizing conventional analog films Nonimage data, such as scanned documents like PDF (portable document format) is also incorporated in DICOM format Dictation of reports can be integrated into the system The recording is automatically sent to a transcript writer’s workstation for typing, but it can also be made available for access by physicians, avoiding typing delays for urgent results Among all clinical specialties, radiology has led the way in developing PACS to its present high standards PACS consists of four major components: the imaging modalities such as radiography, computed radiography, endoscopy, mammography, ultrasound, CT, PET-CT and MRI, a secured network for the transmission of Miscellaneous Cluster patient information, workstations for interpreting and reviewing images and archives for the storage and retrieval of images and reports Backup copies of patient images are also provisioned in case of image lost from the PACS There are several methods for backup storage of images, but they typically involve automatically sending copies of the images to a separate computer for storage, preferably off-site In PACS no patient is irradiated simply because a previous radiograph or CT scan has been lost; the image once acquired onto the PACS is always available when needed Simultaneous multilocation viewing of the same image is possible on any workstation connected to the PACS Numerous postprocessing soft copy manipulations are possible on the viewing monitor Film packets are no longer an issue as PACS as it provides a film less solution for all images PACS can be integrated into the local area network and images from remote villages sent to the tertiary hospital for reporting PACS is an expensive investment initially but the costs can be recovered over a years period It requires a dedicated maintenance It is important to train the doctors, technicians, nurses and other staff to use PACS effectively Once PACS is fully operational, no films are issued to patients PACS breaks the physical and time barriers associated with traditional film-based image retrieval, distribution, and display PACS can be linked to the internet, leading to teleradiology, the advantages of which are that images can be reviewed from home when on call, can provide linkage between two or more hospitals, outsourcing of imaging examinations in understaffed hospitals PACS is offered by virtually all the major medical imaging equipment manufacturers, medical IT companies and many independent software companies 199 Index Page numbers followed by f refer to figure A Abscess formation 59 Absence of radius 139 Absent right radius with congenital heart disease 190f Achalasia cardia 133 Actinomyces 149 Acute exacerbation of bronchial asthma 120f respiratory distress syndrome 58 Allergic bronchopulmonary aspergillosis 74 Alveolar cell carcinoma 87 Anatomically segmental division of lungs Aneurysmal dilatation of distal part of thoracic aorta 107f Anhidrosis 89 Aortopulmonary window 122 Appearance of sternal sutures 151f Arch of aorta 20f Aspergilloma 71 Aspergillus fumigatus 74 Asphyxiating thoracic dystrophy 144 Atherosclerosis 104 Atrial septal defect 116 Atypical location of tubercular cavity 66f Azygos lobe 146 vein 10 B Barium sulfate 175 Bilateral basal bronchiectasis 192f renal cysts 170f Bochdalek’s hernia 54, 56f Bony thorax 7f Botox injections 135 Bronchial carcinoma 196f Bronchiectasis 59 Bronchocele 79 Bronchogenic carcinoma 88f Bronchopneumonia 60f, 140, 141f C Calcified guinea worm 191f Calcium channel blockers 135 Candida albicans 149 Carbon dioxide 176 202 Chest Radiology Carcinoma 86f breast 32 esophagus 135, 162 lung 87 of bronchus 87 Cervical rib 34 Chest wall 27 Chronic obstructive pulmonary disease 48 Classification of T-E fistula 139 Coarctation of aorta 108 Coccidioides immitis 149 Combined small cell lung carcinoma 157 Combo sign 69 Compression of mediastinal structures 131 Congenital heart disease 139f Connective tissue disorders 100 Consolidation anterior segment of right upper lobe 194f lingular segment 60f right upper lobe 193f Constrictive pericarditis 103 Conventional units 177 Coronary arteries 21, 172f, 173f and branches 22f CT angiography 171 contrast media 173 coronary angiography 21 guided FNAC 185 precision biopsy 187 Cyclotron 156, 157f D Detection of radiation 184 Diaphragm 53 Diaphragmatic hernia 56f Diaphyseal aclasis 39 Dilatation of distal thoracic aorta 109 Dilated pulmonary arteries 121f Dilation of esophagus 134 Direct digital radiography 197 Diseases of airway 79 Dominant coronary artery 21 Dracunculiasis medinensis 191f Dressler’s syndrome 100 E Echinococcus granulosus 65 Electron beam CT 167 Emphysematous chest 74 Endoscopic dilatation 135 Enlarged lymph node 122f Enophthalmos 89 Epicardial fat pad 83 lipoma 83 Esophageal atresia 140f Esophagus 133 Index Evaluation of bony chest wall 34 soft tissues 27 Eventration of diaphragm 53 F Fallot’s tetralogy 196f Fungal ball 71, 146, 149 Intermittent positive pressure ventilation 50 Invasion of superior vena cava 132f Invasive thymoma 132f Iodinated intravascular agents 173 Ionization 185 Ipsilateral arm pain 89 J G Jeune’s syndrome 144 Giant lung bullae 75 Guinea worm 29 K H Kartagener syndrome 79 Klebsiella 58, 141 Heller’s myotomy 135 Hemopneumothorax 50 Hiatus hernia 54 Hilar adenopathy 73 Hodgkin’s disease 129 lymphoma 131f Holt-Oram syndrome 138, 139f, 190f Horner’s syndrome 89 Hydatid cyst 65, 70f Hydropneumothorax 50, 59 Hyperlucent lung 50f L Large mediastinal lymph node mass 131f Left circumflex artery 26 plural calcification 191f pulmonary artery 132f Left-to-right shunt 116 Lower esophageal sphincter 134f Lung metastasis 159 Lymphoma 58 I M Idiopathic interstitial pulmonary fibrosis 76, 77f, 190f Inter-costal drainage 50, 51 Main pulmonary artery 121 Measurement of cardiothoracic ratio 6f 203 204 Chest Radiology Medial basal segment Mediastinal adenopathy 63f borders 3f lymphoma 160 neurofibroma 127f Mediastinum 122 Membranous VSD 118 Meniscus sign 69 Mesothelioma 51 Miosis 89 Miscellaneous cluster 165 Mitral stenosis 113, 114f MRI in tumors of lung 98 Multiple consolidated fractures 192f myeloma 41 small nodular dense opacities 73f Muscular VSD 118 Mycobacterium bacilli 61 tuberculosis 58 Mycoplasma 141 pneumonae 58 N National Commission for Radiation Protection 180 Neoplasms bronchogenic carcinoma 58 Neurofibroma 125 Neurogenic tumors 125 Nocardia 149 Non-Hodgkin’s lymphoma 129, 130f Non-small cell lung carcinoma 156 O Oblique coronal plane 26f Occupational lung disease 73 Open pneumothorax 50 Oreo Cookie sign 102 Origin of renal arteries 109 Osteochondromas 29f Ostium primum ASD 116 secondum ASD 116 Overriding of aorta 112 P Pancoast tumor 88 Parasitic tapeworm 65 Patent ductus arteriosus 116 foramen ovale 116 Pectoralis major muscle 30f muscles 33f Pectus excavatum 36, 36f Pediatric chest 138 Pericardial cyst 124 effusion 102f, 103 PET-CT gantry 156f Picture archiving and communications system 197 Index Plain CT abdomen 105f Pleural calcification 47 effusion and empyema 59 Pneumoconiosis 71 Pneumocystis carinii 58 Pneumomediastinum 50, 120f, 123, 124f Pneumopericardium 118, 120f Pneumothorax 48 Poland’s syndrome 29 Polydioxanone 150 Portable document format 198 Positron emission tomography- computed tomography 154 Posterior descending artery 23 left ventricular branches 23 Postmyocardial infarction 100 Pregnant radiation worker 184 Prestenotic dilatation of esophagus with air fluid 136f Pretracheal lymph node 123, 123f Principles of radiation protection 181 Proximal femoral focal deficiency 142, 144f Pseudallescheria boydii 149 Pseudodextrocardia 30f Pseudomonas pneumoniae 141 Ptosis 89 Pulmonary arterial hypertension 120 artery 123f, 131f, 153f embolism 151 hamartoma 87 metastasis 89 tuberculosis 61 Pulsations of central pulmonary arteries 117f Pyopneumothorax 50 R Radiation protection actions 181 safety measures 176 officer 181, 183 Respiratory distress syndrome 142 Return of normal caliber of descending aorta 111f Right coronary artery 21 ventricular hypertrophy 112 outflow tract obstruction 112 S Septal defect 116 Situs ambiguous 149 inversus 195f Skeletal lesions 34 metastasis 37 Small cell lung carcinoma 156 205 206 Chest Radiology Soft tissue lesions 27 Solitary pulmonary nodule 85, 86f, 158 Sprengel deformity 37 Staphylococcus aureus 58, 141 Sternal sutures 149 Streptococcus pneumoniae 58 Subcutaneous emphysema 120f Systemic lupus erythematosus 160, 174 Traction bronchiectasis 80 Traumatic contusion 58 Tubercular cavity 66f Tuberculous effusions 102 lung cavity 67f Tumors 83 Types of esophageal atresia 140f T Units of radiation 177 Unknown primary tumor 163 Tension pneumothorax 48, 50 Tetralogy of Fallot 112 Thoracic aortic aneurysm 105 neuroblastoma 127 outlet syndrome 34 Thoracoabdominal aortic angiogram 109 Three-dimensional imaging 170 Thymoma 131 Tracheoesophageal fistula 138 U V Ventricular septal defect 112, 116, 118 Visceroatrial situs 195f W Wasting of hand muscles 89 Water-lily sign 69 Window level and window width 168 ... Hyderabad, Andhra Pradesh India viii Chest Radiology Sushil Kachewar MD (Radiology) Associate Professor Rural Medical College Loni, Maharashtra India Varsha Rangankar MD (Radiology) Associate Professor... estimated from the PA view of chest It is the ratio between the maximum transverse diameter of the heart and the maximum width of thorax above the Chest Radiology Fig 1.5 X-ray chest PA view shows measurement... —Hariqbal Singh Contributors Abhijit Pawar DNB (Radiology) Parvez Sheik MBBS DMRE Aditi Dongre MD (Radiology) Roshan Lodha DMRD Amol Nade DMRE Santosh Konde MD (Radiology) Assistant Professor Shrimati