(BQ) Part 2 book The chest X-ray - A systematic teaching atlas presents the following contents: Patchy lung changes, focal opacities, linear and reticular opacities, foreign bodies, thoracic trauma, intensive care unit.
Matthias Hofer Patchy Lung Changes Opacities Cha pter Goals: When analyzing patchy changes in the radiographic density of the lung, the first step is to differentiate between opacities (areas of increased density, which appear lighter) and hyperlucent areas (areas of increased lucency, which appear darker) After working through this chapter, you should be able to: i : • list the differential diagnoses for a unilateral "white lung"; • recognize typ1cal forms of atelectasis involving specific lobes and segments; • explain how radiographic parameters can 1nfluence opacities and lucent areas in the lung; '•;;; ~,-~~ ~ ··:p~= _ - _- ~ · op·.of PL~ural :Eff.us~c)n · ~ >1 ~ : ; : - - - - - - - - - - - - · - - - - ·~ ' -> - - • , ~• no· of "White -~~ng·: · ' - • p.1 07 - p.1 oa -:- "7' - - - _ - ~ I p.11 o , ~- u ffi·~·-~q~~j~~J.~~~-tl.l1~~: ~~~;=p~: ~ 11 ~.~T~~~te: 1!-:~~M}lflic~ii!~.:~:~~J; 112 [~-~Lo\~er L~~&~TeEI~STh~'.=-·- :~/'u-·: p.113 • distinguish atelectasis (airless lung) from a massive effusion or hemothorax; • describe adjunctive methods for the investigation of patchy opacities; - ; I • distinguish phys1olog1callung opacities from pathological opacities; : ·$;r~_scent Si,gi]~ Segmental Atelectasis p.114 DO of Segmental Atelectasis p.115 - , ~- -~ ~-"''5)· .- Pne~D"loni~ ~M ·· , p.116 5."p.117 Hyperlucent Areas • detect a pneumothorax or impending tension pneumothorax at an early stage; • correctly classify emphysematous changes Quiz- Test Yourself! p.121 I tf I ~I f Pleural Effusion Pleural effusions may occur in the setting of heart failure, renal disease, tumors, and inflammatory processes Even large pleural effusions usually leave some residual ventilation at the apex ( in Figs 106.1a, 106.2) before they become so Fig 106.1a II Fig 106.1b Radiographs typically show a slight mediastinal shift toward the contralateral side ( + ), as in Figure 106.2 If the effusion is accompanied by compression atelectasis, however, the volume of the affected lung may remain constant and will not extensive (Fig 106.1b) that they create a fully established "white lung" (Fig 106.1c) These films illustrate a malignant effusion in a patient with bronchial carcinoma (BC) Fig 106.1c cause a mediastinal shift (Fig 106.3) In typical cases the opacities caused by the pleural effusion (41) will form a raised lateral meniscus in the posteroanterior (PA) radiograph (Fig 106.4) ' ~I I; ' ':1 ~H ' 41 I Fig 106.2 Fig 106.3 An early sign of a small, incipient effusion is blunting of the costophrenic angle This refers to the isolated clouding of one or both costophrenic sinuses, which normally taper inferiorly to a sharp, clear angle This sign may also be a useful differentiating feature from inflammatory infiltrates, 41 ' Fig 106.4 which, unlike pleural effusions, tend to spare the cardiaphrenic angles in their initial stage Another, indirect sign of pleural effusion may be broadening of the intercostal spaces, which typically appear normal or narrowed in atelectasis Cresce nt Sign The "crescent s1gn" of pleural effusion 1s a predominantly lateral opacity (") that can be attributed to summation effects· The aerated lung parenchyma of the middle lobe (ML) or lower lobe (LL) (34) 1s surrounded by a horseshoe-shaped fluid collectiOn (41) that increases the absorption of roentgen rays Circumferential spread of the effusion is restricted on the medial s1de by the hilum and pleural reflections In the PA pro ection, then, the roentgen rays ( l ) must pass through more fluid in the lateral chest wall than farther medially (Fig 107.2) Thus the collection appears to slope upward on the lateral s1de even though equal amounts of fluid surround the lung anteriorly and posteriorly The lateral radiograph often shows definite penetration of the effusion ( ) into the oblique interlobar fissure (30) (Fig 107.3) Extension of the effusion (41) into the horizontal fissure (31) IS often seen in the PA radiograph (Fig 107.4) and may mim1c a linear or focal opacity (see alsop 125) Horseshoeshaped effusion surrounding the lung 41 Summation effect of roentgen ray absorption by the effusion: Fig 107.2 Fig 107.1 41 Fig 107.4 Fig 107.3 41 Fig 107.5 Ultrasound may be used as an adjunctive imaging study or to direct a needle procedure (fig 107.5) A sca n from the posterior side demonstrates the effusion (41 ) as a dark, hypoechoic mass located between the posterior chest wall (+),the curved echogenic line of the diaphragm (17), and the compressed portion of the LL (34), whose residual air content Fig 107.6 casts a faint acoustic shadow ( t ) In a sca n from the left anterolateral side (fig 107.6), the splee n (44) can be identified below the diaphragm (17), and a smaller hypoechoic effusion (41 ) can be seen above the spleen The technique of percutaneous pleural fluid aspiration is described on pages 60-61 I Differential Diagnosis of Pl eural Effusion Regarding the quantification of effusions, it is estimated that a fluid volume of approximately 175-500 ml must be present in order to be detected in the upright PA radiograph This threshold is only about 150 ml in the lateral radiograph but increases to 500-1000 ml in the supine radiograph (Fig 108.1) Supine radiographs, however, may give rise to a technical problem that causes decreased lucency in one lung and can mimic the appearance of a layered-out pleural effusion (Fig 108.2) Do you remember how this effect is produced? If not, please refer back to page 26 RLD Cd G:1 • Lateral: -50ml 150ml 200-500 ml 500-1000 ml Fig 108.1 In doubtful cases the differential diagnosis can be further narrowed by obtaining a lateral decubitus radiograph (Fig 108.3) This position will cause the effusion (41) to layer along the lateral chest wall ( • + ) An ipsilateral decubitus radiograph can detect even a very small fluid collection at a very early stage It is important to use the correct position, however: LLD for a left-sided opacity and RLD for a rightsided opacity Occasionally, this is the only way to detect a subpulmonic effusion that was not visible in the PA radiograph + + Fig 108.3 Fig 108.2 Other diseases may present with patchy, basal opacification that resembles a pleural effusion Consider the example in Figure 108.4a and note the left border of the cardiac silhouette Would you expect to see this pattern with an effusion, which typically encircles the lung? Of course not The delineation of the left cardiac border ( ") (see p 28) sig nifies atelectasis (36) of the left LL, whi ch appears as a posterior opacity in the lateral radiograph (Fig 108.4b) With massive cardiac enlargement in cor bovinum (fig 108.5), the heart may extend to the left chest wall and mimic the appearance of a homogeneous pleural effusion 36 Fig 108.4a Fig 108.4b Fig 108.5 Differential Diagnosis of Pleural Effusion Other causes of patchy basal opacities include congenital and acquired diaphragmatiC hern1as involving the displacement of abdominal organs into the thoracic cavity (see also p 98) Figure 109.1a shows a plain radiograph of a diaphragmatic hernia Besides bilateral pleural effusions ( t t ), the radiograph also shows an indeterminate homogeneous opacity in t Fig 109.1a the left base ( • ) The rad1ograph after oral contrast administration ( t1) positively identifies the opacity as an abdominal viscus that has herniated into the chest (Fig 109.1b) The changes ( ) may be more pronounced in newborns and in patients with large diaphragmatic defects This case (Fig 109.2) illustrates an enterothorax t Fig 109.1b Fig 109.2 In rare cases, areas of pneumonic infiltration that no longer contain aerated lung tissue may resemble a homogeneous pleural effusion This is illustrated by a case of right-sided pneumonia (•) in Figure 109.3 (see also p 116) In breast cancer patients who have developed very advanced carcinomatous lymphangitis, the normal reticulostriate pattern (see p 152) sometimes progresses to a more homogeneous opacity like that seen in the right lower zone (ll) in Figure 109.4a The lateral radiograph of the same patient (Fig 109.4b) shows that the anterior opacity is accom- Fig 109.3 Fig 109.4a panied by numerous focal pu lmonary lesions Layered-out effusions also require differentiation from hemothorax, in which a postoperative or posttraumatic hemorrhage collects in the pleural space and may compress the lung Examples of hemothorax are shown on page 186 and page 207 Fig 109.4b II Differential Diagnosis of "White lung" "White lung" refers to the homogeneous, total or subtotal opacification of an entire lung on the chest radiograph It may be caused by conditions other than pleural effusion First it is necessary to determine whether the affected side shows an increase in volume, no volume change, or a decrease in volume Table 110.1 lists the causes of white lung that are suggested by these findings Differential Diagnosis of "White Lung" Increase in volume • • • • • Massive pleural effusion Large pulmonary tumors Pleural mesothelioma Diaphragmatic hernia Cardiomegaly Decrease in volume • Atelectasis (e.g., in bronchial carcinoma] • • Tuberculosis (contraction due to scarring] Previous pneumonectomy • • Aplasia or agenesis of the lung Pleural plaques or fibrothorax Table 110.1 Large thoracic tumors like the T-cell non-Hodgkin lymphoma (21) in Figure 110.1 a produce a mass effect that displaces the heart and mediastinum to the contralateral side ( + ) While conventional radiographs will not show residual ventilation on the affected side (or at most some apical residual air), the corresponding computed tomography (CT) scan (Fig 110.1b) can demonstrate residual ventilation ( t ) as well as chestwall invasion by the tumor ( ~ )with much greater clarity Figure 110.2a, b illustrates the same phenomenon in a small child with a thoracic primitive neuroectodermal tumor (PNET) This case shows complete atelectasis (36) of the lung, which is compressed from the left side, as well as pronounced displacement of the heart (4, 5) toward the right side by the tumor (21), which already contains central hypodense areas of liquefaction By contrast, the radiograph of a newborn with right pulmonary agenesis (Fig 110.3) shows an ipsilateral mediastinal shift toward the side of the opacity along with compensatory hyperinflation of the left lung Fig 110.1a Fig 110.2a Fig 110.3a Fig 110.1b Fig 110.2b Fig 110.3b I •J ·~ I I Upper lobe Atelectasis NAt lectas1s" 1s defined as the absence of ventilation (airlessness) m a portion of the lung, while "dyselectasis" refers to a decrease m vent1lat1on (hypoventilation) In the case of the upper lobes (Uls), Figure 111.1 shows the typical patterns by which the volume of the affected UL (32) is reduced to the area shown m dark blue ( ( ) Initially, the loss of ventilation may produce a diffusely homogeneous but incomplete hazmess like that shown in Figure 111.2a In this case the atelectasis of the left UL is associated with a compensatory upward expansion of the left LL The decreased lobar volume is manifested in the lateral radiograph by anterior displacement of the oblique fissure ( • in Fig 111 b) Note the slight shift of the superior mediastinum ( +) toward the affected s1de The atelectasis may also cause a complete, homogeneous opacification, however (Fig 111.3a, b), which is again assoc1ated with an Ipsilateral mediastinal shift and has also caused a slight elevat1on of the hem1diaphragm ( t ) Upward displacement of the horizontal fissure on the right side is a common finding Fig 111.1 t Fig 111.2a Fig 111.3a Fig 111 Fig 111.2b Fig 111.3b Fig 111.5 On the other hand, upward retraction of the hilum or a streaky density (') adjacent to the homogeneous opacity in the apical zone (AZ) (Fig 111 4) should raise suspicion of a tumor In the case shown, the patient also had osteolytic rib lesions ( ) that correlated with malignant chest-wall invasion by a Pancoast tumor Homogeneous opacification of the UZs is occasionally found in elderly patients who underwent oil injections into the pleural cavity (')for the treatment of tuberculosis (TB) at an earlier age (Fig 111.5) Typically the opacity has smooth margins and may be mistaken for lobar or segmental atelectasis '' Middle Lobe Atelectasis Atelectasis of the right ML may have various presentations (Fig 112.1) In some cases the ML may show homogeneous opacification with no change m size (Fig 112.2) Sparing of the cardiophrenic angle ( ~) is occasionally observed in these cases In cases with longstanding bronchial obstruc- f tion by a mucous plug or a bronchial carcinoma that has penetrated mto a bronchus, the atelectatic ML shows a progressive decrease in volume as it contracts toward the nght cardiac border and hilum (• in Fig 112.3) ·' , ·'~ ·· ' ; I !I ~, Right lateral Fig 112.1 I • Fig 112.2a Fig 112.2b Fig 112.3a Fig 112.3b Lower lobe Atelectasis As the Lls become atelectatic, they also exhibit a fairly typical retraction pattern on rad1ographs (Fig 113.1a) and axial CT scans (Fig 113.1b) Both Lls contract in the medio- basal direction on PA radiographs and in the posterobasal d1rect1on on lateral radiographs PA Fig 113.1b Fig 113.1a When LL atelectasis is viewed in the PA radiograph alone, as srown in Figure 113.2a, it may appear as a homogeneous opacity that closely resembles ML atelectasis (see p 112) In the case shown, the loss of volume in the ML has caused marked elevation of the ipsilateral hemidiaphragm ( t ) This patient also shows multiple Central venous catheters (CVCs) and a previous valvular replacement ( + ) Ask yourself what Differential Diagnosis of l l Atelectasis In many cases, however, only CT can determine whether we are dea ling with atelectasis alone or with a compressiOn-induced ventilation disturbance that is secondary to a large effusion The patient in Figure 113.3 had a large malignant effus1on that resulted in LL atelectasis The radiograph also shows numerous pulmonary nodules that are metastatic to the malignant underlymg disease (here: thyroid carcinoma) phenomenon could be responsible for the streaky horizontal opacity (~)in the MZ of the right lung (seep 125 and p 140) In the CT scan from the same patient (Fig 113.2b), dystelectatic and atelectatic lung tissue (36) can be seen posterior to the sections of the diaphragm leaflet and liver (19) A fine pleural effusion (41) is seen around the posterolateral aspect of this tissue 19 Fig 113.2a Fig 113.2b Fig 113.3a Fig 113.3b The differential diagnosis of atelectatic opacities also includes bilateral basal opacities caused by neurogenic tumors (see Fig 78.1a), mediastinal abscesses (see Fig 79.1a), pericardia! cysts (see Fig 92.1a), and small fat pads along the cardiac border • Segmental Atelectasis ~ The diagrams below show the typical patterns of opacity that are associated with atelectatic segments in both lungs One may well encounter variations and deviations from the areas shown here, however Most segmental atelectases are characterized by re latively narrow intercostal spaces with elevation of the ipsilateral hemidiaphragm and an ipsilateral Right lateral PA Left lateral Right lateral mediastinal shift (Table 114.11 ) By contrast, pleural effu are typically assoc iated with widenin g of the interc spaces, blunting of the cardioph renic ang le, and a cc lateral mediastinal shift For practice, please write then of the affected segments below the corresponding dia (remember the mnemonic device!) PA Left lateral Right lateral PA Left La , r ••• Fig 114.1 Fig 114.2 Fig 114.3 Fig 114.4 Fig 114.5 Fig 114.6 Fig 114.7 Fig 114.8 Fig 114.9 Signs of Atelectasis • Typical shape and topography of the opacified segments or lobes (see above) ~ • I Fig 114.10 , Displacement of fissures toward the focal change (+ local decrease in vascularity with increased lucency) • Hyperinflation of adjacent lung areas Signs of More Extensive Atelectasis (e.g., affecting an entire lobe) I II '' I I •l,.,,' • Ipsilateral elevation of the hemidiaphragm • Ipsilateral mediastinal shift • Narrowed intercostal spaces Table 114.11 I !II liil Solution to p.122: A rounded, nonhomogeneous area of confluent linear and focal opacities is visible on the right side and obscures the right cardiac border ("silhouette sign") The right costophrenic angle is clear (important differentiating sign from pleural effusion) This radiograph is overexposed (pu lmonary vessels are seen on ly in the retrocardiac area) DD: Pneumonia, left pneumothorax, emphysema (despite absence of flattened diaphragm leaflets on deep inspiration), atelectasis (although the opacity looks too nonhomogeneous for atelectasis) Diagnosis: Pneumonia of the right ML The lateral radiograph (Fig 214.1) demonstrates the exact location !1.1 Solution to p.137: A cursory look at this film may l:iil suggest an intrapulmonary mass in the left UZ But the lobu lated opacities on the right scapula are consistent with chondromatosis (chondroma formation in bones and joints), which also affects the left sternoclavicular joint The lesion, then, is extrapulmonary You are correct in thinking that we have not prepared you for a case of this kind But please approach this cha ll enge with an open mind We just want to remind you: Always scrutinize the soft tissues of the chest wall so that you can avoid errors of interpretation Incidental finding: The right subclavian eve is correctly positioned in the sve There is no evidence of pneumothorax m Solution to p.137: The object of this problem was not 1:11 to have you make an accurate diagnosis but to remind you of the options that should be considered in the differential diagnosis of multiple pulmonary nodules If the patient were a newborn, you would also have to consider meconium aspiration (see Fig 133.4) Miliary tuberculosis should also be considered, given the patient's history and possible weakened immune status Diagnosis: Mu ltiple metastases from thyroid carcinoma, which has one peak age incidence in children and another in older adu lts The patient is too young for stage II sarcoidosis, however 1!!1 l:iil Fig 214.1 EliJ Solution to p.122: Homogeneous opacity in the right ,Ia Nodular masses on the right hilum Opaque area with streaky, nodular, and confluent features in the right MZ Peripheral opacity along the right chest wa ll with blunting of the costophrenic angle (also on the left side) Increased lucency on the left side No signs of pulmonary congestion DD: Loculated subpulmonic effusion with cepha lad extension Pleural fibrosis Prior radiotherapy Enlargement of right hilar lymph nodes Diagnosis: Be of the right lung with hilar lymph node metastases and a concomitant malignant effusion There is compensatory hyperinflation of the left lung Solution to p.137: This radiograph shows predominantly centra l dilatation of the pulmonary vascular calibers (" ~) and moderate cardiomega ly ( ), although the radiograph was taken at only a moderate depth of inspiration (seep 25 and Fig 215.1) If you look closely, you will see sternal cerc lage wires (52) at the right mediastina l border, indicating previous heart surgery The horizontal fissure (31) is accentuated, and a biconvex opacity ( •) is projected over the fissure on the right lateral chest wall Does the "lemon" shape sound familiar? Diagnosis: Mild pulmonary venous congestion with predominantly left-sided cardiomegaly and bilateral pleural effusions, including a loculated effusion in the horizontal fissure of the left lung If you would like to exclude a tumor, one way to so is to reexamine the patient after cardiac recompensation (a little furosemide was adequate in this case) Answer Key 215 ' ,.-52 31 Fig 215.1 m Fig 215.2a Solution to p.137: Figure 215.2a is a lateral radiograph of the same patient In what segment is the large, globular density located? If you are not sure, refer back to page 12 The patient, incidentally, was a heavy smoker, and this accounted for her chronic bronchitis The lucency at the center of the mass suggests the possibility of a lung abscess But the fever in this case was the result of an ascending urinary tract infection Diagnosis: The pulmonary lesion was, unfortunately, a bronchial carcinoma (21 ) with central necrosis (64) (Fig 215.2b) Ill Solution to p.138: Admittedly, the quality of the radio~ graph is not very good But if you look closely, you will notice that the left clavicle is obscuring a cavity located within an opacified area The axia l CT scan (Fig 215.3) and positive tuberculin skin test in this case confirmed open pulmonary tuberculosis You, the guards, and the prison inmates would have been at risk for infection- but you caught the problem in time Fig 215.2b IJ!I lill Solution to p.138: Residual, bilateral enlargement of the hilar lymph nodes is still apparent, although the dominant finding is multiple focal opacities indicating pulmonary mvolvement by sarcoidosis Clinically experienced readers will pardon us for giving obvious clues in the history (typical age of predilection and associated symptom), but it 1s important for less experienced readers to become familiar with this set of findings 11:1 lilim Solution to p.138: The radiograph shows multiple ring shadows with sharp inner margins and somewhat ill-defined outer margins, which are typical of abscess cavities You saw the PA radiog raph of this HIV- and HCVinfected patient earlier on page 135 El Fig 215.3 11:1 Solution to p.138: A large hyperlucent cavity is ~ present in the right apicolateral region, surrounded by an ill-defined area of increased tlensity in the right UZ with upward retraction of the right hilum and a pronounced ipsilateral mediastinal shift The focal opacities and pleural fibrosis are located mainly in the upper zones The differential diagnosis would include an abscess following an upper lobectomy, a BC, or tuberculosis The latter was the correct diagnosis in this case (fig 216.1) m Solution to p.138: Unfortunately, it is not unusual for radiograph request forms to contain scant information on the jJattent's history (Try to avoid this in your own practice!) The radiograph shows bilateral hilar lymph node enlargement and calcifications (") plus unsharpness of the right cardiac border with right pericardiac opacity The patient had resolving ML atelectasis (36) in a setting of sarcoidosis (Fig 216.3) Additionally, there are regional hyperlucencies consistent with pulmonary emphysema Fig 216.1 Fig 216.3 ~~ Solution to p.1 40: The three vertica l lucent bands are, from anterior to posterior, the trachea and the spaces between the scapulae The relatively dense cortical lines of the scapulae create the appearance of intervening hyperlucent zones m Fig 216.2 m Solution to p.138: This radiograph shows a complex pattern with a calcified pleural peel ( +) on the right side and numerous focal opacities in the lung The area of increased density at the right apex also harbors a BC (') which was responsible for the sympathetic nerve lesion (Fig 216.2) Postinflammatory calcification is also noted in the left hilar lymph nodes Solution to p.140: Differentiating between a pneumothorax and the medial scapular border With a mantle pneumothorax, the area lateral to the pleural boundary line appears hyperlucent, or darker than the lung medial to it, and is avascular (see p 120) With insufficient lateral rotation of the scapula (see p 24), the area lateral to the scapular boundary line appears hypolucent or lighter than the area medial to it This is the exact opposite of the relative densities that are seen with a pneumothorax f"-11 liiii Solution to p.140: Companion shadow of the clavicle This line is horizontal and para llel to the clavicle and is caused by skin and subcutaneous tissue that are tangential to the roentgen ray beam (see p 52) Answer Key 217 m Solution to p.154: Differentiating criteria Silicosis Asbestosis Sites of predilection for fibrotic changes: UZ, MZ LZ, MZ Spirometric ventilation defects? Obstructive Restrictive Very typical features and their location: Eggshell lymph node calcifications Bilateral, perihilar Pleural plaques Usually basal and anterolateral Table 217.1 liDJ Solution to p.154: You will find the signs of pulmonary congestion listed in Table 143.3 (p 143) and also on the pull-out sheet, which consists of four pocket-sized checklist cards ~ Solution to p.154: A pattern of fine confluent and Ul linear opacities is always suspicious for inflammatory infiltration when it is unilateral or localized and there are no signs of cardiomegaly or pulmonary vascular dilatation (if evaluable, since vascular markings are often effaced within areas of pneumonia-unlike pleura l effusions) A positive air bronchogram is typical of pneumonia, but occasionally it may occur in association with peribronchial edema due to congestion With an interstitial infiltration pattern, the differential diagnosis should also include fungi, viruses, parasites, and atypical pathogens Equivocal cases should be investigated by microbiological analysis of sputum, bronchial secretions, or pleural aspirate and serological testing for elevated antibody titers, eosinophilia, etc JZ11 lill1 Solution to p.154: Pneumocystis carinii pneumonia (PeP) typically develops in immunocompromised patients (corticosteroids, HIV, chemotherapy) Other typical features are an interstitial pattern of markings and the absence of concomitant pleural effusions or hilar lymph node enlargement (seep 116) Early detection is essential, as it may warrant the prompt discontinuation of chemotherapy, for example, and the initiation of antibiotics EIJ Solution to p.155: A comparison of the two sides in Figure 155.1 shows ground-glass opacity of the right lung with no signs of congestion (the left hilar vessels are not dilated, and there are no Kerley lines) The diaphragm leaflets are elevated on both sides (supine radiograph or poor depth of inspiration), but in themselves they cannot account for the increased linear and reticular markings in the right perihilar region or the unsharpness of the right cardiac border (silhouette sign, see p 28) The left hilum appears normal Diagnosis: Right middle lobar pneumonia Associated findings: The catheter introduced through the left jugular vein is positioned slightly too high, and the catheter on the right side has been advanced too far into the right atrium and should be withdrawn by about 3-4 em The third catheter is a gastric tube ~~ Solution to p.155: The child in Figure 155.2 shows increased linear and reticular markings in the left lung and, to a lesser degree, in the right midzone with no cardiomegaly and no detectable pleural effusion The clinical presentation is very helpful in making the correct interpretation Diagnosis: Varicella pneumonia, more pronounced on the left side than on the right EliJ Solution to p.155: Both radiographs in Figure 155.3 are significantly rotated, as indicated by the displacement of the trachea toward the right side and the position of the clavicles Because of this rotation, the left hilum is obscured by the cardiac silhouette in Figure 155.3a and there is apparent accentuation of the right hilum The radiograph taken the next day show a marked progression of pleural effusions with pronounced cardiomegaly Positive air bronchograms are not seen within the opacities The rapid progression is not consistent with inflammatory infiltrates Diagnosis: Progressive pulmonary venous congestion Caution: With possible widening ot the superior mediastinum, you should recommend a follow-up examination after cardiac recompensation Mediastinal hematoma should be considered in postoperative cases E1 ' m Solution to p.156: Despite the marginal quality of the l6il radiograph, you can see faint linear markings in both basal lung regions and concomitant effusions The cardiac size is borderline, and there are no signs of congestion Malignant cells were detected in pleural aspirate Diagnosis: Carcinomatous lymphangitis in the lung due to metastatic breast cancer ~ Solution to p.156: The radiograph in Figure 156.2 Ul shows a diffuse linear and reticular pattern of induration involving both lungs Diagnosis: Pulmonary fibrosis In exploring the history, you would want to look for possible causes (exposure to organic or inorganic dusts, seep 150) and ask about medications and previous infections You should also try to exclude collagen diseases and metabolic defects (cystic fibrosis, alpha-1-antitrypsin deficiency, etc.) RI!P.I lialiil Answer to the question in the text: The following shotgun pellets can be identified in the extrapulmonary soft tissues: (a) one in the right diaphragm leaflet, (b) one in the upper part of the right lateral chest wall, and (c, d) two closely adjacent pellets in the soft tissues of the right side of the neck Three intrapulmonary pellets (e, f, g) are lodged in the right lung and one (h) is in th e left lung r=P-1 li6il Solution to p.156: Of course, the goal in this case was not to make a correct diagnosis Both radiographs in Figure 156.3 show linear and reticular opacities chiefly involvmg the left UZ and MZ, and the right MZ, the latter showing confluent small opacities The second radiograph shows lateral hyperlucency on the right side with no residual pulmonary vascular markings CT scans were also obtained and showed pleural thickening, enlarged mediastinal lymph nodes, and cavitating lesions in the left LL The differential diagnosis includes pulmonary involvement by lymphoma, Kaposi sarcoma, atypical mycobacteria, and right-sided pneumothorax Recommendation: Microbiological or serological tests to identify the infecting organism and determine its antibiotic sensitivity, and closed pleural drainage on the right side close to the left mediastinal border (Fig 218.1a) The lateral radiograph (Fig 218.1b) shows an additional pellet (i) close to the anterior diaphragm, which is easily missed in the PA radiograph The pellet in the chest wall (b) and the intrapulmonary pellets (e-h) are also clearly visualized, but pellets c and d are obscured by the soft-tissue shadows of the neck and cannot be positively identified -a Fig 218.1a Fig 218.1b EJl Solution to p.182: The PA radiograph (Fig 219.1) shows a pacemaker ( t ) and also a port system for ciH:~mulher apy auminislr aLion The reservoir ( Jf ) of the port system and the catheter ( ) can be identified The catheter tip ( + ) is correctly positioned m the SVC This pacemaker is a VVI device with a cable whose tip (~)is on the floor of the right ventricle The radiograph also shows cerclage wires (52) from a previous sternotomy The gastric bubble (18) is clearly visible below the left hemidiaphragm Fig 219.1 Solution to p.182 : A pacemaker unit with two Iiiii electrodes, one in the right atrium ( • ) and one in the right ventricle ( + ), is projected over the left lung Within the cardiac silhouette are two tilting-disk mechanical heart valves ( }placed in the aortic and mitral valve positions The cerclage wires (52) are also well defined An ECG lead l•l is projected over the right lung, and a tracheostomy tube (~}is correctly positioned with its tip above the carina By looking closely, you can identify an indwelling gastric tube (')to the left of the tracheostomy tube (Fig 219.2) m Solution to p.182: The PA radiograph shows a PDA coil ('Y) that was implanted to occlude a patent ductus arteriosus The spiral shape of the device ('Y) is seen more clearly on the lateral radiograph The coil is correctly positioned in the patent ductus (Fig 219.3) lill a Fig 219.3 Fig 219.2 I 11:1 Solution to p.196: The patient had a borderline personality d1sorder and a history of repeated selfinflicted inJuries, some severe Close scrutiny of this radiograph reveals that a fine needle has been passed into the right superior thoracic aperture, causing a significant pneumothorax and hemothorax on the right side The "opacity" in the right pericardiac area IS caused by bunched pulmonary vessels (an effect of elastic recoil toward the hilum) liY Fig 220.1a fl 11:1 tail Solution to p.196: The patient in Figure 196.2 tumbled several meters down a steep slope while hiking in the Sw1ss Alps The supine radiograph shows definite mediastinal widenmg consistent w1th a paravertebral and/ or mediastinal hematoma A CT examination was also performed (Fig 220.1a-c), confirming the suspected hematoma and also showing a longitudinal fracture of the manubrium sterni ( • ) with a retrosternal hematoma ( ) a comminuted fracture of the T3 vertebral body (•) with no paravertebral hematoma, fractures of the first through fourth ribs on the left side, and of the first and second ribs on the right side Fig 220.1c Fig 220.1b Solution to p.203: The tip of the endotracheal tube is projected onto the sternoclavicular joi nts and is an adequate distance from the carina The chest tube is correctly positioned on the left side The tip of the pulmonary artery catheter inserted by the left subclavicular route is correctly positioned in the right pulmonary artery The tip of the eve inserted by the left subclavicular route is correctly positioned in the SVC The depth of the gastric tube cannot be assessed in this case because of the superimposed cardiac silhouette Its extracorporeal portion is projected over the right UZ fliJ Solution to p.208: Because the ventilation pressure is lost when the patient is extubated, the chest radiographs of many freshly extubated patients appear slightly congested compared with the previous ventilated radiographs (see p 200) Also, most extubated patients have a decreased depth of inspiration leading to apparent widening of the cardiac silhouette and bilateral accentuation of the hilar vessels (all effects are increased by the supine position, seep 24) Ill lilil Solution to p.208: Foreign material: The radiograph shows a Tracheoflex tracheostomy tube in the correct position The depth of the gastric tube is obscured by the cardiac silhouette and cannot be assessed Lung: An extensive positive air bronchogram (see p 144) is visible in the left retrocardiac region Multiple fine opacities are visible in the right lung The left lung is generally more lucent than the right lung, probably the result of an angled scatter- reduction grid in a rotated projection Diagnosis: Left lower lobe pneumonia, possible right lower lobe pneumonia Follow-up is recommended Answer Key m Solution to p.208: Foreign material: The endotracheal tube is correctly positioned The pulmonary artery catheter was inserted by the left subclavicular route, and its tip is visible in the right pulmonary artery The CVC was introduced through the right jugular vein, and its tip is projected at the junction of the right brachiocephalic vein with the SVC lung: Both lungs are fully expanded with no signs of pneumothorax A pattern of confluent small and larger opacities is visible in the MZ and LZ (lingula + LL) of the left lung The calibers of the pulmonary vessels are normal, at most showing a small degree of perihilar accentuation Heart: Mild cardiomegaly predominantly affecting the left side Summary: The increased density of the left lung may be caused by residual lavage fluid, and there is suspicion of residual inflammatory infiltrates in the lingula and left LL II!' Solution to p.208: When you look closely at this expiratory (!) radiograph, you will observe posterolatera l fracture lines (29) in at least three ribs (fifth through seventh) on the right side These fractures are responsible for the hemothorax that is causing haziness on the right side Foreign material: The tip of the endotracheal tube {48) is correctly positioned approximate ly em from the tracheal bifurcation (14c) The pleural drain on the right side (67) extends posteriorly to the floor of the costodiaphragmatic recess; it appears too low only because of the poor depth of inspiration The other lines represent ECG leads (52) Diagnosis: Posterolateral fractures of the fifth through seventh ribs with a right hemothorax lilil 221 fl:ll Solution to p.208: Foreign material: The endotracheal tube (48) is correctly positioned The tip of the pulmonary artery catheter is visible at the orig in of the right pulmonary artery ( ).A Demers catheter(*) has been introduced by the left subclavicular route for hemodialysis (see p 165) Its tip ( t ) is projected at the center of the right atrium A CVC (59) has been passed through the right jugular vein, and its tip is also in the right atrium A fourth CVC, introduced from the left side, is also in the right atrium and should be withdrawn by approximately em from its current position The left pleura l dra in (67) is correctly positioned, and the sternal cerclage wires appear to be intact and undisplaced The radiopaque marker on the IABP (")is projected onto the aortic arch or proximal descending aorta (a lateral radiograph is not available) lung: The left lung is fully expanded (with possible slight residual pneumonia in the left apica l lobe) Dilatation of perihilar vessels and Kerley B lines are noted in both lungs There is no evidence of inflammatory infiltrates Heart: The heart shows mild (for a supine radiograph), predominantly left-sided cardiomega ly with a subtle pneumoperica rdium (38, probably due to postoperative residua l air) Summary: Signs of predominantly central pulmonary edema (left-sided heart failure? overhydration? renal function?) Three of the catheters are in the right atrium (see above) lill El Fig 221 I:P.I If you would like to test your knowledge further, we suggest turning back to the Chapter Goa ls listed at the beginning of each chapter Read through each of the learning points and provide detailed answers or descriptions to see how well you have accomplished the various goals Good luck! Ia: Fig 221 Radiation Safety Always consider the ALARA principle ("as low as reasonably achievable") before exposing any patient to diagnostic radiation The effective dose is the most useful parameter for assessing exposure, as it takes into account the individual radiosensitivi- ties of different tissues The unit of measurement for the effective dose is the millis1evert (mSv) In the table below, the dose levels of conventional chest radiographs are compared with those of computed tomography (CT) scanning and with the average annual exposure to ionizing radiation Effective Dose E Radiation Source Average total annual exposure in Germany Natural exposure (radon, terrestrial cosmic, etc ) Fallout from Chernobyl, nuclear weapons testing, etc Ionizing radiation 1n medicine, average total Thoracic CT (breast, lung); dose depends on the examination technique Conventional chest radiographs in two planes Percentage -4.20 mSv - 2.40 mSv -0.03 mSv - 1.50 mSv -5-10 mSv -0.20 mSv 100.0% 57.0% 0.7% 35.7% 120-240% 5.0% The effective dose from a single posteroanterior ( PA) radiograph without a lateral projection is substantially lower These figures not mean that the radiation dose from conventional chest radiographs is harmless, but they allow a rational assessment of the exposure level, which is quite low in relation to other sources Technical Principles The roentgen ray film itself is mounted in a light-proof cassette between two intensifying screens that are in direct contact with the film These intensifying screens are made of substances that emit light when exc1ted by roentgen rays This secondary light emission produces up to 95% of film blackening; only about 5% is produced by the direct action of the roentgen rays themselves This secondary light is emitted in random directions, however, and so it could cause undesired blurring of the exposed film To obtain a high-quality image, then, it is essential that the intensifying screen be pressed tightly against the film This film-screen combination has made it possible to reduce the patient dose substantially below the levels required in earlier techniques (see below) As a rule, film-screen systems with a film speed of 400 are currently used for chest radiographs (a tradeoff between image resolution and Intensification) The film itself consists of a base material that is coated usually on both s1des, with a radiation-sensitive emulsion of silver bromide or silver chloride Primary roentgen ray quanta or secondary light quanta incite a chemical reduction process that causes film blackening, and this effect is amplified when the film is processed Thus, body areas that are more transparent to roentgen rays, such as aerated lung tissue, cause a greater degree of film blackening than less permeable structures such as bone (see p 8) During fixation of the exposed film, nonreduced silver salts are removed from the emulsion As a result, areas that receive little or no exposure to roentgen rays appear lighter on the image, while more heavily exposed areas appea r dark This gives the radiograph the appearance of a "negative" image Digital Systems Increasing ly, analog film-screen combinations (see above) are being replaced by digital systems, whose technical details are beyond our present scope The main advantages of digital systems are the ability to postprocess the image data (brightness contrast etc.) and a reduced risk of overexposure or underexposure in very low or very high dose ranges Lower doses result in a "nosier" image, but, unlike analog systems, provide just as much image information as higher doses Moreover digital images can be stored as computer files in hospital archives and can be quickly accessed by authorized colleagues for evaluation and consultation Quality Criteria Technically acceptable chest radiographs should have the following characteristics: PA radiographs: • The scapulae are not supenmposed over the upper lung zones (they are adequately rotated out of the field) • The proJection is not rotated, i.e., the spinous process of the T3 vertebra is centered and is equidistant from the clavicles • Coverage: The 1mage encompasses both lateral costophrenic angles, all of the thoracic organs, and the soft tissues of the neck • Adequate depth of inspiration: The diaphragm is not superimposed over the posterior segments of the ninth ribs Additional rules for analog images: • The image is not overexposed if peripheral pulmonary vessels can be seen • The image is not underexposed if the spinal column and large lower lobe vessels can be seen within th lateral radiographs: • Arms are elevated so that the (upper) arms are not superimposed over the lungs • The projection IS not rotated i.e., the right and left ribs are projected over one • Suffictently short exposure time: The heart, diaphragm, and great vessels are sharply outlined • Not overexposed Pulmonary vessels are visible in the retrocardiac space (RCS) • Not underexposed: Pulmonary vessels are projected over the cardiac silhouette n1t ~ "4-_95" ~~ ~ ~~ q\'-\~ "~8 ~ MAY 007 For entnes that appear on more than one page, the boldfaced numbers indicate page(s) on which the term is described in particular deta1l AAI pacemaker 167, 169 Abscess· Pulmonary abscess 135, 145 Med1ast1nal abscess 79 Fungal abscess 136 Acm1 16 Acrom1oclav1cular JOint 40·41 AdenomatoSIS of the lung 129 Agenesis of the lung 110 Air bronchogram 143, 144 Air-fluid levels 136, 153, 192 Alpha·! antitrypsin deficiency 151 Alveoli 16 Am1odarone,lung changes due to 147 Amputation, of the arm 37 Anatomy 7·22 Innervation of the lung 22 Interstitium 21 Oiv1s1ons of the lung 10, 16 Pulmonary vessels 18, 22 LymphatiC dramage 21 Mediastinum 20 Segments 12, 14·15 Skeleton B 39 Tracheobronchial tree 13 Ang1ography of the lung 19 Ankylosmg spondyht1s 47 147 AnthracOSIS 150 Annuloplasty 175 Ant1glomerular basement membrane d1sease 147 Aort1c balloon pump 171 Aortic aneurysm 93·94 Aortic coarctation 42 88 Aortic d1ssection 94 Aortic valve d1sease 83·85, 95 Aortic stent 171 AROS 201 ·202 Artenovenous malformation 125 AsbestosiS 53, 56, 149 Aspergilloma 136 Asp1rat1on 119 Contrast med1um 124 Mecon1um 133 Fore1gn body 179 AspergillOSIS 136, 147 AtelectaSIS Lobar 111-113, 147 Segmental 114-115 Round 140 Atnal dilatation, left 84, 141 AVM 125 Azygos lobe I vem 140 Balloon pump (aortic) 171 Barrel chest 118 B1furcat1on angle (tracheal) 13, 72 175 Bileaflet heart valve 173 Bioprosthet1c heart valves 174 Blalock-Taussig operat1on 87 Blood divers1on, upper-lobe 25, 141 Blunting of costophrenic angle 106 Boeck disease (sarcoidosis) 74, 131, 133, 150 Bronchial carcinoma 22 76, 117, 127-129, 152 Bronchiectasis 135, 151 Bronchioli 16 Bronchogram (air) 143, 144 Bullae 119 Butterfly pattern of edema 142 Caged·ball heart valve 174 Card1ac silhouette, age effects 27 Cardiac valve disease 82-87 Card1ac valve replacement 172·176 Cardiomegaly 27, 81, 141-143 Cardiothoracic ratio 27, 81 Cardiomegaly 27, 81,141-143 Cardioversion 170 Caseation (in tuberculoSIS) 132 Catheter insertion (CVC) 159·161 Catheterization 130 Catheter, umbilical 202 Cavities, intrapulmonary 135 Central necrosis, in bronch1al carcmoma 129 Central venous catheter (CVCl 158-163, 199 Insertion 159·161 Checking the pos1t1on of 162, 166 Cervical rib 39 Checklists Fore1gn bodies 181 Signs of congestion 143 Chest wall hematoma 37 Chondrosarcoma 124 Chondrosis 45 Churg·Strauss granulomatosis 147 Clavicle, fracture of 40 Coarctation of the aorta 42, 88 Colon segment interposed (for esophageal carcmoma) 97 Compression atelectasis 106 Congestion, pulmonary venous 77 141-143, 200 Checklist of s1gns 143 Contrast examination (oral of the esophagus) 84, 97, 141 Contrast medium, aspiration of 12 Contusion pulmonary 130, 189 Cor bovinum 108 Corona radiata 129 Costophrenic angle, blunting of 106 Crescent sign 107 Crying lung (in children) 31 CTR 27,81 Cutaneous emphysema 193 Cystic fibrosis 151 DOD pacemaker 167-168 De Bakey class1f1catlon 94 Defibrillators 170 Demers catheter 158 DepressiOn of the hem1d1aphragm 191 D1alysis catheter 165 Diaphragmatic hermas 98, 109 D1sc space infection 79 DISH (Forestier disease) 46 Dose, radiat1on 222 Drug-mduced pneumoma 147 Ductus arteriosus 86 Dyselectasis 111 , 147 Edema, pulmonary 141-143, 200 Effective radiation dose 222 Effusions 90, 106-108, 125, 141, 153,200 Quantification of 108 Elevation of the hemidiaphragm 58 Embolism, pulmonary 19, 207 Risk of 175 Emphysema (cutaneous) 38 99, 118-119, 126, 145, 193 Endobronchial tubes 177 ff Endotracheal tube 177 Enterothorax 109 Eosinophilia 132 Esophagus Atres1a 96 D1vert1cula 96 Carcmoma 97 Stent 178 Euler-LiiJeStrand reflex 29, 141 Fallot, tetralogy of 87 Farmer's lung 150 FAST 194-195 Fibrosis, pulmonary 150 Figure sign, in coarctation of the aorta 88 Film·focus distance 24 Film-screen combination 222 Fissures, pulmonary 11, 111 Fore1gn body aspiration 119, 179 Forest1er d1sease (DISH) 46 Fractures 42, 184-186 (ribs), 188 (vertebrae) Ganglioneuroma 78 Gas exchange 16 Gastric bandmg 47 Gastric pull·up transposition 97 Ghon focus (in tuberculosis) 132 Gorter 68 Granuloma, ben1gn 124 Granulomatosrs Churg-Strauss 147 Granulomatosrs Wegener 134, 147 Ground-glass opacity 21, 141, 146 Hair braids 37 Hamartoma 124, 125 Hampton's sign 207 Hematoma Chest wall 37 Extrapleural 186 Splenic 195 Hem1diaphragm Elevation of 58 Oepress1on of 191 Hem1thorax view 185 Hemopencardium 194 Hemothorax 109, 186·187, 194-195 (FAST), 207 Hernras 98, 109 Heart size of 27 81 Heart valves (prosthetic) 172-176 Hiatal hernra 98 Hrckman catheter 144, 158 HIV patients 146 Honeycomb pattern 150 Humerus, fractures of 41 Hyperkyphosrs 47 Hyperlucencres 8, 118-120 IABP 171, 208 lCD defibrillators 170 Image interpretation, sequence of 30 Innervation of th e lung 22 Intensifying screens 222 Interstitium 21 Intra-aortic balloon pump 171 Intrapulmonary cavities 135 Intubation 117, 177, 198 IROS 201-202 Kartagener syndrome 151 Kerley lines 21, 77, 142, 143 Valvular heart disease 82·87 Koller's pouch 195 Upper-lobe blood diversion 25, 141 Kyphosis, of the thoracic sp1ne 47 Lambert canals 16 laceration, pulmonary 190 Lemon s1gn (of effusion) 125, 200 Lenk's rule 59 Leukem1a 68 Lobar anatomy 10-11 Lobules 16 lobe azygos 140 Loftier inhltrate 132 Lofgren syndrome 131 Lower-zone predominance, of pulmonary blood flow 25 Lucenc1es Lung cancer 22, 76, 117, 127-129, 152 Lung changes due to Amiodarone 147 lung, anatomical d1v1sions of 10, 16 Lung cancer, see Bronchial carcmoma Lymphatic drainage 21·22 Lymphangioma 71 lymphangitiS, carcmomatous 109, 152-153 Lymph node enlargement 72-74 lymphoma 69,74-75, 110 Magn1hcat1on effects 24 Mantle pneumothorax 190 Mastectomy 36 Meconium aspiration 133 Med1astmum Abscess 79 ClassificatiOn 65·66 Emphysema 38, 99, 193 Borders 20, 32, 64 Widemng 47 ff Sh1ft 99-100, 106, 120, 191 Menetner disease 48 Mesothelioma 59 Metallic P1ercings 125 Metastases Pulmonary 126, 134 lymph nodes 72-74 Skeletal 43-44 M1dline sh1ft 99-100, 106, 120, 191 M1sd1rected mtubauon 117, 177, 198 M1tral valve d1sease 82, 84·85 Morrison's pouch 194 MRI compatibility 176 Muscular hypertrophy, atrophy 37 Mycolic abscess 136 Neck dissection 37 Necros1s 129 (in lung cancer), 136(abscess) Neuroblastoma 78 Nipples 37 Notchmg of the ribs 42, 87-88 · - Oral contrast examination (of the esophagus) 84, 97, 141 Opac1t1es, on chest radiographs 8, 26, 36 Opac1ty, ground-glass 21, 141, 146 Osteochondrosis 45 Osteolytic lesions 43-44, 58 Osteosarcoma 124 Pacemaker systems 167-170 Pancoast tumor 58, 129 Paras11e 132 PEEP vent1lat1on 140 Perfus,on 29 Pencard1um 90-92 Pers1stent ductus arteriosus 86 Phren1c nerve paralysis 58, 115, 129 P1ano key s1gn 40 Piercing 124 Plaques 53, 56, 149 Plasmacytoma 115 Pleural effusions 106-108, 125, 141, 153 Pleural fibrosis 54-55 Pleural folds 51 -52, 140 Pleural mesothelioma 59 Pleural plaques 53, 56, 149 PNET 110, 117 Pneumatocysts 16 Pneumocomosis 148 150 Pneumocystis carimi 146 Pneumomed1astmum 38, 99, 193 Pneumon1a 109, 116, 144-147 fungal 133, drug-induced 147 PneumonitiS (postirradiatiOn) 153 Pneumopericardium 91 Pneumothorax 120, 190-192 Port·A·Cath system 153, 158, 164 Positive an bronchogram 143, 144 PostirradiatiOn changes 153 Pnmary complex hn tuberculosis) 119, 132 Prosthetic heart valves 172-176 "Pruning" of pulmonary vessels 118 Pulmonary adenomatOSIS 129 Pulmonary agenesis 110 Pulmonary atresia 77 Pulmonary blood flow, lower-zone predominance, of 25 Pulmonary catheter 130, 166 199 Pulmonary contusion 130 189 Pulmonary edema Alveolar 143 In ICU patients 200 Interstitial 141, 142 Pulmonary embolism 19, 207 Pulmonary fibrOSIS 150 Pulmonary metastases 126 134 Pulmonary valve stenosiS 87 Pulmonary vems, anomalous termination of 140 Pulmonary vessels 18, 22 · Quality criteria 222 Quartz dust inhalat1on 148-150 Quiz questions 32-34, 48·49, 62, 101·103, 121·122, 137·138, 140, 154-156, 196,209-221 Radiation 153 Radiation dose 222 Radiation pneumonitiS 153 Radiation safety 222 Radiographic techmque 24 Radiographic interpretation, sequence of 30 RCS (retrocardiac space) 20 Replacement of cardiac valves 172-176 Rib fractures 42, 184·186 R1b notching, in coarctation of the aorta 42, 87-88 Rockwood classification 41 Round atelectasis 140 ASS (retrosternal space) 20 Sarcoidosis (Boeck disease) 74, 131, 133, 150 Scar emphysema 150 Scatter-reduction gnd 26, 108, 118 Scheuermann disease 46 Schmorl nodes 48 Scmtigraphy (rad1onuclide imaging) 153,207 Scoliosis 46 Segmental anatomy 12, 14 15 Seldinger techmque 159-161 Seminoma, metastases from 134 Sheldon act 158, 165 Sideros1s 150 Signet rmg Sign 151 Silhouette s1gn 28, 116, 145 SiliCOSIS 149 Sjogren syndrome 147 Skeletal dysplasia 42 Skeleton Acromioclavicular joint 40-41 Clavicular fracture 40 Degeneration 45-46 Humeral fracture 41 Metastases 43·44 R1b fractures 42, 184-186 Sternal fracture 188 Thoracic skeleton anatomy of 8-9 Vanants 39 Vertebral body fracture 188 Small cell lung cancer 127 If Soft-tissue emphysema 126 spme, thoracic kyphosis of 47 Spirometry 149 Splenic hematoma 195 Splemc cysts 48 Spondylitis, ankylosmg 47, 147 SpondylOSIS deformans 45 Stanford classificatiOn 94 Stent AortiC 171 Esophageal 178 Sternal fracture 188 Supme radiographs 25 Surfactant 16 Tangential shadows Technical pnnciples of radiography 222 TEE (transesophageal echocardiographyl 207 Tens1on pneumothorax 120, 191 Teratoma 71 ThoraCIC outlet syndrome 39 Thromboembolism risk of 175 Thymus 70 TIItlng·dJsk valves 173 TNM claSSification of lung cancer 128 lossy class1f1cation 40-41 Tracheostomy tube 177, 178 Tracheal spot films 68 Tracheobronchial tree 13 Tracheomalacia 68 Tracheotomy 177 Transpos1t1on of the great artenes (TGA) 89 Triangle of the vena cava 20 Tncusp1d valve disease 86 Tuberculosis Caseation 132 Cavity 135 Ghon focus 132 Lymph nodes 73-74 Miliary form 133 Primary complex 119, 132 Valsalva maneuver 68 Valve replacement 172-176 Valve disease 82-87 Vanants 39, 140 Vertebral arch, mcomplete closure of 39 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( Right middle lobe infiltrate ) ( Right lower lobe infiltrate ) ... calcifications Otherw1se, however, it is a good rule of thumb that calcified pulmonary nodules are generally benign (Table 124 .2) • + Fig 124 .3 Fig 124 .4 Fig 124 .5 Fig 124 .6a Fig 124 .6b Fig 124 .7 Focal... for associated lesions or a primary tumor The images in Figure 126 .2a-c Fig 126 .2a Fig 126 .2b Postoperative follow-up (Fig 126 .1c) shows elevation of the right hemidiaphragm ( t ) and signs of... 127 .5) demonstrate the course of the azygos vein (15) from the posterior thoracic spine (26 ) to the anteriorly located superior vena cava (SVC) (1) b a Normal case Fig 127 .3 Fig 127 .4 Fig 127 .5a