Peds -- Chest

Front 1

1. What is the DDX of an anterior mediastinal mass in a child?
2. What are other germ cell tumors?
3. What is the DDX of cystic anterior mediastinal mass?
4. In what syndrome is there an increased risk of mediastinal germ cell tumor?

Back 1

1.
- Lymphoma
- Teratoma
- Benign thymic enlargement (thymic rebound after chemotx)
- Thymic tumors are very rare in children (Lymphoma is more common than teratoma)
2. Mixed GCT, chorioCA, endodermal sinus (yolk sac) tumor, embryonal cell CA, seminoma.
3. Cystic germ cell tumor, cystic hygroma, thymic cyst, thymoma (cysts related to hemorrhage and necrosis), lymphoma with cystic degeneration.
4. Klinefelter's syndrome (XXY) has an increased risk of mediastinal germ cell tumor.

Front 2

1. From where does lymphoma arise in the anterior mediastinum?
2. What is the most common AIDS related neoplasm in children?
3. What is the etiology of pleural and/or pericardial effusions in pts with mediastinal tumors?
4. What are the possibilities of a residual soft tissue mass in the anterior mediastinum after chemotx?

Back 2

1. Lymph nodes and/or thymus.
2. NHL
3.
- Pleural effusions can be seen in pts w/ mediastinal lymphoma related to venous or lymphatic compression.
- Pericardial fluid is almost always related to direct tumor extension.
4. Remaining tumor vs. post-treatment fibrosis.

Front 3

1. What is DDX of radiolucent, expanded hemithorax in a neonate?
2. What are the most common locations of congenital lobar emphysema?

Back 3

1. NEONATAL DDX OF RADIOLUCENT, EXPANDED HEMITHORAX
- CCAM (hamartoma consisting of disorganized lung tissue)
- Diaphragmatic hernia
- Congenital lobar emphysema
- Contralateral pulmonary hypoplasia
2. MC locations of CLE: LUL, RML, RUL

Front 4

1. What is the DDX of hyperlucent lung?
2. What are 3 types of CCAM? What is their prognosis.
3. How do you differentiate CLE from CCAM?

Back 4

1. CCAM, CLE, CDH. Note that all three may be radio-opaque at birth.
2.
TYPE 1:
- associated with macrocysts (>2 cm)
- lowest incidence of other associated malformations.
TYPE 2:
- composed of smaller cysts (1-2 cm)
TYPE 3:
- composed of microcysts, < 1 cm (giving the mass a solid appearance).
NOTE: Type 2 and 3 are associated with higher incidence of other associated malformations and thus have worse prognosis. However in general, prognosis is dependent upon what the CCAM does to adjacent structures. CCAM may be associated with hydrops.

3. The hyperinflated lobe of CLE has visible, although attenuated vessels, out to its periphery and lacks septations differentiating from CCAM.

Front 5

1. What is more common: intra- or extra-lobar sequestration?
2. Which is associated with an increased risk of congenital abnormalities?
3. Which type of sequestration can be confused with a paraspinal tumor?
4. What other pulmonary entity has systemic blood supply?

Back 5

1. Intralobar accounts for 75% of sequestrations, whereas extralobar accounts for the remaining 25%.
2. Extralobar sequestration is associated with an increased risk of other congenital abnormalities and are thus usually detected earlier. Intralobar sequestration usually presents as recurrent PNA in the same location.
3. Extralobar sequestration may appear as a paraspinal mass and can be confused with neuroblastoma.
4. Scimitar syndrome can also have systemic arterial blood supply, however, it is not associated with a focal mass.

Front 6

1. What are the 2 common locations of bronchogenic cysts?
2. Do they communicate with the bronchial tree?
3. What does the presence of air-fluid level indicate?
4. What is the DDX of cystic mass in the mediastinum/lung parenchyma?

Back 6

1. Mediastinal and lung parenchyma.
2. Mediastinal bronchogenic cysts usually do not communicate with the bronchial tree whereas the intrapulmonary brochogenic cyst do communicate with the pulmonary tree and thus appear as a solitary round thin walled, air containing cyst.
3. Infection or hemorrhage.
4. CCAM, abscess, congenital diaphragmatic hernia, sequestration, cavitating laryngeal papillomatosis.

Front 7

1. What is the most common arterial supply to a pulmonary AVM?
2. What are the symptoms of pulmonary AVM?
3. What is the DDX of benign solitary pulmonary nodule?

Back 7

1. Pulmonary artery. Less commonly, systemic artery branch.
2. Symptoms can be related to right to left shunting resulting in hypoxemia and paradoxical embolization.
3. Granuloma, pulmonary hamartoma, AVM, bronchial atresia, round PNA.

Front 8

1. How do you differentiate pulmonary agenesis from pulmonary aplasia?
2. What is unique complication of right sided agenesis?

Back 8

1. In pulmonary aplasia, there is a blind ending bronchus. In pulmonary agenesis, the bronchus, pulmonary artery, and pulmonary vein are absent.
2. With right sided agenesis, the heart undergoes a rotation that may lead to entrapment of the left mainstem bronchus leading to severe left lung hyperinflation. Similar complication can occur with right pneumonectomy.

Front 9

1. What are some reasons for non- visualization of the thymus?
2. To what age can a thymus be seen?

Back 9

1. Nonvisualization of the thymus may be secondary to stress or steroid therapy. It will rebound to its original size following resolution of the inciting condition.
2. Thymus can be seen upto 9 years of age.

Front 10

1. What are the typical features of respiratory distress syndrome?
2. TTN?
3. Meconium aspiration?
4. Neonatal pneumonia?

Back 10

1. Small lung volumes with ground glass opacities in a premature infant.
2. Normal to large lung volumes with interstitial opacities with small pleural effusions and fluid within the fissure. Resolves in 24 hours.
3. Large lung volumes in post-term infant with coarse opacities.
4. Large lung volumes with perihilar streaky opacities and pleural effusion in infant with PROM or mother with GBBS infection.

Front 11

1. What are short and long term complications of respiratory distress syndrome?
2. What is bronchopulmonary dysplasia and what are its imaging manifestations?

Back 11

1. Short term: pulmonary interstitial emphysema, pneumothorax, and pneumomediastinum. Long term complications are bronchopulmonary dysplasia, recurrent infections, and hyperinflation.
2. Four weeks of positive pressure ventilation may lead to interstitial fibrosis with exudative necrosis and honeycombing -- Bronchopulmonary dysplasia (BPD). It appears as interstitial fibrosis, cyst-like - empysematous changes and increased lung volumes.

Front 12

1. What features are suggestive of staph pneumonia?
2. What is the mechanism of formation of pneumatoceles and what is their course?
3. To what age are round PNA seen? What is the bug?
4. What is the advantage of IV contrast in cases of consolidated lung?

Back 12

1. Empyema is an early complication and pneumatocele are a late complication of staphylococcal PNA.
2. Pneumatoceles are thought to be a form of PIE and local emphysema caused by airway obstruction through a check valve mechanism. Pneumatoceles may pop and leak into the pleural space, causing pneumothorax. Pneumatoceles often resolve within 6 weeks.
3. 8 years 2/2 poor collateral flow. Strep PNA.
4. IV contrast helps in delineation of an abscess as a rim enhancing fluid collection.

Front 13

1. What are the imaging manifestations of primary TB?
2. What is a ghon complex?
3. What is the mechanism of reactivation TB?

Back 13

1. Lobar consolidation, hilar adenopathy, pleural effusion.
2. Calcified granuloma and mediastinal adenopathy.
3. The primary infection is kept in check by macrophages in the form of granumlomas which may contain some living bacilli. When a pt is immunosuppressed, the bacilli are no longer kept in check.

Front 14

1. What are the two types of lymphomas?
2. What are the different types of Hodgkin lymphoma?
3. How is lymphoma staged?
4. What are the different types of Non-Hodgkin lymphoma?

Back 14

1. Lymphoma is divided into Hodgkin and non-Hodgkin lymphoma (NHL).
2. Hodgkin disease accounts for 5% of all lymphoma cases. Hodgkin disease is divided into four types: lymphocytic predominant, nodular sclerosing, mixed cellularity, and lymphocyte depleted.
3. Staging involves the Ann Arbor classification and is based on the number of nodal sites and their location.
4. NHL is divided into two categories based on histology, lymphoblastic and nonlymphoblastic. Nonlymphoblastic is further subdivided into histiocytic and undifferentiated (Burkitt and non-Burkitt types).

Front 15

1. What is the DDX of multiple large pulmonary nodules?
1. What is the DDX of multiple small pulmonary nodules?

Back 15

1. Mets (Wilms' tumor, osteosarcoma, Ewing sarcoma) and Septic Emboli.
2.
- Varicella (may calcify)
- Thyroid mets (may calcify)
- Granulomas
- Laryngeal papillomatosis
- LIP

Front 16

What is the DDX of primary lung neoplasm in a child?

Back 16

- Bronchogenic CA
- Sarcoma (Leiomyosarcoma and Rhabdomyosarcoma)
- Hemangiopericytoma
- Askin tumor: rare tumor arising from the chest wall. It is a subset of Ewing sarcoma characterized histologically by the presence of small round blue cells. It is a highly malignant tumor with guarded prognosis

Front 17

1. What is the etiology of Swyer-James syndrome?
2. What is the ddx of unilateral hperlucent lung?
3. What airway abnormality is frequently demonstrated on CT scans of patients with Swyer-James syndrome?

Back 17

1. Viral infection, most commonly adenovirus, leading to fibrotic necrotizing bronchiolitis with fibrosis and scarring of the bronchi and bronchioles. Other etiologies are cryptogenic, toxic fume inhalation, bone marrow and lung transplantation rejection, rheumatoid arthritis, inflammatory bowel disease, and drug toxicity (penicillamine).
2. Foreign body aspiration, hypoplastic lung, pulmonary hypoplasia, mucus plugging, pulmonary sling.
3. Bronchi ecstasies.

Front 18

1. In which patient population is LIP seen?
2. What is the underlying abnormality?

Back 18

1. HIV+ babies
2. LIP results in diffuse lymphocytic infiltration of the alveolar septa, interlobular septa, and subpleural and peribronchial lymph channels.
3. LIP appears as a diffuse, symmetric reticulonodular or nodular infiltrate with or without the presence of hilar and mediastinal adenopathy.

Front 19

1. What is Kawasaki disease?
2. What are the symptoms?
3. What is the dreaded complication?

Back 19

1. Kawasaki disease or mucutaneous lymph node syndrome is an infectious inflammatory entity that affects mainly infants and children.
2. Conjunctivitis, fever, strawberry tongue, lymphadenopathy, desquamating hands and feet, angular stomatitis.
3. coronary aneurysms and infarction.

Front 20

What are the features of Scimitar syndrome?

Back 20

- anomalous pulmonary venous return
- ipsilatetal pulm artery is small.
- systemic blood supply is common.
- hypolucent lung due to small ipsilatetal pulmonary artery.
- associated with asd. 
- marked mediastinal shift to the right due to right lung hypoplasia (may mimic dextrocardia).

Front 21

What is the most common cause of a thoracic inlet mass in a child?

Back 21

Lymphangioma

Front 22

Wha is ddx of small thorax?

Back 22

SKELETAL DYSPLASIA
- Jeune's (aphyxiating thoracic dystrophy)
- Thanatophoric dysplasia
- Achondrogenesis

OLIGOHYDRAMNIOS
- PROM
- Renal agenesis
- Renal obstruction

Front 23

What are some lesions in the nose that may cause obstruction?

Back 23

1. Anterior inlet stenosis (occurs proximal to choanal atresia, single central incisor, brain abnormality)
2. Choanal atresia
3. Polyps
4. Tumor
5. Trauma
6. Encephalocele
7. Dacrocystocele

Front 24

What are some lesions in the nasopharynx that may cause obstruction?

Back 24

1. Large adenoid and lingual tonsils (if you see thickening of the retropharyngeal soft tissues as well, think mono)
2. Lymphoma (non-Hodgkin)k: may involve Waldeyer's ring (adenoid, tonsils)
3. Retropharygeal abscess
4. Juvenile angiofibroma
5. Teratoma

Front 25

What are key features of choanal atresia?

Back 25

- Bony choanal atresia is more common than membranous.
- Bilateral choanal atresia is more common than unilateral.

Front 26

What is the DDX of epiglottic thickening?

Back 26

- Acute epiglottitis
- Caustic ingestion
- Angioneurotic edema

Front 27

What are the causes of airway obstruction at the level of the oropharynx?

Back 27

- Palatine tonsils (infxs mono)
- Peritonsillar abscess
- Macroglossia
- Micrognathia
- Teratoma
- Lingual thyroid
- Thyroid duct cyst
- Ranula

Front 28

What are the causes of airway obstruction at the level of the supraglottis?

Back 28

- Croup/membranous croup
- Epiglottitis
- Aryepiglottic fold cyst
- Hemangioma/lymphangioma (stridor may increase as these get larger after birth; they eventually involute).

Front 29

What are the causes of airway obstruction at the level of the trachea?

Back 29

- Tracheomalacia/inominate artery impression
- Congenital stenosis from complete cartilaginous rings (can be seen in pulmonary sling)
- Stenosis (post-traumatic, granuloma, web)
- Vascular ring
- Tracheal foreign body
- Esophageal foreign body
- Lymphoma
- Granulomatous disease
- Papilloma

Front 30

Double aortic arch

Back 30

2 impressions on esophagus (superior impression by right aortic arch, inferior impression on left is caused by left aortic arch)
Reverse s sign describes the impression on the esophagus.
Right arch is higher, bigger, and posterior.
80% descend on the left side after confluence.
Surgical site is on the left side to clip the smaller aortic arch.
20% have chd

Front 31

1. What should you think if you have a spontaneous pneumothorax in a child?

Back 31

1. Spontaneous ptx should raise the question of pulmonary hypoplasia. Pulmonary hypoplasia can be due to renal abnormalities. Therefore, do an ultrasound of the kidneys.

Front 32

What are the findings in acute chest syndrome?

Back 32

- New airspace opacity accompanied by chest pain, fever, leukocytosis in a pt with sickle cell disease.
- May be due to infection, fat embolism, rib infarction.
- Highest incidence in kids 2-4 years old.
- Look for airspace consolidation in the lower lobes, H-shaped vertebral bodies, AVN of humeral heads, rib enlargement from marrow expansion, calcified spleen, RUQ cholecystectomy clips.

Front 33

How do you differentiate between Swyer James syndrome and congenital absence of the pulmonary arteries?

Back 33

- Swyer James will have associated air trapping on expiration views.
- Note both d/o present with small, hypolucent lung with an absent/small hilum.
- likely due to adenoviral infection causing bonchiolitis obliterans before the age of 8 years, when the full complement of alveoli has formed. This leads to obliteration of the distal bronchioles, fewer alveoli, and hypoplasia of the vasculature.
When Swyer James syndrome affects just one lobe, it may be mistaken for congenital lobar emphysema.

Front 34

Pulmonary interstitial emphysema

Back 34

Bubble like or linear lucencies that radiate from the hila.
- 2/2 barotrauma which results in increased alveolar pressure and rupture. Air may dissect proximally (pneumomediastinum) or distally (PTX).
- Occurs in ventilated infants in the first week of life. NOTE: BPD occurs later and appears gradually, whereas PIE has an abrupt onset.
- Treated by adjusting ventilator settings.
- If PIE affects just one lobe or if it persists and forms an air filled mass, it can appear similar to CCAM or CLE.
- On CT, air engulfs the pulmonary vessels which appear as a round soft tissue density surrounded by abnormal lucency.

Front 35

Lemierre syndrome

Back 35

- Infection of the lateral pharyngeal space that spreads into the carotid sheath causing septic thrombosis of the internal jugular vein.
- Can be complicated by septic pulmonary emboli. Look for nodules that cavitate.

Front 36

Middle mediastinum

Back 36

- Vascular abnormality (pulmonary sling)
- Bronchogenic cyst
- Lymph node

Front 37

Plasma cell granuloma

Back 37

- Rare, aggressive primitive pleural based or parenchymal neoplasm presents as a soft tissue mass or as a lung cyst.
- Mets to CNS, bone, and liver.