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260 Cards in this Set
- Front
- Back
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Lung- Anatomical segmental anatomy
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RUL- Apical, Anterior, Posterior LUL- Apicoposterior, Anterior
RML- Lateral, medial Linugula- Superior, Inferior LUL/RLL- Superior, Medial basal, Anterior basal, Lateral basal, Posterior basal |
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Anterior Junction Line
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2 mm linerar line that projects over the trachea. Represents the anterior right and left pleura.
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Posterior Junction Line
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Extends above the clavicles. Reprsents the posterior right and left pleura.
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Azygoesophageal recess
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Interface between RLL air and mediastinum.
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Left Paraspinal Line
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Extends form aortic arch to diaphragm
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Right Paratracheal stripe
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Normally less than 4 mm, never extends below the right bronchus.
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Pulmonary Embolism CT Protocal
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100 cc Omni 350 at 3ml/sec with 25-30 second delay. Scans reconstructed form the dome of the diaphragm as 2.5 mm thick slices with 1mm spacing.
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Spectrum of pulmonary infections
Lobar Pneumonia |
Spread through pores of kohn and canals of lambert to entire lobe. Bronchi not affected therefore airbronchograms. No volume loss. Round pneumonia in kids. Most commonly d/t S. pneumoniae, K. pneumoniae, S. aureus, H. influenzae, fungal
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Spectrum of pulmonary infections
Bronchopneumonia |
Primarily affect the bronchi and adjacent alveoli, may have some volume loss, bronchial spread results in multifocal patchy opacities. Most commonly d/t S. aureus, gram -, H. inluenzae, mycoplasma
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Spectrum of pulmonary infections
Nodules |
Variable in size with indistinct margins. Most commonly d/t Fungal ( Histo, Apergillus, Crypto, Coccidio), Bacterial (legionella, nocardia), septic emboli (S aureus).
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Spectrum of pulmonary infections
Cavitary lesions |
Abscess: necrosis of lung parenchyma+/- bronchial communication, Fungus ball ( air crescent sign), Pneumatoceles. Commonly d/t Anarobes, fungus, TB
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Spectrum of pulmonary infections
Diffuse opacities |
Reticulonodular pattern: interstitial peribronchial areas of inflammation (viral). Alveolar location (PCP). Milliary pattern: hematogenous spread (TB).
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Complications of pneumonia
Parapneumonic effusion |
1. Exudation, free flowing
2. Fibropurulent: loculated 3. Organization, erosion into lung or chest wall |
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Complications of pneumonia
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Empyema
bronchopleura fistula bronchiectasis pulmonary fibrosis adenopathy |
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Nonclearance of pneumonia after appropiate treatment
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Antiobiotic resistance
other pathogen recurrent infection tumor |
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TB
Primary infection |
1. Consolidation- (1-7 cm), cavitation is rare, lower lobe 60%>upper lobes, lymphadenapathy in 95%, pleural effusion in 10%
2. Caseation- 2-10 weeks after infection 3. Calcification |
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TB
Secondary infection - Location |
Typically apical and posterior segments of upper lobes and superior segment of lower lobes, rarely in anterior segments of upper lobes (in contradistinction to histoplasmosis)
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TB
Secondary infection |
Patchy upper lobe opacites with frequent cavitation, can also have miliary pattern.
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Nontuberculous Mycobacterial infection
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Can be indistinguishable from TB.
Atypical features such as bronchiectasis and bronchial wall thickening are common. Nodules common in older women. |
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Nocardia
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Common opportunistic invader in lymphoma, steroid therapy, transplant patients, pulmonary alveolar proteinosis.
Focal consolidation, cavitation, irregular nodules. |
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Spectrum of infection
Viral pneumonia |
Acute interstitial pneumonia: diffuse or patchy interstitial pattern, thickening of bronchi, thickend interlobar septae
Lobular inflammatory rxn: multiple nodular opacities 5-6 mm (varicella) Hemorrhagic pulmonary edema: mimics bacterial pneumonia Pleural effusion: absent or small Chronic interstitial fibrosis: bronchiolitis obliterans |
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Spectrum of infection
Fungal pneumonia |
Acute phase: pneumonic type opacity ( may be segmental, nonsegmental, or patchy), miliary in immunocompormised pts.
Reparitive phase: nodular lesions +/- cavitations and crescent sign. Chronic phase: calcified lymph nodes or pumonary focus with fungus. Disseminated disease occurs in immunocompromised pts. |
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Types of Aspergillosis
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1. ABPA
2. Aspergilloma 3. Invasive 4. Semiinvasive |
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ABPA
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Hypersensitivity
bronchiectasis and mucus plugging |
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Aspergilloma
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Occur in preexisting cavity, saprophytic growth
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Invasive aspergilliosis
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Severly impaired immune status, vascular invasion, parencymal necrosis
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Seminvasive aspergillosis
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normal or impaired immune status with chronic local growth, local cavitary formation
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AIDS
The disease is characterized by: |
Lymphadenapathy
Opportunistic infections Tumors:lymphoma, KS Other: LIP, Spontaneous pneumonthorax (development of cystic spaces, interstitial fibrosis form PCP) |
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Spectrum of chest findings in AIDS
Nodules |
Kaposi sarcoma
Septic infarcts Fungal ( Crypto, Aspergillus) |
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Spectrum of chest findings in AIDS
Large opacity: consolidation, mass |
Hemorrhage
NHL Pnuemonia |
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Spectrum of findings in AIDS
Linear or interstitial opacties |
PCP
Atypical mycobacteria Kaposi sarcoma |
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Spectrum of findings in AIDS
Lymphadenapthy |
Mycobacterial infection
KS Lymphoma Reactive hyperplasia (rare in thorax) |
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Spectrum of findings in AIDS
Pleural effusion |
KS
Mycobacterial, fungal infxn Pyogenic empyema |
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PCP infection
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CXR: bilateral perihilar or diffuse interstitial pattern
HRCT: GGO predominately in upper lobe with cysts Progression to diffuse consolidation within days. Multiple upper lobe cysts or pneumatoceles cause pneumothorax or BP fistulas. Pleural effusions and lymphadenapathy is uncommon. |
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Charatacterize chest neoplasms by location
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1. Lung
2. Pleura 3. Mediastinal 4. Airway 5. Chest wall |
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Pulmonary neoplams
malignant |
1. Bronchogenic carcinoma
2. Lymphoma 3. Mets 4. Sarcomas (rare) |
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Pulmonary neoplasms -low grade malignancy
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1. Carcinoid (90%)
2. Adenoid cystic carcinoma (6%) 3. Mucoepidermoid carcinoma ( 3%) 4. Pleomorhpic carcinoma (1%) |
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Pulmonary neoplasms- benign
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1. Hamartoma
2. Papilloma 3. Leiomyoma 4. Hemangioma 5. Chemodectoma 6. Pulmonary blastoma 7. Chondroma 8. Multiple pulomary fibroleiomyomas 9. Pseudolymphoma |
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Bronchogenic carcinoma
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1. Adenocarcinoma (40%)
2. Squamous cell carcinoma (30%) 3. Small cell carcinoma ( 15%) 4. Large cell carcinoma (1%) 5. Adenosquamous carcinoma |
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Paraneoplastic syndromes
Metabolic MSK Other |
Metabolic: Cushings (ACTH), SIADH (ADH), Carcinoid (serotonin), Hypercalcemia (PTH, bone mets), Hypoglycemia (insulin like growth factor)
MSK: neuromyopathies, Clubbing (HPO) Other: Acanthosis nigricans, thrombophlebitis, anemia |
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Tumor Staging
T1, T2, T3, T4 |
T1: < 3 cm; limited to lung
T2: >3cm; >2 cm distal to carina T3: Tumor of any size with direct extension to: chest wall, superior sulcus, diaphragm, pleura, pericardium, within 2 cm of carina T4: Mediastinal organs, carinal, vertebral body, malignant pleural effusion |
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Tumor Staging
N0, N1, N2, N3 |
N0: No lymph nodes
N1: Ipsilateral hilar nodes N2: Ipsilateral mediastinal or subcarinal nodes N3: Contralateral hilar or mediastinal nodes; supraclavicular nodes |
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Tumor Staging
M0, M1 |
M0: No mets
M1: Mets |
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Lymph node anatomy
Thoracic society classification |
2R, 2L: paratracheal
4R, 4L: superior tracheobronchial 5, 6: ant. mediastinum 7: subcarinal 8,9: posterior mediastinum 10R, 10L: bronchopulmonary 11R, 11L: pulmonary 14: diaphragmatic |
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Lung tumors met to:
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Liver (common)
Adrenal glands (common) Other : brain, bone, kidney |
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Bronchoaveolar carcinoma
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Solitary nodule, Small nodules, chronic airspace disease
Airbronchogram Absent adenopathy Cavitation may be seen (Cheerio sign) |
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Squamous cell carcinoma
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Cavitary mass (30%)
peripheral nodule (30%) central obstructing lesion causing lobar collapse chest wall invasion |
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Pancoast tumor
Usually squamous cell ca |
Horner syndrome
Pain radiating to arm (invasion of pleura, bone, brachial plexus, or subclavian vessels) |
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Small cell carcinoma
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Most aggressive 80% mets at diagnosis
massive bilateral lymphadenapthy +/- lobar collapse brain mets |
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Large cell carcinoma
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Usually large mass (>70% are >4 cm at diagnosis)
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Carcinoid
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80% centrally located
segmental or lobar collapse common periodic exacerbation of atelecatasis endobronchial mass 20% peripheral may enhance with contrast |
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hamartoma
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well circumscribed
chondroid (popcorn) calcification fat is pathognomonic |
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Mets with lynphatic dissemination
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breast
stomach pancreas larynx cervix |
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Other mets with high propensity for lungs
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colon
melanoma sarcoma |
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mets with rich vascular supply draining into systemic venous system
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RCC
Sarcoma trophoblastic tumors testicle thyroid |
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Calicified lung mets
1. Bone tumors 2. Mucinous tumors |
1. Bone: Osteosarcoma, chondrosarcoma
2. Mucinous: Ovarian, thyroid, pancreas, colon, stomach 3. Mets after chemotherapy |
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Cannon ball mets
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1. Head and neck tumors
2. Testicular and ovarian cancer 3. Soft tissue tumors 4. Breast cancer 5. Renal cancer 6. Colon cancer |
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IPF
HRCT features |
peripheral, basal, subpleural reticulation and honeycombing +/- GGO
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NSIP
HRCT features |
bilateral, pathcy, subpleural GGO, +/- reticulation
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RB-ILD
HRCT features |
GGO, centrilobular nodules, +/- centrilobular emphysema
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AIP
HRCT features |
GGO, traction bronchiectasis and architectural distortion
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COP
HRCT features |
Subpleural and peribronchial consolidation +/- nodules in lower zones
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DIP
HRCT features |
GGO, lower zone, peripheral
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LIP
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GGO, +/- poorly deifned centrilobular nodules, thin walled cysts and air trapping may be found
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Sarcoid
Multisystemic involvement |
Lacrimal gland enlargement, chronic meningitis, choroido-retinitis, nasal mucosal lesions, salivary gland involvment, lymphadenapathy, pulmonary disease, hepatomeglay, splenomegaly, cor pulmonale, hypercalciuria, lacy bones, erythema nodosum
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Sarcoid
Stages |
O- Normal chest
1- Adenapathy (50%) - Garland triad 2. Adenapathy with pulmonary opacities (30%)- reticulonodular pattern, acinar pattern may coalesce to consolidation, large nodules >1 cm 3. Spulmonary opacities without hilar adenapathy (10%) 4. Pulmonary fibrosis, upper lobes with bullae |
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Sarcoid- CT features
Lung Lymphnodes Bronchi Endstage |
Lung- nodules (90%), along lymphatic distribution, linear pattern (50%), GGO (25%), subpleural thickening (25%), pseudoalveolar consolidation (15%)
Lymphnodes - Adenapathy (80%) Bronchi- Wall abn (65%), Luminal abn (25%), bronchiectasis (10%) Endstage - Upper lobe fibrosis, bullae, traction bronchectasis |
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Lymphoporliferative disorders
1. Nodal 2. Pulmoary parenchyma |
1. Nodal- Castlemans, infectious mononuclueosis, Angioimmunoblastic lymphadenapathy (drug hypersensitivity)
2. Pulmonary- Plasma cell granuloma, pseudolymphoma,LIP, lymphommtoid granulomatosis |
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Plasma cell granuloma
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solitary lung mass 1-12cm
no or very slow growth cavitation or calcification uncommon |
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Lymphangioleiomyomatosis
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young women with spontaneous pneumothorax, chylothorax, hempotysis, progressive dyspnea.
Numerous cystic spaces (90%), overinflation, irregular opacities |
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Collagen vascular diseases
overall |
Lower lungs more frequent
Vasculitides of large arteries Most common complication is infection ( immunosuppressed medications) |
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Rheumatoid arthritis
Radiographic findings |
Bibasilar patchy alveolar opacities are early findings, dense reticulnodular pattern is most frequent findings, pleural involvement 20%, Endstage is honeycombing and PAH
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Ankylosing Spondylitis
Radiographic findings |
Upperlobe fibrotic scarring, infiltration, cystic air space, ossification of spinal ligaments, sacroileitis, cardiomyopathy
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Systemic Lupus erythematosus
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Pleural thickening and recurrent effusions
Acute Lupus: vasculitis and hemorrhage resulting in focal opacities in bases, Alveolar opacities may progress to ARDS, Elevating diaphragm, atelectasis at bases |
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Progressive systemic sclerosis
with scleroderma with CREST |
Interstitial fibrosis
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Wagener's granulomatosis
radiographic findings |
multiple nodules with cavitations (common), interstitial, reticulnodular opacities at lung bases (early), diffuse opacities d/t atelectasis, confluent nodules and masses, pulmonary hemorrhage, supeimposed infection, pleural effsuion (25%)
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Lymphomatoid granulomatosis
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Multiple nodules are smaller than those in wegener's, not numerous, and tend to cavitate
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Churg-Strauss- Allegic angitis and granulomatosis
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similar to PAN, but have pulmonary disease and sthma. Affects skin, kidneys, lung, heart, CNS, and eosinphilia
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Langerhans cell histiocytosis
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Solitary bone lesion
Small cystic spaces in lung parenchyma 3-10mm poumonary nodules spares CPA's Apical reticulnodular pattern pneumothorax (30%) |
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Idiopathic pulmonary hemorrhage
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recurrent hemorrhage results in fibrosis
children <10 diffuse air space pattern (similar to goodpasture) hilar adenapathy |
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Amyloid
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Adenopathy and calcifications common
Plain film nonspecific, multiple nodules or diffuse linear pattern Pulmonary involvment can be either focal or diffuse requires biopsy |
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Neurofibromatosis
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Progressive pulmonary fibrosis
Bullae in upper lobes and chest wall chest wall and mediastinal neurofibromas intrathoracic meningoceles ribbon deformities of the ribs |
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Pulmonary alveolar microlithiasis
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Sandlike microcalcifications
bilateral symmetrica involvement pulmonary activity on bone scan |
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Alveolar proteinosis
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Bilateral batwing pattern, acinar pattern may be confluent, crazy paving on CT
Complications: nocardiosis, aspergillosis, cryptococcosis |
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Drug induced lung disease
Diffuse interstitial opacties |
cytotoxic agents: bleomycin, methotrexate, carmustine,cyclosphosphamide
gold salts |
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Drug induced lung disease
Pulmonary nodules |
cyclosporine
oil aspiration |
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Drug induced lung disease
Focal ASD |
amiodarone ( high iodine content)
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Drug induced lung disease
Diffuse ASD |
Cytotoxic agents
Tricyclic antidepressants salicylate penicilamine anticoagulents |
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Drug induced lung disease
Adenapathy |
Phenytoin
cytoctoxic agents |
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Drug induced lung disease
Pleural effusions |
drug induced SLE
bromocryptine Methysergide |
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Pneumoconiosis
Benign: radiographic abn are present while there are no symptoms |
tin: stannosis
barium: baritosis iron: siderosis |
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Pneumoconiosis
Fibrogenic: symptomatic |
silica: silicosis
asbestos: asbestosis coal workers pneumoconiosis (CWP) |
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Silicosis
mining, quarrying, sandblasting 20-40 years of exposure |
Nodules (1-10mm), calcific nodules, upper lobes>lower lobes, coalescnet nodules cause areas of conglomerate opacities
hilar adenapathy common (eggshell calc) Progressive massive fibrosis (usually pos segment of upper lobes, vertical oreintation, cavitation due to ishemia or superinfiection, bilateral, retract hila superiorly Main DDX-neoplasm, TB, fungus |
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CWP
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radiographical indistinguishable from silicosis
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Asbestos related pleural disease
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pleural plaques bilateral, posterlateral mid and lower chest
diffuse pleural thickening pleural calcifications (ddx hemothorax, TB, empyema, surgery) benign pleural effusions, sterile |
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Round atelectasis
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Round mass in lung periphery
Thickened pleura Mas is most dense at periphery Mass is never completely surronded by lung Atelectasis forms an acute angle with pleura comet tail tine volume loss, diplaced fissure |
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Asbestosis
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Reticular linear patterns, intially in a subpleural location, progression form bases to apices, honeycombing at later stages, no hilar adenapathy
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malignacy in asbestos
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7000 increase in mesothioloma
7x increase in bronchogenic ca 3x increase of GI neoplasm |
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Hypersensitivity pneumonitis
farmers lung, bird fancier lung, humidifier lung, bagossosis, malt workers lung, maple bark strippers lung, mushroom workers lung |
Diffuse GGO, reticulondular pattern which can progress to interstitial fibrosis with honeycombing and PAH
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Chronic beryliium disease
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reticulonodular pattern with progression to fibrosis, bilateral hilar node enlargment
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Pulmonary infiltrations with eosinphilia
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Loeffler's syndrome-benign transient idiopathic pulmonary opacities
Chronic eosinophilic pneumonia- severe chronic pneumonia predominantly peripheral opacities |
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Goodpastures syndrome
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pulmonary hemorrhage:consolidation with air bronchogram, clearing of hemorrhage in 1-2 weeks, repeated hemorrhage leads to hemosiderosis and fibrosis
renal findings |
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Tracheobronchial tumors
benign (10%) malignant (90%) |
1. Benign- papilloma, hamartoma, adenoma
2. Malignant- squamous cell carconoma, adenoid cystic carcinoma, mucoepdermoid, carcinoid, mets (local extension- thyroid, esophogeal, lung) (Hematogenous spread- melanoma, breast cancer) |
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Saber sheath trachea
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reduced coronal diameter (<50% of sagittal diameter). Only affects the intrathoracic trachea, 95% have COPD, tracheal ring calcification is common.
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Tracheopathia osteplastica
benign, rare condition |
foci of carticage and bone develop in the submucosa of the tracheobronchial tree. Sparing of the posterior membranous portion. narrowed lumen. distal 3/4 of the treachea and the proximal bronchi most commonly involved.
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Relapsing polychondritis
Need > 3 criteria 1. Recurrent chondritis of the auricles 2. Inflammation of ocular structures (conjuctivitis, scleritis, keratitis) 3. Chondritis (painful) of laryngeal/tracheal cartilage 4. Cochlear or vestibular damage |
Diffuse narrowing ( slitlike lumen) and thickening of the tracheal wall
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Tracheobronchomalacia
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Collapsed walls of trachea and bronchi, recurrent pneumonia
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Tracheobronchomegaly ( Mounier-Kuhn Disease)
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Atrophy and dysplasia of trachea and proximal bronchi. A/w Ehlers-Danlos.
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COPD- progressive obstruction to airflow.
1. Chronic bronchitis 2. Emphysema |
1. Chronic bronchitis- tubular shawdows with increased lung markings (dirty chest), accenutation of linear opacities throughout the lung
2. Emphysema- flattening of diaphragm, saber sheath trachea, increase retrosternal air space,decreased # of vessels in abnormal lung, |
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Emphysema
1. Panacinar 2. Centroacinar 3. Paraseptal |
1. Panacinar- lower lobes, homogenous distribution, alpha 1 antitrypsin deficiency, smoking
2. Centroacinar- upper lobes, patchy, chronic bronchitis, smoking 3. Paraseptal- Along septal lines, peripheral, smoking |
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Asthma
radiographic features |
airtrpping, hyperinflation, flattened diaphragms, increased retrosternal space, limited diaphragmatic excursion, bronchial wall thickening ( tramlines)
Complications: infection, mucous plugs, ABPA, obstruction, pneumonmediastinum, pneumothorax |
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Bronchiectasis
Congenital |
Abnormal secretions: cystic fibrosis
Bronchial cartilage defiency: Williams-campbell Abnormal mucociliary transport: kartageners Pulmonary sequestration |
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Bonchiectasis
Post infectious |
childhood infection
chronic granulomatous infection ABPA Measles |
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Broncheictasis
Bronchial obstruction |
neoplasm
Inflammatory nodes Foreign body Aspiration |
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Bronchiectasis
Radiographic findings |
Tramline: horizontal,// lines corresponding to thickened dilated bronchi, bronchial wall thickening, indistinctness of central vessels due to peribronchovascular inflammation, atelectasis
HRCT- signet ring, thicked bronchial walls |
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Cystic Fibrosis
Radiographic features |
Bronchiectasis, peribronchial thickening, mucous plugging, predominantly in upper lobes and superior segments of lower lobes, adenapathy, PAH, recurrent pneumonias
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Bronchiolitis obliterans
1. Obliterative 2. Proliferative |
1. obliterative - exposure to toxic fumes, bone marrow transplant, viral infxns, drugs
2. proliferative - acute infections, respiratory bronchiolitis, BOOP, COPD ( asthma, chronic bronchitis) |
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Bronchiolitis obliterans
radiographic features |
Nodules - tree in bud appearance
GGO with consolidation Mosiac pattern (obliterative) decreased size and number of vessels in affected lung bronchiectasis bronchial wall thickening |
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Pneumothorax
Iatrogenic trauma cystic lung disease parenchymal necrosis other |
Iatrogenic - Biopsy, barotrauma
Trauma - lung lac, trachebronchial rupture Cystic lung - bulla, blelb, emphysema, PCP, honeycombing, LAM, LCH Parenchymal necrosis - lung abscess, cavitary neoplasm, radiation necrosis Other- catemenial |
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Lung contusion
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contusions appear 6-24 hours after trauma and resolve by 7-10 days.
If does not resolve may represent post lac hematoma, aspiration, pneumonia, atelectasis, ARDS |
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Fat embolism
has high mortality rate |
Suspect when inititally clear lungs and sudden onset dyspnea in pt with fractures, interstitial and alveolar hemorrhagic edema has a varied appearance, opacities become evident only 48 hours after the incident, clear i 3-7 days
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Trachebronchial tear
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pneumothorax not relieved by chest tube placement R>L (75% occur within 2 cm of carina)
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Diaphragmatic tear
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90% occur on left side, airfluid level above diaphragm, elevation of hemidiaphragm, abnormal location of NG tube
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Esophegeal tear
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mediastinal widening, left pleural effusion, hydropneumothorax, pneumomediastinum, effusion wth low pH and high amylase levels
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Mediastinoscopy complications
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<2%
mediastinal bleeding, pnumothorax vocal cord paralysis ( recurrent nerve injury) |
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Bronchoscopy complications
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injury to teeth, transient pulmonary opacities (5%), fever, pneumothorax and hemorrhage if biospied
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Wedge resection complications
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air leak
contusion recurrence of tumor |
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Median sternotomy complications
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1-5%
mediastinal hemorrhage mediastinitis sternal dishiscence false aneuryms phrenic nerve paralysis Osteomyelitis of sternum |
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Chest tube placement complications
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Horner syndrome (pressure on sympathetic ganglion)
False aortic aneurysm |
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Pneumonectomy
radiographic features |
2/3 hemithorax fills with fluid in 4-7 days, gradual fill in of air bubble
gradual shift of mediastinum toward pneumonectomy side contralateral lung may be herniated across Complication: Bronchopleural fistula |
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Lobectomy
radiolgraphic features |
remaining lobes expand to fill the void, splaying of vessels
slight shift of mediastinum and elevation of hemidiaphragm |
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postpneumonectomy syndrome
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airway obstruction that occurs after pulmonary resections and is due to extreme shift of the mediastinum or rotation of hilar structures. Most commonly after R pneumonectomy.
Airway obstruction: air trapping, recurrent pneumonia and bronchiectasis. Narrowing of bronchi or trachea, bronchomalacia, hyperinflation of contralateral lung. |
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Bronchopleural fistula
Predisposition: active inflammations (TB), necrotizing infection, tumor in bronchial margin, devascularization of stump, preoperative irradiation, contamination of pleural space |
persistant of progressive pneumothorax, sudden shift of mediastinum to normal side
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Lobar torsion
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most commonly RML rotates on bronchovascular pedicle resulting in obstruction of venous flow, ischemia, necrosis
may look like mobile opacity at different locations on different views |
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cardiac herniation
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most often occurs following right pneumonectomy, heart rotated to right, intrapericarial air, presence of notch, intracardiac kinking of catheters, snow cone appearance of heart border
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Lung transplantation
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Pulmonary edema within 4-5 days d/t capillary leak, last 1-several weeks
Acute rejection- non specific findings - biopsy Chronic rejection- bronchiolitis obiterans, bronchiectasis Infections invovle transplanted lung airway leaks at anastomotic site |
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PAH
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Psys>30 mm Hg
P mean 25 mmHg Normal adult ( sys 20, dias 10, mean 14) |
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Precapillary causes of hypertension
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Vascular - increased flow (L-R shunts), chronic PE, vasculitis, drugs, idiopathic
Pulmonary- emphysema, intersitial fibrosis, fibrothorax, chest wall deformities, alveolar hypoventilation |
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Post capilliary causes of PAH
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Cardiac- LV failure, mitral stenosis, Atrial tumor,
Pulmonary venous- idiopathic venocclusive disease, thrombosis |
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PAH
radiographic features |
Enlarged main PA (>2.9 cm)
Rapid tapering of PA towards periphery, calc of PA (late finding), cardiomegaly (cor pulmonale), PA: aorta ratio> 1. HRCT - mosiac attenuation |
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Pulmonary edema
radiographic features |
heart size
blood flow, kerley lines, edema, air bronchograms, effusions |
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Pulmonary edema-causes in adults
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LV failure form CAD, mitral regurgitation, ruptured chordae, endocarditis
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Pulmoary edema cause in neonates
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TAPVC below diaphragm, hypoplastic left heart, cor triatriattum
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Pulmonary edema
renal and injury causes |
renal failure
volume overlod Septic shock, fat embolism, inhalation, aspiration, drowning |
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Grading of pulmonary edema
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I. 10-17 mm Hg Cephalizaiton
2. 18-25 mm Hg interstital edema, peribronchial cuffing, kerley lines 3. alveolar edema 25 mm hg |
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Polyarteritis Nodosa
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Necrotizing vasculitis
Renal, hepatic, and visceral aneurysm |
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Allergic granulomatous angiitis
Churg strauss |
granulomatous vasculitis
allergic history and eosinophila |
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Hypersensitivity vasculitis
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leukocytoclostic vasculitis
skin |
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takaysu's artertis
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giant cell arteritis
aortic arch |
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henoch schonlien purpura
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leukocytoclastic vasculitits
skin, gi, renal |
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temporal arteritis
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giant cell arteritis
carotid branches |
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wegener's granulomatosis
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necrotizing granulomatous vasculitis
upper and lower respiratoy tracts, glomerulonephritis |
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Pulmonary AVM
Congenital (60%) OWR Acquired ( 40%) |
Location: lower lobes 70%>ml>ul
feeding artery and drainin vein enhance strongly Complications: stroke 20%,abcess (10%), rupture ( hemothorax and hemoptysis 10%) |
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Pulmonary varix
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dilated vein near left atrium
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aortic nipple
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normal in 10% population
should measure less that 4 mm diameter |
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Pulmonary venoocclusive disease
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Edema without cephalization, pleural effsuions, cardiomegaly, 2 PAH, small central pulmonary veins, central and gravity dependent GGO, smoothly thickend interlobular septa, normal sized left atrium, centrilobular nodules
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visceral pleura
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covers lung
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parietal pleura
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covers rib, diaphragm, mediastinum
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Pneumothorax managment
Indications for intervention |
symptomatic pneumothorax
pneumothorax>20% enlarging pneumothorax on subsequent CXR tension pneumothorax poor lung function or contralteral lung disease |
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Pneumothorax intervention
technique |
1. 2-4 anterior intercostal space, midclavicular line or 6-8 intercostal space midaxialary line or posterior
2. Local anesthesia, skin nick 3. Place 8-12 French catheters using a trocar technque. For the anterior approach small heimlich valve sets may be used 4. After the lung is fully re-expanded for 24 hours, the catheter is place on water seal for 6 hours and then removed if there is no pneumothorax |
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Persistant pneumothorax in pateint with chest catheter
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peristent leak form airways
loculated pneumothorax anterior pneumothorax obstructed cathter |
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Empyema drainage
technique |
1. Choose entry site to largest collection using US or CT
2. Local anesthesia 3. Diagnostic tap with 18 guage need. Sent for bacteriologic testing 4. Choice of drainage catheters: 10-16 Fr pigtail for liquid effusions (trocar technique), 24 Fr for thicker collections (seldinger technque) 5. Catheter to suction 6. Intrapleural urokinase may be necessary for loculated effusions. 80,000 units of urokinase are administered in 150 ml of saline 3 times per day for 30 minutes for 3 days. |
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Pleural effusions
1. Transudate 2. Exudate |
1. Transudate- ultrafiltrate of plasma; highly fluid, low in protein, devoid of inflammatory cells
2. Exudate- increased permeability of microcirculation; rich in protein, cells and debris |
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Causes of pleural effusions
1. Tumor 2. Inflammation 3. Cardiovascular 4. Congenital 5. Metobolic 6. Trauma |
1. Tumor- bronchogenic ca, pleural mets, mesothelioma, lymphoma
2. Inflammation- pneumonia, TB, empyema, collagen vascular disease, abdominal disease (pancreatitis, subphrenic abscess, boerhaaves syndrome, meigs syndrome (benign ovarian fibroma)) 3. CV- CHF, PE, Renal failure 4. Congenital- hydrops 5. Metabolic- hypoproteinemia |
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Pleural effusions
how much on PA, Lateral and lateral decubs? |
PA- >175 ml to visualize in lateral CPA
Lateral >75 ml to visualize in pos CPA Lateral decub >25ml to see |
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Abcess vs empyema
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Abscess- caused necortizing pneumonia, shape round, sharp or irregular margins, thick walled, no split pleural, vessels and bronchi within, treat w/ abx, drainage
Empyema- abscess extends to pleural, elliptical along chest wall, sharp margins, thin wall, +split pleura sign, vessel and brochi are displaced, treat with drainage |
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Chylothorax
causes |
tumor (especially lymphoma)
trauma idiopathic LAM (rare) filiariasis (rare) |
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Fibrous tumor of pleura
benign 80% invasive locally 20% |
well delineated solitary pleural based mass, often lobulated, pedunculated (30%), mass may flop into different locations, invasion in invasive form, may have pleural effusion, necrosis
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malignant mesothelioma
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Pleural thickening with effusion (60%), hemithoracic contraction, pleural calcification (5%)
CT best to show full extent of chest wall and mediastinal and diaphragmatic involvement |
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Phenic nerve paralysis
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bronchogenic ca
neuropathies, post infectious, nutritional spinal cord injury, myelitis CNS injury, stroke cardiac surgery Erb's palsy (birth trauma) |
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Other causes of diaphragmatic paralysis
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muscular disorders- mystenia, polymyositis, muscular dystrophy,
idiopathic (70%) |
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Anterior mediastinal tumors
Thymoma |
Adults
30% invasive Associations- myasthenia gravis, aplastic anemia, hypogammaglobulinemia, red cell aplasia Homogenous soft tissue mass, contrast enhancement, some have cystic spaces, calcifications 20%,drop mets |
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Anterior mediastinal tumors
thymolipoma |
children and adults
contains fatty and soft tissue elements large and displaces mediastinal structures, may mimic liposarcoma |
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Anterior Mediastinal tumors
benign thymic hyperplasia |
Enlarged thymus without focal masses, fat interspersed in parenchyma
Normal 20 years old <13mm causes-maysthenia, thyrotoxicosis, SLE, CVD, Scleroderma, RA, chemotherapy, addison's disease, acromegaly |
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Anterior mediastinal tumors
thyroid masses |
goiter
adenoma carcinoma |
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Anterior mediastinal tumors
Germ cell tumors |
"SECTE"
Seminoma Embryonal cell ca Choriocarcinoma Teratoma (70%) endodermal sinus tumor ( yolk sac ) |
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Anterior mediastinal tumors
tertoma |
20% malignant
variable content (calc 30%, fat, fat-fluid levels, cystic areas, soft tissue) |
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Anterior mediastinal tumors
Hodgkin's lymphoma |
Reed sternberg cell
bimodal age 30 and 70 years old Sup medastinal nodal involvement 95% contiguous progression from one lymph node group to next lung involvement 15% pleural effusions 15% |
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Lymphoma pearls
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Recurrence-outside of treatment field (paracardiac)
5% treated Hodgkins develope aggressive leukemias radiation pneumonitis occurs 6-8 weeks after completion of the radiation and evolves to mature fibrosis by 1 year |
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Non hodgkins lymphoma
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60% orginate in lymph nodes
40% in extranodal sites increased in transplant pts, AIDS, congenital immunodeficiency, CVD |
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Middle mediastinum tumors
bronchopulmonary foregut cysts |
round mass of water/protein density
Bronchogenic -mediastinal 75%, pulmonary 25% Esophgeal duplication are along the esophagus |
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Castleman's disease
(Giant benign lymphnode hyperplasia) |
Bulky mediastinal mass lesion (3-12cm) ant>mid>pos
dense homgenous enhancement nodal calcification may be present involvment of neck, axilla, pelvic nodes rare. |
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Fibrosing mediastinitis
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Histo, idiopathic
may result in obstruction of pulmonary arteries, veins, bronchi. calcified nodes |
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Posterior mediastinal tumors
Neural tumors |
Peripheral nerve- schwannoma, neurofibroma
Sympathetic ganglion- ganglioneuroma, ganglioneuroblastoma, neuroblastoma paraganglion cells- paraganglioma |
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Posterior mediastinal tumors
Para vertebral masses |
extramedullary hematopoiessis- bilateral pos. massses, cortical bone changes by CT, anemia, marked contrast enhancment
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Universal DDX
TIC MTV |
tumor
inflammation/ infection congenital metabolic trauma/iatrogenic vascular |
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RUL collapse
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Elevation of minor fissure
shift of trachea to right elevation of righ hilum thickening of right paratracheal stripe |
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RML collapse
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Best seen on lordotic views
rml syndrome, recurrent atelectasis despite an open orifice: absent collateral circulation, bronchus surrounded by enlarge lymph nodes, bronchiectasis |
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RLL collapse
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triangular opacity in right retrocardiac region on PA film with obliteration of diaphragm
posterior displacement of right margin opacity over spine |
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LUL collapse
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difficult to see, haze density easily confused with loculated effusion
luftsichel sign anterior displacement of major fissure on lateral view |
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LLL collapse
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left retrocardiac triangular opacity on PA
Posterior displacement of major fissure on lat view |
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Relaxation atelectasis
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pleural effusion, pneumorthorax, bullous disease
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Resorptive atelectasis
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secondary to obstruction
platelike, discoid atelectasis |
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adhesive atelectasis
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depletion of surfactant, ARDS, radiation injury
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Causes of consolidation
WATER blood pus protein cells |
Water- cardiac pulmonary edema, renal pulmonary edema, lung injury, pulmonary edema
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Consolidation
water BLOOD pus protein cells |
Trauma
bleeding disorder Type II antigen antibody reaction Good pastures Henoch-scholein purpura Infarct vasculitis |
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consolidation
water blood PUS protein cells |
Infection
Inflammatory- Hypersensitivity pneumonitis, eosinophilia, COP, Aspiration, Sarcoid |
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Consolidation
water blood pus protein CELLS |
bronchogenic carcinoma
lymphoma |
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Consolidation
water blood pus Protein cells |
Alveolar protienosis
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Pulmonary renal syndromes
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Goodpastures
wegeners SLE Henoch schonlein purpur PAN penicilliamine hypersensitivity |
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ARDS
causes |
Massive pneumonia
Trauma Shock Sepsis Pancreatitis Drug overdose Near drowning Aspiration |
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Chronic Airspace disease
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Tumors- BAC, lymphoma
Inflammation- TB, fungus, eosinophilic pneumonia, pneumonitis, COP, Alveolar sarcoid Other- Alveolar proteinosis, hemorrhage, lipoid pneumonia, chronic aspiration |
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Solitary pulmonary nodule
DDX |
Tumor- Primary CA, hamartoma, met
Inflammation- Histo, TB, cocciciomycossis Other- AVF, varix, infarct Congenital- sequestration, bronchial cyst Misc- round pneumonia, locuated effusion, mucous plug, subpleural lymph node |
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Multiple pulmonary nodules
DDX |
Mets
Abscess- pyogenic (s aureus, histo) immunocompromised (Nocardia, legionella) Granulomatous- TB, Aspergillus, Histo, sarcoid, rheumatoid, wegeners, necrotizing granulomatous vasculitis, histiocytosis |
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Milliary pattern
DDX |
Infection- TB, Histo
Tumor- thyroid, melanoma, breast, choriocarcinoma, BAC, LCH Silicosis Sarcoid |
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Calcified lung nodules
Larger (>1cm) DDX |
Tumor- medullary thyroid ca, mucinous or osteogenic mets
Infection- varicella, histo, coccidio, tb, shistosomiasis Other- silicosis |
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Calcified lung nodules
Very small (0.1-1mm sandlike) DDX |
Alveolar microlithiasis
Chronic pulmonary venous hypertension "metastatic" calcification from severe renal disease |
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Large (>6cm) thoracic mass
DDX |
Pulmonary- tumor (bronchogenic ca, met), abscee, round atelectasis, intrapulmonary sequestration, hydatid disease
Extrapulmonary- Fibrous tumor of the pleura, loculated effusion, torsed oulmonary lobe, chest wall tumor (Askin tumor), AAA, mediastinal masses |
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Cysts
Parenchyma-lined space, filled with air or fluid. DDX |
Pneumatocele (posttraumatic/infxn)
Bulla/bleb Cystic bronciectasis Congenital cyst(intrapulmonary bronchogenic cyst, CCAM, sequestration) Hydatid cyst (oinion skin appearance) |
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Cavity
Parenchymal necrosis due to inflammation or tumor DDX |
Abscess (Pyogenic Staph>Klebsiella> strept)(immunocompromised Nocardia, legionella)
Cavitated tumor( Squamous cell ca, sarcoma, lymphoma, TCC) Cavitated granulomatous- Fungus (aspergillus, coccidio), TB, Sarcoid, Wegeners, rheumatoid, necrotizing granulomatous vasculitis Cavitated posttraumatic hematoma |
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Air Crescent Sign in Cavity
DDX |
Aspergillosis
Mucormycosis Actinomycosis Septic emboli Klebsiella TB Tumors |
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Small Cystic Disease
DDX |
True cyst- LCH, LAM, cystic form of PCP, honeycombing form any endstage interstitial disease
No cyst wall- emphysema |
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Radiographic patterns interstitial dz
Linear/reticular: Reticulonodular: Nodular: GGO: Honeycombing: |
Linear/reticular: thickened interlobular septa, fibrosis
Reticulonodular: inflammation in peribronchovascular interstitioum Nodular: granulomas GGO: usually acute interstitial disease Honeycombing: end stage lung disease |
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General approach to interstitial disease: d/t thickening of interlobular septa, alveolar walss, and interstitium.
Fluid Inflammation Tumor |
Fluid: edema, venous obstruction, proteinaceous material
Inflammation: infection(viral, granulomatous, PCP) idiopathic(IPF, sarcoid), CVD, extrensic agents (pneumoconiosis, drugs) Tumor: LCH, Lymphangitic spread, desmoplastic rxn) |
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Upper lobe distribution
"CASSET P" |
Cystic fibrosis
Ankylosing spondylitis Silicosis Sarcoid Eosinophilic granuloma (spares CPA) TB PCP |
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Lower lobe distribution
"BADAS" |
Bronchiectasis
Aspiration Drugs,DIP Asbestosis Scerloderma and other CVD |
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Acute process
"HELP" |
Hypersenitivity
Edema Lymphoproliferative Pneumonitis (viral) |
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Chronic Process
"LIFE" |
Lymphangitic spread
Inflammation/Infection Fibrosis Edema |
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Increased lung volumes
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Cystic fibrosis
Eosinophilic granuloma LAM |
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Decreased lung volumes
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IPF
Scleroderma |
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Pleural disease
Plaques: Effusion: |
Plaques: Asbestosis
Effusion: CHF, lymphangitic carcinomatosis, RA |
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Lymph nodes
Enlarged: Calcified: |
Enlarged: Malignant adenopathy, TB, fungus, sarcoid
Calcified: silicosis |
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GGO
DDX |
Allergic hypersensitivity
Acute interstitial disease (DIP, IPF, VIRAL) PCP BOOP Eosinophilic pneumonia Pulmonary edema |
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Reticulonodular opacities
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Pulmonary edema
Viral, mycoplasma, PCP Lymphangitic spread Pulmonary fibrosis (IPF, secondary fibrosis) Asbestosis |
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Nodular Opacities
DDX |
Hematogenous infection
Hematogenous mets Sarcoid Pneumoconiosis LCH |
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Cystic spaces
DDX |
LAM
Cystic PCP LCH Honeycombing |
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Crazy Paving on HRCT
DDX |
Pulmonary alveolar proteinosis
ARDS PCP Lipoid pneumonia |
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Halo pattern of GGO
DDX |
Early invasive aspergillosis in leukemic
Hemorrhage around tumor Post biopsy pseudonodule |
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Peripheral GGO and consolidation
DDX |
BOOP
Infarcts Septic emboli CVD Contusion DIP Drug toxicity Eosinophilic pneumonia Fibrosis Sarcoidosis |
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Honeycombing on HRCT
DDX |
UIP
Scleroderma/RA Asbestosis Chronic Hypersensitivty pneumonitis Sarcoidosis Silicosis LCH Drug toxicity:bleomycin |
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Diseases spread alon bronchovascular bundle
DDX |
Sarcoidosis
Lymphoma Lymphangitic spread of tumor TB Kaposi's sarcoma |
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Tree in bud appearance
DDX |
Infection: TB, bronchopneumonia, fungal, asian panbronchiolitis, viral pnumonia
Bronchial: bronchiolitis Congenital: cystic fibrosis, dyskinetic cilia syndrome Other: ABPA, lymphangitic ca, LCH |
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Hyperlucent Lung
DDX |
Airways: Obstruction (emphysema, asthma, mucous plug), small airway obliteration (swyer james, bronchiolitis obliterans)
Cysts Congenital: hypogenetic lung syndrome, CLE Vascular: PE, pulmonary artery stenosis Chest wall abn: mastectomy, Poland's syndrome Pleural: pneumothorax |
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Small lung
DDX |
Hypogenetic lung syndrome
Agenesis of pulmonary artery Chronic atelectasis Bronchiolitis obliterans |
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Endobronchial lesions, focal
DDX |
Tumors: Squamous cell ca, adenoidcystic ca, mucoepidermoid ca, small cell ca, carcinoid
Mets: RCC, melanoma, colon, breast, thyroid Other: hamartoma, hemangioma Inflammatory: TB Other: mucous plug, foreign body, trauma, broncholith |
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Diffuse tracheal abn, increased diameter of lumen
DDX |
Tracheobronchomegaly (Mounier-Kuhn)
Pulmonary fibrosis Tracheomalacia |
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Diffuse tracheal abn, decreased diameter of lumen
DDX |
Saber sheath trachea
Tracheopathia osteochondroplastica Tracheomalacia Relapsing polycondritis Amyloidosis Sarcoidosis Wegener's disease Tuberculous and fungal stenosis |
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Bronchiectasis
DDX |
Post infx: Any childhood infxn, recurrent aspiration, ABPA, Chronic granulomatous infxn
Bronchial obstruction: Neoplasm, foreign body Congenital: Cystic fibrosis, bronchial cartilage deficiency (Williams Campbell), abnormal mucociliary transport (kartagener's) |
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Upper lobe bronchiectasis
DDX |
Cystic fibrosis
TB Radiation ABPA |
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Mucoid impaction
DDX |
Asthma
Cystic fibrosis ABPA Congenital bronchial atresia |
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Pleural based mass
DDX |
Tumor: mesothelioma, fibrous tumor of the pleura, malignant thymoma, lymphoma, mets (breast, lung, prostate, thyroid, renal), lipoma,
Extrapleural tumors: infectious (TB), asbestos related, actinomycosis, trauma, surgery, chest tubes |
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Calcified pleural plaques
DDX |
TB
Asbestos related plaques Fluid (empyema, hematoma) Talc |
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Elevated hemidiaphragm
DDX |
Nerve paralysis: tumor, surgery, Erb's paralysis
Pain: rib fx, pleuritis, pneumonia, PE Mass lesions: Abdominal mass, subphrenic collection, diaphragmatic hernia, pleural tumor, subpulmonic effusion |
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Anterior mediastinal masses
DDX |
Thymic masses
Germ cell tumors Lymphadenapathy Aneurysm and vascular abn Thyroid |
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Thymic masses
DDX |
Thymic cyst
Thymolipoma Thymoma Thymic carcinoma Thymic carcinoid Thymic lymphoma |
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Germ cell tumors, anteior mediastinum
DDX |
Seminoma
Embryonal cell carcinoma Choriocarcinoma Teratoma |
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Cystic anterior mediastinal mass
DDX |
Thymic cyst
Cystic thymoma Teratoma Bronchogenic cyst (usually middle) Pericardial cyst |
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Superior mediastinal mass
DDX |
Descending through inlet: Thyroid, adenopathy, lymphatic cysts, cystic hygroma
Ascending through inlet: small cell ca Lymphoma Aneurysm and vascular anomalies |
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Middle mediastinum mass
DDX |
Adenopathy: sarcoid, TB, fungal, beryllium exposure, mets, lymphoma, leukemia
Congenital cysts: bronchogenic cysts, pericardial cyst Aneurysm: aorta and branches, pulmonary artery Esophagus: Hiatal hernia, neoplasm, diverticula, megaesophagus (achalasia, HH, colonic interposition) Other: Mediastinal hemorrhage, mediastinal lipomatosis, CA, aberant RSA with diverticulum, varices, neurinoma from recurrent laryngela nerve, tracheal malignancy, pancreatic pseudocyst |
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Low attenuation lymphnodes
DDX |
TB and fungal infxn in AIDS (ring enhancement)
Necrotic mets lymphoma (occasionally) |
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Vascularized lymph nodes
DDX |
Castlman's disease
Vascular mets (RCC, thyroid, small cell, melanoma) |
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Calcified lymph nodes
DDX |
TB
Fungal Histo Sarcoidosis Silicosis Radiation therapy |
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Posterior mediastinal mass
DDX |
Neurogenic:schwannoma, neurofibroma, ganglioneuroma, neuroblstoma, pheochromocytoma, paraganglioma meningomyelocele
Thoracic spine: neoplasm, hematoma, hematopoiesis, discitis Vascular: aneurysm, azygous continuation of IVC |
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CPA mass
DDX |
Fat pad
Diaphragmatic hernia pericardial cyst Cardiophrenic lymph nodes Aneurysm Dilated right atrium Anterior mediastinal mass Primary lung or pleural mass |
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Fatty Mediastinal Lesion
DDX |
Mediastinal lipomatosis
Morgagni hernia with omentum Bochdleck hernia with omentum Periespohageal fat herniation Liopma Liposarcoma Thymlipoma Germ cell tumor |
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High density mediastinal lesions
DDX |
Calcified lymph nodes
Calcified primary mass (tumor, goiter, aneurym), hemorrhage |
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Densely enchancing mediastinal mass
DDX |
aneurysm
Vascular abn Esophageal varices Hypervascular tumors (paraganglioma, mets) Goiter Castleman's disease |
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Prominent Hila
DDX |
Tumor: central bronchogenic ca, lymphoma
Adenopathy: infectious (TB, Fungi, histo) inflammatory (sarcoid, silicosis) Tumor ( oat cell, lymphoma, mets Pulmonary artery enlargement |
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Eggshell calcifications in hilar nodes
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Silicosis
Treated lymphoma Granulomatous disease Sarcoid |
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Pneumomediastinum
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Pulmonary:asthma, barotrauma, childbirthk pneumothorax
Mediastinum:tracheo bronchial lac, esophogeal perf, mediastinal surgery, boerhaave's Abdomen: intra/retroperitoneal bowel perf, abd surgery Head and neck: esophageal rupture, facial fx, dental or retropharyngela infection, mediastinitis |
