Resp 01: Radiologic Anatomy Of Thorax

Front 1

What are the components of the upper airway?

Back 1

- Sinuses
- Nasopharynx
- Oropharynx
- Proximal trachea

(connected to upper airway via eustacian tube:)
- Middle ear
- Mastoids / Temporal bone

Front 2

What are the most commonly imaged structures of the upper airway?

Back 2

- Sinuses (most common)
- Temporal bone

Front 3

Why would you image the sinuses?

Back 3

- Chronic sinusitis and complications
- Acute sinusitis
- Post-operative
- Tumors
- Trauma

Front 4

Why would you image the temporal bone?

Back 4

To look at middle ear and mastoids/temporal bone:
- Hearing loss
- Trauma
- Infection

Front 5

What imaging modalities do you use to image the sinuses?

Back 5

- CT (L=axials w/ reformatted images, R=direct coronals)
- Radiographs (less commonly used)

Front 6

Case: 22 yo male presents to clinic w/ mild cough for 3 days. Vital signs are normal and patient is afebrile. What, if any, imaging tests should be ordered?

Back 6

None - not every patient needs imaging

Front 7

What sinuses can be viewed in this axial section?

Back 7

- Maxillary sinuses (at top of image)
- Sphenoid sinuses (posterior / below maxillary sinuses in image)

Front 8

What is the gray structure that is found within the Sphenoid Sinuses?

Back 8

Mucosal thickening (common in fall)

Front 9

What sinuses can be viewed in this coronal section?

Back 9

- Ethmoid Sinuses (in between orbits)
- Maxillary Sinuses (below orbits)

Front 10

What can be seen at the bottom of the maxillary sinuses?

Back 10

Mucosal thickening and fluid which suggests acute sinusitis (not diagnostic, but in correct clinical setting, it can suggest acute sinusitis)

Front 11

What sinuses can be viewed in this axial section?

Back 11

Frontal Sinuses

Front 12

What sinuses can be viewed in this coronal section?

Back 12

- Frontal Sinuses
- Maxillary Sinuses

Front 13

What is interesting about the frontal sinuses?

Back 13

Not everyone has frontal sinuses, some have only one, and some have enlarged frontal sinuses

Front 14

What can be seen in this CT?

Back 14

Acute Sinusitis (probably did not require imaging and could have been treated based on clinical grounds)

- Really thick mucosal thickening on L maxillary sinus
- Small mucosal thickening in R maxillary sinus with an air bubble trapped in the secretions

Front 15

What can be seen in this CT?

Back 15

Nasal Polyposis
- Tumor involving nasal cavity, normally they are air filled
- Here they are filled with soft tissues, patient can't breath through their nose

Front 16

Why would you get a CT of the temporal bones?

Back 16

- Not to diagnose an ear infection
- Only if you are worried about their being a complication (fever doesn't go away, pain out of proportion, or worried about involvement of cranial structures)

Front 17

What is a potential complication of untreated otitis media?

Back 17

Mastoiditis (infxn of mastoid air cells)

Front 18

What is a potential complication of untreated otitis externa?

Back 18

Osteomyelitis

Front 19

What can be seen in this image?

Back 19

Tympanic membrane

Front 20

What can be seen in this image?

Back 20

Stapes on Oval Window

Front 21

Under what circumstances is imaging of the trachea not indicated?

Back 21

Unusual to image for infections;
- Trachiitis
- Bronchitis

Front 22

Under what circumstances is imaging of the trachea indicated?

Back 22

- Epiglottitis
- Tracheal papillmoatosis
- Croup

Front 23

What can be seen in this image?

Back 23

Croup = Steeple Sign on lateral X-ray
- Kids have "barking cough"

Front 24

What can be seen in this image?

Back 24

Bacterial Trachiitis
- Trachea is narrowed
- Lots of tissue thickening
- Material in trachea indicates sloughed membranes d/t infection
- Needs to be aggressively treated d/t risk of compromised airways

Front 25

What can be seen in this image?

Back 25

Epiglottitis:
- Inflammation of the epiglottis
- Looks like thumb print instead of a thin structure
- Not seen very commonly anymore d/t Haemophilus vaccine
- Emergency situation and may require tracheotomy to breathe

Front 26

What can you see on coronal view of the trachea?

Back 26

A = clavicle
B = thyroid gland
Tracheal rings
L & R bronchi

Front 27

What can happen if the thyroid gland enlarges?

Back 27

Can impinge on the trachea

Front 28

When do you commonly do imaging of the trachea?

Back 28

After endotracheal tube

Front 29

Which bronchus is the endotracheal tube more likely to extend into? Why?

Back 29

- R bronchus because it extends almost straight down
- L bronchus makes more of an angle
- 10:1 ratio of R to L

Front 30

What's the difference between these two images?

Back 30

Same image but L focuses on soft tissue and R focuses on lung tissue

Front 31

What can you see in the lungs of the R image?

Back 31

Black spots = cystic areas = COPD

Front 32

L image shows inspiration and R image shows expiration, what is happening?

Back 32

- L image: trachea is wide open
- R image: trachea is closed because it can't maintain its rigid shape (tracheomalacia); leads to wheezing and inability to clear secretions, may lead to pneumonia

Front 33

What happens in Tracheomalacia?

Back 33

Flaccidity of the tracheal support cartilage which leads to tracheal collapse especially when increased airflow is demanded
(R image - trachea closes during expiration)

Front 34

What is virtual bronchoscopy? What is it used for?

Back 34

Imaging tool that lets you "fly through bronchi" on computer to find nodules or other pathology on trachea so that surgeon can know where to remove the abnormal structures

Front 35

What do you need to consider when reading a chest x-ray?

Back 35

1. View (what view is this, what view do I need?)
2. Technical aspect / considerations (what is the quality of this image? how does patient's weight affect viewing?)
3. Pattern (use patterned search so you don't miss anything)
4. Projectional anatomy (looking at 2D image of 3D structures)
5. Important signs to identify and further characterize lesion

Front 36

What are the types of views that can be done for a chest x-ray?

Back 36

- PA (posterior to anterior), lateral
- AP (anterior to posterior), upright
- AP, supine
- Decubitus
- Oblique views
- Lordotic

Front 37

What is the most common, best quality view for a chest x-ray?

Back 37

PA, lateral (posterior to anterior)

Front 38

What view for a chest x-ray should you do if the clavicle is in the way?

Back 38

Lordotic - have patient lean shoulders back

Front 39

What is the pattern to use for evaluating a chest x-ray?

Back 39

1. Mediastinum (look for abnormal contours)
2. Hilum (look at pulmonary a/v, lymphadenopathy)
3. Lung parenchyma (look at each lung individually in L to R, up to down pattern; then look at both lungs simultaneously same way to compare)
4. If there is a nodule determine if it is in rib or lung, and if lung what lobe - may need to use another view to triangulate)
5. Look for pleural effusion
6. Look at bones

Front 40

What normal structures can sometimes appear as a nodule in lung?

Back 40

- Nipple shadow
- Old healed fractured rib

Front 41

What lobes are on the right side? What is their relationship to one another?

Back 41

- Right Upper Lobe, Right Middle Lobe, and Right Lower Lobe
- RML and RLL overlap

Front 42

What lobes are on the left side? What is their relationship to one another?

Back 42

- Left Upper Lobe (w/ lingula) and Left Lower Lobe
- They overlap a lot

Front 43

What are the implications of the lobes overlapping?

Back 43

- You may not be able to tell which lobe has the abnormality
- Will need a lateral view to determine whether it is middle or lower lobe

Front 44

What kind of imaging tests are used for cross-sectional imaging of chest?

Back 44

- CT
- MRI (but not used very often in evaluation of pulmonary infections)

Front 45

Why are MRIs not used very often for cross-sectional imaging of the chest?

Back 45

- Cannot image lung parenchyma well
- Motion artifacts

Front 46

How can chest imaging be useful for pulmonary infections?

Back 46

Often the pattern of disease can be described

Front 47

What is a round pneumonia (round infiltrates) indicative of?

Back 47

Almost always Streptococcus pneumonia causing pulmonary infection

Front 48

What is chest wall invasion by pulmonary infection indicative of?

Back 48

Classically, Actinomyces (but could be another bacteria)

Front 49

What is the diagnosis of this chest x-ray? What clues?

Back 49

Bronchopneumonia
- Patient w/ cough and low grade fever for four days
- Area of increased density in R lower lung base
- Slightly asymmetric
- Lung apices are nice and dark

Front 50

What is the diagnosis of this chest CT? What clues?

Back 50

Bronchopneumonia (usually don't require CT)
- "Tree in bud" opacification
- Appearance of trees in spring when they first get their buds

Front 51

What helpful signs should you look for in pneumonia?

Back 51

Silhouette sign:
- R cardiac border: RML infiltrate
- R diaphragm border: RLL infiltrate
- L cardiac border: Lingual infiltrate

Air bronchogram sign: pneumonia

Front 52

What is the diagnosis of this chest x-ray? What clues?

Back 52

Lobar Pneumonia in RUL
- Minor fissure is elevated
- RUL is full of pus and has collapsed
- Can't see mediastinum on R side because of a soft tissue-soft tissue interface
- Linear lucencies in RUL = air bronchograms (patent air waves)

Front 53

What is the diagnosis of this chest x-ray? What clues?

Back 53

Multifocal Infiltrate Pneumonia
- Have infiltrates in: R perihilar region, RML, and lingua
- Lung apices are okay, no pleural effusion (need to look for that w/ pneumonia)

Front 54

What is the diagnosis of this chest x-ray? What clues?

Back 54

RML infiltrate pneumonia (loss of cardiac border on R side, the RML is adjacent to R heart border)

Front 55

What is the diagnosis of this chest x-ray / CT? What clues?

Back 55

Lobar Consolidation Pneumonia of RML
- Infiltrate goes up to fissure (no communication between lobes)
- Silhouettes out R heart border
- Confirmed location based on CT

Front 56

What is the diagnosis of this chest CT? What clues?

Back 56

Patent bronchi in an area of collapsed and consolidated lung (RML)

Front 57

What is the diagnosis of this chest x-ray? What clues?

Back 57

Miliary TB:
- Innumerable small nodules

Front 58

What is the diagnosis of this chest CT? What clues?

Back 58

Miliary TB:
- Innumerable small nodules
- TB loves the upper lobes especially

Front 59

What is the diagnosis of this chest CT? What clues?

Back 59

Histoplasmosis:
- Calcified nodules in lung parenchyma
- From indolent infection from being in outdoors (very common)

Front 60

This patient was treated with antibiotics, but still has this notable infiltrate on chest x-ray and CT. What is the diagnosis?

Back 60

Blastomycosis - nothing specific for it, but because it wasn't relieved by antibiotics, this is more likely

Front 61

What is the diagnosis of this chest CT? What clues?

Back 61

Aspirgillosis infection - mass is an Aspirgilloma
- If you moved the patient around and re-imaged them the Aspirgilloma would move around whereas a tumor would not

Front 62

How do you tell the difference between Aspergilloma and Squamous Cell Carcinoma?

Back 62

- Aspergilloma will move around in lung cavity as patient moves, so different positions for imaging will show movement
- Squamous Cell Carcinoma will stay in one place
- Need ultimate diagnosis w/ bronchoscopy

Front 63

What are the four clinical scenarios of getting an Aspergillus infection?

Back 63

- Severely immunosuppressed (invasive Aspergillus)
- Immunosuppressed (semi-invasive Aspergillus)
- Normal immunity but w/ abnormal lungs (Aspergilloma)
- Hyper-immune (ABPA - allergic bronchopulmonary Asperigillosis

Front 64

What is the diagnosis of this chest CT? What clues?

Back 64

Invasive Aspergillosis
- Nodules throughout entire chest
- Ill defined nodular densities
- More common in severely immunosuppressed

Front 65

46-yo male w/ AIDS. Presents w/ low grade fever and cough. Hypoxic. Chest radiograph shows minimal patchy densities.

Next test?

Back 65

CT - because immunosuppressed need to start treating immediately

Front 66

What is the diagnosis of this chest CT? What clues?

Back 66

PCP (Pneumocystis Pneumonia)

Front 67

What are the findings for viral lung disease?

Back 67

Wide spectrum of non-specific findings:
- Normal
- Patchy infiltrates
- Diffuse, severe infiltrates

Front 68

What is worrisome about a viral lung disease?

Back 68

Risk for superimposed bacterial pneumonia

Front 69

What is the diagnosis of this chest x-ray? What clues?

Back 69

Varicella Pneumonia:
- Calcified nodules are sequelae of varicella pneumonia
- Get these nodules after the varicella pneumonia is treated/healed
- Looks similar to Histoplasmosis, but in Histo usually there are not as many of these nodules and you also can get hilar node calcifications

Front 70

What is the diagnosis of this chest x-ray? What clues?

Back 70

Acute Respiratory Distress Syndrome
- Overwhelming pneumonia that wasn't treated soon enough
- Extensive, diffuse infiltrates on both sides
- Air bronchograms
- Pleural effusion

Front 71

What is the cheapest way to determine if a pleural effusion is loculated or free flowing?

Back 71

Decubitus Radiograph - have patient lay on side to see if the fluid moves

Front 72

What is the diagnosis of this chest x-ray? What clues?

Back 72

Bilateral Pleural Effusions

Front 73

What is the diagnosis of this chest x-ray? What clues?

Back 73

Large R Pleural Effusion

Front 74

What is the diagnosis of this chest CT? What clues?

Back 74

R pleural effusion