chest x-ray made easy aypee...

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rsChest X-rayMade Easy®

Jayp

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rsChest X-rayMade Easy®

SECOND EDITION

D Karthikeyan DMRD DNBSenior Consultant RadiologistChennai, Tamil Nadu, India

Deepa Chegu MBBS DMRD Consultant Radiologist

Chennai, Tamil Nadu, India

New Delhi | London | Panama

The Health Sciences Publisher

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rsHeadquarters

Jaypee Brothers Medical Publishers (P) Ltd4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314Email: [email protected]

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© 2017, Jaypee Brothers Medical Publishers

The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or reg-istered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each prod-uct to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or dam-age to persons or property arising from or related to use of material in this book.This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.Every effort has been made where necessary to contact holders of copyright to obtain permission to repro-duce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.

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Chest X-ray Made Easy®

First Edition: 2007

Second Edition: 2017ISBN: 978-93-5025-563-6

Printed at

Jaypee Brothers Medical Publishers (P) Ltd

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rsPREFACE TO THE SECOND EDITION

Traditionally, plain X-rays provide the earliest opportunity in many instances for diagnosing various pathologies of the chest providing a cost-effective rapid screening tool. In this era of modern cross-sectional imaging, plain radiograph is often undervalued, and the most significant limitation of the chest X-ray seems to be the lack of interest and experience among the students. This book tries to present an easy-to-use practical approach to chest X-rays and we have included a short Chapter on correlation with high-resolution computed tomography (HRCT) lungs for a better perception of the anatomy. We hope that we can rekindle the interests among medical students and various postgraduates to this simple but powerful diagnostic tool.

D Karthikeyan Deepa Chegu

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rsTraditionally, plain X-rays provide the earliest opportunity in many instances for diagnosing various pathologies of the chest providing a cost-effective rapid screening tool. In this era of modern cross-sectional imaging, plain radiograph is often undervalued, and the most significant limitation of the chest X-ray seems to be the lack of interest and experience among the students. This book tries to present an easy-to-use practical approach to chest X-ray. We hope that we can rekindle the interests among medical students and various postgraduates to this simple but powerful diagnostic tool.

D Karthikeyan Deepa Chegu

PREFACE TO THE FIRST EDITION

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rs1. Chest X-ray 1

Objectives of Chest X-ray 2Standard Views 2Special Views 2Techniques 4Technical Considerations 6Fissures 14Mediastinum and Heart 19Diaphragm 27Comparison with Previous X-rays 30Hidden Areas 33Air Bronchogram 38Pleural Disease 49Diaphragm 66Hiatal Hernia 68Diaphragmatic Injury 69

2. Disease Pattern 93Tracheostomy 132Central Venous Line 133Endotracheal Tube 133Pacemaker 134Thoracostomy Tube 135Nasogastric Tube 136

3. Differential Diagnosis 137Normal Chest X-ray—Landmarks 138Coin Lesion on CXR 139CXR: Cardiac 156

4. Chest X-ray Correlations with HRCT 163Case 1 165Case 2 166Case 3 167Case 4 168

CONTENTS

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CHEST X-RAY MADE EASYx

Case 5 169Case 6 170Case 7 171Case 8 172Case 9 173Case 10 174Case 11 175Case 12 176Case 13 177Case 14 178Case 15 179Case 16 180Case 17 181Case 18 182Case 19 183Case 20 184Case 21 185Case 22 186Case 23 187Case 24 188Case 25 189Case 26 190Case 27 191Case 28 192Case 29 193Case 30 194

Appendices 195

Index 209

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rsChapter 4

Chest X-ray Correlations with HRCT

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CHEST X-RAY MADE EASY164

INTRODUCTION

Plain radiography remains the standard for screening and to some extent detection of diffuse pulmonary processes in an ICU setting. One of the main limitations of plain radiography in the evaluation of diffuse pulmonary parenchymal disease is the superimposition of structures due to the projectional format of that imaging method. As computed tomography offers an unobstructed cross-sectional view of the thorax, its role has become a main stay in defining early detection and characterization of diffuse parenchymal lung diseases. After more than a decade of technical developments, thin-section high resolution computed tomography (HRCT) has emerged as a accurate method to assess diffuse abnormalities of the pulmonary parenchyma. In this chapter, CXR and HRCT findings are correlated to give the reader a comprehensive understanding while they attempt to interpret X-rays in training.

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CHEST X-RAY CORRELATIONS WITH HRCT 165

CASE 1

Diagnosis: Solitary pulmonary nodule. Chest X-ray PA and axial NECT and coronal contrast reformats show the left lung upper lobe nodule with a calcific speck. Note: CT helps in assesment of location, enhancement and matrix characteristics.

Figure 4.1

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CASE 2

Diagnosis: Allergic bronchopulmonary aspergillosis (ABPA). Chest X-ray and HRCT images showing central bronchiectasis with proximal tubular opacities suggestive of ABPA. CT sections show the exact anatomical location and associated parenchymal changes in the form of bronchiolar nodules.

Figure 4.2

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CASE 3

Diagnosis: Provisional diagnosis of pneumocystis pneumonia (PCP). Chest X-ray showing bilateral hazy opacities with an apparent mid-basal gradient in a febrile immunocompro-mised patient, HRCT section showing ground-glass opacities.

Figure 4.3

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CASE 4

Diagnosis: Situs inversus, CT shows the bronchovascular relations easily, and also helps in ruling out early bronchi-ectasis as in this patient with Kartagener’s syndrome.

Figure 4.4

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CASE 5

Diagnosis: Consolidation. Chest X-ray and coronal HRCT reformats in minimum intensity projection showing right upperlobe consolidation. CT reformats helps to trace even the segmental bronchi.

Figure 4.5

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CASE 6

Diagnosis: Benign lesions like bronchogenic/duplication cyst. Chest X-ray shows a left apical well-marginated smooth opacity, CT images show the matrix of the lesion and its relationship with adjacent structures like esophagus, trachea and neck vessels.

Figure 4.6

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CASE 7

Diagnosis: Interstitial fibrosis—secondary to scleroderma. Chest X-ray shows bilateral reticular changes and thin walled lucent opacities in a basal gradient, CT section shows bilateral honeycombing with dilated esophagus which prompted the correct diagnosis.

Figure 4.7

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CASE 8

Diagnosis: Possible neurogenic tumor. Chest X-ray shows right upper zone paratracheal opacity with smooth margin. Axial CECT shows the exact location and matrix of the lesion located in the right costo vertebral junction.

Figure 4.8

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CASE 9

Diagnosis: Suspected chronic eosinophilic pneumonia. Chest X-ray shows bilateral peripheral consolidative changes, HRCT section shows the distribution of the peripheral subpleural consolidative disease process and matrix change.

Figure 4.9

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CASE 10

Diagnosis: Subacute extrinsic allergic alveolitis. Chest X-ray shows minimal doubtful bilateral hazy opacities, HRCT sections show centrilobular nodular opacities which are characteristic finding in extrinsic allergic alveolitis (EAA).

Figure 4.10

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CASE 11

Diagnosis: Active Koch’s lesion. Chest X-ray shows right mid-zone consolidation with cavitary changes, HRCT image shows cavitary consolida-tion with adjacent transbronchial nodular spread in both lungs.

Figure 4.11

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CASE 12

Diagnosis: Pulmonary edema. Chest X-ray showing bilateral perihilar opacities, HRCT lung showing confluent alveolar opacities. CXR is useful in the critical care setting where repeat images can be obtained to assess dynamic changes.

Figure 4.12

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CASE 13

Diagnosis: Postoperative infective consolidation (most lesions resolved on 1 week follow-up). Chest X-ray and HRCT lungs showing multifocal consolidative changes, HRCT helps in assessing the amount of aerated lung in these cases with extensive opacities and helps in planning invasive treatment if needed.

Figure 4.13

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CASE 14

Diagnosis: Pulmonary microlithiasis. Chest X-ray shows bilateral dense reticulonodular shadows, HRCT lung in bone window setting shows typical dense nodularities.

Figure 4.14

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CASE 15

Diagnosis: Miliary Koch’s. Chest X-ray in a febrile patient shows suspicious hard to perceive miliary nodules. HRCT lungs shows discrete diffuse miliary nodules.

Figure 4.15

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CASE 16

Diagnosis: Infective nodules. Chest X-ray AP projection in a febrile diabetic patient with respiratory distress showing multiple random nodules. CT lung shows the distribution of these nodules well. In the acute setting based on the distribution of nodules and associated features like cavitation and halo sign it is possible to characterize the nature of infections.

Figure 4.16

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CASE 17

Diagnosis: Koch’s lymphadenopathy. Chest X-ray shows right hilar and paratracheal soft tissue opacities suggestive of nodes. CECT shows typical hypodense rim enhancing nodes characteristic of Koch’s.

Figure 4.17

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CASE 18

Diagnosis: Bronchiolitis Chest X-ray shows bilateral ill-defined nodular opacities. HRCT coronal reformats show the nature and distribution of bronchiolar opacities.

Figure 4.18

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CASE 19

Diagnosis: Infective bronchiolitis—probably Koch’s. Chest X-ray shows right mid-zone nodular opacities. HRCT section shows right upper lobe posterior segment bron chiolar tree in bud appearance.

Figure 4.19

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CASE 20

Diagnosis: Healed Koch’s lesions. Chest X-ray shows multiple bilateral high density opacities with fibrotic changes, CT section shows calcific densities reflecting healed Koch’s lesions with sequelae.

Figure 4.20

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CASE 21

Diagnosis: Retrocardiac bronchiectasis. Chest X-ray shows left lower zone retrocardiac lucencies, HRCT section show bronchiectatic changes. CT helps in delineating the correct segmental anatomy and associated complications to help plan treatment.

Figure 4.21

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CASE 22

Diagnosis: Right lower zone and middle lobe medial sub-segmental atelectasis. Chest X-ray shows a linear right lower zone and middle lobe opacity, CT sections show the peripheral plate atelecta-sis with right middle lobe medial segment subsegmental atelectasis.

Figure 4.22

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CASE 23

Diagnosis: Cryptogenic organizing pneumonia. Chest X-ray shows multiple peripheral opacities, HRCT section shows peripheral subpleural consolidation, some of the nodules showed reverse halo sign (arrow) suggesting the diagnosis of COP.

Figure 4.23

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CASE 24

Diagnosis: Metastatic osseous mediastinal node from right humeral osteosarcoma. Chest X-ray shows right mediastinal calcified node. Right humeral prosthesis is seen (postoperative status osteosarcoma). CT section shows the osseous matrix of the right mediastinal node.

Figure 4.24

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CASE 25

Diagnosis: Massive left pleural effusion. Chest X-ray shows opaque left hemithorax. CT section shows massive left pleural effusion with underlying passive atelectasis of left lung. CT often helps in diagnosing the cause of opaque hemithorax helping to guide treatment.

Figure 4.25

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CASE 26

Diagnosis: Endstage left lung. Chest X-ray shows volume loss of left hemithorax with secondary changes of tracheal and mediastinal shift. Coronal CT sections show the cystic end stage changes of left lung parenchyma with compensatory changes of the right lung. CT helps in surgical planning.

Figure 4.26

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CASE 27

Diagnosis: Right pneumothorax with ICD tube. Right upper lung contusion with laceration and rib fractures. Chest X-ray shows right pneumothorax with subcuta-neous emphysema and ICD, right upper lobe opacity with central lucency and rib fractures. Coronal CT image shows the parenchymal contusion with central lucencies suggesting a diagnosis of associated pulmonary laceration. CT is extremely useful tool in trauma assessment as it characterizes injuries involving all compartments.

Figure 4.27

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CASE 28

Diagnosis: Left prominent costophrenic fat pad. Chest X-ray shows a left CP angle opacity obscuring the margins in a febrile patient thought to be pleural effusion, CT section helps in correct diagnosis of fat.

Figure 4.28

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CASE 29

Diagnosis: Lymphangioleiomyomatosis (LAM) Chest X-ray shows right pneumothorax with bilateral thin walled lucent opacities. HRCT section shows lung to be replaced by numerous thin walled cysts with some intervening parenchyma. Right pneumothorax also noted. CT helps in correct diagnosis of LAM.

Figure 4.29

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CASE 30

Diagnosis: Left bronchial web with left obstructive emphysema. Chest X-ray shows lucent left hemithorax. Axial CT helps in the correct diagnosis of left bronchial web. Volume rendered CT image shows hyperinflation of left hemithorax and the left bronchial stenosis.

Figure 4.30

chest x-ray made easy aypee...

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