practical approach to the pediatric chest xray ix congress of the latin american society of...
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Practical approach to the pediatric chest Xray
IX Congress of the Latin American Society of Pediatric Radiology
Buenos Aires on September 7-9, 2005
Mutsuhisa Fujioka, M.D.Chairman, The Asian and Oceanic Society for Pediatric Radiology
Professor and Chairman, Department of Radiology, Dokkyo University School of Medicine
Valoraction practica de la RX de torax
Editorial board members
Managing Editors
(Africa, Asia, Australasia, Europe, and elsewhere outside the Americas)Dr. S. ChapmanThe Birmingham Children’s Hospital NHS TrustSteelhouse LaneBirmingham B4 6NHUnited Kingdom [email protected]
(The Americas)Dr. T. L. SlovisChildren’s Hospital c/o: CRCM3901 Beaubien BoulevardDetroit, MI 48201, [email protected]
Assistant Editors
Dr. D. FrushDuke University Medical Center Div of Pediatric Radiology (Box 3808)1905 McGovern Davison Children’s Hlth. Ctr.Durham, NC 27710, [email protected]
Dr. G. SebagDepartment of Paediatric RadiologyHồpital Robert Debré48, boulevard Sérurier75935 Paris Cedex, [email protected]
Honorary Editor
Dr. W. E. BerdonColumbia Presbyterian Medical Center, Babies HospitalDept of Radiology (3-318)3959 BroadwayNew York, NY 10032-1590, [email protected]
Editorial Board
CardiovascularT. Chung, HoustonJ. A. Culham, VancouverM. Oddone, GenoaS. Laurin, LundC. Holmqvist, Lund
ChestV. Donoghue, DublinE. Effmann, SeattleM. Fujioka, UtsunomiyaJ. Lucaya, BarcelonaB. Newman, Pittsburgh
EducationJ. Reid, ClevelandJ-N. Dacher, Rouen
Experimental DesignK. Applegate, Indianapolis
Genetics – Molecular ImagingR. Lachman, Santa MonicaW. McAlister – St. Louis
General Paediatric RadiologyS. Andronikou, Cape TownM. Argyropoulou, IoanninaP. Babyn, TorontoA. Daneman, TorontoH. Ducou Le Pointe, ParisF. Gudinchet, LausanneI-O, Kim, SeoulH. Lederman, San PauloP. Strouse, Ann ArborG. Taylor, BostonR. Teele, Auckland
GastrointestinalG. Benz-Bohm, CologneD. Bloom, DetroitD. Eggli, HersheyM. Hernanz-Schulman, NashvilleK. McHugh, LondonD. Pariente, BicetreC. Sivit, Cleveland
InterventionalP. Chait, TorontoP. Clapuyt, BrusselsJ. Donaldson, ChicagoD. Roebuck, LondonR. Towbin, Philadelphia
MusculoskeletalM. Azouz, MiamiH. Carty, LiverpoolC. Hall, LondonD. Jaramillo, BostonG. Kalifa, ParisM. Keller, WilmingtonT. Laor, Cincinnati
NeuroradiologyC. Adamsbaum, ParisN. Boddaert, ParisF. Brunelle, ParisB. Koch, CincinnatiM. Nelson, Los AngelesC. Robson, BostonY. Sato, Iowa City
OncologyH. Brisse, ParisS. Kaste, MemphisJ. Meyer, WilmingtonC. Owens. London
PerinatalC. Garel, ParisL. Garel, MontrealL. Guibaud, LyonE. Simon, Philadelphia
TechnologyM. Claudon, NancyW. Huda, SyracuseT. Metens, BrusselsW.K. Rorhschneider, HeidelbergK. White, Salt Lake CityC. Willis, HoustonP. Winkler, Stuttgart
UroradiologyF. Avni, BrusselsB. Coley, ColumbusK. Darge, WuerzburgR. Fotter, GrazU. Willi, ZurichM. Zerin, Detroit
Book ReviewsJ. Haller, TeaneckM. Hassan, Paris
Statistics, Information, Technology and EditingH. Fischer, DetroitW. Grever, DetroitR. Thomas, Detroit
Manuscripts must be sent to the appropriate Managing editor only. Please ensure that the manuscript complies with the “Instructions to authors: at http://link.springer.de/link/service/journals/00247/instr.htm
A practical approach to the pediatric chest radiograph
Steps for reading
1. Detection
2. Differentiation
Change in size and shape of normal anatomical structures.
Soft tissue, bones, heart, aorta, trachea, main bronchi, thymus, hili, esophagus, pleura, diaphragms, pulmonary arteries, veins, bronchial walls, gastric air bubble, liver, spleen
What are we looking for?
Abnormality(increased or decreased opacity) which should not be present in normal individual
What are we looking for?
ground-glass opacity(haziness)
consolidation
nodule or mass
linear, reticular or band like shadow
calcification
Increased lung opacity
hyperlucency(air trapping or pneumothorax)
lung cyst or bulla
honeycomb
cavitary nodule or mass
cystic bronchiectasis
Decreased lung opacity and cystic abnormalities
Features of Lung Diseasein High Resolution CT
Ground-Glass Opacity
Consolidation
Pulmonary Nodule
Bronchiolar Disease and Tree-in-Bud
Air Trapping
Septal Thickening
Parenchimal Bands
Honeycombing
Mosaic Perfusion
Architectural Distortion
Air-Filled Cystic Lung Lesions
Dependent Increased Attenuation
Emphysema
Halo Sign
Signet Ring Sign
Crazy Paving Pattern
Change in size and shape of normal anatomical structures can rather be easier to be detected by the findings of chest radiograph rather than those of CT.
Therefore for adequate interpretation of pediatric chest radiographs, we should be aware of gross abnormal findings which might be overlooked by particular reasons.
However it is very important to know what kind of abnormality is not demonstrable on usual chest radiograph but well demonstrated on CT or HRCT.
2yo Bilateral pneumonia: Lingula of the left upper lobe, right lower lobe
Detection of Pneumonia using Silhouette sign
2yo Bilateral pneumonia: Lingula of the left upper lobe, right lower lobe
Positive SS along left cardiac border
Detection of Pneumonia using Silhouette sign
2yo Bilateral pneumonia: Lingula of the left upper lobe, right lower lobe
Negative SS along right cardiac border
Detection of Pneumonia using Silhouette sign
How to detect abnormal findingssilhouette sign
silhouette out (Positive silhouette sign)
Pneumonia and/or atelectasis of the lingula of the left upper lobe
Subsegmental pneumonia of the S10 of the left lower lobe
Positive silhouette sign of the posterior portion of the left hemidiaphragm
Quiz 2
Detection of abnormal findings
Any abnormality in the central shadow in a child with habitual vomiting?
anterior junction line
posterior junction line
azygoesophageal line
aortic-pulmonic window
aortic pulmonary stripe
left paraspinal line
right paratracheal stripe
posterior tracheal band ( lateral )
tracheo-esophageal stripe ( lateral )
aortic nipple
How to detect abnormal finding
Mediastinal interfaces and lines
Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Two mediastinal lines, the anterior and posterior junction lines, are occasionally seen on normal plain radiographs. The descending aorta and SVC interfaces are commonly seen on normal chest radiographs; their absence may suggest mediastinal or pulmonary abnormalities. The azygoesophageal and left paraspinal interfaces are not commonly seen on normal chest radiographs.
Yoon HK, et al: Mediastinal interfaces and lines in children: radiographic-CT correlation. Pediatr Radiol(2001)31:406-412
right paratracheal stripe
Abnormal shadow hidden by the central shadow or the diaphragmatic domes
mediastinal reflection
tracheal bronchus(pig bronchus)
tracheal bronchus
atelectasis
Abnormality of the right paratracheal stripe
Inspiratory phase Expiratory phase
Air trapping of the left lung due to check valve mechanism
Peanut aspiration
How to detect abnormal finding
Major findin number
Radiopaque foreign body 5
Normal chest 6
Air trapping 17
Parenchymal radiopacity 12
Air trapping with parenchymal radiopacity 12
g
Findings on plain chest radiographs in foreign body aspiration(52 children)
Foreign body in the main bronchus
Inspiratory phase Expiratory phase
Scintigraphy of the pulmonary blood flow
Any abnormality in the lung in an infant with fever and dyspnea ?
Detection of abnormal findings
Quiz 6
9yo bronchial asthma
Inspiratory phase Expiratory phase
After treatment
Air Trapping:HRCT findings
GGO
Mosaic pattern
Equipment : wider latitude film-screen system, computed radiography(CR) flat panel digital radiography(DR)
Technical factors : high kV, Bucky film
Additional views : lateral view decubitus view, plain abdomen ultrasonography, CT
How to improve the detectablity of the lesions hidden by the central shadow or diaphragmatic domes ?
Reading : silhouette sign, posterior mediastinal lines
Limitaion : ground glass opacity(GGO) peripheral lesions adjacent to the pleura, thin atelectasis perpendicular to the X-ray beam
How to improve the detectablity of the lesions hidden by the central shadow or diaphragmatic domes
Reading : silhouette sign, posterior mediastinal lines
Limitaion : ground glass opacity(GGO) peripheral lesions adjacent to the pleura, thin atelectasis perpendicular to the X-ray beam
CT(HRCT) may easily provide final answer but the indication should be limited only by clinical reasons not merely by radiological reasons!!!!
How to improve the detectablity of the lesions hidden by the central shadow or diaphragmatic domes
1 To make a list of diseases or conditions as many as possible in each category
2 To exclude a specific disease or condition one by one from the list
3 To leave those not to be excluded by former process
Differential diagnosis
Incorrect diagnosis may be lead when the correct diagnosis is not included from beginning
1. Technical
2. Normal
3. Congenital
4. Inflammatory
5. Neoplastic
6. Traumatic or Iatrogenic
Categories to be checked
Differential diagnosis
1) Spherical Pneumonia
2) Plasma Cell Granuloma (Postinflammatory Pseudotumors Sclerosing Hemangioma Fibrous Histiocytoma, Fibrous Xanthoma etc)
3) Pulmonary Granuloma ( tuberculoma, histoplasmoma)
4) Pulmonary Arteriovenous Malformation
5) Mucoid Impaction
6) Round Atelectasis
7) Pulmonary Hematoma
8) Pulmonary Sequestration
9) Intrathoracic Ectopy of abdominal organ
Pseudotumor in the lung
1. Technical
2. Normal
3. Congenital
4. Inflammatory
5. Neoplastic
6. Traumatic or Iatrogenic
Check all categories below then you may certainly always reach correct diagnosis!!!
Conclusion