Diagnostic Imaging of Airway Diseases
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Transcript of Diagnostic Imaging of Airway Diseases
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ChestAirway Diseases
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Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology Department , Zagazig University Hospitals
EgyptFINR (Fellowship of Interventional
Neuroradiology)[email protected]
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Knowing as much as possible about your enemy precedes successful battle
and learning about the disease process precedes successful management
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Airway Diseasesa) Tracheal Diseases b) Chronic bronchial Diseasesc) Upper Airway Obstruction in Children
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a) Tracheal Diseases :1-Neoplastic Diseases2-Non-Neoplastic Diseases
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1-Neoplastic Diseases :a) Benignb) Malignant
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a) Benign :1-Incidence2-Types
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1-Incidence :-Only 10% of tracheobronchial tumors are
benign-Benign tumors are typically < 2 cm
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2-Types :a) Papilloma :-Common laryngeal tumors in childrenb) Hamartoma :-Fat density is diagnostic-Often calcified (popcorn pattern)c) Lipoma :-Rounded homogeneous fat attenuation lesion-90 % in males d) Adenoma :-Rare
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Papilloma
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Small and well-defined posterolateral lesion projecting into tracheal lumen , Papilloma
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Hamartoma
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Lipoma
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CT+C (a) shows a low-attenuation (-5 HU) endobronchial nodule (black arrow) in the bronchus intermedius , post-obstructive atelectasis of the right lower lobe can be seen (white arrow) , CT (b) obtained at the level of the left brachiocephalic vein shows a low attenuation (-95 HU) nodule in the trachea
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b) Malignant :1-Incidence2-Types
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1-Incidence :-90 % of all tracheobronchial tumors are
malignant
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2-Types :a) Primary :-SCC (most common)-Adenoid cystic carcinoma (2nd common)-Mucoepidermoid-Carcinoid
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Chest X-ray showing lobulated lesion at the level of the carina (red arrow)
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CT+C shows nearly complete central tracheal obstruction with the tumor
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Rounded mass at the level of carina causing significant reduction of the lumen of both bronchi , Squamous cell carcinoma
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CT shows the tracheal mass extending and obliterating the right main bronchus
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CXR (a) shows an upper right paratracheal opacity narrowing the tracheal lumen (arrow) , CT+C (b) confirms the eccentric lobulated soft tissue mass that origins from the right anterolateral tracheal wall and narrows the lumen of the upper trachea , coronal MPR image at mediastinal window setting (c) better depicts the entire extent of the lesion
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Mediastinal mass arising from the posterolateral wall of the trachea (a characteristic feature) with invasion of mediastinal fat and esophagus , Cystic adenoid carcinoma
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Adenoid Cystic Carcinoma
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CT (a) shows an irregular thickening of the left tracheal wall with a lobulated mass protruding into the tracheal lumen (arrow) , CT (b) shows irregular thickening of the left posterolateral tracheal wall with nodular intraluminal extension of tumor (arrow)
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Carcinoid
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b) Mets :1-Local Extension (common) :-Thyroid cancer-Esophageal cancer-Lung cancer2-Hematogeneous Mets (rare) :-MelanomaBreast cancer
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Direct extension to the tracheal lumen of anaplastic thyroid cancer
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CT shows a large proximal esophageal mass with asymmetric impression on the posterior tracheal wall suggestive of invasion
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Irregular right lateral wall of the trachea secondary to direct extension from small cell carcinoma of the lung
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Tracheal and bronchial metastases from melanoma
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2-Non-Neoplastic Diseases :1-Saber Sheath Trachea2-Tracheopathia Osteoplastica (TPO)3-Tracheobronchomalacia4-Tracheobronchomegaly5-Relapsing Polychondritis6-Post-intubation Tracheal Stenosis
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7-Post-infectious Tracheal Stenosis & T.B.8-Tracheobronchial Diverticula9-Bronchial Anthracofibrosis10-Amyliodosis11-Wegner’s Granulomatosis12-Tracheal / Bronchial Narrowing ,
Stenosis or Occlusion
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1-Saber Sheath Trachea :a) Pathologyb) Radiographic Features
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a) Pathology :-Refers to diffuse coronal narrowing of the
intrathoracic portion of the trachea with concomitant widening of the sagittal diameter , extrathoracic segment of the trachea is always preserved
-It is pathognomonic for COPD-More common in males
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b) Radiographic Features :-Marked decrease in the coronal diameter of
the intrathoracic trachea associated with an increase in its sagittal diameter
-Tracheal ring calcification is common
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Saber-sheath trachea , notice sparing of extrathoracic trachea and coronal narrowing of the intrathoracic segment
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2-Tracheopathia Osteoplastica (TPO) :a) Pathologyb) Radiographic Features
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a) Pathology :-Foci of cartilage and bone develop in the
submucosa of the tracheobronchial tree-Benign , rare condition-Only affects the anterior and lateral walls
with sparing of the posterior membranous portion
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b) Radiographic Features :-Calcified tracheobronchial tree , nodules ,
osteocartilaginous growth-Thickening of tracheal cartilage-Narrowed lumen-Distal three fourths of the trachea and the
proximal bronchi are most commonly involved
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Diffuse stricture of the tracheal lumen due to an irregular thickening of the lateral walls
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3-Tracheobronchomalacia :a) Pathologyb) Radiographic Features
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a) Pathology :-Refers to weakening of tracheal and bronchial walls -May be primary or secondary :1-Primary (uncommon) :-Occurs in children-May be associated with laryngomalacia2-Secondary (more common) :-Ageing-Prolonged intubation , especially in those with tracheostomy-COPD-Chronic or recurrent infection
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b) Radiographic Features :-Collapsed walls of trachea and bronchi-Inspiratory only CT is unable to make the
diagnosis-Diagnosis usually requires airway assessment
after a forced expiration (Dynamic Expiration)-A hallmark of TM is the frown sign, a crescent
bowing of the posterior membranous tracheal wall at expiratory CT scans
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On inspiration On expiration
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Axial inspiratory CT (a,b) show a normal shape of the tracheal and bronchial lumen , Expiratory CT (c,d) show a severe collapse of the airways with an inward bowing of the posterior wall (frown sign) , mild air-trapping is also evident in both lungs
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Tracheomalacia in COPD patient , notice collapse of more than 50% of the tracheal lumen in expiratory image on the right
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Significant collapse on expiratory images (below) of trachea and main bronchi , Tracheobronchomalacia
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Significant collapse on expiratory images (below) of trachea and main bronchi
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4-Tracheobronchomegaly :a) Pathologyb) Radiographic Features
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a) Pathology :-Also known as Mounier-Kuhn syndrome-Rare condition characterized by markedly
dilated airways leading to recurrent infections
-It appears in young patients (third and fourth decade)
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b) Radiographic Features :-Tracheobronchomegaly is diagnosed when
the tracheal diameter is bigger than 3 cm
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Markedly enlarged trachea and main bronchi in asymptomatic man
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CT shows severe dilatation of the trachea (a) and the right main stem bronchus (b) associated with fibrotic consolidations and traction bronchiectasis in the upper lobes , more evident on the right (a)
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5-Relapsing Polychondritis :a) Pathologyb) Radiographic Features
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a) Pathology :-Recurrent inflammation of cartilaginous
structures including tracheal cartilages-The etiology is unknown but it is likely
immune-mediated-Tracheal involvement is present in half of
patients with a slightly higher prevalence in women
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b) Radiographic Features :-Wall thickening with increased attenuation that
may range from a subtle increase to clear calcifications
-A key fact for diagnosis is the preservation of the posterior wall of the trachea formed by muscular and fibrous tissue and lacking cartilaginous rings , this particular appearance allows diagnosis with a high degree of confidence
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Tracheal wall thickening with calcifications involving anterior and lateral walls with preservation of the posterior wall. Notice moderate and diffuse stenosis of the tracheal lumen on the MIP image
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Axial CT show smooth tracheal (a) and bronchial (b) wall thickening with calcifications , the typical sparing of the posterior membranous walls of the airways can be seen (arrows)
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6-Post-intubation Tracheal Stenosis :-The placement of endoluminal tubes in the
large airways may cause a reparative fibrotic process at the cuff site (in tracheal intubation) or at the stoma site (in tracheostomy) leading to a tracheal narrowing
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CT (a) shows an eccentric stenosis of the subglottic tracheal lumen on the right (arrow) , external VR image (b) along the long axis of the trachea better depicts the stricture extent and the typical appearance of “hourglass” of the trachea
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7-Post-infectious Tracheal Stenosis & T.B. :-Central airways may be involved in 10-40% of
cases of pulmonary parenchymal tuberculosis by lymphatic spread or local invasion from mediastinal affected lymph nodes
-The most frequent site of stenosis is the lower third of the trachea and the main stem bronchi
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CT (a,b) show enlarged lymph nodes (arrows) in the right paratracheal region and subcarinal region that infiltrate distal trachea and right main bronchus walls determining airway lumen narrowing , coronal CT reformation (c) and VR image (d) better illustrate the extension of the lesions throughout the tracheobronchial tree
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8-Tracheobronchial Diverticula :-May be congenital or acquired-Congenital usually very small with a very
narrow communication with the airway , whereas the acquired is bigger and usually have a wide communication with the airway
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Congenital diverticulum , Axial CT (a) show an air-filled right paratracheal cyst (arrow) at the cervico-thoracic junction , coronal MPR (b) better depicts the apparent communication (arrow) with the tracheal lumen by a narrow neck.
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Acquired diverticulum , Axial CT (a) and oblique MPR image (b) show a large air-filled paratracheal cyst (arrow) at the cervico-thoracic junction , the large dimension and the broad base are consistent with an acquired diverticulum
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Right paratracheal diverticulum , notice narrow connection between diverticulum and tracheal lumen
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9-Bronchial Anthracofibrosis :-Benign condition affecting more
frequently elderly women-The term refers to the bronchoscopic
finding of dark anthracotic pigments in the bronchial wall with subsequent bronchial narrowing or obliteration in patients without a relevant history of pneumoconiosis or smoking
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-The most commonly reported finding on CT scans is lobar or segmental post-obstructive atelectasis , multifocal stenoses of lobar and segmental bronchi with peribronchial soft tissue thickening and calcified or noncalcified lymph nodes may also be seen
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CT+C (a) shows partial atelectasis of right upper lobe with smooth narrowing of right main bronchus and obstruction of right upper lobe bronchus , an enlarged lymph node (arrow) adjacent to involved bronchus can be seen , axial non-enhanced CT (b) shows obstructed right middle lobe bronchus resulting in partial atelectasis of right middle lobe , calcified lymph nodes adjacent to right middle lobe bronchus are also present (black arrows) , lingular segmental bronchus is thickened with adjacent enlarged lymph nodes containing calcification (white arrow)
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10-Amyliodosis :-Diffuse involvement of the tracheobronchial
tree beginning from the trachea and large bronchi extending sometimes to segmental bronchi
-CT shows multifocal , nodular or circumferential wall thickening of soft-tissue density with a smooth surface and possible concentric calcifications
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Axial CT (a,c) show diffuse circumferential and smooth wall thickening with mild calcifications of the trachea , main stem bronchi and lobar bronchi bilaterally , axial CT (b) shows an almost complete occlusion of the right upper lobar bronchus with a distal chronic post-obstructive atelectasis of the anterior segment of the right upper lobe (arrow)
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Circumferential thickening of the tracheal wall with irregular appearance in virtual bronchoscopy image
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11-Wegner’s Granulomatosis :-Late complication of the disease-CT shows focal or more often diffuse
circumferential wall thickening
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Smooth subglotic wall thickening , Wegener granulomatosis
![Page 88: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/88.jpg)
Asymmetric thickening of the tracheal wall progressing to significant lumen stenosis of subglotic position , Wegener granulomatois
![Page 89: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/89.jpg)
12-Tracheal / Bronchial Narrowing , Stenosis or Occlusion :
a) In the Lumenb) In the Wallc) Outside the Wall
![Page 90: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/90.jpg)
a) In the Lumen :1-Foreign body2-Mucus plug3-Misplaced endotracheal tube4-Broncholithiasis
![Page 91: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/91.jpg)
b) In the Wall :-See Before + Bronchial Atresia
![Page 92: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/92.jpg)
c) Outside the Wall :1-Lymph nodes2-Mediastinal tumors 3-Enlarged left atrium4-Aortic aneurysm5-Anomalous origin of left pulmonary artery from right
pulmonary artery :-Producing compression of the right main bronchus as it
passes over it between the trachea and esophagus to reach the left hilum
-PA CXR shows the right side of the trachea to be indented and the vessel is seen end-on between the trachea and esophagus on the lateral view
![Page 93: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/93.jpg)
![Page 94: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/94.jpg)
Aberrant left pulmonary artery , aberrant artery extends between trachea & esophagus indenting both (arrows)
![Page 95: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/95.jpg)
b) Chronic Bronchial Diseases :1-COPD2-Emphysema3-Bronchial Asthma4-Bronchiectasis5-Cystic Fibrosis6-Bronchiolitis Obliterans
![Page 96: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/96.jpg)
1-COPD :a) Pathologyb) Clinical Picturec) Radiographic Features
![Page 97: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/97.jpg)
a) Pathology :-Represents a spectrum of obstructive airway diseases-It includes two key components which are chronic
bronchitis and emphysema-In contrast to asthma , the histologic changes of COPD
are irreversible and gradually progress over time-In chronic bronchitis , there is diffuse hyperplasia of
mucous glands with associated hypersecretion and bronchial wall inflammation
-Emphysema involves the destruction of alveolar septa and pulmonary capillaries leading to decreased elastic recoil and resultant air trapping
![Page 98: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/98.jpg)
b) Clinical Picture : More in smokers1-Blue Bloaters : Bronchitis-Bronchitis , tussive type of COPD-Episodic dyspnea due to exacerbation of bronchitis-Young patients-Cyanosis2-Pink Puffers : Emphysema-Emphysematous type of COPD-Progressive exertional dyspnea due to the emphysema-Elderly patients
![Page 99: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/99.jpg)
c) Radiographic Features :1-Plain Radiography2-CT
![Page 100: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/100.jpg)
1-Plain Radiography :-Findings of chronic bronchitis are
nonspecific and include increased bronchovascular markings (dirty lung sign) and cardiomegaly
![Page 101: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/101.jpg)
CXR shows increased bronchovascular markings
![Page 102: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/102.jpg)
Dirty Lung sign
![Page 103: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/103.jpg)
-Emphysema manifests as lung hyperinflation with flattened hemidiaphragms , a small heart and possible bullous changes , on the lateral radiograph, a "barrel chest" with widened AP diameter may be visualized , the "saber-sheath trachea" sign refers to marked coronal narrowing of the intrathoracic trachea (frontal view) with concomitant sagittal widening (lateral view)
![Page 104: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/104.jpg)
CXR shows the signs of hyperinflation of the lungs (flattening of hemidiaphragms , widening of retrosternal and retrocardiac spaces green and yellow stars respectively) and loss of regular vascular branching pattern
![Page 105: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/105.jpg)
Bullous changes
![Page 106: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/106.jpg)
Saber sheath trachea
![Page 107: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/107.jpg)
2-CT :-In chronic bronchitis , bronchial wall
thickening and increased lung markings (dirty lung appearance) may be seen , repeated inflammation can lead to scarring with bronchovascular irregularity and fibrosis
![Page 108: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/108.jpg)
CT shows bronchial wall thickening
![Page 109: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/109.jpg)
CT in patient with chronic bronchitis showing thickening of the bronchial walls (red arrows) and mucous within the bronchi (yellow arrows)
![Page 110: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/110.jpg)
-Emphysema is diagnosed by alveolar septal destruction and airspace enlargement which may occur in a variety of distributions
-Centrilobular emphysema is predominantly seen in the upper lobes
-Panlobular emphysema predominating in the lower lobes-Paraseptal emphysema tends to occur near lung
fissures and pleura-Formation of giant bullae may lead to compression
of mediastinal structures while rupture of pleural blebs may produce spontaneous pneumothorax / pneumomediastinum
![Page 111: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/111.jpg)
Centrilobular Emphysema
![Page 112: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/112.jpg)
Panlobular Emphysema
![Page 113: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/113.jpg)
Paraseptal Emphysema
![Page 114: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/114.jpg)
Bullous Emphysema
![Page 115: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/115.jpg)
CT shows a focal area of emphysema (yellow arrow) , pneumothorax (red arrow)
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2-Emphysema :a) Pathologyb) Clinical Picturec) Radiographic Featuresd) Differential Diagnosis
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a) Pathology :-Abnormal enlargement of distal airspaces with destruction
of alveolar walls with or without fibrosis-More in smokers-There are three morphologic sub types of emphysema
which are named according to their relationship to the secondary pulmonary lobule :
1-Centrilobular Emphysema :-Is the most frequently encountered type and affects the
proximal respiratory bronchioles-More in the upper zones-It is strongly associated with smoking
![Page 118: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/118.jpg)
2-Panlobular Emphysema :-Affects the entire secondary pulmonary lobule ,
more in the lower zones-Seen particularly in alpha-1-antitrypsin (AAT)
deficiency (exacerbated by smoking) 3-Paraseptal Emphysema :-Affects the peripheral parts of the secondary
pulmonary lobule near lung fissures and pleura-It is also associated with smoking and can lead to
the formation of subpleural bullae and spontaneous pneumothorax
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Centrilobular Panlobular Paraseptal
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Centrilobular Panlobular Paraseptal
![Page 122: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/122.jpg)
b) Clinical Picture :-The clinical features of emphysema should be
distinguished from the signs and symptoms of chronic bronchitis
-Patients with emphysema often referred to as pink puffers
-Patients with chronic bronchitis often referred to as blue blotters
-However in clinical practice features of these two syndromes coexist as chronic obstructive pulmonary disease
![Page 123: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/123.jpg)
c) Radiographic Features :1-Plain Radiography2-CT
![Page 124: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/124.jpg)
1-Plain Radiography :a) Hyperinflation :-Flattened hemidiaphragm(s) : most reliable sign , highest
level of the dome is <1.5 cm above a straight line drawn between the costophrenic and the vertebrophrenic junctions
-Increased and usually irregular radiolucency of the lungs-Increased retrosternal airspace-Increased AP diameter of chest-Widely spaced ribs-Sternal bowing-Tenting of the diaphragm-Saber sheath trachea
![Page 125: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/125.jpg)
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Normal Diaphragm Flattened Diaphragm
![Page 127: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/127.jpg)
Normal Flattening of the diaphragm
![Page 128: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/128.jpg)
Increased radiolucency , increased AP diameter of chest
![Page 129: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/129.jpg)
Normal retrosternal space Increased
![Page 130: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/130.jpg)
Normal Widely spaced ribs
![Page 131: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/131.jpg)
b) Vascular changes :-Decreased number of vessels in areas of
abnormal lung-Absence of peripheral pulmonary vessels-Fewer arterial branches-Central pulmonary artery increased in size
![Page 132: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/132.jpg)
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Hyperlucency of the lungs with fewer vascular markings and prominence of the pulmonary arteries (arrows)
![Page 134: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/134.jpg)
2-CT : In all three sub types, the emphysematous spaces are not bounded by any visible wall
a) Centrilobular Emphysema :-It is predominantly located in the upper zones of
each lobe (i.e. apical and posterior segments of the upper lobes and superior segment of the lower lobes) has a patchy distribution
-It appears as focal lucencies (emphysematous spaces) which measure up to 1cm in diameter located centrally within the secondary pulmonary lobule often with a central or peripheral dot representing the central bronchovascular bundle
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b) Panlobular Emphysema :-Predominantly located in the lower lobes ,
has a uniform distribution across parts of the secondary pulmonary lobule which are homogeneously reduced in attenuation
![Page 137: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/137.jpg)
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c) Paraseptal Emphysema :-Located adjacent to the pleura and septal lines
with a peripheral distribution within the secondary pulmonary lobule , the affected lobules are almost always sub-pleural and demonstrate small focal lucencies up to 10mm in size
-Any larger than 10mm and they should be referred to as subpleural blebs or subpleural bullae
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Bullous Emphysema
![Page 141: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/141.jpg)
Emphysema with pneumothorax
![Page 142: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/142.jpg)
Emphysema with superimposed infection
![Page 143: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/143.jpg)
d) Differential Diagnosis :-Cystic lung disease , all have visible walls1-Lymphangiomyomatosis (LAM)2-Pulmonary Langerhans cell histiocytosis
(LCH)3-Honeycomb lung : usually reduced lung
volumes
![Page 144: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/144.jpg)
3-Bronchial Asthma :a) Pathologyb) Radiographic Features
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a) Pathology :-Hyperirritability of airways causes reversible
airway obstruction (bronchial smooth muscle contraction , mucosal edema , hypersecretion of bronchial secretory cells : bronchospasm)
-The etiology is unknown (IgE participation)
![Page 146: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/146.jpg)
b) Radiographic Features :1-Plain Radiography2-CT
![Page 147: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/147.jpg)
1-Plain Radiography :-Plain films can be normal in upto 75% of
patients with asthma-Severe or chronic asthma :Air trapping , hyperinflation : flattened
diaphragm , increased retrosternal airspace
![Page 148: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/148.jpg)
![Page 149: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/149.jpg)
Gloved finger sign , finger like projections from hilum from bronchial mucoid impaction in allergic bronchopulmonary aspergillosis or asthma
![Page 150: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/150.jpg)
2-CT :-CT is usually used to detect the presence of
complicated associated conditions such as allergic bronchopulmonary aspergillosis and not to directly diagnose asthma
-Bronchial wall thickening , tramlines (also seen in chronic bronchitis , cystic fibrosis , bronchiectasis & pulmonary edema)
![Page 151: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/151.jpg)
Mild bronchial thickening and dilatation
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Central bronchiectasis , a hallmark of allergic bronchopulmonary aspergillosis (right arrow) and the peripheral tree-in-bud appearance of centrilobular opacities (left arrow) which represent mucoid impaction of the small bronchioles
![Page 153: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/153.jpg)
4-Bronchiectasis :a) Pathologyb) Clinical Picturec) Radiographic Featuresd) Differential Diagnosis
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a) Pathology :-Refers to irreversible abnormal dilatation of the
bronchial tree-Types :1-Cylindrical bronchiectasis :-Bronchi have a uniform caliber , do not taper and
have parallel walls (tram track sign when viewed in a sagittal section and signet ring sign when viewed in a coronal section)
-Commonest form
![Page 155: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/155.jpg)
2-Varicose bronchiectasis :-Beaded appearances where dilated bronchi have
interspersed sites of relative narrowing-Uncommon3-Cystic bronchiectasis : More in lower lobes-Severe form with cyst-like bronchi that extend to the
pleural surface , air-fluid levels are commonly present4-Traction bronchiectasis :-Bronchiectasis which result from the traction of fibrotic lung
surrounding an airway
![Page 156: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/156.jpg)
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![Page 158: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/158.jpg)
Cylindrical bronchiectasis
![Page 159: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/159.jpg)
Cylindrical Bronchiectasis
![Page 160: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/160.jpg)
Varicose bronchiectasis
![Page 161: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/161.jpg)
Cystic bronchiectasis
![Page 162: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/162.jpg)
Cystic bronchiectasis
![Page 163: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/163.jpg)
Traction bronchiectasis
![Page 164: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/164.jpg)
b) Clinical Picture :-Bronchiectasis typically presents with
recurrent chest infections , production of copious amounts of sputum and hemoptysis
-Hemoptysis is often the only symptom and is encountered in up to 50% of case
![Page 165: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/165.jpg)
c) Radiographic Features :1-Plain Radiography2-CT
![Page 166: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/166.jpg)
1-Plain Radiography :-Tram-track opacities (horizontal , parallel lines
corresponding to thickened , dilated bronchi) are seen in cylindrical bronchiectasis
-Air-fluid levels may be seen in cystic bronchiectasis
-Bronchial wall thickening (best seen end-on)-Increase in bronchovascular markings
![Page 167: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/167.jpg)
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Thin-walled, cystic structures in right lower lobe (white arrow) , some with air-fluid levels (yellow arrows)
![Page 170: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/170.jpg)
![Page 171: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/171.jpg)
CXR (a) shows thickening of the bronchial walls and “tramlines” in the middle and lower regions of the lungs suggestive of bronchiectasis, confirmed on CT (b,c)
![Page 172: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/172.jpg)
2-CT :a) Increased bronchoarterial ratio :-Bronchi appear larger than accompanying vesselsb) Bronchial wall :-Thickened wall (normally wall of bronchus should
be less than half the width of the accompanying pulmonary artery branch)
-Signet ring sign , focally thickened bronchial wall adjacent to pulmonary artery branch
-Tram track sign , tube like parallel lines representing thickened bronchial walls
![Page 173: Diagnostic Imaging of Airway Diseases](https://reader036.fdocuments.in/reader036/viewer/2022062503/587171ce1a28ab58758b7a45/html5/thumbnails/173.jpg)
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Signet ring
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Tram Track sign
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Cystic bronchiectasis with air fluid level
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d) Differential Diagnosis :Conditions that may mimic cystic bronchiectasis include :1-Langerhans cell histiocytosis (LCH)2-Lymphangiomyomatosis (LAM)3-Lymphocytic interstitial pneumonitis (LIP)4-Pulmonary manifestations of AIDS5-Pneumocystis pneumonia (PCP)6-Emphysema (To distinguish emphysema from
bronchiectasis, expiratory scans will show air trapping in bullae while cystic bronchiectasis will collapse)
7-Cystic pulmonary metastases
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5-Cystic Fibrosis :a) Pathologyb) Clinical Picturec) Locationd) Radiographic Featurese) Differential Diagnosis
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a) Pathology :-Caused by an abnormality in the cystic fibrosis
transmembrane conductance regulator protein (CFTR) which regulates the passage of ions through membranes of mucus-producing cells
-Dysfunction of exocrine glands causing thick tenacious mucus that accumulates and causes bronchitis and pneumonia
-Reduced mucociliary transport : airway obstruction with massive mucus plugging
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b) Clinical Picture :1-Pulmonary, 100% :-Chronic cough-Recurrent pulmonary infections : colonization of plugged airways by
Staphylococcus and Pseudomonas-Progressive respiratory failure-Finger clubbing : hypertrophic osteoarthropathy from hypoxemia2-GI tract :-Pancreatic insufficiency , 85% : steatorrhea , malabsorption-Liver cirrhosis-Rectal prolapse-Neonates : meconium ileus, meconium peritonitis, intussusception3-Other :-Sinusitis : hypoplastic frontal sinus, opacification of other sinuses-Infertility in males
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c) Location :-Predominantly upper lobes , superior
segments of lower lobes and central (perihilar) distribution
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d) Radiographic Features :1-Plain Radiography2-CT
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1-Plain Radiography :-Chest x-rays are insensitive to the early changes of cystic
fibrosis, with changes seen on HRCT in 65% of patients with CF and normal CXR
-Later changes include :1-Bronchiectasis2-Hyperinflation3-Lobar collapse4-Pulmonary arterial enlargement due to pulmonary arterial
hypertension is seen in patients with long standing disease
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CXR shows diffuse interstitial disease with bronchiectasis and nodular densities of mucoid impaction
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CXR shows hyperinflation and predominantly upper lobe bronchiectasis
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2-CT :a) Bronchiectasis :*Progresses with time from cylindrical to varicose to cystic*Severity :-Mild: lumen equal to adjacent blood vessels-Moderate: lumen 2 to 3 times the size of adjacent blood
vessels-Severe : lumen >3 times the size of adjacent blood vessels*Peribronchial wall thickening , wall thickness > the
diameter of adjacent blood vessels
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b) Mosaic attenuation pattern :-Due to air trapping-Best seen on expiratory scansc) Mucus plugging within bronchi :-Finger in glove appearance
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e) Differential Diagnosis :1-Allergic bronchopulmonary aspergillosis (ABPA) 2-Tracheobronchomegaly (Mounier-Kuhn
syndrome)3-Williams-Campbell syndrome4-Langerhans cell histiocytosis (LCH)5-Lymphangiomyomatosis (LAM)6-Congenital cystic bronchiectasis
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6-Bronchiolitis :a) Pathologyb) Radiographic Featuresc) Swyer-James syndrome
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a) Pathology :-Inflammatory and fibrotic types :a) Inflammatory Bronchiolitis :1-Infectious :-Acute or chronic infection (viral ,
mycoplasma & mycobacterial)2- Hypersensitivity Penumonitis :-Organic or inorganic inhaled agents
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3-Respiratory Bronchiolitis :-Cigarette smoking4-Follicular and Lymphocytic :-Sjögren's syndrome , rheumatoid arthritis &
immunodeficiency5-Panbronchiolitis :-Idiopathic6-Bronchiectasis :-Cystic fibrosis & previous infection
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b) Fibrotic (Constrictive) Bronchiolitis :-Postinfectious , toxic fumes ,
transplantation , cryptogenic , collagen vascular diseases & drugs
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b) Radiographic Features :1-Plain Radiography2-CT
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1-Plain Radiography :-Can be normal or non specific , some
associated features include :a) Hyperinflationb) Attenuation of vascular markingsc) Occasionally : reticular or reticulo-nodular
markings
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Lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant with severe bronchiolitis
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Nonspecific hyperinflation with flattening of the hemidiaphragms on lateral CXR , as well as increased AP diameter and prominent size of retrosternal clear space , mild bilateral symmetric perihilar peribronchial prominence
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2-CT :a) Direct Signs :-Thickening of the bronchiolar wall by inflammatory cells
results in centrilobular nodules and V- or Y-shaped branching linear opacities that represent the tree-in-bud pattern
-Inflammatory cellular infiltration in the peribronchiolar alveoli results in poorly defined centrilobular nodules that often have an attenuation less than that of soft tissue
-Bronchiolectasis is a less common direct sign of bronchiolitis and is found most commonly in chronic forms of bronchiolitis , the dilated bronchioles are identifiable close to the pleural surface
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Multiple poorly defined centrilobular nodules, many of which connect to branching linear structures (arrows) , tree-in-bud pattern
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Diffuse fine poorly defined centrilobular nodules (arrows) with more patchy ground-glass opacity posteriorly
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Centrilobular nodules with tree-in-bud pattern (arrowheads), bronchiolectasis (arrow), and cylindric bronchiectasis
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b) Indirect Signs :-Air trapping is an indirect sign of obstructive
small airways disease and may be identified by the presence of mosaic attenuation on inspiratory CT that is accentuated with expiratory imaging
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Multiple patchy areas of low attenuation in both lungs , note mild bronchial wall thickening and cylindric bronchiectasis
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Expiratory high-resolution CT image shows accentuation of areas of decreased attenuation , confirming presence of air trapping
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c) Swyer-James Syndrome (Mcleod) :1-Pathology2-Radiographic Features
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1-Pathology :-The late sequela of bronchiolitis in
childhood-Is a rare lung condition that manifests
as unilateral hemithorax lucency as a result of post-infectious obliterative bronchiolitis
-The condition typically follows a viral respiratory infection (adenovirus) in infancy or childhood
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2-Radiographic Features :a) Plain Radiographyb) CT
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a) Plain Radiography :-It is generally characterized on radiographs
by a unilateral small lung with hyperlucency and air trapping
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b) CT :-CT shows the affected lung as being
hyperlucent with diminished vascularity , the size of the majority of the affected lobes are smaller although occasionally they can be normal
- Bronchiectasis may be present although this is not a universal finding
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c) Upper Airway Obstruction in Children :(i) Approach(ii) Causes of Upper Airway Obstruction
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(i) Approach :-Inspiratory stridor is the most common
indication for radiographic upper airway evaluation
-Obtain 3 films :*Lateral neck : full inspiration , neck
extended*AP & lateral chest : full inspiration , include
upper airway
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-Primary diagnostic considerations : a) Congenital abnormalities (webs , malacia)b) Infection (epiglottitis , croup , abscess)c) Foreign body (airway or
pharyngoesophageal)d) Masses (lymphadenopathy , neoplasms)
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-If upper airway is normal , consider : 1-Pulmonary causes (foreign body ,
bronchiolitis)2-Mediastinal causes (vascular rings ,
slings)3-Congenital heart disease (CHD)
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-Normal Appearance :*Three anatomic regions : 1-Supraglottic region2-Glottic region : ventricle and true cords3-Subglottic region*Epiglottis and aryepiglottic folds are thin structures*Glottic shoulders are seen on AP view*Adenoids are visible at 3 to 6 months after birth*Normal retropharyngeal soft tissue thickness (C1-
C4) = three-fourths vertebral body width
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(ii) Causes of Upper Airway Obstruction :a) Congenital Abnormalities (webs ,
malacia)b) Infection (epiglottitis , croup , abscess)c) Foreign Body (airway or
pharyngoesophageal)d) Masses (lymphadenopathy , neoplasms)
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a) Congenital Abnormalities :1-Laryngomalacia2-Tracheomalacia3-Webs4-Tracheal Stenosis5-Subglottic Stenosis6-Choanal Atresia
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1-Laryngomalacia :-Common cause of stridor in the 1st year of
life and usually resolves by 2 years -Immature laryngeal cartilage leads to
supraglottic collapse during inspiration-Diagnosis is established by fluoroscopy
(laryngeal collapse with inspiration)
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2-Tracheomalacia :-Weakness of tracheal wall which may be primary or
secondary :a) Primary :-Premature infants -Cartilage disorders (polychondritis , chondromalacia &
MPS)b) Secondary :-Following prolonged intubation-With TOF / osophageal atresia-With vascular ring or other extrinsic vascular compression-With long standing external compression by tumor
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3-Webs :-Most common in larynx
4-Tracheal Stenosis :-Diffuse hypoplasia , 30%-Focal ringlike stenosis , 50%-Funnel-like stenosis , 20%
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5-Subglottic Stenosis :-Fixed narrowing at level of cricoid-Failure of laryngeal recanalization in utero
6-Choanal Atresia :-Most common congenital nasal abnormality-Bilateral in 33 % or unilateral (R>L)-Bony (90 %) or membranous , complete or incomplete-Diagnosis is done by failure to pass a catheter through the
nose
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b) Infection :1-Epiglottitis2-Croup3-Retropharyngeal Abscess4-Edema5-Retropharyngeal Hemorrhage
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1-Epiglottitis :a) Incidenceb) Clinical Picturec) Radiographic Featuresd) Differential Diagnosis
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a) Incidence :-Life threatening bacterial infection of the
upper airway-Most commonly caused by Haemophilus
influenzae-Age : 3 to 6 years
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b) Clinical Picture :-Fever-Dysphagia-Drooling-Sore throat
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c) Radiographic Features :-Key radiographic view : lateral neck-Thickened epiglottis-Thickened aryepiglottic folds (hallmark)-Subglottic narrowing due to edema , 25% :
indistinguishable from croup on AP view-Distention of hypopharynx
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d) Differential Diagnosis :-Other causes of enlarged epiglottis or
aryepiglottic folds : 1-Caustic ingestion2-Hereditary angioneurotic edema3-Omega-shaped epiglottis (normal variant
with normal aryepiglottic folds)4-Stevens-Johnson syndrome
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2-Croup :a) Incidenceb) Clinical Picturec) Radiographic Features
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a) Incidence :-Age : 6 months to 3 years (younger age
group than epiglottitis)-Most commonly caused by parainfluenza
virus-Subglottic laryngotracheobronchitis
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b) Clinical Picture :-Barking cough-Upper respiratory tract infection-Self limited
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c) Radiographic Features :-Key view : AP view-Subglottic narrowing (inverted “V” or
“steeple sign”)-Steeple sign : loss of subglottic shoulders-Lateral view should be obtained to exclude
epiglottitis
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3-Retropharyngeal Abscess :a) Incidenceb) Clinical Picturec) Radiographic Featuresd) Differential Diagnosis
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a) Incidence :-Typically due to extension of a suppurative
bacterial lymphadenitis , most commonly S. aureus , group B streptococci , oral flora
-Age : <1 year-Other causes include foreign body
perforation and trauma
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b) Clinical Picture :-Fever-Stiff neck-Dysphagia-Stridor (uncommon)-Most cases present as cellulitis rather than
true abscess
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c) Radiographic Features :-Widened retropharyngeal space (most
common finding)-Air in soft tissues is specific for abscess-May contain air fluid level-Straightened cervical lordosis-CT : rim enhancement
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d) Differential Diagnosis :-Retropharyngeal hematoma-Neoplasm (i.e. rhabdomyosarcoma)-Lymphadenopathy
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4-Edema : (Laryngeal)-Caused by :a) Angioedema (allergic , anaphylactic or
hereditary)b) Inhalation of noxious gasesc) Trauma
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5-Retropharyngeal Hemorrhage :-Due to :1-Trauma2-Neck surgery3-Direct carotid arteriography4-Bleeding disorders-Widening of the retropharyngeal soft tissue
space
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c) Foreign Body :1-Incidence2-Location3-Radiographic Features
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1-Incidence :-Common cause of respiratory distress-Age : 6 months to 4 years
2-Location :-right bronchi > left bronchi > larynx ,
trachea
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3-Radiographic Features :a) Bronchial foreign body :-Unilateral air trapping causing hyperlucent
lung , 90%-Only 10% of foreign bodies are radiopaque-Expiratory film or lateral decubitus makes
air trapping more apparent
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b) Tracheal foreign body :-CXR is usually normal-Foreign body usually lodges in sagittal
plane
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d) Masses :1-Grossly Enlarged Tonsils & Adenoids2-Nasal Angiofibroma3-Antrochoanal Polyp4-Subglottic Hemangioma5-Respiratory Paplillomatosis6-External Compression
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1-Grossly Enlarged Tonsils & Adenoids :a) Incidenceb) Radiographic Features
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a) Incidence :-The tonsils consist of lymphoid tissue that
encircles the pharynx-Three groups : pharyngeal tonsil (adenoids) ,
palatine tonsil and lingual tonsil-Tonsils enlarge secondary to infection and may
obstruct nasopharynx and/or eustachian tubes-Rarely , bacterial pharyngitis can lead to a
tonsillar abscess (quinsy abscess), which requires drainage
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-Specific causes include :1-Mononucleosis (Epstein-Barr virus)2-Coxsackievirus (herpangina , hand-foot-
mouth disease)3-Adenovirus (pharyngoconjunctival fever)4-Measles prodrome (rubeola)5-β-Hemolytic Streptococcus (quinsy
abscess)
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b) Radiographic Features :-Mass in posterior nasopharynx (enlarged
adenoids)-Mass near end of uvula (palatine tonsils)-CT is useful to determine the presence of a
tonsillar abscess
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2-Nasal Angiofibroma
3-Antrochoanal Polyp
4-Subglottic Hemangioma :-The most common subglottic soft tissue mass in
infancy-Occurs before 6 months of age-Produces asymmetrical narrowing of the
subglottic airway
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5-Respiratory Paplillomatosis :-Occur anywhere from the nose to the lungs-Irregular soft tissue masses which may
cavitate around the glottis or in the trachea
6-External Compression :-From Other Mediastinal Structures
(lymphadenopathy)
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