Radiopathology of Respiratory tract

Dr Wawan Kustiawan SpRad,M.Kes,DFM.

Content
I. Disorder of A. Diaphragm B. Pleura C. Thoracic wall II. Lung parenchym disorder A. Radiopaque disorder 1. Diffuse 2.Patchy 3. Noduler 4. Linear B. Radioluscent disorder 1. Local 2. Diffuse

Diaphragm abnormality
1. Abnormality in function - Fixation / immobility
* Phrenicus nerve paralysis * Pleuritis * Subdiaphragm abcess Relative immobility COPD Paradoxal movement - Inspiratory Phrenicus nerve paralyse - Expiratory

2. Abnormality in position - Bilateral elevation - Ascites - Obesity - Pregnancy - Unilateral elevation - Gastric or colonic distention

- Decrease in size of hemithorax - Liver or splenic enlargement - Bilateral low position of diaphragm - COPD - Asthenic type - Bilateral Pneumothorax - Unilateral low position of diapraghm - Unilateral check valve obstruction of
bronchus

3. Abnormality in shape Scalloping / tenting - Normal variation - Diaphragm tumor - Pleural tumor - Subdiaphragm tumor - Subpulmonary tumor

4. Abnormality in integrity a. Congenital - Diaphragm muscle abnormality eventration - Diaphragmatic hernia b. Diaphragmatic rupture - Trauma

5. Abnormality in density - Calcification of diaphragm - Free air in diaphragmatic muscle interstitial emphysema of thoracic wall

6. Abnormality in number (Accessory diaphragm) - Rare Second leaf of right diaphragm separating right inferior lobe R - Left diaphragm elevation - Depression / thickening of major fissure - Retrosternal : triangular shape opaque shadow - Sometimes accompanied by pulmonary hypoplasia

THE PLEURA
1. Abnormality of shape, position, size Widening of pleural cavity
- Pneumothorax - Hydrothorax - Chylothorax - Emphyema - Neoplasm

2. Abnormality in density a. Increased density (opaque) - Neoplasm / pleural tumor - Calcification / fibrosis - Hydrothorax
b. Diminished density ( lucent) - Pneumothorax

Mesotelioma

Pneumothorax - Air in pleural cage - Ro : - Radiolucent pocket of free air

located between the parietal pleura and visceral pleura - No bronchovascular marking With Pleural effusion hydropneumothorax

Pneumothorax
Etiologies -Traumatic - Spontaneus - Theurapeutic Expiratory stand :for small pneumothorax

Hydrothorax : pleural effusion

-Ro

- Increased opacity shadow (air

bronchogram (-) - Concave upper border - Localized effusion hard to differentiate with pulmonary processes (Vanishing tumor)

Pleural tumor
Benign Lipoma - Fibroma - Angioma Malignant - Mesothelioma - Sarcoma Mesothelioma : from the endothelial pleura layer

Pleural tumor
Benign Lipoma - Fibroma - Angioma Malignant - Mesothelioma - Sarcoma Mesothelioma : from mesothelial layer

Pleural tumor
2 type Noduler : > often Diffuse effusion
Metastase : From bronchogenic Ca From Mammae From Lymphosarcoma

Pleural fibrosis & Pleural adhesion

Fibrosis : pleural thickening Adhesion : between

Lung parietalis pleura Lung diaphragmatica pleura Lung mediastinalis pleura

THORACIC WALL DISORDER

1. a. Thoracic wall shape & size disorder Hemithorax widening Massive pleural effusion Unilateral lung tumor Tension pneumothorax Check valve emphysema Hernia diaphragmatica that pushed the mediastinum

b. Shrinking of hemithorax Whole lung atelectasis Pleural / lung fibrosis N. phrenicus paralysis Lung hipogenesis / hipoplasia
c. Thoracic cage asimetric One side of hemithorax is shrinking while the other side is enlarging Atelectasis + compensatoir emphysema

d. Congenital disorder

Achondroplasia : Short costae, thick, flat Thanata phoric dwarfism Cleidocranial dysostosis Osteogenesis imperfecta Multiple fracture Barrel chest Cont..

d. Congenital disorder

Pectus excavatus : sternal

depression Pectus carinatus Hour glass chest : Multiple fracture from costae & chest muscle paralysis Hiperparathyroid

1. a.

b.

Thoracic wall density disorder Deminishing density Generalized osteophorosis / osteolysis Osteogenesis imperfecta Hyperparathyroid Hypovitaminosis C & D Achondroplasia / Thanatoporic

Increasing density (Sclerosis) Prostatic Ca metastase

II. Lung parenchymal disorder A. Radio opaque disorder 1. Diffuse homogen 2. Patchy 3. Noduler 4. Linear
B. Radio lucent disorder 1. Generalized 2. Local

Diffuse homogenous radioopaque Disorder

a. b. c. d. e. f. g.

Pulmonary atelectasis Pneumonia Epituberculosa Lung infarct Lung squester. Pleura effusion. Tumor

Atelectasis

Et/ Corpus alienum Neoplasm Mucus plug Bronchial stricture / spasm

Atelectasis Ro : Primary Sign Fissural shift Hypoaeration radio opaque Crowded of bronchovascular marking

Secondary sign
Compensatory effect to pulmonary
collaps Diaphragm elevation Mediastinal shift Hilar transposition Compensatory emphysema

Atelectasis classification Generalized atelectasis Radioopaque shadow covering the whole left/right lung Tracheal / Mediastinal pulling Compensatory emphysema Herniation

Lobar atelectasis
Superior lobe
Hilus pulled upward Trachea pulled Wedging with apex in hilus

Medial lobe
Traction of the heart , hazy border Triangular shaped shadow beside the heart

Inferior lobe
Inferior lobe twisted pulled downward, medially backward Traction of the major fisure

Lobulus atelectasis
Fleischner line ( Diag < moveable) post op

Neonatal atelectasis
HMD Segmental atelectasis

Pneumonia
Lung parenchymal inflamation that radiologicaly shows a consolidation process affecting segmen / lobus in lung

Classification
Morphologi : Lobar, lobuler Etiology : virus, bacterial

Radiology appearance : (generally) Increasing density / inhomogen opaque

shadow affecting one/ few segmen / lobus No volume decrease / still visible air bronchogram Sometimes accompanied by hilar node enlargement Recovery : Reticular shadow

Viral pneumonia
Ro Reticulo noduler appearance in both lung field Patchy Generalised consolidation process

Bacterial pneumonia
Pneumococ pneumonia Usually lobar consolidation basal Pleural effusion rare

Staphylococ pneumonia
Usually affecting children / baby / elderly Superinfection with influenza Often with pleural effusion + cavitation

Friedlander pneumonia
Usually on elderly Usually lobar consolidation mostly right and top Accompanied by cavitation Clinical appearance severe

Varicella Zoster pneumonia

Epituberculosa
Non specific reaction from lung tissue around primary tuberculosa lesion

Pulmonary TBC
TBC on paediatric TBC on adult

Infection by
Oral Inhalation

Pulmonary infarction
Etiology Tumor Pneumothorax Atelectasis Vein obstruction Disturbance of pulmonal drainage Chronic cardiovascular disease

Ro Poligonal homogenous opaque

shadow, triangular or round shaped depending on the obstruction zone Usually in intersection between 2 pleura in lung base Cont..

Ro (cont..)
If emboli without infarction, the affected
area ussualy appear more lucent because of the ischaemic area perifer to the emboli Enlarged heart Sometimes accompanied by Pulmonary hipertension Radiological appearanced ussually disappear in 4-7 days

Nodular opaque radiological disorder Classification 1. Big nodule : > 2-3 cm

a. Solitary Lung abcess Primary lung carcinoma Pulmonary adenomatosis alveoler cell ca

 Solitary large metastase Hamartoma A-V aneurism Pulmonary sequestration = Accessories

lobe b. Multiple Multiple pulmonary metastasis tumor Pneumoconiosis

2. Small nodule 0,5-2 cm

3. Granuler nodule < 0,5 cm

Big nodule disorder : Solitary 1. Lung abscess

Ro: Round cavity, distinct border with wall consist of granulation tissue Usually around pleura and could rupture in into the pleura causing fistel Sometimes with air-fluid level

DD 1. Caverne TBC Irregular cavity, distinct border with TBC lesion around them Mostly in apex
2. Cavity in malignancy Thick wall, irregular border

3. Pulmonary cyst Thin walled sometimes multiple Sometimes Accompanied by emphysema

4. Mycotic processes cavitation Thin walled with fungus ball inside Positional change fungus ball changed Often with fistula

Pulmonary Carcinoma a. Bronchogenic Ca

Often Male > Female Right > often Age : 50 60 Related : Smoking, Radioactive material, TBC

a. Bronchogenic Ca

Classified into : a. Central type b. Perifer noduler c. Pneumonic type d. Miliar type

b. Pancoast tumor In apex sulcus posterior medius Posterior costae 1- 3 destruction with vertebral
erosion Cervicalis symphatis paralysis Horner syndrome

3. Alveolar Ca = Pulmonary adenomatosis Female = Male 40 years Ro: Small nodule on both lung field with large
masses in pulmonary base No visible node enlargement but shows nodal consolidation in perihiler Pleura ussualy not affected Heart normal