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
Content
I. Disorder of
A. Diaphragm
B. Pleura
C. Thoracic wall
II. Lung parenchym disorder
A. Radiopaque disorder
1. Diffuse
2. Noduler
3. Linear
B. Radioluscent disorder
1. Local
2. Diffuse
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
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. Thoracic wall shape & size disorder
a. 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. Thoracic wall density disorder
a. Deminishing density
Generalized osteophorosis / osteolysis
Osteogenesis imperfecta
Hyperparathyroid
Hypovitaminosis C & D
Achondroplasia / Thanatoporic

b. Increasing density (Sclerosis)

Prostatic Ca metastase
II. Lung parenchymal disorder
A. Radio opaque disorder
1. Diffuse homogen
2. Noduler
3. Linear

B. Radio lucent disorder

1. Generalized
2. Local
Diffuse homogenous radioopaque
Disorder

a. Pulmonary atelectasis /
collapse
b. Pneumonia
c. Epituberculosa
d. Lung infarct
 Atelectasis

Et/
Corpus alienum
Neoplasm
Mucus plug
Bronchial stricture / spasm
Atelectasis

Ro :
Primary Sign
Fissural shift
Hypoaeration radio opaque
Crowding 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
Cor pulled, hazy border
Triangular shaped shadow beside the heart

Inferior lobe
Inferior lobe twisted pulled downward,
medially backward
Pulling 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
Spoting
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
Epituberculosa
Non specific reaction from lung tissue around
primary tuberculosa lesion

Pulmonary TBC
TBC on paediatric
TBC on adult

Infection by
Oral
Inhalation
Adult TBC
1. Minimal lesion
No cavitation
Unilateral
Affecting apex to thoracal 4-5

2. Moderate lesion
Unilateral / bilateral
Lesion rarely more than one lung
Lesion is solid in more than 1/3 of lung
Cavitation is less than 4 cm
3. Far advance : > moderate lesion

4. Chronic fibroid
Constriction because of fibrosis
Shrinking of hemithorax
Tracheal deviation / pulled
Hilus pulled upward
Shrinking of intercostal space
Pulled diaphragm / heart
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
Position Apex
Basis
2/3 medial

3. Smooth nodule (Granuler) < 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 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
Left > 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
4. Hamartoma
Overgrowth of few tissue such as smooth
muscle fibrous cartilage tissue and vascular

Ro :
Round shadow, distinct border
diameter 2,5 9 cm
Soft tissue density
Calsification inside : pop corn
calcification
5. A-V Aneurysma = Pulmonary
Angioma
Dilatation of arterial-vein shunt
Fluoroscopy : Pulsating masses

Ro:
Medial lobe, Inferior lobe
Vascular appearance from hilar turn
to mass shadow (noduler)
6. Pulmonary sequestration /
Accesorius lobe
Intralobar / extralobar
One lung segment / Group lung segment
Bronchial branching separated from
normal
2/3 cases positioned on left postero
basal segment
6. Pulmonary sequestration /
Accesorius lobe
Ro :
Solid mass on left / right lung base
Infected / Connected with bronchus
air fluid level surounded by infected lung
tissue
Large multiple noduler disorder
1. Multiple metastasis tumor
From adjacent organ:
Oesophagus
Thyroid
Mammae
Emboli through
Pulmonary artery
Bronchial artery
Metastase in lung gave appearance of
a. Golf ball type
Sarcoma
Renal clear cell
Seminoma
b. Coin lesion type
Thyroid
Gaster
Ovarium uterus
Lymphosarcoma
Chorio Ca
c. Milliary type
Thyroid Ca
Mammae Ca
Sarcoma

d. Pleural metastase : Pleura

effusion
e. Pneumonic type
Oesophagus
Lung
Mammae

f. Lymphatic type
Lung
Gaster
Mammae
Pancreas
2. Pneumoconiosis
Occupational disease
Pulmonary disorder caused inhaled by foreign
substance

Lung reaction if invaded by foreign substance

Fibrosis : Silicate
No reaction : Siderosis
Pneumonitis & fibrosis : Beryllium, Mangan, Gas
Fibrosis / allergy : Cotton linen, Bagase, Sugar
Carcinogen : Radioactive, Asbestosis, Arsenic
Silicosis
Symptom appear after 3 years

R :
1. Lymphatic stage
Vascular + Lymph marking increasing
Homogenous shadows in base
2. Nodule stage
Nodules

3. Conglomeration &
Emphysematous stage
Nodules conglomerate
Asbestosis
Diffuse interstitial fibrosis on both lung
field
No nodule
Small bullae or bleb
Pleural fibrosis

Siderosis
Sclerosing only on smaller nodule
Berrylosis
Factory worker that produce chemical
used in petromax
R :
Like milliary tuberculosis
Increased bronchovascular marking
Confluent lesion, sometimes hazy
 Small nodule disorder
Depending on position
Apex : Pulmonary TBC

Undefined
TBC
Mycosis
Bronchopneumonia
 Small noduler disorder
Basis
Bronchiectasy + Secondary infection
Hypostatic pneumonia

In 2/3 lung medially

Pulmonary oedema
Bronchopneumonia
Small noduler, poorly defined,
irregular confluent
In middle and basis (ussually)
Pulmonary oedema
Infusion overload
Renal failure oedema
Heart failure oedema
CNS disease : cerebral tumor / post op
Collagen disease
Rheumatoid arthritis
Periarthritis nodosa
Scleroderma
Gas / fluid inhalation
Pulmonary oedema
Ro
Smooth / small noduler in medial
Ussualy >> cor
 Small multiple nodule disorder
Many, most important disorder are
Milliary TBC
Milliary carcinoma
Pneumocoliosis
Bronchiolitis
Alveolar cell Ca
Milliary mycosis
Cont..
 Sarcoidosis
Pulmonary amyloidosis
Bronchiectasy with secondary
infection
Interstitial bronchopneumonia
Rheumatic bronchopneumonia
Pulmonary congestion
Radioopaque disorder with increased lines

Lines shadow is caused by :

Arteries
Vein
Lymphatic
Bronchus
Artery
Active hyperemi

Ro
Straight line shadows
Distinct border
Diameter < vein
Hili doesnt enlarge
Vein
Pasive hyperemi
On Pulmonary congestion Decomp.
Cordis
Ro
Snaking lines
Poorly defined
Diameter > artery
Hili enlarged
Bronchus
Chronic infection on bronchus expand to
peribronchial connective tissue fibrosis
Chronic Bronchitis, Pneumoconiosis
Pulmonary oedema, Emphysema
Ro
Honeycomb
Reticular in lung base
Lymph. vessel
Mediastinal node enlargement
Lymphoma and lymphogen
metastase of malignant tumor
Ro
Stelate line shadow expanding from
hilus perifer
Enlarged hili, kerley lines
 Cor pulmonale chronicum
Lung chronic disorder that cause heart
disorder
Emphysema pulmonum
Vascular sclerosis
Pulmonal stenosis
Congestive heart disease with left to the right
shunt
Pulmonal fibrosis
Ro
Right ventricle >
Apex is upward and rounded
Bulging of pulmonal segment
(enlargement of Pulmonary
artery)
Pulmonary emphysema
Increased bronchial lines
Pulmonary congestion on heart failure
Passive hyperemia
Ro:
Vein dilatation
Dilatation of Pulmonary artery Secondary
Enlarged Hili
Shadowing in 2/3 medial
Cor >>, left > right
Sometimes accomp. by pleural effusion
Diaphragma elevation if accomp, by ascites /
hepatomegali
 Bronchiectasis
Patophysiology
a. Bronchial wall inflamation Peribronchial
scarring bronchi became unelastic
intraluminal pressure increase dilatation
of bronchus
b. Secondary inflamation on bronchus scar
tissue bronchial dilatation
Type :
Cylindrical
Sacculer
Varicose
Ro:
In latter stage shows reticular
shadowing/ honeycombing
Bronchial wall thickening
Pulmonary fibrosis
Fibrosis from interstitial tissue,
perivascular and peribronchial
On
Scleroderma
Lipoid storage disease
Inhalation agent
Radiation
Drugs : Bleomycin
Ro:
Diffuse Reticular shadows &
Emphysema in base / middle field
Flatening of costae
Diffuse radiolucency
Low position diaphragm
Small heart (tear drops)
 Pulmonary disorder with increasing
radiolucency
Extrapulmonary
a. Air trapped in normal space :
Pneumothorax
b. Air trapped in abnormal space :
Hernia diaphragmatica
Subphrenic colon interposition
Diaphramatic eventration
Intrapulmonary
a. Circumscript cavity
Cyst
Abscess
b. Diffuse
1. Over distention
Ball valve type obstruction
Emphysema
2. Vascular
Congestive pulmonary stenosis
Pulmonary emboli ( without infarction)
Pulmonary arterial displasia
Pulmonary cyst
Spherical cavity, thin walled, non
granulomatous, filled with air /
fluid
Classification
A. Solitary
Congenital cyst
Infection cyst
Neoplastic cyst

B. Multiple
Apex
Bleb
Blulla
Basal
Bronchiectasis cyst
Pneumatocele cyst
Undefined
Tuberculosa complication
Complication of other infiltrative
processes
Ro:
Spherical cavity in all projection
except in wedge location :
eq : near diaphragm

DD:/
Encapsulated pneumothorax
 If filled full with air
radioopaque
If Ruptured to bronchus air
fluid level
If infected thick walled, loss
of sharp defined became one
with lung
Congenital cyst
Origin
Embryonal primary lobe
Endoderm disorder mucosa like gaster
Connected / not connected with digestive
tract
Solitary thin walled with fluid
Connected with bronchus air fluid
level
Hydatid cyst / echinococcus
Cyst s Outer wall fibrous
tissue
Wall that border daughter &
granddaughter cyst hyalin
tissue
Filled with fluid
Ro
If ruptured ordinary cyst
If ruptured separated ectocyst
from adventitia tunica cyst
showed with double walled
Rarely calcified
Cyst > 10 cm
Bleb & Bulla
Bulla : Vesicular emphysema
area in lung tissue
Bleb : Interstitial emphysema
that located between visceral
pleura and lung tissue
Giant Bulla
Soliter, unilateral asym, lung
Bulla will pushes mediastinum
& diaphragma DD:
Pneumothorax
If very large DD:
pneumothorax
Pneumatocele
Pure interstitial emphysema
Wall from bronchial alveolus
adventitia tunica
In suppurative pneumonia
Pulmonary emphysema
Dilatation of part / whole lung that
filled with excessive air
Classification
a. General / Local
b. Acute / Chronic
c. Static / Progresive
Acute emphysema
1. Acute obstructive emphysema
Obstruction : Airways ball valve
obstruction
2. Acute vesicular emphysema
Obstruction on bronchioles because of
inflamation processes in bronchioli /
lung
In staphylococ pneumonia
3. Acute interstitial emphysema
Air is forced into pulmonary
interstitial
In: Pertussis
Penetration wound in thorax
4. Mediastinal Emphysema
Air is entering mediastinum On
Trauma : Tracheal perforation /
oesophagus mediastinum
In Pertussis
Ro : Luscent lines in mediastinum
Chronic emphysema
Etiologi : Unknown
In : Chronic cough / people that
work with wind producing
instrument
Ro
Widening of thorax transversal and AP
diameter
Flatening of costae
Lung hyperlucency
Interstitial fibrotic app. Small and narrow
heart
Enlargement and wide vascular
Lateral photo shows enlargement of
anterior mediastinum
Senile emphysema
Atrophy of alveoly wall that caused
chronic pulmonary emphysema
because of interstitial fibrosis
 Compensatory bullous emphsema
Cause : vanishing disease
If the process is progresive in one
periode serial photo
Presenting with cor pulmonale
Pulmonary segmen bulging, vascular,
bulging and widening of hili