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RESPIRATORY SYSTEM

IMAGING
• Dr. Inge Friska, SpRad
IMAGING OF NASAL CAVITY & PARANASAL SINUSES

• Paranasal sinuses embryology & development

• Maxillary & ethmoid sinuses during fetal life

• Frontal & sphenoid sinuses develop during


the early years of life

• Radiographic imaging :

• X-ray (AP, lateral & Waters)

• CT scan
AP LATERAL WATERS
ACUTE SINUSITIS
• An acute inflammation of the nasal and paranasal sinus mucosa that last
less than four weeks

• Clinical presentation : Fever, headache, postnasal discharge of thick sputum,


nasal congestion and abnormal smell

• Etiology : following viral upper respiratory tract infection, dental caries,


allergy, nasal septal deviation

• Radiographic imaging :

• X-ray : Opacification of the sinuses and air/fluid level best seen in the
maxillary sinus

• CT scan :

• Better anatomical delineation and assessment of inflammation


extension, causes and complications.

• Peripheral mucosal thickening, air/fluid level, air bubbles within the fluid
and obstruction of the ostiomeatal complexes
CHRONIC SINUSITIS

• Ongoing long term sinus infection-inflammation that


often develops secondary to a prolonged/refractory
acute sinus infection.

• Radiographic imaging :

• CT scan :

• Sclerotic thickened bone involving the sinus wall


from a prolonged mucoperiosteal reaction. 

• Intrasinus calcification may be present.


PHARYNX

• Mucosa-lined musculomembranous tube, 12 - 14 cm

• Nasopharynx, oropharynx,
laryngopharynx/hypopharynx
RETROPHARYNGEAL ABSCESS
• A potentially life-threatening infection involving the
retropharyngeal space which requires prompt diagnosis
and aggressive therapy.

• 75% of cases occurring before the age of 5 years

• Radiographic imaging :

• X-ray :

• Soft tissue swelling posterior to the pharynx, with a


widening of the prevertebral soft tissue stripe

• CT scan

• MRI
PERITONSILLAR ABSCESS

• Collection of pus that lies between the tonsillar


capsule and superior pharyngeal constrictor muscle.
It is generally thought to result as a complication of
tonsilitis

• Radiographic imaging :

• CT scan :

• 75% specific and 100% sensitive

• Rim-enhancing fluid collection within an enlarged


and inflamed tonsil
CHEST  IMAGING

• Basic examination : posteroanterior (PA) & lateral


chest radiograph

• Projections : Anteroposterior (AP), lateral, top lordotic

• Positions : erect, supine, decubitus, oblique

• Full inspiration
 

PA AP
CTR

• CTR = cardio - thoracic ratio

• a = 1 maximal horizontal
cardiac diameter

• b = maximal horizontal thoracic


diameter (inner edge of ribs /
edge of pleura)
a
• CTR = a / b

Normal should be less than 0.5 b


PNEUMONIA
• Infectious pulmonary process

• Characterized by inflammatory exudate in alveoli &


interstitium

• Classification :

• Etiology : bacterial, fungal, aspiration, viruses, other


microorganism

• Morphology of nature and extent of inflammatory


exudate : lobar pneumonia, bronchopneumonia,
interstitial pneumonia

• Location : community acquired pneumonia, hospital


acquired pneumoni
RADIOLOGIC PATTERN OF PNEUMONIA

 
LOBAR  PNEUMONIA

• Alveolar or airspace consolidation

• Causative organisms are inhaled

• Radiologic findings :

• Homogenous opacification of the involved lobes or


segments

• Patent bronchi within homogenous consolidation —


> air bronchogram
BRONCHOPNEUMONIA
• = lobular pneumonia, suppurative peribronchiolar
inflammation and subsequent patchy consolidation
of one or more secondary lobules of a lung in
response to bacterial pneumonia

• Radiologic findings :

• Multiple small nodular or reticulonodular opacities


which tend to be patchy and/or confluent. This
represents areas of the lung where there are
patches of inflammation separated by normal lung
parenchyma.

• The distribution is often bilateral and asymmetric,


predominantly involves the lung bases
INTERSTITIAL  PNEUMONIA

• Inflammatory infiltration of lung connective tissue.


Spreading of inflammatory process to the
interlobular septa and lymphocytic infiltration of
the peribronchial alveoli

• Radiologic findings :

• Linear and reticular opacities most marked in the


perihiler lung
VIRAL RESPIRATORY TRACT INFECTION

• Avian influenza (H5N1)  RNA viruses (orthomyxoviridae)


• Radiographic finding :
• Bilateral perihilar peribronchial thickening
• Interstitial infiltrates
• Air space consolidation
• Imaging findings alone are not sufficient for the definitive
diagnosis of viral pneumonia.
• Radiographic patterns can be variable dependant on virus
as well as host factors
PULMONARY TUBERCULOSIS
• Incidence & prevalence of TB : developing countries, endemic regions, HIV,
DM, steroid therapy

• Divided : primary & post primary

• Radiographic findings :

1. Primary TB

• Initial focus infection can be located anywhere within the lung in


children, upper / lower. zone in adults.

• Patchy areas, lobar consolidation

• Ghon lesion : focus of caseating granuloma

• Ipsilateral hilar and mediastinal lymphadenopathy

• Pleural effusion (>> adults)

• Cavitation is rare
PULMONARY TUBERCULOSIS
2. Post Primary TB

• = reactivation TB / secondary TB

• Occurs years later, decreased immune status

• Location : posterior segments of upper lobe (apex) & superior


segments of lower lobe (segment 6)

• Radiographic findings :

• Patchy consolidation, poorly defined linear & nodular opacities

• Cavitas

• Tuberculoma : well defined rounded mass typically in upper


lobes

• Endobronchial spreading
PULMONARY TUBERCULOSIS

Milliary TB

• Hematogenous dissemination of uncontrolled TB


infection

• Seen both in primary & post primary TB

• Radiographic findings :

• Miliary deposits appear as 1-3 mm diameter


nodules, uniform in size and uniformly distributed
LUNG ABSCESS
• Collection of pus within the lung, and potentially life
threatening. They are often complicated to manage
and difficult to treat.

• Radiologic findings :

• Most arise within areas of pneumonic consolidation


and are marked by development of a discrete area
of low density necrosis and cavitation.

• Posterobasal segment >>

• Radiologic progression may be quite rapid. Rupture


of an abscess into a draining bronchus produces a
cavity with an air−fluid level
ASPIRATION PNEUMONIA
• Caused by direct chemical insult due to the entry of a
foreign substance, solid or liquid., into the respiratory
tract

• Almost always occurs in the most dependent portions


of the lung

• Upright : lower lobes, right side >> left

• Recumbent : superior segments of the lower lobes /


posterior segments of the upper lobes

• Radiographic findings :

• Airspace opacification in a lobar or segmental


PNEUMOTHORAX
• Air in pleural space

• Three categories :

• Primary spontaneous

• No known underlying lung disease

• Tall and thin people

• Ex : Marfan syndrome

• Secondary spontaneous

• Underlying lung is abnormal (bullae, abscess)

• Iatrogenic / traumatic
PNEUMOTHORAX

• Radiographic finding :

• CHEST X-RAY

• Visible visceral pleural edge

• No lung markings are seen peripheral to visceral


pleural edge

• Peripheral space is radioluscent compared to adjacent


lung

• Lung collapse

• Shifting of mediastinum  tension pneumothorax


TENSION PNEUMOTHORAX
HEMITHORAX OPACITY

• Major causes :

• Atelectasis

• Pleural effusion

• Pneumonia

• Post pneumectomi
ATELECTASIS

• Lung collapse

• Categorized based on underlying mechanism :

• Obstructive atelectasis  obstruction of an airway

• Passive atelectasis  pleural effusion /. pneumothorax

• Compressive atelectasis  SOL

• Cicatrisation atelectasis  scarring / fibrosis

• Adhesive lung atelectasis  surfactant deficiency


ATELECTASIS
• Categorized based on morphology :

• Linear

• Lobar

• Segmental

• Round

• Radiographic findings :

• Increased density (opacity) of the atelectatic portion of the lung

• Displacement of the fissure toward the area of atelectatic

• Crowding of pulmonary vessels and bronchi

• Compensatory overinflation of unaffected lung


PLEURAL EFFUSION
• Collection of fluid within the pleural space

• Radiographic findings :

• PA view : 250 ml  evident

• Lateral : 75 ml

• Lateral decubitus : 15-20 ml  most sensitive

• AP / PA chest

• Blunting of costophrenic angle with meniscus sign

• Fluid within horizontal / oblique fissure

• Large volume  mediastinal shift


PLEURAL EFFUSION

• Lateral view :

• Able to identify a smaller amount of fluid at posterior


costophrenic angle

• Lateral decubitus : most sensitive

• Right lateral decubitus

• Left lateral decubitus

• Supine :

• Increased density
NORMAL MENISCUS SIGN
PA ERECT LATERAL VIEW
RIGHT LATERAL DECUBITUS
LEFT LATERAL DECUBITUS
SUPINE ERECT
LOCULATED PLEURAL EFFUSION
MASSIVE LEFT PLEURAL EFFUSION
BRONCHIECTASIS
• Abnormal irreversible dilatation of the bronchial tree

• Clinical presentation : recurrent chest infection, chronic productive cough &


haemoptysis

• Causes :

• Post infection : necrotizing bacterial infection

• Congenital

• Bronchial obstruction

• Types according to morphology :

• Cylindrical

• Varicose

• Cystic

• Best imaging : HRCT (Hight resolution CT)


BRONCHIECTASIS

• Features :

• Bronchus visualised within 1 cm of pleural surface

• Lack of tappering

• Increased bronchoarterial ratio

• N  1 : 1 – 1,5

• Bronchiectasis  1 : > 1.5

• Bronchial wall thickening


BRONCHIECTASIS
• CYLINDRICAL
BRONCHIECTASIS

• Bronchi have a
uniform calibre, do
not taper & have
parallel walls  tram
track sign & signet
ring sign

• Coarse linear
shadowing

• Commonest

• CT : signet ring sign


BRONCHIECTASIS

• VARICOSE
BRONCHIECTASIS

• Beaded
appearance

• Relatively
uncommon
BRONCHIECTASIS

• CYSTIC (SACCULAR)
BRONCHIECTASIS

• Severe form

• Cyst like bronchi


that extend to the
pleural surface

• Air fluid level

• CT : cluster of
grapes sign
BRONCHIAL ASTHMA

• Hyper-reactivity of the airways to a variety of allerfic,


infectious, toxic and psychic stimuli

• Chronic airway inflammation and reversible obstruction

• 75% patients  normal chest X-ray

• Clinical presentation : wheeze, shortness of breath, chest


tightness, cough

• Radiographic findings :

• Pulmonary hyperinflation

• Bronchial wall thickening : peribronchial cuffing


CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

• Include two component :

• Chronic bronchitis small airway disease

• Emphysema

• Risk factor : cigarette, industrial exposure, cystic fibrosis,


alpha-1 antitrypsin deficiency, etc

• Clinical presentation : dypsnoea on exertion, wheezing,


productive cough, pursedlip breathing

• Morphological subtypes : centrilobular (centriacinar),


panacinar, paraseptal
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

• Radiographic findings :

• Chronic bronchitis :

• Increased bronchovascular markings

• Emphysema :

• Lung hyperinflation

• Widened intercostal space

• Flattened hemidiaphragms

• Small heart

• Possible bullous changes