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  1. 1. DAVID SUTTON PICTURES DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL
  2. 2. DAVID SUTTON 1 THE NORMAL CHEST: METHODS OF I NVESTIGATION AND DIFFERENTIAL DIAGNOSIS
  3. 3. Radiograph taken at 60 KV
  4. 4. Fig. 1.2 (A,B) Radiographs of patient in Fig. 1.1 taken at 1 70 kVp. Note the improved visualization of the main airways, vascular structures and the area behind the heart including the spine.
  5. 5. • Fig. 1.3 Encysted pleural fluid. (A) PA film. A right pleural effusion with a large well-defined midzone mass. (B) Lateral film. Loculated fluid is demonstrated high in the oblique fissure.
  6. 6. • Fig. 1.4 Collapse of the left lung. (A) PA film. (B) Lateral film. Only the right hemi diaphragm is visible. The radiolucency of the lower vertebrae is decreased.
  7. 7. • Fig. 1.5 Subpulmonary pleural fluid. (A) Erect PA radiograph. There is apparent elevation of the left hemidiaphragm. Increased translucency of the left lung is due to a left mastectomy. Note the abnormal axillary fold (arrow). (B) Left lateral decubitus film (with horizontal beam). Pleural fluid has moved to the most dependent part of the left hemithorax (arrows).
  8. 8. • Fig. 1.6 Elevated left main bronchus (arrows) and widened carina. Patient with mitral valve disease and an enlarged left atrium.
  9. 9. • Fig. 1.7 Normal thymus in a child, projecting to the right of the mediastinum (arrows).
  10. 10. Fig. 1.8 Pneumoperitoneum after laparotomy. The thin right cupola (small arrow) is outlined by the adjacent aerated lung and the free abdominal gas. Posterior consolidation (large arrow) obscures the outline of the diaphragm posteriorly.
  11. 11. Fig. 1.9 Azygos fissure. The azygos vein is seen to lie at the lower end of the fissure (arrow).
  12. 12. Fig. 1.10 Right inferior accessory fissure.
  13. 13. Fig. 1.11 Left-sided horizontal fissure.
  14. 14. Fig. 1.12 Ring shadow of the anterior segment bronchus of the left upper lobe seen end-on.
  15. 15. Fig. 1.13 Pulmonary vein (open arrow) draining into pulmonary confluence (closed arrow).
  16. 16. Fig. 1.14 The anatomy of the main bronchi and segmental divisions. Nomenclature approved by the Thoracic Society (reproduced by permission of the Editors of Thorax).
  17. 17. UPPER LOBE 1. Apical bronchus 2. Posterior bronchus 3. Anterior bronchus Right Left MIDDLE LOBE LINGULA 4. Lateral bronchus 4. Superior bronchus 5. Medial bronchus 5. I inferior bronchus LOWER LOBE 6. Apical bronchus 6. Apical bronchus 7. Medial basal (cardiac) 8. Anterior basal bronchus 8. Anterior basal bronchus 9. Lateral basal bronchus 9. Lateral basal bronchus 10. Posterior basal bronchus 1 0. Posterior basal bronchus
  18. 18. Fig. 1.14 The anatomy of the main bronchi and segmental divisions. Nomenclature approved by the Thoracic Society (reproduced by permission of the Editors of Thorax).
  19. 19. Fig. 1.15 The approximate positions of the pulmonary segments as they can be seen on the PA and lateral radiographs.
  20. 20. Fig1.17 Presentation of acinus
  21. 21. Fig. 1.17 Kerley B lines. Thickened interlobular septa in a patient with mitral valve disease.
  22. 22. Fig:1.18 Middle Mediastinal Lymph Nodes
  23. 23. Fig. 1.21 Thymoma. Obliteration of the retrosternal space.
  24. 24. Fig. 1.20 Normal lateral film. Note the retrosternal and retrocardiac clear spaces (open arrows) and the increased translucency of the lower vertebrae. The axillary folds (straight black arrows) and scapulae (curved black arrows) overlie the lungs. The tracheal translucency is well seen (small black arrows)
  25. 25. Fig. 1.21 Thymoma. Obliteration of the retrosternal space.
  26. 26. Fig. 1.22 (A) PA film. A moderate sized left pleural effusion and a small right effusion. (B) Lateral film. There is loss of translucency of the lower vertebrae, thickening of the oblique fissure (open arrow) and absence of the left hemidiaphragm, with loss of the right hemidiaphragm posteriorly (small arrows).
  27. 27. Fig. 1.23 Right middle lobe consolidation, demonstrating the silhouette sign with loss of outline of the right heart border.
  28. 28. Fig. 1.24 Right lower lobe consolidation. (A) Shadowing at the right base but the cardiac border remains visible. (B) Lateral film. Consolidation in the posterior basal segment of the lower lobe with obliteration of the outline of the diaphragm posteriorly and loss of translucency of the - lower vertebrae.
  29. 29. Fig. 1.25 Left upper lobe collapse. A carcinoma was present at the hilum. (A) Shadowing in the upper zone with loss of outline of the upper cardiac border. The aortic knuckle is outlined by compensatory hyperinflation of the superior segment of the lower lobe. There is tracheal deviation. (B) Anterior displacement of the collapsed lobe and greater fissure.
  30. 30. Fig. 1.26 Air bronchograms. An air bronchograms is clearly seen in the consolidated right upper lobe. A proximal carcinoma was present, although i t is unusual for an air bronchograms to occur in the presence of a neoplasm.
  31. 31. Fig. 1.27 Hyaline membrane disease. Extensive homogeneous consolidation with a prominent air bronchograms.
  32. 32. Fig. 1.28 Right upper lobe consolidation. Upper bowing of the horizontal fissure indicates some collapse. There is an acinar pattern with some confluence.
  33. 33. Fig. 1.29 Acute intra-alveolar pulmonary oedema with a bat's wing distribution.
  34. 34. Fig. 1.30 Fibrosing alveolitis. Diffuse interstitial shadowing in the lower zones.
  35. 35. Fig. 1.31 Miliary tuberculosis. Widespread fine nodular shadowing without confluence.
  36. 36. Fig. 1.32 Siderosis. Extensive dense miliary shadowing in an iron-foundry worker.
  37. 37. Fig. 1.33 Bronchocele with typical gloved-finger branching pattern.
  38. 38. Fig. 1.34 (A) A large lung abscess with a fluid level distal to a hilar carcinoma. There is an old right upper lobe collapse with compensatory emphysema. (B) Note bulging of the oblique fissure adjacent to the abscess (arrows).
  39. 39. Fig. 1.35 Sarcoidosis. Fibrosis mainly affecting the upper zones with elevation of the hila and tenting of the right hemidiaphragm. A 55-year-old woman with a
  40. 40. Fig. 1.36 Pneumatocele. Child with a staphylococcal pneumonia. Consolidation in the right upper lobe and a pneumatocele adjacent to the right heart border (arrows).
  41. 41. Fig. 1.37 Bronchiectasis due to bronchopulmonary aspergillosis.
  42. 42. Fig. 1.38 Reticulum cell sarcoma of right lower rib with an extra pleural mass.
  43. 43. Fig:1.39 Posteriorly positioned bronchial carcinoma with destruction of adjacent rib
  44. 44. Fig. 1.40 Hamartoma with popcorn calcification.
  45. 45. Fig:1.41 Multiple calcified metastasis from a chondrosarcoma of right tenth rib
  46. 46. Fig. 1.42 Arteriovenous malformation with dilated feeding and draining vessels.
  47. 47. Fig. 1.43 Staphylococcal abscesses. Multiple cavitating abscesses in a young male heroin addict. Bilateral effusions also present
  48. 48. Fig. 1.44 Large irregular thick-walled cavitating neoplasm with air-fluid level.
  49. 49. Fig. 1.45 Bullous emphysema with curvilinear shadows in the right lung and an associated paucity of vascular markings.
  50. 50. Fig. 1.46 Aspergillus mycetoma. A large mycetoma within an old tuberculous cavity in a fibrotic upper lobe. The mycetoma is surrounded by an air crescent
  51. 51. Fig. 1.47 Apical plombage. Hollow Lucite spheres with fluid levels which have formed because of leakage of the walls of the spheres.
  52. 52. Fig. 1.48 Pulmonary tuberculosis. Numerous calcified foci in both upper zones with left upper lobe fibrosis.
  53. 53. Fig. 1.49 Chickenpox. Widespread small calcified opacities following a previous chickenpox pneumonia.
  54. 54. Fig:1.50 Pancoast tumour. There is apical shadowing on the right side simulating pleural thickening. Note destruction of the first rib.
  55. 55. Fig. 1.51 A woman with her hair in a plait overlying the upper mediastinum and simulating mediastinal widening.
  56. 56. Fig. 1.52 Right middle lobe collapse. (A) Loss of definition of the right heart border with adjacent shadowing. (B) Lobar collapse with displacement of the fissures clearly shown.
  57. 57. Fig. 1.53 Pulmonary agenesis. The right lung is absent. The heart and mediastinum are displaced to the right. Note herniation of the left lung across the midline (arrows). The rib spaces are narrowed on the right.
  58. 58. Fig. 1.54 'Golden S sign.' Collapsed right upper lobe with mass at right hilum.
  59. 59. Fig. 1.55 A young man with Hodgkin's disease. An enlarged lobulated right hilum typical of bronchopulmonary glandular enlargement.
  60. 60. Fig. 1.56 Obstructive emphysema. This child inhaled a peanut. (A) Inspiratory film shows a hypertransradiant right lung. (B) Expiratory film. There is air trapping on the right side with further shift of the mediastinum to the left.
  61. 61. Fig. 1.57 Right posterior oblique (55°) tomogram of right hilum. PA = pulmonary artery; V = pulmonary vein; uL = upper lobe bronchus; i b = intermediate bronchus; mL = middle lobe bronchus; LL = lower lobe bronchus.
  62. 62. Fig. 1.58 Oat cell carcinoma. (A) Peripheral mass adjacent to the ribs. (B) Oblique tomogram shows an irregular mass with thin strands extending into the surrounding lung.
  63. 63. Fig: 1.59 Extensive pulmonary embolism within both lower lobe arteries and right middle lobe artery
  64. 64. Fig. 1.60 3D surface-rendered image from segmented dataset of a pediatric chest scan. The umbilical vein (visible due to an in situ catheter) and abdominal aorta are both depicted in red below the diaphragm, a right-sided chest drain is also present.
  65. 65. Fig. 1.62 Cutting needle biopsy of right mid-zone mass under CT control (carcinoid). The low-attenuation artifact shows the precise position of the needle tip.
  66. 66. Fig. 1.64 High-resolution sections through the thorax demonstrate the segmental bronchi. (A) Upper section; upper lobe segmental bronchi are seen passing perpendicular to the plane of the slice. (B) At the level of origin of right upper lobe bronchus. The proximal upper lobe segmental bronchi are well seen. (C) At the level of origin of left upper lobe bronchus. The oblique and horizontal fissures are shown. (D) On each side the apical segment lower lobe bronchi are seen posteriorly, as well as the middle lobe bronchus and parts of the lingular bronchi anteriorly. (E) The lower lobe bronchi are dividing on each side into segmental bronchi. (F) The right lower lobe bronchus has divided into medial, anterior, lateral and posterior basal segmental bronchi. The left lower lobe bronchus has divided into anterior, lateral and posterior basal segmental bronchi.
  67. 67. Fig. 1.67 Large areas of reduced pulmonary density (arrowheads) and bulla (arrow) in emphysema
  68. 68. Fig. 1.68 Carcinoma of the lung incorporating calcification (arrow) from previous tuberculous granuloma. The tumour is extending into the mediastinum to encase the left common carotid and subclavian arteries (arrowheads).
  69. 69. Fig. 1.69 Tubular bronchiectasis in a patient with cystic fibrosis
  70. 70. Fig. 1.71 HRCT 3-mm section. Fibrosing alveolitis. Note the predominantly peripheral involvement. (Courtesy of Dr P. M. Taylor.)
  71. 71. Fig. 1.73 HRCT asbestosis. Note the thickened septa and fibrous parenchymal and sub pleural bands
  72. 72. Fig. 1.74 HRCT soft-tissue window demonstrates asbestos-related pleural disease with posteromedial calcified pleural plaques (arrows).
  73. 73. Fig. 1.75 Rounded atelectasis with 'comet tail' of vessels running into the mass which is adherent to the pleura. Adjacent calcified pleural plaque i s evident (arrow). There is also oral contrast medium in the oesophagus (arrowheads).
  74. 74. Fig. 1.76 HRCT lymphangitis carcinomatosa from carcinoma of the breast. Note the thickened interlobular septa. (Courtesy of Dr P. M. Taylor.)
  75. 75. Fig. 1.82 Occult metastasis in the posterior costophrenic sulcus (arrow).
  76. 76. Fig. 1.83 HRCT rheumatoid lung with cavitating nodules, broncbiectasis and emphysema.
  77. 77. Fig. 1.84 Pleural effusion and ascites-note the relationship of the fluid to the right diaphragmatic curs with pleural fluid lying posterior to (and therefore above) the curs (arrow). Ascitic fluid is evident around the spleen and anterolateral to the liver.
  78. 78. Fig. 1.85 Pleural metastatic tumour from carcinoma of the breast, encasing the lung with consequent volume loss, crowding of the ribs and a malignant effusion. Note the contralateral mastectomy.
  79. 79. Fig. 1.87 Normal lung perfusion (A) and ventilation (B) images.
  80. 80. Fig. 1.88 Pulmonary embolism. Perfusion images (A) show multiple segmental perfusion defects while ventilation images (B) are normal.
  81. 81. Fig 1.89 Artefacts on perfusion images produced by clumping of albumin particles in the syringe at the time of injection.
  82. 82. Fig. 1.93 Bullous emphysema. SPECT images showing multiple areas of reduced perfusion particularly affecting lung apices, as shown on coronal (A) and axial (B) slices, and truncated apices shown on 3D volume-rendered image (C). (Courtesy of Dr R. Robertson).
  83. 83. Fig. 1.94 Unsuspected lung metastases shown by somatostatin receptor scintigraphy. (A) Primary pancreatic islet cell tumour (large arrow) with small lung lesions (small white arrows). (B) An occult lung metastasis in a patient with abdominal carcinoid.
  84. 84. Fig. 1.96 Respectable carcinoma of the lung. FDG-PET (A) and CT (B) images show primary tumour but no mediastinal lesions; correct staging was confirmed at surgery and histology. (Courtesy of the Clinical PET Centre, Guy's and St Thomas's Hospitals, London.)
  85. 85. Fig.1.98 Recurrent tumor after lung resection. FDG-PET images show active deposits in right lung, mediastinum, liver and bone. (Courtesy of the Clinical PET Centre, Guy's and St Thomas's Hospitals, London.)
  86. 86. Fig. 1.99 Benign solitary lung nodule. The lesion shown on CT (A) and on the PET transmission image (B) is inactive on the FDG-PET image (C). (Reproduced with permission from Maisey et al.)
  87. 87. Fig. 1.102 High-resolution CT. Left lower lobe bronchiectasis.
  88. 88. Fig. 1.112 Rickets. Enlargement and cupping of the anterior ends of the ribs (large arrow). Note the metaphyseal changes in the humeri (small arrow).
  89. 89. Fig. 1.117 Eventration. (A) The left cupola is elevated and the heart displaced to the right. (B) The lateral film shows the elevated left cupola with adistended stomach and a normal right cupola.
  90. 90. Thanks

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