DAVID SUTTON PICTURES ONLY FOR STUDY

1. 6DISEASES OF THE AIRWAYS: COLLAPSE
AND CONSOLIDATION
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 6.1 Tracheo-oesophageal fistula. A lateral
chest radiograph shows the fistula between the
trachea and the oesophagus (arrow). The
oesophagus is air filled (arrowheads).

4. • Fig. 6.2 Relapsing polychondritis. (A) CT scan just
above level of aortic arch shows diffuse thickening of
tracheal wall with abnormal calcification and
narrowing of the tracheal lumen. (B) CT scan just below
level of carina shows identical abnormalities extending
into both main bronchi.

5. • Fig. 6.3 Squamous carcinoma of the trachea. (A)
Close-up of the lateral chest X-ray demonstrates
narrowing of the trachea with irregularity of the
posterior wall (arrows). (B) AP tomogram
demonstrating lobulated filling defects within the
tracheal air column.

6. • Fig. 6.4 Adenoid cystic carcinoma of the trachea. (A) CT
demonstrates a , mass within the left lateral tracheal wall
causing only slight distortion of the lumen. The
extraluminal component extends into the adjacent
mediastinal fat (arrows). (B) CT image 2 cm cranial to the
lesion demonstrates normal tracheal wall thickness.

7. • Fig. 6.5 There is a stricture (arrows) of the
trachea following tracheostomy 10 years
earlier.

8. • Fig. 6.6 Mounier-Kuhn syndrome. There is
dilatation of the trachea in association with
bronchiectasis (arrows). There are also
multiple paraseptal bullae (curved arrow).

9. • Fig. 6.7 Kartagener's syndrome. (A) There is dextrocardia
and widespread bronchiectasis, most obvious at the left
base. (B) A lateral view demonstrates an air-fluid level
(arrows) within a dilated bronchus.

10. • Fig. 6.8 Bronchiectasis. Tramline shadows are
visible through the heart shadow.

11. • Fig. 6.9 Bronchiectasis. Multiple ring shadows, many
containing air-fluid levels, are present throughout the
lower zones of this patient with cystic bronchiectasis.

12. • Fig. 6.10 Cylindrical or tubular bronchiectasis. CT
image at the level of the hila demonstrates
widespread bronchiectasis, particularly well seen
is the apical segment of the right lower lobe. The
bronchi fail to taper and have irregular thickened
walls.

13. Fig. 6.11 Cystic bronchiectasis. A CT image
through the upper lobes demonstrates
multiple ring shadows. More caudal images
reveal these to be due to irregularly dilated
bronchi.

14. • Fig. 6.12 Bronchiectasis with mucus plugging. A
CT scan through the posterior costophrenic
recesses showing multiple fluid-filled dilated
bronchi causing a string of rounded opacities in
the posterior costophrenic angle. (Same patient
as illustrated in Fig. 6.1 3.)

15. • Fig. 6.13 Bronchiectasis. CT image through the right lower lobe
reveals dilated subsegmental bronchi. Note how the bronchi are
larger than the accompanying vessels. Several bronchi demonstrate
the signet ring sign (arrows). Plugging of peripheral smaller bronchi
is evident (curved arrow).

16. • Fig. 6.14 Bronchiectasis with air trapping. CT
image at end expiration demonstrates areas of
relatively higher and lower attenuation. The
lower attenuation areas indicate air trapping.

17. • Fig. 6.15 Cystic fibrosis. (A) Chest X-ray
during an acute chest infection showing left
perihilar and right midzone consolidation. (B)
Close-up of the right midzone demonstrating
multiple ring shadows and tramlines due to
extensive bronchiectasis. (C) Six months later
the acute changes have resolved leaving a
background of bronchiectasis.

18. Fig. 6.15 Cystic fibrosis. (A) Chest X-ray during an acute chest
infection showing left perihilar and right midzone
consolidation. (B) Close-up of the right midzone
demonstrating multiple ring shadows and tramlines due to
extensive bronchiectasis. (C) Six months later the acute
changes have resolved leaving a background of bronchiectasis.

19. • F19. 6.16 Cystic
fibrosis. There are
widespread
bronchiectatic
changes and a large
right pneumothorax;
a small left apical
pneumothorax is
also present.

20. • Fig. 6.17 Asthma in a woman of 64. (A) During an
asthmatic attack the lungs are hyperinflated, the
diaphragms being depressed and flattened. (B)
During remission the chest radiograph is normal.

21. • Fig. 6.18 Chronic bronchitis in a man of 62. Small
poorly defined opacities are present throughout
both lungs, producing the 'dirty chest'. This
contrasts with the clear lungs in Fig. 6.1713.

22. • Fig. 6.19 Emphysema in a man of 54. The lungs are hyperinflated,
the diaphragm being low and flat. The peripheral vascular pattern is
attenuated in the right mid and left mid and lower zones. The
central pulmonary arteries are enlarged, indicating pulmonary
arterial hypertension. The heart is elongated.

23. • Fig. 6.20 Emphysema in a man of 52. Lateral film
shows increased lung volume, which is producing a
barrel chest. The retrosternal space is deeper than
normal and extends more inferiorly than normal.

24. • Fig. 6.21 Multiple bullae. (A) CT scan through the
level of the right main pulmonary artery reveals
multiple bullae predominantly in the right lung.
(B) CT scan further toward the lung bases
revealing several further bullae. Some of these
have well-defined walls.

25. • Fig. 6.22 Bilateral upper zone bullae in a man of 35. 'Routine' chest
X-ray-no history or symptoms of respiratory disease. Both upper
zones are occupied by large bullae which are compressing the
upper lobes. There is no evidence of generalised emphysema or air
trapping. The level and shape of the diaphragm are normal.

26. • Fig. 6.23 Emphysema with bullae in a man of 61. The lungs are
hyperinflated. A giant bulla occupies most of the left hemithorax,
compressing the left lung. Strands of lung tissue (arrowheads) are
seen crossing this bulla. Small bullae (arrows) are also present in
the right lung.

27. • Fig. 6.24 Emphysema with infected bulla in a man of 48. (A) The
lungs are hyperinflated. The right upper zone is occupied by a
large bulla, and another bulla is seen adjacent to the left heart
border (arrows). The central pulmonary arteries are enlarged. (B)
Following a chest infection the left-sided bulla has filled with fluid
and appears completely opaque.

28. • Fig. 6.25 Unilateral emphysema in a man of 30 with a history of repeated chest infections as a
child, but no current respiratory symptoms. (A) Inspiratory film shows normal right lung and
hypertransradiant left lung with small left pulmonary artery. (B) Expiratory film demonstrates
displacement of mediastinum to the right and restricted movement of the left hemidiaphragm,
indicating air trapping in the left lung. (C) CT scan through the upper lobes of a different patient
with unilateral emphysema. At end expiration there is air trapping within the left lung where the
vessels are relatively attenuated.

29. • Fig. 6.25 Unilateral emphysema in a man of 30 with a history of
repeated chest infections as a child, but no current respiratory
symptoms. (A) Inspiratory film shows normal right lung and
hypertransradiant left lung with small left pulmonary artery. (B)
Expiratory film demonstrates displacement of mediastinum to the
right and restricted movement of the left hemidiaphragm,
indicating air trapping in the left lung. (C) CT scan through the upper
lobes of a different patient with unilateral emphysema. At end
expiration there is air trapping within the left lung where the
vessels are relatively attenuated.

30. • Fig. 6.26 Obliterative bronchiolitis due to graft-versus-host
disease. (A) Close-up view of the right lower zone reveals patchy
areas of higher and lower attenuation and thin-walled dilated
bronchi. (B) Obliterative bronchiolitis in a different patient. A CT
scan obtained at end expiration shows marked variation in the CT
attenuation within the lungs. The relatively hypodense areas have
failed to deflate due to small airways disease.

31. • Fig. 6.27 Panbronchiolitis. There are multiple
branching opacities representing distended
and occluded small airways.

32. • Fig. 6.28 Cryptogenic organising pneumonia in a
70-year-old man with chronic consolidation. The
appearances had been unchanged for several
weeks despite multiple courses of antibiotics.

33. • Fig. 6.29 Cryptogenic organising pneumonia.
There is a wedge-shaped pleurally based patch of
consolidation containing an air bronchogram. The
diagnosis was confirmed following a
percutaneous needle biopsy.

35. • Fig. 6.31 Bronchial atresia. There is a well-defined
opacity in the right lower lobe surrounded by a patch
of emphysematous lung (arrowheads).

36. • Fig. 6.32 Complete
collapse of the left
lung. A newborn child
with complex cyanotic
heart disease. The tip
of the endotracheal
tube (arrow) is beyond
the carina (asterisk)
and down the right
bronchus, causing
collapse of the left
lung and
compensatory
hyperinflation of the
right lung which has
herniated across the
midline (arrowheads).

37. • Fig. 6.33 Complete collapse of the left lung due to a left hilar
tumour. (A) The chest radiograph demonstrates deviation of the
trachea and shift of the mediastinum to the left. Air-soft-tissue
interfaces are seen due to herniation of the right lung across the
midline (arrowheads). (B) CT scan demonstrates herniation of both
the retrosternal lung and the azygo-oesophageal reflection. The
oesophagus contains a small amount of air (arrow).

38. • Fig. 6.34 Right upper lobe collapse. (A) PA
projection. Note how lesser fissure is drawn
upward, and often curved, toward the apex and
mediastinum. (B) Right lateral view. Lesser fissure
also displaced upward. Note some forward
displacement of greater fissure above the hilum.

39. • Fig. 6.35 (A) PA film shows a mass (white arrowhead) above the right
hilum, and elevation of the horizontal fissure (black arrowheads). There is
compensatory hyperinflation of the right lower lobe. (B) Lateral film shows
anterior displacement of part of oblique fissure (arrowheads). (C) CT scan
of right upper lobe collapse in a different patient (images on mediastinal
window settings.)

40. • Fig. 6.35 (A) PA film shows a mass (white arrowhead)
above the right hilum, and elevation of the horizontal
fissure (black arrowheads). There is compensatory
hyperinflation of the right lower lobe. (B) Lateral film shows
anterior displacement of part of oblique fissure
(arrowheads). (C) CT scan of right upper lobe collapse in a
different patient (images on mediastinal window settings.)

41. • Fig. 6.36 Right middle lobe collapse. In both
projections the lesser fissure fissure is drawn
downward. In the PA view (A) the fissure
finally merges with the mediastinum and
disappears. Note in the lateral view (B) that
the lower part of the greater fissure may be
displaced forward.

42. • Fig. 6.37 Right middle lobe collapse. (A) PA film shows
loss of definition of the right heart border indicating
loss of aeration of the middle lobe. (B) A lateral film
shows partial collapse of the middle lobe evident as a
wedge-shaped opacity (arrows).

44. • Fig. 6.39 Right lower lobe collapse. (A) Normal preoperative film.
(B) Following coronary artery bypass surgery there is right lower
lobe collapse with depression and medial rotation of the hilum,
elevation of the right hemidiaphragm and hyperinflation of the
right upper lobe.

45. • Fig. 6.40 Left lower lobe collapse. No fissure is
visible in the PA projection. The lateral view
shows that the greater fissure is displaced
posteriorly as in collapse of the right lower lobe.
The upper part of the fissure may also be drawn
downward as well as backward.

46. • Fig. 6.41 (A) Sixty-six-year-old man with squamous cell carcinoma of the left lower lobe. The oblique fissure is
displaced posteriorly (black arrows).The left hemidiaphragm is obscured by the collapsed lobe, but the position
of the stomach bubble (white arrows) indicates that the left hemidiaphragm is elevated. (B) Postoperative film
of patient with aortic valve replacement. The shadow of the collapsed left lower lobe (black arrowheads) is
seen through the shadow of the heart (white arrowheads). (C) Fifty-seven-year-old man with oat cell carcinoma
occluding the left bronchus (arrow). The left lower lobe is collapsed, obscuring the left hemidiaphragm. The
mediastinum is shifted to the left, and part of the hyperinflated right lung has herniated across the midline
(arrowheads).(D) Left lower lobe collapse demonstrated on CT. There is mixed density within the collapsed
lung, probably due to fluid-filled bronchi.

47. • Fig. 6.41 (A) Sixty-six-year-old man
with squamous cell carcinoma of the
left lower lobe. The oblique fissure is
displaced posteriorly (black arrows).The
left hemidiaphragm is obscured by the
collapsed lobe, but the position of the
stomach bubble (white arrows)
indicates that the left hemidiaphragm is
elevated. (B) Postoperative film of
patient with aortic valve replacement.
The shadow of the collapsed left lower
lobe (black arrowheads) is seen through
the shadow of the heart (white
arrowheads). (C) Fifty-seven-year-old
man with oat cell carcinoma occluding
the left bronchus (arrow). The left lower
lobe is collapsed, obscuring the left
hemidiaphragm. The mediastinum is
shifted to the left, and part of the
hyperinflated right lung has herniated
across the midline (arrowheads).(D) Left
lower lobe collapse demonstrated on
CT. There is mixed density within the
collapsed lung, probably due to fluid-
filled bronchi.

48. • Fig. 6.42 Lingula and left upper lobe collapse in a man with carcinoma at the left hilum. (A) PA
film shows hazy left heart border, indicating loss of aeration of the lingula. A mass is present in the
aortopulmonary window (arrowhead). (B) Lateral film shows collapse-consolidation of the lingula,
with anterior displacement of the lower part of the oblique fissure (arrowheads). The upper part of
the oblique fissure (arrows) is thickened, but in normal position. (C) Five weeks later the left upper
lobe has collapsed. A hazy opacity covers most of the left hemithorax. Vessels in the hyperinflated
left lower lobe can just be seen through the haze, and the aortic knuckle is obscured (arrowhead).
(D) Lateral film shows that the oblique fissure is now displaced anteriorly (arrows).

49. • Fig. 6.42 Lingula and left upper lobe collapse in a man with carcinoma at the left hilum. (A) PA
film shows hazy left heart border, indicating loss of aeration of the lingula. A mass is present in the
aortopulmonary window (arrowhead). (B) Lateral film shows collapse-consolidation of the lingula,
with anterior displacement of the lower part of the oblique fissure (arrowheads). The upper part of
the oblique fissure (arrows) is thickened, but in normal position. (C) Five weeks later the left upper
lobe has collapsed. A hazy opacity covers most of the left hemithorax. Vessels in the hyperinflated
left lower lobe can just be seen through the haze, and the aortic knuckle is obscured (arrowhead).
(D) Lateral film shows that the oblique fissure is now displaced anteriorly (arrows).

50. • Fig. 6.43 Left upper lobe collapse. (A) The greater fissure does not become
visible in the PA projection. When the degree of collapse is fairly complete
the lobe shows a uniform loss of translucency (this may be due to
accompanying consolidation), which increases in density as the degree of
collapse increases. Vessel markings seen through this opacity are those in
the overexpanded lower lobe. (B) In the lateral view, initially the fissure
moves bodily forward, the lingula remaining in contact with the diaphragm.
With increasing collapse the lingula retracts upward, and the bulk of the
upper lobe moves posteriorly, and becomes separated from the sternum by
aerated lung. This is usually overexpanded lower lobe, though occasionally
a portion of the right lung may herniate across the midline.

51. • Fig. 6.44 Left upper lobe collapse due to squamous cell carcinoma. (A) PA film shows typical
upper zone haze, through which is seen the elevated and enlarged left hilum, and vessels of
the hyperinflated lower lobe. The contour of the aortic knuckle is indistinct, but the
descending aorta is sharply outlined. (B) Lateral film shows the collapsed left upper lobe
between the anteriorly displaced oblique fissure (arrow heads) and part of the hyperinflated
lower lobe. (C) CT demonstration of left upper lobe collapse. Calcified lymph nodes due to
previous tuberculosis are visible.

52. • Fig. 6.44 Left upper lobe collapse due to squamous cell
carcinoma. (A) PA film shows typical upper zone haze, through
which is seen the elevated and enlarged left hilum, and vessels of
the hyperinflated lower lobe. The contour of the aortic knuckle is
indistinct, but the descending aorta is sharply outlined. (B) Lateral
film shows the collapsed left upper lobe between the anteriorly
displaced oblique fissure (arrow heads) and part of the
hyperinflated lower lobe. (C) CT demonstration of left upper lobe
collapse. Calcified lymph nodes due to previous tuberculosis are
visible.

53. • Fig. 6.45 Rounded atelectasis in a patient with a history of asbestos
exposure. (A) Chest radiograph shows en face pleural plaque on the right
with calcified pleural plaques over the dome of the right diaphragm
(arrowheads). There is the suggestion of a right infrahilar mass. (B) High
resolution CT demonstrates indrawing of the bronchovascular structures
into a pleurally based mass. The appearances are typical of rounded
atelectasis. There is widespread calcified pleural plaque.

54. • Fig. 6.46 Air bronchogram. (A) CT shows patent air-filled
bronchi surrounded by widespread pulmonary consolidation
due to an acute bacterial chest infection. (B) Chest radiograph
of a different patient following aspiration of gastric contents
demonstrating widespread air-space shadowing containing air
bronchograms.

55. • Fig. 6.47 (A) Right lower lobe consolidation associated
with volume loss demonstrated on CT. Note the air-filled
bronchi. (B) Ultrasound scan, The air bronchograms are
evident as echogenic linear structures (arrows). (C) Fluid
bronchograms in a different patient (arrows); arrowheads
indicate the position of the diaphragm.

56. • Fig. 6.47 (A) Right lower lobe consolidation associated
with volume loss demonstrated on CT. Note the air-filled
bronchi. (B) Ultrasound scan, The air bronchograms are
evident as echogenic linear structures (arrows). (C) Fluid
bronchograms in a different patient (arrows); arrowheads
indicate the position of the diaphragm.

57. Fig. 6.48 Right upper lobe consolidation in a 6-year-old boy with
aortic valve disease. (A) Opacity in the right upper zone obscures
the upper mediastinum. (B) The lateral film shows consolidation
anterior to the upper part of the oblique fissure (arrows), mostly in
the posterior segment of the right upper lobe.

58. • Fig. 6.49 Right middle lobe consolidation in a 37-year-old man with
squamous cell carcinoma of the right middle lobe. (A) PA film shows
homogeneous opacity limited by horizontal fissure (arrows) and obscuring
the right heart border. (B) Lateral film shows consolidation bounded by
horizontal fissure (arrowheads) and lower half of oblique fissure (arrows).

59. • Fig. 6.50 Right lower lobe consolidation. Pneumonia complicating
chronic bronchitis. (A) PA film shows right lower zone shadowing
obscuring the diaphragm but not the right heart border
(arrowheads). (B) Lateral film shows shadowing with air
bronchogram, limited by oblique fissure anteriorly (arrowheads).
The left hemidiaphragm is visible (arrows) but the right is obscured.

60. • Fig. 6.51 Left upper lobe and lingula consolidation. A 70-year-old man
with left upper lobe carcinoma. (A) Patchy consolidation obscures the left
heart border and aortic knuckle. (B) The consolidation is bounded
posteriorly by the oblique fissure (arrowheads).