Radiopathology of Respiratory

tract
Dr Wawan kustiawan
Sp R,M.kes,DFM
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
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. 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
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
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
Hili tracted upward
Shrinking of intercostal space
Traction 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. 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