8 MISCELLANEOUS CHEST

CONDITIONS

DAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 8.1 Rib fractures and haemopneumothorax in a woman injured in an automobile accident. The left seventh and eighth ribs are fractured (white arrowheads). A pneumothorax (black arrowheads) is present, and a fluid level (arrows) is seen in the pleural space.

• Fig. 8.2 Massive chest trauma in a woman involved in an automobile accident. Gross subcutaneous emphysema extends over the chest wall, outlining muscle planes. The right clavicle is fractured. Several ribs were fractured, but this is not seen on this film. Mediastinal emphysema separates pleura from the descending aorta (white arrowheads). A mediastinal haematoma is present (white arrows). Widespread lung contusion is obscured by the subcutaneous emphysema. Note tracheostomy tube (black arrow), left pleural tubes, with side hole indicated (black arrowhead), Swan-Ganz catheter and ECG lead.

Fig. 8.3 Rupture of diaphragm in a man of 58 who fell from a building 13 years before, breaking ankles and injuring chest, and now presenting with persistent vomiting. The chest radiograph demonstrates distended stomach in the left hemithorax, confirmed by barium swallow. Thoracotomy revealed stomach herniating into left pleural cavity through a 5-cm rent in the left hemidiaphragm.

• Fig. 8.4 Penetrating chest injury-man with bullet wound. (A) Large pneumothorax (arrowheads), and bullet in chest wall. (B) Following insertion of pleural tube (black arrowhead), the lung re-expands, revealing haematoma in bullet track. Band shadow in lower zone (white arrowheads) represents subsegmental atelectasis.

• Fig. 8.5 Pulmonary contusion and haemothorax in a man with a gunshot injury. Subcutaneous emphysema is present over the chest wall (arrows), and dense shadowing extends over most of the hemithorax.

• Fig. 8.6 Pulmonary contusion and haematoma in a youth of 18 trampled on by a bull. (A) Extensive consolidation is present throughout both lungs, particularly in the left upper zone. Subcutaneous emphysema is seen over the right hemithorax. Bilateral pleural tubes and a nasogastric tube (arrows) are present. (B) Six days later the contusion has resolved and multiple pulmonary haematomas and some extrapleural haematomas have become visible. (C) One month later the haematomas are smaller.

• Fig. 8.6 Pulmonary contusion and haematoma in a youth of 18 trampled on by a bull. (A) Extensive consolidation is present throughout both lungs, particularly in the left upper zone. Subcutaneous emphysema is seen over the right hemithorax. Bilateral pleural tubes and a nasogastric tube (arrows) are present. (B) Six days later the contusion has resolved and multiple pulmonary haematomas and some extrapleural haematomas have become visible. (C) One month later the haematomas are smaller.

• Fig. 8.7 Pulmonary contusion in a man following an automobile accident. (A) Extensive consolidation throughout right lung. Left lung was clear. No rib fractures. (B) Four days later the shadowing has resolved.

• Fig. 8.9 (A) Chest radiograph obtained immediately following a stab wound to the chest. There is a pulmonary haematoma evident on the left. (B) Radiograph 3 months later demonstrates only partial resolution.

• Fig. 8.10 Ruptured trachea with dyspnoea and chest pain in a man suffering a deceleration injury. (A) Pneumomediastinum with linear lucencies in the mediastinum and displacement of mediastinal pleura (arrowheads). (B) One hour later, following a bout of coughing, a left pneumothorax has developed. Bronchoscopy revealed a ruptured trachea.

• Fig. 8.11 Pneumomediastinum in a man after an automobile accident. Note linear lucencies in the mediastinum extending into the neck, and subcutaneous emphysema over the supraclavicular fossa (arrows). The mediastinal pleura is outlined by air and displaced laterally (arrowheads).

• Fig. 8.12 Complications of positive-pressure ventilation. Diffuse consolidation in a boy aged 15 following presumed viral pneumonia. Note endotracheal tube (white arrow) and Swan-Ganz catheter, both well positioned. Pneumomediastinum is indicated by linear lucencies in the mediastinum, lateral displacement of the mediastinal pleura (black arrows) and infrapericardial air, producing the 'continuous diaphragm' sign (arrowheads). There is extensive bilateral subcutaneous emphysema.

• Fig. 8.13 Mediastinal haemorrhage in a youth of 18 after an automobile accident. (A) Chest radiograph shows bilateral widening of the superior mediastinum. The aorta is obscured. (B) Arch aortogram demonstrates an aneurysm of the aortic isthmus (arrowheads) with intimal tear (arrows).

• Fig. 8.14 Aortic rupture. Fifty-six-year-old male patient with a severe deceleration injury and a remote history of sternotomy for coronary artery bypass grafting. (A) Supine chest radiograph demonstrates questionable mediastinal widening, surgical emphysema and a left chest tube. (B) Contrast-enhanced CT scan at the level of the aortic arch reveals a small mediastinal haematoma (black arrows) adjacent to the oesophagus, which contains a nasogastric tube. The mediastinum is of normal width. (C) Arch aortogram demonstrating an intimal tear at the usual site (arrows).

• Fig. 8.14 Aortic rupture. Fifty-six-year-old male patient with a severe deceleration injury and a remote history of sternotomy for coronary artery bypass grafting. (A) Supine chest radiograph demonstrates questionable mediastinal widening, surgical emphysema and a left chest tube. (B) Contrast-enhanced CT scan at the level of the aortic arch reveals a small mediastinal haematoma (black arrows) adjacent to the oesophagus, which contains a nasogastric tube. The mediastinum is of normal width. (C) Arch aortogram demonstrating an intimal tear at the usual site (arrows).

• Fig. 8.15 Esophageal rupture following difficult endoscopy. Following the procedure a check radiograph demonstrated pneumomediastinum (not shown) and a localised perforation was detected on contrast swallow.

• Fig. 8.16 (A) Typical sharply truncated rib defect following right thoracotomy (right upper lobectomy for carcinoma). (B) Late postsurgical changes following periosteal stripping at time of left fifth interspace thoracotomy for mitral valvotomy. There is a wavy line of calcification below the affected rib (arrows).

• Fig. 8.17 Normal postpneumonectomy appearance: 1 day (A), 6 days (B), 5 weeks (C) and 8 weeks (D) postoperatively. The pneumonectomy space is gradually obliterated by the rising fluid level and mediastinal shift.

• Fig. 8.17 Normal postpneumonectomy appearance: 1 day (A), 6 days (B), 5 weeks (C) and 8 weeks (D) postoperatively. The pneumonectomy space is gradually obliterated by the rising fluid level and mediastinal shift.

• Fig. 8.18 Bronchopleural fistula. (A) Thirteen days after right pneumonectomy the space is filling with fluid and the mediastinum is deviated to the right. (B) Two days later, after the patient coughed up a large amount of fluid, the fluid level has dropped and the mediastinum has returned to the midline. Bronchoscopy confirmed a right bronchopleural fistula.

• Fig. 8.19 Haemorrhage following cardiac transplantation. (A) Four hours following return from surgery the chest radiograph reveals opacification of the right upper zone. Ultrasound at the patient's bedside confirmed a large fluid collection. (B) After insertion of a chest drain there has been partial resolution of the appearances.

• Fig. 8.20 Mediastinal haematoma. Enhanced CT scan demonstrates a soft-tissue density non-enhancing mass in the anterior mediastinum 3 days following cardiac surgery (arrows).

• Fig. 8.21 Haemopneumopericardium in a woman 2 days after closure of atrial septal defect. The pericardium is outlined by air (white arrowheads), which does not extend as high as the aortic arch. A fluid level (black arrowheads) is present in the pericardium, and there are bilateral pleural effusions.

• Fig. 8.22 Infected mediastinal collection following oesophagectomy. (A) The gastric conduit (arrows) is discernible separately from the collection (C) and small bilateral effusions. (B) Drainage accomplished by CT-guided pigtail catheter insertion with the patient in a semiprone position.

• Fig. 8.23 Postsurgical mediastinitis. Two cases. (A) CT 3 weeks following aortic valve replacement in a patient with signs of infection. There is a small retrosternal air and fluid collection, subsequently drained. Note the enlarged azygos vein (arrow) due to previous thrombosis of the superior vena cava. (B) Infected mediastinal collection in a different patient several weeks following atrial septal defect closure. Note the large pulmonary trunk (PA).

• Fig. 8.25 (A) Ivor Lewis oesophagectomy. There is a rib defect, air under the diaphragm and a gas-filled gastric conduit in the right chest. This is outlined by a rim of pleural fluid (arrowheads). (B) Dilated gastric pull-up in a different patient. An air-fluid level is seen in the distended conduit in the left chest due to outflow obstruction at the site of the mobilized pylorus. Right basal atelectasis is present.

• Fig. 8.26 Thoracoplasty. The first five right ribs have been removed. Left upper lobe fibrosis, bilateral apical calcification and extensive left pleural calcification are due to tuberculosis.

• Fig. 8.27 Plombage. (A) Several hollow balls have been inserted extrapleurally at the left apex. The balls are slightly permeable, and the shallow fluid levels do not indicate a complication. (B) CT through right apical Iucite balls in a different patient demonstrating characteristic appearance.

• Fig. 8.28 Oleothorax. Plombage has been performed by instilling kerosene (paraffin) extrapleurally through a thoracotomy with excision of the fifth rib. A thin rim of calcification has developed in the extrapleural collection. Some kerosene has tracked inferiorly behind the lung and produced a calcified pleural plaque which is seen en face (arrowheads).

• Fig. 8.29 The admission chest radiograph (not shown) of a patient with acute viral encephalitis was clear. Six hours later a film following emergency intubation reveals extensive bilateral basal and perihilar air space shadowing due to massive aspiration of gastric contents. A Swan- Ganz catheter is in situ with the tip projected more peripherally than ideal in the left lung.

• Fig. 8.30 Mediastinal haematoma. Following unsuccessfully attempted in the left lung. placement of a central venous line via the right subclavian vein, a large extrapleural haematoma (arrows) is present.

• Fig. 8.31 Perforation of innominate vein. (A) A central venous catheter (arrowheads) has been introduced via the left jugular vein. Its tip points inferiorly, rather than to the right along the axis of the innominate vein. A pleural effusion (arrows) is present. (B) Next day the effusion is larger. Injection of contrast medium into the catheter (larger arrowheads) demonstrates extravasation and communication with the pleural effusion.

• Fig. 8.32 Nasogastric tube coiled in oesophagus. The tube does not reach the stomach, but has folded back on itself (arrows).

• Fig. 8.33 Nasogastric tubes in right bronchus. (A) The nasogastric tube (arrows) passes down the trachea and into the right bronchus. The patient had been 'fed' via the tube, causing patchy consolidation in the right lung. A temporary pacing electrode (arrowheads) is present. (B) This patient, with chronic renal failure, developed peritonitis following peritoneal dialysis. Drains are present in the abdomen. A nasogastric tube (white arrows) has been passed beyond an endotracheal tube (black arrow) and into the right bronchus. Two venous lines are present; the right-sided catheter (arrowheads) is well placed for central venous pressure measurements.

• Fig. 8.34 Endotracheal tube too low. The tip of the endotracheal tube (arrowhead) is beyond the carina (asterisk) and in the right bronchus. A well-positioned Swan-Ganz catheter is present.

• Fig. 8.35 (A,B) Multiple injuries in a patient following an automobile accident. CT obtained due to a persistent pneumothorax despite apparently satisfactory tube position. The chest tube can be seen entering the lung parenchyma (black arrows). Note also the extensive parenchymal changes due to ARDS, and the right-sided pulmonary haematomas (white arrows).

• Fig. 8.36 Intra-aortic balloon pump. Post coronary artery bypass surgery. (A) Bilateral pleural and mediastinal drains and endotracheal tube are present. The pump is well sited, and its balloon is seen to be inflated (arrowheads). (B) The drains have been removed. When this radiograph was exposed the balloon was deflated.

• Fig. 8.37 Fractured pacing wire. Patient with surgically repaired complete atrioventricular canal. A permanent transvenous pacing system is present; the power unit is in the left axilla; the electrode (arrowheads) reaches the right ventricle by traversing the innominate vein, superior vena cava and right atrium. The electrode is fractured (white arrowhead). Note disconnected epicardial electrodes (black arrow) and ECG electrodes (white arrows).

• Fig. 8.38 Radiation pneumonitis in a man of 45 with diffuse histiocytic lymphoma who developed upper thoracic spinal cord compression. (A) After surgical decompression the lungs are clear and the patient commenced radiotherapy to the spine. (B) Ten weeks later there is paraspinal consolidation with air bronchograms. (C) Fourteen weeks after treatment paraspinal pulmonary fibrosis has developed. The changes correspond to the shape of the treatment portal.

• Fig. 8.39 Mediastinal fibrosis following radiotherapy several years previously. The sharp margins of the fibrosis correspond to the edges of the radiation field.

• Fig. 8.40 Radiation pneumonitis in a woman of 32, one year after a left mastectomy for carcinoma. Surgical clips overlie the left axilla. (A) Medial left upper zone opacity (arrowheads) is caused by metastasis to left internal mammary lymph nodes. (B) Eighteen days later, following radiotherapy, the left upper mass has gone. (C) Sixteen weeks after treatment there is extensive consolidation in the left mid and upper zones. (D) Five months after treatment there is gross left upper lobe fibrosis, the mediastinum has shifted to the left and the left hemidiaphragm is elevated. The patient remained asymptomatic throughout this time.

• Fig. 8.40 Radiation pneumonitis in a woman of 32, one year after a left mastectomy for carcinoma. Surgical clips overlie the left axilla. (A) Medial left upper zone opacity (arrowheads) is caused by metastasis to left internal mammary lymph nodes. (B) Eighteen days later, following radiotherapy, the left upper mass has gone. (C) Sixteen weeks after treatment there is extensive consolidation in the left mid and upper zones. (D) Five months after treatment there is gross left upper lobe fibrosis, the mediastinum has shifted to the left and the left hemidiaphragm is elevated. The patient remained asymptomatic throughout this time.

• Fig. 8.41 Massive radiation fibrosis. Patient with Hodgkin's disease treated with mediastinal irradiation and chemotherapy (MOPP-bleomycin). Note gross bilateral upper lobe fibrosis with extensive air bronchogram.

• Fig. 8.42 Radiation-induced osteonecrosis. (A) Chest radiograph obtained 15 years after left mastectomy and radiation therapy demonstrates a dense opacity projected over the left second rib. (B) On CT there is a calcified mass arising from the second rib. Long-term follow-up showed no evidence of progression.

• Fig. 8.43 Radiation-induced sarcoma. (A, B) There is a soft-tissue mass arising within the anterior chest wall in a patient treated 1 4 years previously for a right breast carcinoma. Note direct extension from subcutaneous tissues through the chest wall musculature into mediastinal fat.

• Fig. 8.44 CT image from a CT pulmonary angiogram at the level of the right main pulmonary artery. There is a large filling defect due to thrombus. Note the minor streak artefact arising from the dense contrast in the superior vena cava, and the small right pleural effusion.

• Fig. 8.45 Utility of CTPA in patients with pre-existing lung disease. (A) The initial HRCT through the lungs of this patient with sudden worsening of breathlessness demonstrates changes consistent with the known extrinsic allergic alveolitis. (13) The CTPA images demonstrate thrombus in the segmental and subsegmental vessels in the right lower lobe. (C) HRCT in a different patient at We time of CTPA. There are diffuse lung changes consistent with the known diagnosis pneumocystis carinii pneumonia . ( D) The CTPA study demonstrates that there are also multiple pulmonary

• Fig. 8.45 Utility of CTPA in patients with pre-existing lung disease. (A) The initial HRCT through the lungs of this patient with sudden worsening of breathlessness demonstrates changes consistent with the known extrinsic allergic alveolitis. (13) The CTPA images demonstrate thrombus in the segmental and subsegmental vessels in the right lower lobe. (C) HRCT in a different patient at We time of CTPA. There are diffuse lung changes consistent with the known diagnosis pneumocystis carinii pneumonia . ( D) The CTPA study demonstrates that there are also multiple pulmonary

• fig.8.46 Chest radiograph of 2weeks after heart and Lung transplantation Apart from the epicardial pacing wire there is little evidence of the mum surgery. ??????????????

• Fig. 8.47 Post-transplantation lymphoma following heart and lung transplantation. The chest radiograph (A) and CT (B) demonstrate widespread pulmonary nodules 2-3 cm in size which developed within 2 months of surgery. There was also mediastinal and hilar lymph node enlargement. Needle biopsy confirmed B-cell lymphoma which proved rapidly fatal.

• Fig. 8.48 Two years following heart and lung transplantation there is a large pulmonary nodule at the left lung base. This was one of several coexistent nodules that cleared rapidly following antiviral treatment administered after biopsy confirmed benign polyclonal lymphoproliferation.

• Fig. 8.49 (A) Chest radiograph in a patient 2 weeks following left lung transplantation for fibrosing alveolitis. Note the surgical defect in the posterior part of the left fifth rib. (B) HRCT through the lungs of a patient who has recently undergone right lung transplantation for emphysema related to alpha-l-antitrypsin deficiency. Note the displacement of the midline structure due to the relatively large emphysematous left lung.

• Fig. 8.50 Invasive Aspergillus infection following heart and lung transplantation. HRCT reveals the presence of small foci of infection in the posterior costophrenic recesses. Despite the development of new symptoms the chest radiograph had been normal.

• Fig. 8.51 Bronchiolitis obliterans following transplantation. There is marked bronchial dilatation in the lower lobes bilaterally, although the lung parenchyma appears unremarkable.

• Fig. 8.52 ARDS. Fat embolism from multiple skeletal trauma. Diffuse alveolar opacities.

• Fig. 8.53 (A) Staphylococcal toxic shock. Extensive alveolar opacification. Staphylococcus aureus was isolated from a vaginal tampon. (B) HRCT in a different patient with ARDS demonstrates the anterior-posterior gravitational gradient of lung density, with occasional spared secondary pulmonary lobules.

• Fig. 8.54 ARDS. CT demonstrates extensive mediastinal and subcutaneous emphysema as well as a parenchymal bulla (arrow) possibly related to high pressure ventilation. Note the typical anterior-posterior density gradient in lung attenuation due to the effects of gravity.

• Fig. 8.55 CT in a patient with ARDS demonstrates diffuse lung changes and a shallow pneumothorax on the right. In addition there is a loculated rounded abscess in the right lower lobe that was not apparent on the chest radiograph.