Curriculum Vitae s504

SYNOPSIS A STUDY OF NORMAL ANATOMICAL AND MORPHOLOGICAL VARIATIONS OF LUNG THROUGH CT THORAX

BY:DR.MANJUNATH.M AJIMS MANGALORE CURRICULUM VITAE Name : DR. VISHNU SHARMA.M Date of Birth & Age : May 17, 1970 Present Designation : Professor & HOD Department : Pulmonary Medicine College : A.J. Institute of Medical Sciences City : Mangalore Residential Address : SANTHRUPTHI, Battagudda Nodu Lane Bejai, Mangalore

Phone & Fax Number With Code: Office : 0824-2225533 Residence : 0824-2216321 E- Mail Address: [email protected] Mobile Number : 9448126321 Date of Joining Present Institution: Jan 14, 2004 as Associate Professor 2. Qualification Qualification College University Year Registratio Name Of n No. Of The State UG & PG Medical With Date Council M.B.BS KozhikodeMedica CalicutUnive Mar, 39,862, Dt Karnataka lCollege, rsity 1993 Nov Medical 21,1994 Council MD (T.B & Jawaharlal Pondicherry Mar, 39,862, Dt Karnataka Resp. Institute Of Post- University 1998 Nov Medical Diseases) Graduate Medical 21,1994 Council Educ, & Research D.N.B National Board Of May 21829 Dt. T.C. Examinations, 1998 Dec Medical New Delhi 29,1999 Council

3. Details ofthe Previous Appointments/ Teaching Experience Designati Departme Name of From To Total on nt Institution DD/MM/YY DD/MM/YY Experien ce In Years & Months PG TB & Jawaharlal Institute Apr 03, 1995 Mar 31,1998 3 Years. Resident Chest Of Post – Graduate Medical Education And Research Pondicherry Assistant TB & KasturbaMedicalCo Nov 16,1998 Sep 15,1999 10 Professor Chest llege, Mangalore Months

Assistant TB & K.SHegdeMedical Sep 16,1999 Jan 13,2004 4 Years 4 Professor Chest Academy, Months Mangalore Associate TB & A.J Institute Of Jan 14,2004 Feb 29,2008 4 Years 2 Professor Chest Medical Sciences, Months Mangalore Professor TB & A.J Institute Of March 1,2008 Till Date & Head Chest Medical Sciences, Mangalore CURRICULAM VITAE

Name : Dr Manjunath.M Date of birth : 22-07-1987 Present designation : PG Junior Resident Department : Pulmonary Medicine College : A.J Institute of Medical Science City : Mangalore Nature of appointment : Full Time Whether belongs to : Others Present Address of employee : Room 602 RESIDENTS HOSTEL A.J.Institute of Medical Science Mangalore

Date Of Joining Present Institution : JULY 30, 2013as PG Junior resident Academic qualifications: Qualification College University Year Registration Name Of No. Of UG & The State PG With Date Medical Council MBBS VIMS BELLARY RGUHS 2011 05M1237 Karnataka University Medical Council DM/M. Ch NA NA NA NA NA

3. Details ofsthe Previous Appointments/ Teaching Experience Designation Department Name of From To Total Institution DD/MM/YY DD/MM/Y Experience Y In Years & Months PG/Junior Pulmonary A.J Institute AUGUST 1, Till date Resident Medicine of medical 2013 science Mangalore RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

ANNEXURE II

SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE DR.MANJUNATH.M AND ADDRESS POSTGRADUATE STUDENT DEPT OF PULMONARY MEDICINE A.J.INSTITUTE OF MEDICAL SCIENCES MANGALORE- 575004

2 NAME OF THE INSTITUTION A.J.INSTITUTE OF MEDICAL SCIENCES MANGALORE

3 COURSE OF STUDY AND MD TB AND CHEST DISEASES SUBJECT

4 DATE OF ADMISSION TO 30 JULY 2013 COURSE

: “A STUDY OF NORMAL ANATOMICAL AND 5 TITLE OF THE TOPIC MORPHOLOGICAL VARIATIONS OF LUNG SEEN THROUGH CT THORAX” 6 BRIEF RESUME OF INTENDED WORK

6.1. NEED FOR THE STUDY:

Knowledge of anatomical variations of lung that includes fissures,lobes and tracheobronchial variations is important to clinicians ,radiologists and cardiothoracic surgeons.It helps in independent and accurate interpretation of imaging technologies such as chest X-ray,CT scans,MRI studies and bronchoscopy.

So far majority of studies conducted are cadaveric.There is paucity of studies in this aspect based on chest CT images.A proper interpretation of chest CT images , keeping in mindthe anatomical variations is very important to differentiate from other pathological conditions.It will be helpful for cardiothoracic surgeons to plan resection properly.Recognition of tracheobronchial variations will provide important benefits in bronchoscopic procedures,pulmonary resection surgeries,intubation process and endobronchial theraphy.

6.2. REVIEW OF LITERATURE:

6.3LOBES AND FISSURES

Lungs1 are divided into lobes by the oblique(major) and horizontal(minor)fissures.

The left lung has two lobes separated by a major fissure,and the right lung has three lobes

separated by one minor or horizontal and one major, or oblique fissure.The major fissure on

each side is indicated by drawing a line from the spine of the second dorsal

vertebra,downwards and outwards along the fifth rib as it leaves the vertebral column, to the

sixth costochondral junction in front.When the scapula is tilted ,by putting the hand on the

head,the vertebral border lies along the line of the fissure.The extra transverse fissure,on the

right side ,is indicated by drawing a horizontal line from the sternum,at the level of the fourth

costal cartilage, to meet the line of the main fissure laterally,in the mid axillary line,at the

level of the fifth rib or interspace.

On CT2 the major fissures are consistently visualized as continous ,smooth,thin linear

opacities .On 5-10mm thick sections they are seen as radiolucent bands,lines or dense bands.The minor fissure is visualized on CT as a curvilinear line or band of increased attenuation that forms a quarter circle or semicircle in its highest aspect(cephalic to the origin of middle lobe bronchus).On thicker sections ,the fissure is seen most commonly as a radiolucent area relatively devoid of vessels when compared with the same region in the left lung.

In one study of excised lungs ,an incomplete fissure was found between the right lower and upper lobe in 75% cases,between right lower and middle lobes in 45% cases, between the left lower and upper lobes in about 40% cases,similar figures have been found in lungs examined by thin section CT.

Some of the natural variants are the absent major/minor fissure ,incomplete major fissure- which fall short of the hilum.Commonly observed –accesory fissures which are often unappreciated or mis interpreted on radiographs and CT scans, usually occurs at the boundaries between bronchopulmonary segments. Most commonly are azygous fissures

,superior accessory fissure,left minor fissure,inferior accessory fissures.

In cadaveric3 studies of Medlar in his examination of 1200 pairs of lungs found that the horizontal fissure was absent in 45.2% and incomplete in 17.1% of the right-sided lungs. In a study by Lukose4 et al incomplete and absence of horizontal fissure was reported in 21% and

10.5% respectively. Bergman5reported incomplete and absence of horizontal fissure in 67% and 21% respectively in right sided lungs. Meenakshi6 et alreported that the horizontal fissure was absent in 16.6% and was incomplete in 63.3% of right lungs.

6.4TRACHEO-BRONCHIAL VARIATIONS;

The trachea is a midline structure,a slight deviation to the right after entering the thorax is a normal finding and should not be misinterpreted as a evidence of displacement.The walls of trachea are parallel except on left side just above the aorta bifurcation,where the aorta impresses a smooth indentation.The trachea,main bronchi ,and intermediate bronchus have a smoothly serrated contour created by the indentations of the cartilage rings in their walls at regular intervals.  The trachea7 divides into right and left main bronchi at the carina.The left runs more horizontally than the right,above the left atrium.

 The right bronchus divides into the right upper lobe bronchus,which in turn divides into anterior,apical and posterior segmental bronchi and the bronchus intermedius.This latter gives off middle lobe and apical lower lobe bronchi,then divides into the four basal segmental bronchi:anterior ,medial,posterior and lateral.The middle lobe bronchus divides into medial and lateral segmental bronchi.

 The left main bronchus gives off upper and lower lobe bronchi;the upper lobe bronchus divides into apico-posterior and anterior segmental bronchi and a lingular bronchus that in turn divides into superior and inferior bronchi.The left lower lobe bronchus gives off an apical bronchus and then divides into anterior,lateral and posterior segmental bronchi.There is no left medial basal segmental bronchus.

As already indicated there are innumerable variations from the prevailing pattern,many of are rare, but some of them with an incidence of 50%percents.

Normal variants:Tracheal bronchus8-which arises from trachea superior to carina.

Accessory cardiac8 bronchus-which arises from inferior medial wall of right main or intermediate bronchus.

Segmental and subsegmental variations-eg.slight upward shift of takeoff of posterior division of the posterior basal brochus responsible for sub superior segment of the lower lobe.

On CT9 scan bronchi coursing horizontal plane are seen along their long axes.these include right and left upper bronchi,anterior segmental bronchi of upper lobe,middle lobe and superior segmental bronchi of lower lobe.

Bronchi coursing vertically, cut in cross section are seen as circular lucencies, these include apical segment of right upper lobe,apico-posterior segmental bronchus of left upper lobe,the bronchus intermedius and basal segmental bronchi.

Bronchi coursing obliquely are seen as oval lucencies and are less visualized on CT scan.These include lingular bronchus,superior and inferior segmental lingular bronchus,medial and lateral segmental bronchus of right middle lobe.

In Turkey researchers Abdurrahman abakay10 et al, investigated result of 2550 consecutive reports of bronchoscopy retrospectively. Major variations of the tracheobronchial tree were found in 2.6% of patients examined by bronchoscopy. In that study, the most frequent finding was a bifurcate pattern in the right upper lobe (47.7%). The variations were localized in the right upper lobe in 71.6% of patients. Male predominance was observed in all anatomic variations .

Clinical implications:

As the fissures forms the boundaries for the lobes of lungs ,knowledge of lobar anatomy is significant in performing lobectomies and segmental resection.

Incomplete fissure may lead to the spread of disease like pneumonia from one lobe to adjacent via pores of kahn and canals of lambert in fused area and collateral air drift. It also affects the distribution pattern of pleural effusion,important for planning of lobar resection since there is a high prevalence of air leak in lobar fusion.

Recognition of accessory fissures is important as it limits the spread of disease,mistaken for a minor fissure and they are components of linear atelectasis.Azygos fissure may result in the failure of apical pleura to separate when pneumothorax is present.

Knowledge of common tracheobronchial variations is necessary for diagnostic bronchoscopy. Even accessory bronchus may serve as a source of infection with resultant hemorrhage ,cough and recurrent pneumonia.A tracheal bronchus may be a potential site for tumour.

6.5 OBJECTIVES OF STUDY:

To study the normal anatomic and morphological variations in fissures/lobes and tracheobronchial division of lung in CT thorax and their incidence pattern. 7 MATERIALS AND METHODS: 7.1 SOURCE OF DATA AND METHOD OF COLLECTION Data will be collected from the patients undergoing CT thorax in the department of Radiodiagnosis of our hospital on outpatient and inpatient basis over a period of 2 years.  Inclusion criteria: all patients undergoing CT thorax in our hospital.  Exclusion criteria: patients in whom normal anatomy of lung and trachea is distorted by disease or any pathology & cases where both lungs are not visualized completely. 7.2 STATISTICAL ANALYSIS Data will be presented using proper charts and diagrams and proper statistical test will be applied.

8 List of references: 1.Golwala.F.A,Vakil.R, Physical diagnosis,13th edition 2010 ,334-335 2. Kuniaki Hayashi, Aamer Aziz, Kazuto Ashizawa, Hideyuki Hayashi, Kenji Nagaoki, Hideaki Otsuji; 1. 2. Radiolographic and CT appearances of the Majorfissures. July 2001 RadioGraphics,21, 861-874. 3. 3. Medlar, EM., 1947. Variations in interlobar fissures. AJR, 57: 723-725. 4. Lukose, R., P.S. Sunitha, M. Daniel, S.M. Abraham and M.E. Alex et al., 1999. Morphology of the lungs: Variations in the lobes and fissures. Biomedicine, 19: 227-23 5.Bergman, R.A., A.K. Afifi and R. Miyauchi, 1999. Variations in peripheral segmentation of right lung and the base of the right and left lungs. Illustrated. Encyclopedia of Human Anatomic Variation. 6.Meenakshi, S., K.Y. Manjunath and V. Balasubramanyam, 2004. Morphological variations of the lung fissuresand lobes. Indian J. Chest Dis. Allied Sci., 46: 179-182. 7.Seaton.A,Seaton.D,Leitch.A.G,Crouton and Douglas’s respiratory diseases 5th edition,Volume 1,9- 10 8.Khurshid I, Anderson LC, Downie GH. Tracheal accessory lobe take-off and quadrifurcation of right upper lobe bronchus: A rare tracheobronchial anomaly. J Bronchology. 2003;10(1):58–60. 9. Dennis Osborn,Peter Vock,J.David Godwin,Paul M. Silverman. CT Identification of BronchopulmonarySegments: 50 Normal Subjects, AJR 142:47-52, January.American Roentgen Ray Society. 10. Abdurrahman Abakay, Abdullah C. Tanrikulu, Hadice Selimoglu Sen, Ozlem Abakay,Ayse Aydin, Ali I. Carkanat, and Abdurrahman Senyigit; Clinical and demographic characteristics of tracheobronchial variations. Lung India. 2011 Jul-Sep; 28(3): 180–183. 9 SIGNATURE OF CANDIDATE:

10 REMARKS OF THE GUIDE:

NAME AND DESIGNATION OF: 11

Dr. VISHNU SHARMA.M 11.1.GUIDE PROFESSOR AND HEAD OF DEPARTMENT

DEPARTMENT OF PULMONARY MEDICINE

A.J.INSTITUTE OF MEDICAL SCIENCES

KUNTIKANA, MANGALORE – 575004

11.2. SIGNATURE

11.3. COGUIDE: --- Dr. PRAVEEN KUMAR JOHN, DNB, DMRD

ASSOCIATE PROFESSOR DEPARTMENT OF RADIO DIAGNOSIS A.J.INSTITUTE OF MEDICAL SCIENCES

KUNTIKANA, MANGALORE – 575004

11.4. SIGNATURE:

11.5. HEAD OF THE Dr. VISHNU SHARMA.M DEPARTMENT: PROFESSOR AND HEAD OF DEPARTMENT DEPARTMENT OF PULMONARY MEDICINE A.J.INSTITUTE OF MEDICAL SCIENCES KUNTIKANA, MANGALORE – 575004 11.6. SIGNATURE:

12 12.1.REMARKS OF THE

CHAIRMAN AND PRINCIPAL:

12.2.SIGNATURE OF THE

PRINCIPAL:

PROFORMA

A. Name of the subject

B. Age: C. Sex:

TYPE OF CT DONE

Variations

1.LOBES/FISSURES

2.TRACHEA

3.BRONCHIAL SEGMENTS