20 BULGING FISSURE SIGN – KLEBSIELLA PNEUMONIA : Due to excessive secretions in infected lungs, the lung expands producing a mass effect exerting pressure on adjacent fissures. In this case the horizontal fissure appears bulged due to upper lobe pathology – klebsiella pneumonia LUNG ABSCESS – AIR FLUID LEVEL WITHIN THE LUNG. In lung abscess the patients presents with signs of infection- high grade fever, elevated counts . On CXR, a thick walled cavity with air-fluid level within the lung parenchyma 21 ASPERGILLOMA/ FUNGAL BALL – AIR CRESCENT SIGN / MONOD SIGN In a pre-existsing cavity of lung gets infected with aspergillous fungus to form a fungal ball that occupies the dependent portion of the cavity There is air surrounding the fungal ball giving a crescentic lucency – MONOD SIGN Air cresentic sign is associated with invasive aspergillosis CENTRAL BRONCHIECTASIS – ABPA Multiple thick walled cystic lesions presnt in the lung parenchyma towards the hilar region – CENTRAL BRONCHECTASIS They maybe associated with fixed or transient infiltrates within the lung , then it s acase of allergic bronchopulmonary aspergillosis 22 MILIARY TB Patient being evaluated for low grade fever, CXR shows multiple tiny discrete nodules in scattered throughout inn both lung fields “ RANDOM DISTRIBUTION OF NODULES IN HRCT” ANIGIOINVASIVE ASPERGILLOSIS: HALO SIGN Central area of opacity & surrounding area of haziness REVERSE HALO SIGN / ATOLL SIGN – COP area of haziness surrounded by opacity. Seen in CRYPTOGENIC ORGANISING PNEUMONIA 23 ADENOID HYPERTROPHY WITH NASOPHARYNGEAL AIRWAY COMPRESSION Child presents with recurrent upper respiratory tract infections , snoring Lateral nasopharyngeal radiograph shows : marked enlargement of adenoid soft tissue resulting in severe narrowing of the nasopharyngeal airway THUMB SIGN – EPIGLOTTITIS The shadow of epiglottis becomes thick & enlarged causing a narrowing of airway on lateral X ray . The swollen epiglottis shadow looks like a thumb & hence called thumb sign 24 STEEPLE SIGN – ACUTE LARYNGO TRACHEO BRONCHITIS The subglottic airway narrows to give the appearance of that of a steeple of the church , hence called STEEPLE SIGN. PLEURAL EFFUSION Best radiograph – lateral decubitus view (10-25 ml) Best investigation/ IOC : USG (5-10ml) 25 BLUNTING OF CP ANGLE : earliest finding on erect PA view (200 ml) Fluid is in the posterior CP angle, & small amount spilled into the lateral CP angle which is visible as blunting of the angle. NORMAL PLEURAL MENISCUS SIGN: 500 ml : with further collection of fluid from above , the fluid will settle down into the dependent part with gravity creating an ill defined concave upper margin - Meniscus OPAQUE HEMITHORAX : differential diagnosis WHITE OUT LUNG Can be any of the following : & are differentiated based on mediastinal shift 26 Massive pleural effusion : mediastinum shift to opposite side Collapse : mediastinal shift to same side due to volume loss Consolidation : no mediastinal shift Mediastinal shift to opposite side OPAQUE HEMITHORAX Effusion on supine film : When the patient is lying supine, the fluid will settle in the posterior chest wall (dependent part) & on X ray ( with beams passing anterior to posterior,) there will be increased density over the entire lung field but since the lung parenchyma is normal ,the vascular markings within the lungs will be visible LAMELLAR PLEURAL EFFUSION Sometimes instead of settling along the posterior chest wall, the fluid will rise up along the lateral wall like a lamella / band 27 LOCULATED / FISSURAL PLEURAL EFFUSION: Usually the pleural effusion is collection of free fluid within the two layers of pleura & hence settle to the dependent part , but at times the fluid gets traped within the fissures – called fissural plural effusion It will appear as an oval shaped opacity on chest X ray with the long axis of the opacity being parallel to the fissure. HISTORY CLINGER : PHANTOM/ VANISHING LUNG TUMOUR in an elderly person with chronic heart failure , with CXR showing a mass like opacity which disappeared completely when the heart failure if treated/ resolved . Pleural effusion on CT : collection of fluid on the dependent part & it appears at the same density as that of water with no enhancement. 28 EMPYEMA –SPLIT PLEURAL SIGN Along with the homogenous collection of fluid along the lateral chest wall, there is a thin rim of enhancement of the parietal & visceral pleura on either side of the collection , suggesting inflammation PNEUMOTHORAX Best radiograph : Expiratory CXR Best investigation/IOC: CT 29 Rx: NEEDLE Things to looks for in CXR of pneumothorax : THORACOTOMY Visceral pleural line (differential radiographic density theory) INTERCOSTAL DRAIN Hyperlucency with absent vascular markings INSERTION Mediastinal shift to opposite side Deep sulcus sign TENSION PNEUMOTHORAX Expanded rib cage On M Mode USG in pneumothorax : BARCODE/STRATOSPHERE SIGN SEASHORE SIGN : normal USG thorax Other signs on USG in pneumothorax : A LINES: horizontally oriented lines , like reverberation artifacts. Absence of pleural sliding Lung point identification sign 30 HYDROPNEUMOTHORAX Air fluid level in pleural cavity MEDIASTINAL TUMOURS First Ix : CXR Best Ix /IOC: CECT; EXCEPTION : Posterior Mediastinal Tumours – MRI (because most of these tumours are neurogenic & MRI is helpful in evaluating the extent, involvement of neighboring structure etc) Overall MC Mediastinal Mass Lesion: THYMOMA MC Anterior Mediastinal Mass Lesion : THYMOMA MC Middle Mediastinal Mass Lesion : LYMPH NODE MASS MC Middle Mediastinal Mass Lesion In Children: DUPLICATION CYCTS MC Posterior Mediastinal Mass Lesion: NEUROGENIC TUMOUR ANTERIOR MEDIASTINAL TUMOURS HILUM OVERLAY SIGN: Cardiac vs mediastinal mass When there is a mass lesion overlapping hilum on CXR & the hilar vessels are visible (HILAR OVERLAY), it is most likely a mediastinal lesion whereas a cardiac lesion will NOT produce HILAR OVERLAY but instead the hilar vessels/ markings will get pushed to the lateral margin of the mass .