diagnostic imaging of airway diseases

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Chest Airway Diseases

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Page 1: Diagnostic Imaging of Airway Diseases

ChestAirway Diseases

Page 2: Diagnostic Imaging of Airway Diseases

Mohamed Zaitoun

Assistant Lecturer-Diagnostic Radiology Department , Zagazig University Hospitals

EgyptFINR (Fellowship of Interventional

Neuroradiology)[email protected]

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Knowing as much as possible about your enemy precedes successful battle

and learning about the disease process precedes successful management

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Airway Diseasesa) Tracheal Diseases b) Chronic bronchial Diseasesc) Upper Airway Obstruction in Children

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a) Tracheal Diseases :1-Neoplastic Diseases2-Non-Neoplastic Diseases

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1-Neoplastic Diseases :a) Benignb) Malignant

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a) Benign :1-Incidence2-Types

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1-Incidence :-Only 10% of tracheobronchial tumors are

benign-Benign tumors are typically < 2 cm

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2-Types :a) Papilloma :-Common laryngeal tumors in childrenb) Hamartoma :-Fat density is diagnostic-Often calcified (popcorn pattern)c) Lipoma :-Rounded homogeneous fat attenuation lesion-90 % in males d) Adenoma :-Rare

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Papilloma

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Small and well-defined posterolateral lesion projecting into tracheal lumen , Papilloma

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Hamartoma

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Lipoma

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CT+C (a) shows a low-attenuation (-5 HU) endobronchial nodule (black arrow) in the bronchus intermedius , post-obstructive atelectasis of the right lower lobe can be seen (white arrow) , CT (b) obtained at the level of the left brachiocephalic vein shows a low attenuation (-95 HU) nodule in the trachea

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b) Malignant :1-Incidence2-Types

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1-Incidence :-90 % of all tracheobronchial tumors are

malignant

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2-Types :a) Primary :-SCC (most common)-Adenoid cystic carcinoma (2nd common)-Mucoepidermoid-Carcinoid

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Chest X-ray showing lobulated lesion at the level of the carina (red arrow)

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CT+C shows nearly complete central tracheal obstruction with the tumor

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Rounded mass at the level of carina causing significant reduction of the lumen of both bronchi , Squamous cell carcinoma

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CT shows the tracheal mass extending and obliterating the right main bronchus

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CXR (a) shows an upper right paratracheal opacity narrowing the tracheal lumen (arrow) , CT+C (b) confirms the eccentric lobulated soft tissue mass that origins from the right anterolateral tracheal wall and narrows the lumen of the upper trachea , coronal MPR image at mediastinal window setting (c) better depicts the entire extent of the lesion

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Mediastinal mass arising from the posterolateral wall of the trachea (a characteristic feature) with invasion of mediastinal fat and esophagus , Cystic adenoid carcinoma

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Adenoid Cystic Carcinoma

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CT (a) shows an irregular thickening of the left tracheal wall with a lobulated mass protruding into the tracheal lumen (arrow) , CT (b) shows irregular thickening of the left posterolateral tracheal wall with nodular intraluminal extension of tumor (arrow)

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Carcinoid

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b) Mets :1-Local Extension (common) :-Thyroid cancer-Esophageal cancer-Lung cancer2-Hematogeneous Mets (rare) :-MelanomaBreast cancer

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Direct extension to the tracheal lumen of anaplastic thyroid cancer

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CT shows a large proximal esophageal mass with asymmetric impression on the posterior tracheal wall suggestive of invasion

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Irregular right lateral wall of the trachea secondary to direct extension from small cell carcinoma of the lung 

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Tracheal and bronchial metastases from melanoma 

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2-Non-Neoplastic Diseases :1-Saber Sheath Trachea2-Tracheopathia Osteoplastica (TPO)3-Tracheobronchomalacia4-Tracheobronchomegaly5-Relapsing Polychondritis6-Post-intubation Tracheal Stenosis

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7-Post-infectious Tracheal Stenosis & T.B.8-Tracheobronchial Diverticula9-Bronchial Anthracofibrosis10-Amyliodosis11-Wegner’s Granulomatosis12-Tracheal / Bronchial Narrowing ,

Stenosis or Occlusion

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1-Saber Sheath Trachea :a) Pathologyb) Radiographic Features

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a) Pathology :-Refers to diffuse coronal narrowing of the

intrathoracic portion of the trachea with concomitant widening of the sagittal diameter , extrathoracic segment of the trachea is always preserved

-It is pathognomonic for COPD-More common in males

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b) Radiographic Features :-Marked decrease in the coronal diameter of

the intrathoracic trachea associated with an increase in its sagittal diameter

-Tracheal ring calcification is common

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Saber-sheath trachea , notice sparing of extrathoracic trachea and coronal narrowing of the intrathoracic segment

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2-Tracheopathia Osteoplastica (TPO) :a) Pathologyb) Radiographic Features

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a) Pathology :-Foci of cartilage and bone develop in the

submucosa of the tracheobronchial tree-Benign , rare condition-Only affects the anterior and lateral walls

with sparing of the posterior membranous portion

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b) Radiographic Features :-Calcified tracheobronchial tree , nodules ,

osteocartilaginous growth-Thickening of tracheal cartilage-Narrowed lumen-Distal three fourths of the trachea and the

proximal bronchi are most commonly involved

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Diffuse stricture of the tracheal lumen due to an irregular thickening of the lateral walls

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3-Tracheobronchomalacia :a) Pathologyb) Radiographic Features

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a) Pathology :-Refers to weakening of tracheal and bronchial walls -May be primary or secondary :1-Primary (uncommon) :-Occurs in children-May be associated with laryngomalacia2-Secondary (more common) :-Ageing-Prolonged intubation , especially in those with tracheostomy-COPD-Chronic or recurrent infection

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b) Radiographic Features :-Collapsed walls of trachea and bronchi-Inspiratory only CT is unable to make the

diagnosis-Diagnosis usually requires airway assessment

after a forced expiration (Dynamic Expiration)-A hallmark of TM is the frown sign, a crescent

bowing of the posterior membranous tracheal wall at expiratory CT scans

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On inspiration On expiration

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Axial inspiratory CT (a,b) show a normal shape of the tracheal and bronchial lumen , Expiratory CT (c,d) show a severe collapse of the airways with an inward bowing of the posterior wall (frown sign) , mild air-trapping is also evident in both lungs

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Tracheomalacia in COPD patient , notice collapse of more than 50% of the tracheal lumen in expiratory image on the right

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Significant collapse on expiratory images (below) of trachea and main bronchi , Tracheobronchomalacia 

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Significant collapse on expiratory images (below) of trachea and main bronchi

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4-Tracheobronchomegaly :a) Pathologyb) Radiographic Features

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a) Pathology :-Also known as Mounier-Kuhn syndrome-Rare condition characterized by markedly

dilated airways leading to recurrent infections

-It appears in young patients (third and fourth decade) 

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b) Radiographic Features :-Tracheobronchomegaly is diagnosed when

the tracheal diameter is bigger than 3 cm

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Markedly enlarged trachea and main bronchi in asymptomatic man

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CT shows severe dilatation of the trachea (a) and the right main stem bronchus (b) associated with fibrotic consolidations and traction bronchiectasis in the upper lobes , more evident on the right (a)

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5-Relapsing Polychondritis :a) Pathologyb) Radiographic Features

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a) Pathology :-Recurrent inflammation of cartilaginous

structures including tracheal cartilages-The etiology is unknown but it is likely

immune-mediated-Tracheal involvement is present in half of

patients with a slightly higher prevalence in women

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b) Radiographic Features :-Wall thickening with increased attenuation that

may range from a subtle increase to clear calcifications

-A key fact for diagnosis is the preservation of the posterior wall of the trachea formed by muscular and fibrous tissue and lacking cartilaginous rings , this particular appearance allows diagnosis with a high degree of confidence

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Tracheal wall thickening with calcifications involving anterior and lateral walls with preservation of the posterior wall. Notice moderate and diffuse stenosis of the tracheal lumen on the MIP image

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Axial CT show smooth tracheal (a) and bronchial (b) wall thickening with calcifications , the typical sparing of the posterior membranous walls of the airways can be seen (arrows) 

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6-Post-intubation Tracheal Stenosis :-The placement of endoluminal tubes in the

large airways may cause a reparative fibrotic process at the cuff site (in tracheal intubation) or at the stoma site (in tracheostomy) leading to a tracheal narrowing

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CT (a) shows an eccentric stenosis of the subglottic tracheal lumen on the right (arrow) , external VR image (b) along the long axis of the trachea better depicts the stricture extent and the typical appearance of “hourglass” of the trachea

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7-Post-infectious Tracheal Stenosis & T.B. :-Central airways may be involved in 10-40% of

cases of pulmonary parenchymal tuberculosis by lymphatic spread or local invasion from mediastinal affected lymph nodes

-The most frequent site of stenosis is the lower third of the trachea and the main stem bronchi

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CT (a,b) show enlarged lymph nodes (arrows) in the right paratracheal region and subcarinal region that infiltrate distal trachea and right main bronchus walls determining airway lumen narrowing , coronal CT reformation (c) and VR image (d) better illustrate the extension of the lesions throughout the tracheobronchial tree

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8-Tracheobronchial Diverticula :-May be congenital or acquired-Congenital usually very small with a very

narrow communication with the airway , whereas the acquired is bigger and usually have a wide communication with the airway

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Congenital diverticulum , Axial CT (a) show an air-filled right paratracheal cyst (arrow) at the cervico-thoracic junction , coronal MPR (b) better depicts the apparent communication (arrow) with the tracheal lumen by a narrow neck.

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Acquired diverticulum , Axial CT (a) and oblique MPR image (b) show a large air-filled paratracheal cyst (arrow) at the cervico-thoracic junction , the large dimension and the broad base are consistent with an acquired diverticulum

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Right paratracheal diverticulum , notice narrow connection between diverticulum and tracheal lumen

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9-Bronchial Anthracofibrosis :-Benign condition affecting more

frequently elderly women-The term refers to the bronchoscopic

finding of dark anthracotic pigments in the bronchial wall with subsequent bronchial narrowing or obliteration in patients without a relevant history of pneumoconiosis or smoking

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-The most commonly reported finding on CT scans is lobar or segmental post-obstructive atelectasis , multifocal stenoses of lobar and segmental bronchi with peribronchial soft tissue thickening and calcified or noncalcified lymph nodes may also be seen

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CT+C (a) shows partial atelectasis of right upper lobe with smooth narrowing of right main bronchus and obstruction of right upper lobe bronchus , an enlarged lymph node (arrow) adjacent to involved bronchus can be seen , axial non-enhanced CT (b) shows obstructed right middle lobe bronchus resulting in partial atelectasis of right middle lobe , calcified lymph nodes adjacent to right middle lobe bronchus are also present (black arrows) , lingular segmental bronchus is thickened with adjacent enlarged lymph nodes containing calcification (white arrow)

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10-Amyliodosis :-Diffuse involvement of the tracheobronchial

tree beginning from the trachea and large bronchi extending sometimes to segmental bronchi

-CT shows multifocal , nodular or circumferential wall thickening of soft-tissue density with a smooth surface and possible concentric calcifications

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Axial CT (a,c) show diffuse circumferential and smooth wall thickening with mild calcifications of the trachea , main stem bronchi and lobar bronchi bilaterally , axial CT (b) shows an almost complete occlusion of the right upper lobar bronchus with a distal chronic post-obstructive atelectasis of the anterior segment of the right upper lobe (arrow)

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Circumferential thickening of the tracheal wall with irregular appearance in virtual bronchoscopy image

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11-Wegner’s Granulomatosis :-Late complication of the disease-CT shows focal or more often diffuse

circumferential wall thickening

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Smooth subglotic wall thickening , Wegener granulomatosis

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Asymmetric thickening of the tracheal wall progressing to significant lumen stenosis of subglotic position , Wegener granulomatois

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12-Tracheal / Bronchial Narrowing , Stenosis or Occlusion :

a) In the Lumenb) In the Wallc) Outside the Wall

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a) In the Lumen :1-Foreign body2-Mucus plug3-Misplaced endotracheal tube4-Broncholithiasis

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b) In the Wall :-See Before + Bronchial Atresia

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c) Outside the Wall :1-Lymph nodes2-Mediastinal tumors 3-Enlarged left atrium4-Aortic aneurysm5-Anomalous origin of left pulmonary artery from right

pulmonary artery :-Producing compression of the right main bronchus as it

passes over it between the trachea and esophagus to reach the left hilum

-PA CXR shows the right side of the trachea to be indented and the vessel is seen end-on between the trachea and esophagus on the lateral view

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Aberrant left pulmonary artery , aberrant artery extends between trachea & esophagus indenting both (arrows)

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b) Chronic Bronchial Diseases :1-COPD2-Emphysema3-Bronchial Asthma4-Bronchiectasis5-Cystic Fibrosis6-Bronchiolitis Obliterans

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1-COPD :a) Pathologyb) Clinical Picturec) Radiographic Features

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a) Pathology :-Represents a spectrum of obstructive airway diseases-It includes two key components which are chronic

bronchitis and emphysema-In contrast to asthma , the histologic changes of COPD

are irreversible and gradually progress over time-In chronic bronchitis , there is diffuse hyperplasia of

mucous glands with associated hypersecretion and bronchial wall inflammation

-Emphysema involves the destruction of alveolar septa and pulmonary capillaries leading to decreased elastic recoil and resultant air trapping

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b) Clinical Picture : More in smokers1-Blue Bloaters : Bronchitis-Bronchitis , tussive type of COPD-Episodic dyspnea due to exacerbation of bronchitis-Young patients-Cyanosis2-Pink Puffers : Emphysema-Emphysematous type of COPD-Progressive exertional dyspnea due to the emphysema-Elderly patients

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c) Radiographic Features :1-Plain Radiography2-CT

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1-Plain Radiography :-Findings of chronic bronchitis are

nonspecific and include increased bronchovascular markings (dirty lung sign) and cardiomegaly

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CXR shows increased bronchovascular markings

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Dirty Lung sign

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-Emphysema manifests as lung hyperinflation with flattened hemidiaphragms , a small heart and possible bullous changes , on the lateral radiograph, a "barrel chest" with widened AP diameter may be visualized , the "saber-sheath trachea" sign refers to marked coronal narrowing of the intrathoracic trachea (frontal view) with concomitant sagittal widening (lateral view)

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CXR shows the signs of hyperinflation of the lungs (flattening of hemidiaphragms , widening of retrosternal and retrocardiac spaces green and yellow stars respectively) and loss of regular vascular branching pattern

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Bullous changes

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Saber sheath trachea

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2-CT :-In chronic bronchitis , bronchial wall

thickening and increased lung markings (dirty lung appearance) may be seen , repeated inflammation can lead to scarring with bronchovascular irregularity and fibrosis

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CT shows bronchial wall thickening

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CT in patient with chronic bronchitis showing thickening of the bronchial walls (red arrows) and mucous within the bronchi (yellow arrows)

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-Emphysema is diagnosed by alveolar septal destruction and airspace enlargement which may occur in a variety of distributions

-Centrilobular emphysema is predominantly seen in the upper lobes

-Panlobular emphysema predominating in the lower lobes-Paraseptal emphysema tends to occur near lung

fissures and pleura-Formation of giant bullae may lead to compression

of mediastinal structures while rupture of pleural blebs may produce spontaneous pneumothorax / pneumomediastinum

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Centrilobular Emphysema

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Panlobular Emphysema

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Paraseptal Emphysema

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Bullous Emphysema

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CT shows a focal area of emphysema (yellow arrow) , pneumothorax (red arrow)

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2-Emphysema :a) Pathologyb) Clinical Picturec) Radiographic Featuresd) Differential Diagnosis

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a) Pathology :-Abnormal enlargement of distal airspaces with destruction

of alveolar walls with or without fibrosis-More in smokers-There are three morphologic sub types of emphysema

which are named according to their relationship to the secondary pulmonary lobule :

1-Centrilobular Emphysema :-Is the most frequently encountered type and affects the

proximal respiratory bronchioles-More in the upper zones-It is strongly associated with smoking 

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2-Panlobular Emphysema :-Affects the entire secondary pulmonary lobule ,

more in the lower zones-Seen particularly in alpha-1-antitrypsin (AAT)

deficiency (exacerbated by smoking) 3-Paraseptal Emphysema :-Affects the peripheral parts of the secondary

pulmonary lobule near lung fissures and pleura-It is also associated with smoking and can lead to

the formation of subpleural bullae and spontaneous pneumothorax 

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Centrilobular Panlobular Paraseptal

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Centrilobular Panlobular Paraseptal

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b) Clinical Picture :-The clinical features of emphysema should be

distinguished from the signs and symptoms of chronic bronchitis

-Patients with emphysema often referred to as pink puffers

-Patients with chronic bronchitis often referred to as blue blotters

-However in clinical practice features of these two syndromes coexist as chronic obstructive pulmonary disease

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c) Radiographic Features :1-Plain Radiography2-CT

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1-Plain Radiography :a) Hyperinflation :-Flattened hemidiaphragm(s) : most reliable sign , highest

level of the dome is <1.5 cm above a straight line drawn between the costophrenic and the vertebrophrenic junctions

-Increased and usually irregular radiolucency of the lungs-Increased retrosternal airspace-Increased AP diameter of chest-Widely spaced ribs-Sternal bowing-Tenting of the diaphragm-Saber sheath trachea

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Normal Diaphragm Flattened Diaphragm

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Normal Flattening of the diaphragm

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Increased radiolucency , increased AP diameter of chest

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Normal retrosternal space Increased

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Normal Widely spaced ribs

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b) Vascular changes :-Decreased number of vessels in areas of

abnormal lung-Absence of peripheral pulmonary vessels-Fewer arterial branches-Central pulmonary artery increased in size

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Hyperlucency of the lungs with fewer vascular markings and prominence of the pulmonary arteries (arrows)

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2-CT : In all three sub types, the emphysematous spaces are not bounded by any visible wall

a) Centrilobular Emphysema :-It is predominantly located in the upper zones of

each lobe (i.e. apical and posterior segments of the upper lobes and superior segment of the lower lobes) has a patchy distribution

-It appears as focal lucencies  (emphysematous spaces) which measure up to 1cm in diameter located centrally within the secondary pulmonary lobule often with a central or peripheral dot representing the central bronchovascular bundle

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b) Panlobular Emphysema :-Predominantly located in the lower lobes ,

has a uniform distribution across parts of the secondary pulmonary lobule which are homogeneously reduced in attenuation

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c) Paraseptal Emphysema :-Located adjacent to the pleura and septal lines

with a peripheral distribution within the secondary pulmonary lobule , the affected lobules are almost always sub-pleural and demonstrate small focal lucencies up to 10mm in size

-Any larger than 10mm and they should be referred to as subpleural blebs or subpleural bullae

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Bullous Emphysema

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Emphysema with pneumothorax

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Emphysema with superimposed infection

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d) Differential Diagnosis :-Cystic lung disease , all have visible walls1-Lymphangiomyomatosis (LAM)2-Pulmonary Langerhans cell histiocytosis

(LCH)3-Honeycomb lung : usually reduced lung

volumes

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3-Bronchial Asthma :a) Pathologyb) Radiographic Features

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a) Pathology :-Hyperirritability of airways causes reversible

airway obstruction (bronchial smooth muscle contraction , mucosal edema , hypersecretion of bronchial secretory cells : bronchospasm)

-The etiology is unknown (IgE participation)

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b) Radiographic Features :1-Plain Radiography2-CT

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1-Plain Radiography :-Plain films can be normal in upto 75% of

patients with asthma-Severe or chronic asthma :Air trapping , hyperinflation : flattened

diaphragm , increased retrosternal airspace

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Gloved finger sign , finger like projections from hilum from bronchial mucoid impaction in allergic bronchopulmonary aspergillosis or asthma

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2-CT :-CT is usually used to detect the presence of

complicated associated conditions such as allergic bronchopulmonary aspergillosis and not to directly diagnose asthma

-Bronchial wall thickening , tramlines (also seen in chronic bronchitis , cystic fibrosis , bronchiectasis & pulmonary edema)

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Mild bronchial thickening and dilatation

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Central bronchiectasis , a hallmark of allergic bronchopulmonary aspergillosis (right arrow) and the peripheral tree-in-bud appearance of centrilobular opacities (left arrow) which represent mucoid impaction of the small bronchioles

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4-Bronchiectasis :a) Pathologyb) Clinical Picturec) Radiographic Featuresd) Differential Diagnosis

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a) Pathology :-Refers to irreversible abnormal dilatation of the

bronchial tree-Types :1-Cylindrical bronchiectasis :-Bronchi have a uniform caliber , do not taper and

have parallel walls (tram track sign when viewed in a sagittal section and signet ring sign when viewed in a coronal section)

-Commonest form 

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2-Varicose bronchiectasis :-Beaded appearances where dilated bronchi have

interspersed sites of relative narrowing-Uncommon3-Cystic bronchiectasis : More in lower lobes-Severe form with cyst-like bronchi that extend to the

pleural surface , air-fluid levels are commonly present4-Traction bronchiectasis :-Bronchiectasis which result from the traction of fibrotic lung

surrounding an airway

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Cylindrical bronchiectasis

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Cylindrical Bronchiectasis

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Varicose bronchiectasis

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Cystic bronchiectasis

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Cystic bronchiectasis

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Traction bronchiectasis

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b) Clinical Picture :-Bronchiectasis typically presents with

recurrent chest infections , production of copious amounts of sputum and hemoptysis

-Hemoptysis is often the only symptom and is encountered in up to 50% of case

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c) Radiographic Features :1-Plain Radiography2-CT

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1-Plain Radiography :-Tram-track opacities (horizontal , parallel lines

corresponding to thickened , dilated bronchi) are seen in cylindrical bronchiectasis

-Air-fluid levels may be seen in cystic bronchiectasis

-Bronchial wall thickening (best seen end-on)-Increase in bronchovascular markings

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Thin-walled, cystic structures in right lower lobe (white arrow) , some with air-fluid levels (yellow arrows)

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CXR (a) shows thickening of the bronchial walls and “tramlines” in the middle and lower regions of the lungs suggestive of bronchiectasis, confirmed on CT (b,c)

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2-CT :a) Increased bronchoarterial ratio :-Bronchi appear larger than accompanying vesselsb) Bronchial wall :-Thickened wall (normally wall of bronchus should

be less than half the width of the accompanying pulmonary artery branch)

-Signet ring sign , focally thickened bronchial wall adjacent to pulmonary artery branch

-Tram track sign , tube like parallel lines representing thickened bronchial walls

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Signet ring

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Tram Track sign

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Cystic bronchiectasis with air fluid level

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d) Differential Diagnosis :Conditions that may mimic cystic bronchiectasis include :1-Langerhans cell histiocytosis (LCH)2-Lymphangiomyomatosis (LAM)3-Lymphocytic interstitial pneumonitis (LIP)4-Pulmonary manifestations of AIDS5-Pneumocystis pneumonia (PCP)6-Emphysema (To distinguish emphysema from

bronchiectasis, expiratory scans will show air trapping in bullae while cystic bronchiectasis will collapse)

7-Cystic pulmonary metastases

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5-Cystic Fibrosis :a) Pathologyb) Clinical Picturec) Locationd) Radiographic Featurese) Differential Diagnosis

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a) Pathology :-Caused by an abnormality in the cystic fibrosis

transmembrane conductance regulator protein (CFTR) which regulates the passage of ions through membranes of mucus-producing cells

-Dysfunction of exocrine glands causing thick tenacious mucus that accumulates and causes bronchitis and pneumonia

-Reduced mucociliary transport : airway obstruction with massive mucus plugging

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b) Clinical Picture :1-Pulmonary, 100% :-Chronic cough-Recurrent pulmonary infections : colonization of plugged airways by

Staphylococcus and Pseudomonas-Progressive respiratory failure-Finger clubbing : hypertrophic osteoarthropathy from hypoxemia2-GI tract :-Pancreatic insufficiency , 85% : steatorrhea , malabsorption-Liver cirrhosis-Rectal prolapse-Neonates : meconium ileus, meconium peritonitis, intussusception3-Other :-Sinusitis : hypoplastic frontal sinus, opacification of other sinuses-Infertility in males

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c) Location :-Predominantly upper lobes , superior

segments of lower lobes and central (perihilar) distribution

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d) Radiographic Features :1-Plain Radiography2-CT

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1-Plain Radiography :-Chest x-rays are insensitive to the early changes of cystic

fibrosis, with changes seen on HRCT in 65% of patients with CF and normal CXR

-Later changes include :1-Bronchiectasis2-Hyperinflation3-Lobar collapse4-Pulmonary arterial enlargement due to pulmonary arterial

hypertension is seen in patients with long standing disease

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CXR shows diffuse interstitial disease with bronchiectasis and nodular densities of mucoid impaction

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CXR shows hyperinflation and predominantly upper lobe bronchiectasis

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2-CT :a) Bronchiectasis :*Progresses with time from cylindrical to varicose to cystic*Severity :-Mild: lumen equal to adjacent blood vessels-Moderate: lumen 2 to 3 times the size of adjacent blood

vessels-Severe : lumen >3 times the size of adjacent blood vessels*Peribronchial wall thickening , wall thickness > the

diameter of adjacent blood vessels

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b) Mosaic attenuation pattern :-Due to air trapping-Best seen on expiratory scansc) Mucus plugging within bronchi :-Finger in glove appearance

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e) Differential Diagnosis :1-Allergic bronchopulmonary aspergillosis (ABPA) 2-Tracheobronchomegaly (Mounier-Kuhn

syndrome)3-Williams-Campbell syndrome4-Langerhans cell histiocytosis (LCH)5-Lymphangiomyomatosis (LAM)6-Congenital cystic bronchiectasis

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6-Bronchiolitis :a) Pathologyb) Radiographic Featuresc) Swyer-James syndrome

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a) Pathology :-Inflammatory and fibrotic types :a) Inflammatory Bronchiolitis :1-Infectious :-Acute or chronic infection (viral ,

mycoplasma & mycobacterial)2- Hypersensitivity Penumonitis :-Organic or inorganic inhaled agents

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3-Respiratory Bronchiolitis :-Cigarette smoking4-Follicular and Lymphocytic :-Sjögren's syndrome , rheumatoid arthritis &

immunodeficiency5-Panbronchiolitis :-Idiopathic6-Bronchiectasis :-Cystic fibrosis & previous infection

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b) Fibrotic (Constrictive) Bronchiolitis :-Postinfectious , toxic fumes ,

transplantation , cryptogenic , collagen vascular diseases & drugs

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b) Radiographic Features :1-Plain Radiography2-CT

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1-Plain Radiography :-Can be normal or non specific , some

associated features include :a) Hyperinflationb) Attenuation of vascular markingsc) Occasionally : reticular or reticulo-nodular

markings

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Lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant with severe bronchiolitis

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Nonspecific hyperinflation with flattening of the hemidiaphragms on lateral CXR , as well as increased AP diameter and prominent size of retrosternal clear space , mild bilateral symmetric perihilar peribronchial prominence

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2-CT :a) Direct Signs :-Thickening of the bronchiolar wall by inflammatory cells

results in centrilobular nodules and V- or Y-shaped branching linear opacities that represent the tree-in-bud pattern

-Inflammatory cellular infiltration in the peribronchiolar alveoli results in poorly defined centrilobular nodules that often have an attenuation less than that of soft tissue

-Bronchiolectasis is a less common direct sign of bronchiolitis and is found most commonly in chronic forms of bronchiolitis , the dilated bronchioles are identifiable close to the pleural surface 

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Multiple poorly defined centrilobular nodules, many of which connect to branching linear structures (arrows) , tree-in-bud pattern

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Diffuse fine poorly defined centrilobular nodules (arrows) with more patchy ground-glass opacity posteriorly

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Centrilobular nodules with tree-in-bud pattern (arrowheads), bronchiolectasis (arrow), and cylindric bronchiectasis

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b) Indirect Signs :-Air trapping is an indirect sign of obstructive

small airways disease and may be identified by the presence of mosaic attenuation on inspiratory CT that is accentuated with expiratory imaging

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Multiple patchy areas of low attenuation in both lungs , note mild bronchial wall thickening and cylindric bronchiectasis

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Expiratory high-resolution CT image shows accentuation of areas of decreased attenuation , confirming presence of air trapping

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c) Swyer-James Syndrome (Mcleod) :1-Pathology2-Radiographic Features

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1-Pathology :-The late sequela of bronchiolitis in

childhood-Is a rare lung condition that manifests

as unilateral hemithorax lucency as a result of post-infectious obliterative bronchiolitis

-The condition typically follows a viral respiratory infection (adenovirus) in infancy or childhood

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2-Radiographic Features :a) Plain Radiographyb) CT

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a) Plain Radiography :-It is generally characterized on radiographs

by a unilateral small lung with hyperlucency and air trapping

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b) CT :-CT shows the affected lung as being

hyperlucent with diminished vascularity , the size of the majority of the affected lobes are smaller although occasionally they can be normal

- Bronchiectasis may be present although this is not a universal finding

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c) Upper Airway Obstruction in Children :(i) Approach(ii) Causes of Upper Airway Obstruction

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(i) Approach :-Inspiratory stridor is the most common

indication for radiographic upper airway evaluation

-Obtain 3 films :*Lateral neck : full inspiration , neck

extended*AP & lateral chest : full inspiration , include

upper airway

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-Primary diagnostic considerations : a) Congenital abnormalities (webs , malacia)b) Infection (epiglottitis , croup , abscess)c) Foreign body (airway or

pharyngoesophageal)d) Masses (lymphadenopathy , neoplasms)

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-If upper airway is normal , consider : 1-Pulmonary causes (foreign body ,

bronchiolitis)2-Mediastinal causes (vascular rings ,

slings)3-Congenital heart disease (CHD)

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-Normal Appearance :*Three anatomic regions : 1-Supraglottic region2-Glottic region : ventricle and true cords3-Subglottic region*Epiglottis and aryepiglottic folds are thin structures*Glottic shoulders are seen on AP view*Adenoids are visible at 3 to 6 months after birth*Normal retropharyngeal soft tissue thickness (C1-

C4) = three-fourths vertebral body width

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(ii) Causes of Upper Airway Obstruction :a) Congenital Abnormalities (webs ,

malacia)b) Infection (epiglottitis , croup , abscess)c) Foreign Body (airway or

pharyngoesophageal)d) Masses (lymphadenopathy , neoplasms)

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a) Congenital Abnormalities :1-Laryngomalacia2-Tracheomalacia3-Webs4-Tracheal Stenosis5-Subglottic Stenosis6-Choanal Atresia

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1-Laryngomalacia :-Common cause of stridor in the 1st year of

life and usually resolves by 2 years -Immature laryngeal cartilage leads to

supraglottic collapse during inspiration-Diagnosis is established by fluoroscopy

(laryngeal collapse with inspiration)

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2-Tracheomalacia :-Weakness of tracheal wall which may be primary or

secondary :a) Primary :-Premature infants -Cartilage disorders (polychondritis , chondromalacia &

MPS)b) Secondary :-Following prolonged intubation-With TOF / osophageal atresia-With vascular ring or other extrinsic vascular compression-With long standing external compression by tumor

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3-Webs :-Most common in larynx

4-Tracheal Stenosis :-Diffuse hypoplasia , 30%-Focal ringlike stenosis , 50%-Funnel-like stenosis , 20%

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5-Subglottic Stenosis :-Fixed narrowing at level of cricoid-Failure of laryngeal recanalization in utero

6-Choanal Atresia :-Most common congenital nasal abnormality-Bilateral in 33 % or unilateral (R>L)-Bony (90 %) or membranous , complete or incomplete-Diagnosis is done by failure to pass a catheter through the

nose

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b) Infection :1-Epiglottitis2-Croup3-Retropharyngeal Abscess4-Edema5-Retropharyngeal Hemorrhage

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1-Epiglottitis :a) Incidenceb) Clinical Picturec) Radiographic Featuresd) Differential Diagnosis

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a) Incidence :-Life threatening bacterial infection of the

upper airway-Most commonly caused by Haemophilus

influenzae-Age : 3 to 6 years

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b) Clinical Picture :-Fever-Dysphagia-Drooling-Sore throat

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c) Radiographic Features :-Key radiographic view : lateral neck-Thickened epiglottis-Thickened aryepiglottic folds (hallmark)-Subglottic narrowing due to edema , 25% :

indistinguishable from croup on AP view-Distention of hypopharynx

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d) Differential Diagnosis :-Other causes of enlarged epiglottis or

aryepiglottic folds : 1-Caustic ingestion2-Hereditary angioneurotic edema3-Omega-shaped epiglottis (normal variant

with normal aryepiglottic folds)4-Stevens-Johnson syndrome

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2-Croup :a) Incidenceb) Clinical Picturec) Radiographic Features

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a) Incidence :-Age : 6 months to 3 years (younger age

group than epiglottitis)-Most commonly caused by parainfluenza

virus-Subglottic laryngotracheobronchitis

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b) Clinical Picture :-Barking cough-Upper respiratory tract infection-Self limited

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c) Radiographic Features :-Key view : AP view-Subglottic narrowing (inverted “V” or

“steeple sign”)-Steeple sign : loss of subglottic shoulders-Lateral view should be obtained to exclude

epiglottitis

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3-Retropharyngeal Abscess :a) Incidenceb) Clinical Picturec) Radiographic Featuresd) Differential Diagnosis

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a) Incidence :-Typically due to extension of a suppurative

bacterial lymphadenitis , most commonly S. aureus , group B streptococci , oral flora

-Age : <1 year-Other causes include foreign body

perforation and trauma

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b) Clinical Picture :-Fever-Stiff neck-Dysphagia-Stridor (uncommon)-Most cases present as cellulitis rather than

true abscess

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c) Radiographic Features :-Widened retropharyngeal space (most

common finding)-Air in soft tissues is specific for abscess-May contain air fluid level-Straightened cervical lordosis-CT : rim enhancement

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d) Differential Diagnosis :-Retropharyngeal hematoma-Neoplasm (i.e. rhabdomyosarcoma)-Lymphadenopathy

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4-Edema : (Laryngeal)-Caused by :a) Angioedema (allergic , anaphylactic or

hereditary)b) Inhalation of noxious gasesc) Trauma

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5-Retropharyngeal Hemorrhage :-Due to :1-Trauma2-Neck surgery3-Direct carotid arteriography4-Bleeding disorders-Widening of the retropharyngeal soft tissue

space

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c) Foreign Body :1-Incidence2-Location3-Radiographic Features

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1-Incidence :-Common cause of respiratory distress-Age : 6 months to 4 years

2-Location :-right bronchi > left bronchi > larynx ,

trachea

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3-Radiographic Features :a) Bronchial foreign body :-Unilateral air trapping causing hyperlucent

lung , 90%-Only 10% of foreign bodies are radiopaque-Expiratory film or lateral decubitus makes

air trapping more apparent

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b) Tracheal foreign body :-CXR is usually normal-Foreign body usually lodges in sagittal

plane

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d) Masses :1-Grossly Enlarged Tonsils & Adenoids2-Nasal Angiofibroma3-Antrochoanal Polyp4-Subglottic Hemangioma5-Respiratory Paplillomatosis6-External Compression

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1-Grossly Enlarged Tonsils & Adenoids :a) Incidenceb) Radiographic Features

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a) Incidence :-The tonsils consist of lymphoid tissue that

encircles the pharynx-Three groups : pharyngeal tonsil (adenoids) ,

palatine tonsil and lingual tonsil-Tonsils enlarge secondary to infection and may

obstruct nasopharynx and/or eustachian tubes-Rarely , bacterial pharyngitis can lead to a

tonsillar abscess (quinsy abscess), which requires drainage

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-Specific causes include :1-Mononucleosis (Epstein-Barr virus)2-Coxsackievirus (herpangina , hand-foot-

mouth disease)3-Adenovirus (pharyngoconjunctival fever)4-Measles prodrome (rubeola)5-β-Hemolytic Streptococcus (quinsy

abscess)

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b) Radiographic Features :-Mass in posterior nasopharynx (enlarged

adenoids)-Mass near end of uvula (palatine tonsils)-CT is useful to determine the presence of a

tonsillar abscess

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2-Nasal Angiofibroma

3-Antrochoanal Polyp

4-Subglottic Hemangioma :-The most common subglottic soft tissue mass in

infancy-Occurs before 6 months of age-Produces asymmetrical narrowing of the

subglottic airway

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5-Respiratory Paplillomatosis :-Occur anywhere from the nose to the lungs-Irregular soft tissue masses which may

cavitate around the glottis or in the trachea

6-External Compression :-From Other Mediastinal Structures

(lymphadenopathy)

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