9 The Paediatric Chest

DAVID SUTTON

DAVID SUTTON PICTURES

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

• Fig. 9.1 Coronal MRI scan (T,-weighted) in a child with a mediastinal mass. Note how the heart and great vessels are readily differentiated by signal void due to blood flow from the glandular masses due to Hodgkin's disease.

• Fig. 9.2 (A) Bronchogram. Water-soluble contrast has been introduced into the trachea and bronchi showing long segment tracheal stenosis. Right apical (pig) bronchus also present. (B) Prone oesophagograrm showing good bolus distension of the oesophagus with a hairline communication between the oesophagus and trachea (which contains contrast along its posterior wall) representing the 'N' or 'H' type tracheo-oesophageal fistula (arrow).

• Fig. 9.3 Chest X-ray showing overinflated left lung in a neonate with crowding of the ribs and opacification of the right hemithorax due to agenesis of the right lung.

• Fig. 9.4 (A) Chest X-ray showing hypoplasia of the right lung with mediastinal shift to the right. (B, C) VQ scans show reduced ventilation and perfusion to the abnormal hypoplastic right lung (posterior view).

• Fig. 9.5 (A) Congenital lobar emphysema/ overinflation. Chest X-ray shows gross overinflation of the right lung which is hypovascular with marked shift of the mediastinum to the left and herniation of the lung into the left hemithorax (arrow). (B) CT of right middle lobe congenital lobar overinflation/emphysema causing shift of the mediastinum to the left with marked distortion of the pleural reflections to the left of the midline.

• Fig. 9.7 (A) Chest X-ray: right cystic hamartomatous/ adenomatous malformation type 1 with multiple cystic lesions in the right lower lobe showing air-fluid levels consistent with infection. (B) Axial CT scan through the lung bases show the thick-walled cysts in the right lower lobe.

• Fig. 9.8 (A) Chest X-ray: cystic hamartomatous/ adenomatous malformation type 3. Extensive ground-glass shadowing with gross overinflation of the right lung and herniation across the midline due to the presence of a CCAM type 3. (B) CT scan of the same patient with extensive overexpansion of the right lung and ground-glass shadowing due to microcysts beyond the resolution of the CT.

• Fig. 9.9 (A) Coronal ultrasound examination of a pulmonary sequestration (arrow) in left lower lobe. The Doppler scan shows a large systemic vessel arising from the aorta to supply the sequestration. (B) Axial ultrasound shows the origin of systemic vessel (arrow) from aorta, confirmed at aortography. fistulas associated with either liver disease, cyanotic heart disease,

• Fig. 9.10 (A) Axial contrast-enhanced CT scan through the lung bases with a large systemic vessel arising from the left side of the aorta (arrow A) supplying a very vascular left-sided extralobar sequestration (ELS) (arrow B). (B) Corona) CT multiplanar reconstruction (MPR) showing the normal lung and beneath this (arrow) the left-sided basal ELS with a draining vein entering the azygous system below the diaphragm.

• Fig. 9.11 Left congenital diaphragmatic hernia. HAStE sequence from coronal MRI of a 32-week fetus showing presence of a left-sided congenital diaphragmatic hernia. The normal right lung is of intermediate to high signal intensity and meconium within the bowel in the left chest is hyperintense (arrow) (similar signal to the amniotic fluid surrounding the fetus). ??????????

• Fig. 9.12 A chest X-ray taken at 2 days of age showing a left-sided congenital diaphragmatic hernia with loops of bowel in the left hemithorax and shift of the heart and mediastinum to the right. The stomach is delinteated by the presence of the nasogastric tube below the level of diaphragm.

• Fig. 9.13 Hyaline membrane disease. (A) Mild changes aged 1 day-fine reticulonodular shadowing with prominent air bronchograms. (B) More advanced changes aged 3 days-marked pulmonary opacification with loss of diaphragmatic and cardiac contours.

• Fig. 19.14 Pulmonary interstitial emphysema. Fine reticular shadowing in the right lung with deviation of the mediastinum contralateraIly. RDS affecting the left lung.

• Fig. 9.15 Bilateral pneumothoraces in hyaline membrane disease. Right intercostal drain.

• Fig. 9.16 Bronchopulmonary dysplasia. Patchy shadowing from areas of loss of volume and fibrosis, with areas of compensatory emphysema, especially in the right upper lobe.

• Fig. 9.17 (A) Meconium aspiration. There is marked overinflation of the lungs with coarse nodular shadowing secondary to meconium aspiration. Bilateral chest drains drain pneumothoraces (persistent in right subpulmonic distribution). (B) Arteriovenous ECMO catheters are present/in situ. Diffuse ground-glass shadowing is present within the collapsed lungs. The arterial cannula (arrow A) has been inserted into the right common carotid artery with its tip in the aortic arch. The venous cannula (arrow B) has been inserted into the right internal jugular vein, and its tip should lie in the right atrium.

• Fig. 9.18 Miliary tuberculosis. Fine nodularity throughout both lungs.

• Fig. 9.19 Pneumocystis pneumonia. Widespread alveolar shadowing.

• Fig. 9.20 Foreign body inhalation. (A) Obstructive emphysema from a foreign body in the left main bronchus. (B, C) Another child showing loss of volume in the left lung with patchy collapse in the apex of the left lower lobe; in inspiration (B) the mediastinum is slightly to the left; in expiration (C) the volume of the left lung changes little with the mediastinum swinging to the right.

• Fig. 9.20 Foreign body inhalation. (A) Obstructive emphysema from a foreign body in the left main bronchus. (B, C) Another child showing loss of volume in the left lung with patchy collapse in the apex of the left lower lobe; in inspiration (B) the mediastinum is slightly to the left; in expiration (C) the volume of the left lung changes little with the mediastinum swinging to the right.

• Fig. 9.21 Advanced cystic fibrosis (mucoviscidosis). Gross peribronchial shadowing with confluent pneumonic shadowing. There is a left pneumothorax with slight displacement of the mediastinum to the right.

• Fig. 9.22 Histiocytosis X. Fine nodularity in both lung fields.

Fig. 9.23 Neuroblastoma. A large left posterior mass deviates the mediastinum to the right, with thinning and separation of the adjacent posterior ends of the ribs.

• Fig. 9.24 Idiopathic pulmonary haemosiderosis. Perihilar shadowing with a reticulonodular pattern in the peripheral lung fields.

• Fig. 9.25 (A) Pulmonary alveolar proteinosis. Chest X-ray showing diffuse alveolar shadowing in a perihilar distribution with some fine linear change in the upper zones. (B) High-resolution CT scan confirming these appearances showing diffuse alveolar exudate with interstitial thickening most marked in the non-dependent areas of the lung. (C) Histological specimen from video-assisted thoracoscopic biopsy of the lung showing diffuse glycoproteinaceous exudate within the alveolar spaces with thickening of the interstitium of the lung which shows marked increase in cellularity.

• Fig. 9.25 (A) Pulmonary alveolar proteinosis. Chest X-ray showing diffuse alveolar shadowing in a perihilar distribution with some fine linear change in the upper zones. (B) High-resolution CT scan confirming these appearances showing diffuse alveolar exudate with interstitial thickening most marked in the non-dependent areas of the lung. (C) Histological specimen from video-assisted thoracoscopic biopsy of the lung showing diffuse glycoproteinaceous exudate within the alveolar spaces with thickening of the interstitium of the lung which shows marked increase in cellularity.