(3) chest general

X-RAYSX-RAYS

By

Prof Dr IBRAHIM DAWOUD

Prof of Surgery

Mansoura University

How to read

Plain X-ray

Plain x-ray (describe the region).

View (PA, lat, oblique).

Position (erect, supine).

Quality.

Exposure.

Chest: Centralization, Bony frame work. Costophrenic angle, Soft tissue shadow.

Abdomen: well prepared or not, radio-opaque shadow, gas shadow.

Bone: Fracture, tumor, inflammation.

Soft tissue mammogram.

Normal Chest X-ray

How to readHow to read

Plain x-ray chest.

Postero-anterior view.

Erect Position . Good Quality. Good Exposure.

Chest: more or less Centralized.

Bony frame work : free .

Costophrenic angle : free on both sides,

Soft tissue shadow: Rt lung collapse with presence of air in the Rt pleural space.

Presence of chest tube in the Rt side of the chest.

Diagnosis most probably

Rt Pneumothorax

Questions:Questions:

Causes Causes

Artificial Spontaneous Traumatic

1- Therapeutic 1- Emphysem bullae 1- Open

2- Diagnostic 2- TB cavity 2- closed

3- Lung cyst

TypesTypes

1- Simple (closed) Pneumothorax

2- Open Pneumothorax

3- Tension Pneumothorax

TreatmentTreatment

How to readHow to read

Plain x-ray chest.

Postero-anterior view

Erect Position . Good Quality. Good Exposure.

Chest: more or less Centralized.

Bony frame work : fracture ribs on the Rt side .

Costophrenic angle : Obliterated on the Rt side with transverse air-fluid level and free on the left side.

Soft tissue shadow: Free

Diagnosis most probably

Rt Hemo-pneumothorax

QuestionsQuestions

Causes Causes

Postoperative Pathological Traumatic

1- Thoracotomy 1- Lung tumors 1- Open

2- Puncture 2- BL disease 2- Closed

Source of bleedingSource of bleeding

1- Systemic: Intercostal V, Heart and great V, Abd organs

2- Pulmonary: From lung parenchyma

PathologyPathology

1- Systemic bl is progressive, pulmon bl rapidly stopped

2- Bl at first defibrinated, then clotting occurs

then organized into F.T. then 2ry inf Empyema

Clinical PictureClinical Picture

InvestigationInvestigation

TreatmentTreatment

1- Systemic

{a} Aspiration {b} Bl Transfusion {c} U.W.S. (site?)

{d} Thoracotomy For major vessel injury

2- Pulmonary

Conservative treatment

3- Clotted H

Thoracotomy---- Decortication may be required

4- Infected H

Early---- Aspiration Late------ Open drainage & Decortication

How to readHow to read

Plain x-ray chest.

Postero-anterior view.

Erect Position . Good Quality. Good Exposure.

Chest: more or less Centralized.

Bony frame work : Multiple simple Fracture ribs on the Rt side (2nd,3rd, 4th, and 5th ribs).

Costophrenic angle : free on both sides,

Soft tissue shadow: Free on both sides.

Diagnosis most probably

Multiple Simple Fracture Ribs

How to readHow to read

Plain x-ray chest.

Postero-anterior view

Erect Position . Good Quality. Good Exposure.

Chest: more or less Centralized.

Bony frame work : Multiple segmented fracture ribs on the left side.

Costophrenic angle : Obliterated on the left side.

Soft tissue shadow: Lt lung collapse with presence of air in the lt pleural space.

Diagnosis most probably

Multiple Segmented Fracture Ribs

(Flail Chest)

QuestionsQuestions

Causes Causes

Direct Violence

Indirect Violence

Muscular Violence

TypesTypes

1- Simple Fracture ribs

2- Stove in Chest

3- Flail Chest

Clinical PictureClinical Picture

InvestigationInvestigation

TreatmentTreatment

1- Simple Fracture

{a} Analgesic {b} Adhesive strapping

{d} Local Novocain Injection

2- Stove In Chest

External Traction by Towel Clips for 2 w

3- Flail Chest

{a} At the scene of the accident

{b} At the casualty room

{c} Definitive treatment

Conditions Requiring Urgent CorrectionConditions Requiring Urgent Correction

Air Way Obstruction Air Way Obstruction

Removal of mechanical debris &Extension of the neck

Tracheostomy or Catheter through the cricothyroid mem

Endotracheal intubation

Tension PneumothoraxTension Pneumothorax

Life-saving large-bore needle followed by UWS

Open PneumothoraxOpen Pneumothorax

Massive Flail ChestMassive Flail Chest

Massive HemothoraxMassive Hemothorax

1500 ml of bl or more

Conditions Requiring Urgent ThoracotomyConditions Requiring Urgent Thoracotomy

Continued Intrapleural Bleeding Continued Intrapleural Bleeding

Rate exceeding 100 ml/H or more for 6 H

Massive Air LeakMassive Air Leak

Complete unilateral atelectasis in the face of a large air leak

Symmetrical downward displacement of the bilateral hila

Acute pericardial tamponadeAcute pericardial tamponade

Acute Ht failure 2ry to valve or septal injuryAcute Ht failure 2ry to valve or septal injury

Widened or widening mediastinumWidened or widening mediastinum

Perforation of intrathoracic esophagusPerforation of intrathoracic esophagus

How to readHow to read

Plain x-ray chest.

Postero-anterior view (1) --- Lateral view (2)

Erect Position . Good Quality. Good Exposure.

Chest: more or less Centralized.

Bony frame work : free .

Costophrenic angle : free on both sides,

Soft tissue shadow: Consolidated area in the Rt lower segment with cavitations and air fluid level inside the cavity

Diagnosis most probably

Rt Lung Abscess

QuestionsQuestions

Causes Causes

1ry necrotizing pneumonia Aspiration pneumonia

Bronchial obstruction Systemic infection

Pulmonary trauma Direct from surrounding

Clinical pictureClinical picture

1- stage of pneumonitis

2- stage of abscess

3- stage of chronicity

Investigations:Investigations:

1- Radiography

2- Sputum examination

3- Bronchoscopy

TreatmentTreatment

1- Antibiotics and internal drainage

By {a} cough {b} bronchoscopy

2- External drainage

{a} Tube pneumonostomy

{b} Pneumonotomy

through a generous incision with rib resection

3- Pulmonary resection:

Indicated in

{a} chronicity with symptoms

{b} serious hemorrhage

{c} Suspicion of associated carcinoma

How to readHow to read

Plain x-ray chest.

Postero-anterior view (1st) lateral view (2nd)

Erect Position . Good Quality. Good Exposure.

Chest: more or less Centralized.

Bony frame work : free .

Costophrenic angle : free on both sides,

Soft tissue shadow: Apical opacity ( coin shadow) in the apex of the left lung.

Diagnosis most probably

Bronchogenic Carcinoma Left lung

(Pancoast tumor)

QuestionsQuestions

PathologyPathology

1- Incidence ( age- sex- site )

2- Etiology (p.p) :(smoking- air pollution- adenoma…)

3- N/E: ( fungating- nodular- ulcer- infiltrating)

4- MP: (Sq CC- small CC- Adenocarcinoma- large CC- other)

5- Complications (including spread)

6- Staging

Clinical PictureClinical Picture

InvestigationsInvestigations

TreatmentTreatment

How to readHow to read

Plain x-ray chest.

Postero-anterior view

Erect Position . Good Quality. Good Exposure.

Chest: more or less Centralized.

Bony frame work : free .

Costophrenic angle : Massive obliteration of the left side

of the chest

Soft tissue shadow: Tracheal and mediastinal shift

to the opposite side.

Diagnosis most probably

Malignant pleural effusion

TYPESTYPES

TansudateTansudate

1- Congestive HF 2- Nephrotic Syndrome

3- Cirrhosis 4- Hypoproteinemia

5- Myxedema 6- Peritoneal dialysis

ExudateExudate

1- Malignancy (1ry or 2ry)

2- Infection

3- Infarction

4- Traumatic

5- Sympathetic ( Pancreatitis- Subphrenic abscess….)

6- Collagen disease

How to readHow to read

Plain x-ray chest.

Postero-anterior view

Erect Position . Good Quality. Good Exposure.

Chest: more or less Centralized.

Bony frame work : free .

Costophrenic angle : free on both sides,

Soft tissue shadow: Multiple opacities (coin shadows) occupying the whole of both lungs.

Diagnosis most probably

Cannon-ball metastases of the lung

How to readHow to read

SOFT TISSUE MAMMOGRAPHYA well defined rounded mass in the upper part of the

breast. It has a rounded border. No pathological calcification. Normal breast architecture. Normal overlying skin. No retraction of the nipple

Mostly Benign Breast Disease

Fibrodenoma

How to readHow to read

SOFT TISSUE MAMMOGRAPHY

A dense shadow(s) in the breast with a very irregular outline, and with fine stippling of calcification .

Disturbed breast architecture. Thickening of the overlying skin. Retraction of the nipple

Mostly Malignant in nature

Biopsy is recommended

MAMMOGRAPHIC CRITERIA

OF CANCER BREAST

MalignantBenign

1ry

signs

High densityLow density

Non-homogenous opacityHomogenous opacity

Irregular borderSmooth outline

MicrocalcificationNo or macrocalcification

2ry

signs

Disturbed architectureNormal

Increased vascularityNormal

Perifocal hazinessRare

Radiological size smaller than clinical size

Same or larger

Retracted nipple, thickened skin

Normal

How to readHow to read

Plain x-ray neck and thoracic inlet.

Postero-anterior view.

Good Quality. Good Exposure.

Patient is more or less Centralized.

Bony frame work :

Presence of bilateral extraribs on both sides of the neck connected to the 7th cervical vertebra and the first rib.

Diagnosis most probably

BILATERAL CERVICAL RIBS

Postoperative

Postoperative

How to readHow to read

Plain x-ray neck and thoracic inlet.

Postero-anterior view.

Good Quality. Good Exposure.

Patient is more or less Centralized.

Bony frame work :

Presence of extrarib on the Rt side of the neck connected to the 7th cervical vertebra and the first rib.

Diagnosis most probably

RIGHT CERVICAL RIBS

How to readHow to read

Plain x-ray skull and mandible.

Lateral view.

Presence of soft tissue shadow in the saubmandibular region with multiple radio opaque shadows.

Diagnosis most probably

Chronic Submandibular Sialadenitis

with Submandibular Stones

How to readHow to read

Plain x-ray skull and mandible.

Lateral view.

Presence of radio opaque shadow in the submandibular region.

Diagnosis most probably

Submandibular Stone