Practical approach to the pediatric chest Xray

Practical approach to the pediatric chest Xray

IX Congress of the Latin American Society of Pediatric Radiology

Buenos Aires on September 7-9, 2005

Mutsuhisa Fujioka, M.D.Chairman, The Asian and Oceanic Society for Pediatric Radiology

Professor and Chairman, Department of Radiology, Dokkyo University School of Medicine

Valoraction practica de la RX de torax

http://www.aospr.org/

Journal

Editorial board members

Managing Editors

(Africa, Asia, Australasia, Europe, and elsewhere outside the Americas)Dr. S. ChapmanThe Birmingham Children’s Hospital NHS TrustSteelhouse LaneBirmingham B4 6NHUnited Kingdom [email protected]

(The Americas)Dr. T. L. SlovisChildren’s Hospital c/o: CRCM3901 Beaubien BoulevardDetroit, MI 48201, [email protected]

Assistant Editors

Dr. D. FrushDuke University Medical Center Div of Pediatric Radiology (Box 3808)1905 McGovern Davison Children’s Hlth. Ctr.Durham, NC 27710, [email protected]

Dr. G. SebagDepartment of Paediatric RadiologyHồpital Robert Debré48, boulevard Sérurier75935 Paris Cedex, [email protected]

Honorary Editor

Dr. W. E. BerdonColumbia Presbyterian Medical Center, Babies HospitalDept of Radiology (3-318)3959 BroadwayNew York, NY 10032-1590, [email protected]

Editorial Board

CardiovascularT. Chung, HoustonJ. A. Culham, VancouverM. Oddone, GenoaS. Laurin, LundC. Holmqvist, Lund

ChestV. Donoghue, DublinE. Effmann, SeattleM. Fujioka, UtsunomiyaJ. Lucaya, BarcelonaB. Newman, Pittsburgh

EducationJ. Reid, ClevelandJ-N. Dacher, Rouen

Experimental DesignK. Applegate, Indianapolis

Genetics – Molecular ImagingR. Lachman, Santa MonicaW. McAlister – St. Louis

General Paediatric RadiologyS. Andronikou, Cape TownM. Argyropoulou, IoanninaP. Babyn, TorontoA. Daneman, TorontoH. Ducou Le Pointe, ParisF. Gudinchet, LausanneI-O, Kim, SeoulH. Lederman, San PauloP. Strouse, Ann ArborG. Taylor, BostonR. Teele, Auckland

GastrointestinalG. Benz-Bohm, CologneD. Bloom, DetroitD. Eggli, HersheyM. Hernanz-Schulman, NashvilleK. McHugh, LondonD. Pariente, BicetreC. Sivit, Cleveland

InterventionalP. Chait, TorontoP. Clapuyt, BrusselsJ. Donaldson, ChicagoD. Roebuck, LondonR. Towbin, Philadelphia

MusculoskeletalM. Azouz, MiamiH. Carty, LiverpoolC. Hall, LondonD. Jaramillo, BostonG. Kalifa, ParisM. Keller, WilmingtonT. Laor, Cincinnati

NeuroradiologyC. Adamsbaum, ParisN. Boddaert, ParisF. Brunelle, ParisB. Koch, CincinnatiM. Nelson, Los AngelesC. Robson, BostonY. Sato, Iowa City

OncologyH. Brisse, ParisS. Kaste, MemphisJ. Meyer, WilmingtonC. Owens. London

PerinatalC. Garel, ParisL. Garel, MontrealL. Guibaud, LyonE. Simon, Philadelphia

TechnologyM. Claudon, NancyW. Huda, SyracuseT. Metens, BrusselsW.K. Rorhschneider, HeidelbergK. White, Salt Lake CityC. Willis, HoustonP. Winkler, Stuttgart

UroradiologyF. Avni, BrusselsB. Coley, ColumbusK. Darge, WuerzburgR. Fotter, GrazU. Willi, ZurichM. Zerin, Detroit

Book ReviewsJ. Haller, TeaneckM. Hassan, Paris

Statistics, Information, Technology and EditingH. Fischer, DetroitW. Grever, DetroitR. Thomas, Detroit

Manuscripts must be sent to the appropriate Managing editor only. Please ensure that the manuscript complies with the “Instructions to authors: at http://link.springer.de/link/service/journals/00247/instr.htm

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A practical approach to the pediatric chest radiograph

Steps for reading

1. 　 Detection

2. 　 Differentiation

Change in size and shape of normal anatomical structures.

Soft tissue, bones, heart, aorta, trachea, main bronchi, thymus, hili, esophagus, pleura, diaphragms, pulmonary arteries, veins, bronchial walls, gastric air bubble, liver, spleen

What are we looking for?

Abnormality(increased or decreased opacity) which should not be present in normal individual

What are we looking for?

ground-glass opacity(haziness)

consolidation

nodule or mass

linear, reticular or band like shadow

calcification

Increased lung opacity

hyperlucency(air trapping or pneumothorax)

lung cyst or bulla

honeycomb

cavitary nodule or mass

cystic bronchiectasis

Decreased lung opacity and cystic abnormalities

Features of Lung Diseasein High Resolution CT

Ground-Glass Opacity

Consolidation

Pulmonary Nodule

Bronchiolar Disease and Tree-in-Bud

Air Trapping

Septal Thickening

Parenchimal Bands

Honeycombing

Mosaic Perfusion

Architectural Distortion

Air-Filled Cystic Lung Lesions

Dependent Increased Attenuation

Emphysema

Halo Sign

Signet Ring Sign

Crazy Paving Pattern

The main role of HRCT is to differentiate fine pathological abnormality.

Change in size and shape of normal anatomical structures can rather be easier to be detected by the findings of chest radiograph rather than those of CT.

Therefore for adequate interpretation of pediatric chest radiographs, we should be aware of gross abnormal findings which might be overlooked by particular reasons.

However it is very important to know what kind of abnormality is not demonstrable on usual chest radiograph but well demonstrated on CT or HRCT.

Detection of abnormal findings

Quiz 1

Any abnormality in the lung in a child with cough and fever ?

Pneumonia and/or atelectasis at the left S8

Positive silhouette sign of the left hemidiaphragm

2yo Bilateral pneumonia: Lingula of the left upper lobe, right lower lobe 　

Detection of Pneumonia using Silhouette sign


Positive SS along left cardiac border



Negative SS along right cardiac border


How to detect abnormal findingssilhouette sign

silhouette out (Positive silhouette sign) 　

Pneumonia and/or atelectasis of the lingula of the left upper lobe

Subsegmental pneumonia of the S10 of the left lower lobe

Positive silhouette sign of the posterior portion of the left hemidiaphragm

Quiz 2


Any abnormality in the central shadow in a child with habitual vomiting?

Esophageal achalasia Esophageal achalasia

anterior junction line

posterior junction line

azygoesophageal line

aortic-pulmonic window

aortic pulmonary stripe

left paraspinal line

right paratracheal stripe

posterior tracheal band （ lateral ）

tracheo-esophageal stripe （ lateral ）

aortic nipple

How to detect abnormal finding

Mediastinal interfaces and lines

left paraspinal lineazygoesophageal line

Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Two mediastinal lines, the anterior and posterior junction lines, are occasionally seen on normal plain radiographs. The descending aorta and SVC interfaces are commonly seen on normal chest radiographs; their absence may suggest mediastinal or pulmonary abnormalities. The azygoesophageal and left paraspinal interfaces are not commonly seen on normal chest radiographs.

Yoon HK, et al: Mediastinal interfaces and lines in children: radiographic-CT correlation. Pediatr Radiol(2001)31:406-412

right paratracheal stripe

Abnormal shadow hidden by the central shadow or the diaphragmatic domes

mediastinal reflection

tracheal bronchus(pig bronchus)

tracheal bronchus

atelectasis

Abnormality of the right paratracheal stripe

Tracheal displacement

Double aortic arch

Abnormality of the right paratracheal stripe

azygos line, paraesophageal line

neuroblastoma

cervicothoracic sign

neuroblastoma

posterior mediastinal line

ＡＬＬ　 extramedullary infiltrates



Bronchogenic cyst



Bronchogenic cyst



Bronchogenic cyst

Pneumomediastinum from asthmatic attack

Any abnormality in the lung in a child with abdominal pain ?


Quiz 3

detection of basilar pneumonia on an abdominal radiograph

Right basilar pneumonia

　


Below the margin of the diaphragamatic domes

Appendicitis ?Lesions hidden by the diaphragmatic domes

Ultrasonography

Plain abdomen

diaphragm

pneumonia

Right basilar pneumonia

ＣＴ

Pulmonary metastasis of Wilms tumor

Decubitus view Ultrasonography

infrapulmonary effusion

Any nodule suggesting metasasis of Wilms tumor ?

Detection of abnormal finding

Quiz 4

A pulmonary metastasis of Wilms tumor


Atelectasis of Ｓ 8 of the left lower lobe

Any evidence of peanut aspiration ?


Quiz 5

Inspiratory phase Expiratory phase

Air trapping of the left lung due to check valve mechanism

Peanut aspiration


Major findin number

Radiopaque foreign body 5

Normal chest 6

Air trapping 17

Parenchymal radiopacity 12

Air trapping with parenchymal radiopacity 12

g

Findings on plain chest radiographs in foreign body aspiration(52 children)


Foreign body in the main bronchus

Foreign body in the main bronchus


Scintigraphy of the pulmonary blood flow

CT for foreign body

Any abnormality in the lung in an infant with fever and dyspnea ?


Quiz 6

bronchiolitis

Hyperlucency of both lungs due to air trapping

bronchiolitis


Is clear lung on radiograph always good for children?

peripheral airway disease

Centrilobular nodules (bronchilitis)

Centrilobular nodules, centrilobular rosettes and clusters, random nodules

Pulmonary Nodule

9yo 　 bronchial asthma


After treatment

Air Trapping:HRCT findings

GGO

Mosaic pattern

Equipment ： wider latitude film-screen system, computed radiography(CR) flat panel digital radiography(DR)

Technical factors ： high kV, Bucky film

Additional views ： lateral view decubitus view, plain abdomen ultrasonography, CT

How to improve the detectablity of the lesions hidden by the central shadow or diaphragmatic domes ?

Reading ： silhouette sign, posterior mediastinal lines

Limitaion ： ground glass opacity(GGO) peripheral lesions adjacent to the pleura, thin atelectasis perpendicular to the X-ray beam

How to improve the detectablity of the lesions hidden by the central shadow or diaphragmatic domes

Reading ： silhouette sign, posterior mediastinal lines

Limitaion ： ground glass opacity(GGO) peripheral lesions adjacent to the pleura, thin atelectasis perpendicular to the X-ray beam

CT(HRCT) may easily provide final answer but the indication should be limited only by clinical reasons not merely by radiological reasons!!!!

How to improve the detectablity of the lesions hidden by the central shadow or diaphragmatic domes

1 To make a list of diseases or conditions as many as possible in each category

2 To exclude a specific disease or condition one by one from the list

3 To leave those not to be excluded by former process

Differential diagnosis

Incorrect diagnosis may be lead when the correct diagnosis is not included from beginning

1. Technical

2. Normal

3. Congenital

4. Inflammatory

5. Neoplastic

6. Traumatic or Iatrogenic

Categories to be checked


What is the mass in the left upper lung ?


Quiz 1

C T

U S

posterior mediastinal thymus

neuroblastomaposterior mediastinal thymusmycoplasm pneumonia

Consolidation in the lung field

Air bronchogram

Right upper lobe pneumonia

Is this neoplasm ?


Quiz 2

spherical pneumonia

spherical pneumonia

1) Spherical Pneumonia

2) Plasma Cell Granuloma (Postinflammatory Pseudotumors Sclerosing Hemangioma Fibrous Histiocytoma, Fibrous Xanthoma etc)

3) Pulmonary Granuloma （ tuberculoma, histoplasmoma)

4) Pulmonary Arteriovenous Malformation

5) Mucoid Impaction

6) Round Atelectasis

7) Pulmonary Hematoma

8) Pulmonary Sequestration

9) Intrathoracic Ectopy of abdominal organ

Pseudotumor in the lung

Bronchopulmonary sequestration

Intralabar bronchopulmonary sequestration

bronchial atresia

Staphylococcal pneumonia



Pulmonary tuberculosis wtih hilar lymphadenopathy, calcified

Primary tuberculosis with calcified lymphnodes

What is the next step ?


Quiz 3

Malignant Small Round Cell Tumor

(MSRCT)

Blind thoracentesis to insert a tube into the tumor!!

York sac tumor Agenesis of the left lung

inverted diaphragm

Tuberculous pleuritis with clacified lymphnodes

What should be considered for differential diagnosis ?


Quiz 4

Swyer-James syndrome

unilateral hyperlucent lungswyer-James syndrome

unilateral hyperlucency

Atresia of the left pulmonary artery

lobar emphysema

bronchial atresia


bronchomalacia

1. Technical

2. Normal

3. Congenital

4. Inflammatory

5. Neoplastic

6. Traumatic or Iatrogenic

Check all categories below then you may certainly always reach correct diagnosis!!!

Conclusion

Thank you for your attention!

Documents

Practical approach to the pediatric chest Xray