6 DISEASES OF THE AIRWAYS: COLLAPSEAND CONSOLIDATION

DAVID SUTTON

DAVID SUTTON PICTURES

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

• Fig. 6.1 Tracheo-oesophageal fistula. A lateral chest radiograph shows the fistula between the trachea and the oesophagus (arrow). The oesophagus is air filled (arrowheads).

• Fig. 6.2 Relapsing polychondritis. (A) CT scan just above level of aortic arch shows diffuse thickening of tracheal wall with abnormal calcification and narrowing of the tracheal lumen. (B) CT scan just below level of carina shows identical abnormalities extending into both main bronchi.

• Fig. 6.3 Squamous carcinoma of the trachea. (A) Close-up of the lateral chest X-ray demonstrates narrowing of the trachea with irregularity of the posterior wall (arrows). (B) AP tomogram demonstrating lobulated filling defects within the tracheal air column.

• Fig. 6.4 Adenoid cystic carcinoma of the trachea. (A) CT demonstrates a , mass within the left lateral tracheal wall causing only slight distortion of the lumen. The extraluminal component extends into the adjacent mediastinal fat (arrows). (B) CT image 2 cm cranial to the lesion demonstrates normal tracheal wall thickness.

• Fig. 6.5 There is a stricture (arrows) of the trachea following tracheostomy 10 years earlier.

• Fig. 6.6 Mounier-Kuhn syndrome. There is dilatation of the trachea in association with bronchiectasis (arrows). There are also multiple paraseptal bullae (curved arrow).

• Fig. 6.7 Kartagener's syndrome. (A) There is dextrocardia and widespread bronchiectasis, most obvious at the left base. (B) A lateral view demonstrates an air-fluid level (arrows) within a dilated bronchus.

• Fig. 6.8 Bronchiectasis. Tramline shadows are visible through the heart shadow.

• Fig. 6.9 Bronchiectasis. Multiple ring shadows, many containing air-fluid levels, are present throughout the lower zones of this patient with cystic bronchiectasis.

• Fig. 6.10 Cylindrical or tubular bronchiectasis. CT image at the level of the hila demonstrates widespread bronchiectasis, particularly well seen is the apical segment of the right lower lobe. The bronchi fail to taper and have irregular thickened walls.

Fig. 6.11 Cystic bronchiectasis. A CT image through the upper lobes demonstrates multiple ring shadows. More caudal images reveal these to be due to irregularly dilated bronchi.

• Fig. 6.12 Bronchiectasis with mucus plugging. A CT scan through the posterior costophrenic recesses showing multiple fluid-filled dilated bronchi causing a string of rounded opacities in the posterior costophrenic angle. (Same patient as illustrated in Fig. 6.1 3.)

• Fig. 6.13 Bronchiectasis. CT image through the right lower lobe reveals dilated subsegmental bronchi. Note how the bronchi are larger than the accompanying vessels. Several bronchi demonstrate the signet ring sign (arrows). Plugging of peripheral smaller bronchi is evident (curved arrow).

• Fig. 6.14 Bronchiectasis with air trapping. CT image at end expiration demonstrates areas of relatively higher and lower attenuation. The lower attenuation areas indicate air trapping.

• Fig. 6.15 Cystic fibrosis. (A) Chest X-ray during an acute chest infection showing left perihilar and right midzone consolidation. (B) Close-up of the right midzone demonstrating multiple ring shadows and tramlines due to extensive bronchiectasis. (C) Six months later the acute changes have resolved leaving a background of bronchiectasis.

Fig. 6.15 Cystic fibrosis. (A) Chest X-ray during an acute chest infection showing left perihilar and right midzone consolidation. (B) Close-up of the right midzone demonstrating multiple ring shadows and tramlines due to extensive bronchiectasis. (C) Six months later the acute changes have resolved leaving a background of bronchiectasis.

• F19. 6.16 Cystic fibrosis. There are widespread bronchiectatic changes and a large right pneumothorax; a small left apical pneumothorax is also present.

• Fig. 6.17 Asthma in a woman of 64. (A) During an asthmatic attack the lungs are hyperinflated, the diaphragms being depressed and flattened. (B) During remission the chest radiograph is normal.

• Fig. 6.18 Chronic bronchitis in a man of 62. Small poorly defined opacities are present throughout both lungs, producing the 'dirty chest'. This contrasts with the clear lungs in Fig. 6.1713.

• Fig. 6.19 Emphysema in a man of 54. The lungs are hyperinflated, the diaphragm being low and flat. The peripheral vascular pattern is attenuated in the right mid and left mid and lower zones. The central pulmonary arteries are enlarged, indicating pulmonary arterial hypertension. The heart is elongated.

• Fig. 6.20 Emphysema in a man of 52. Lateral film shows increased lung volume, which is producing a barrel chest. The retrosternal space is deeper than normal and extends more inferiorly than normal.

• Fig. 6.21 Multiple bullae. (A) CT scan through the level of the right main pulmonary artery reveals multiple bullae predominantly in the right lung. (B) CT scan further toward the lung bases revealing several further bullae. Some of these have well-defined walls.

• Fig. 6.22 Bilateral upper zone bullae in a man of 35. 'Routine' chest X-ray-no history or symptoms of respiratory disease. Both upper zones are occupied by large bullae which are compressing the upper lobes. There is no evidence of generalised emphysema or air trapping. The level and shape of the diaphragm are normal.

• Fig. 6.23 Emphysema with bullae in a man of 61. The lungs are hyperinflated. A giant bulla occupies most of the left hemithorax, compressing the left lung. Strands of lung tissue (arrowheads) are seen crossing this bulla. Small bullae (arrows) are also present in the right lung.

• Fig. 6.24 Emphysema with infected bulla in a man of 48. (A) The lungs are hyperinflated. The right upper zone is occupied by a large bulla, and another bulla is seen adjacent to the left heart border (arrows). The central pulmonary arteries are enlarged. (B) Following a chest infection the left-sided bulla has filled with fluid and appears completely opaque.

• Fig. 6.25 Unilateral emphysema in a man of 30 with a history of repeated chest infections as a child, but no current respiratory symptoms. (A) Inspiratory film shows normal right lung and hypertransradiant left lung with small left pulmonary artery. (B) Expiratory film demonstrates displacement of mediastinum to the right and restricted movement of the left hemidiaphragm, indicating air trapping in the left lung. (C) CT scan through the upper lobes of a different patient with unilateral emphysema. At end expiration there is air trapping within the left lung where the vessels are relatively attenuated.

• Fig. 6.25 Unilateral emphysema in a man of 30 with a history of repeated chest infections as a child, but no current respiratory symptoms. (A) Inspiratory film shows normal right lung and hypertransradiant left lung with small left pulmonary artery. (B) Expiratory film demonstrates displacement of mediastinum to the right and restricted movement of the left hemidiaphragm, indicating air trapping in the left lung. (C) CT scan through the upper lobes of a different patient with unilateral emphysema. At end expiration there is air trapping within the left lung where the vessels are relatively attenuated.

• Fig. 6.26 Obliterative bronchiolitis due to graft-versus-host disease. (A) Close-up view of the right lower zone reveals patchy areas of higher and lower attenuation and thin-walled dilated bronchi. (B) Obliterative bronchiolitis in a different patient. A CT scan obtained at end expiration shows marked variation in the CT attenuation within the lungs. The relatively hypodense areas have failed to deflate due to small airways disease.

• Fig. 6.27 Panbronchiolitis. There are multiple branching opacities representing distended and occluded small airways.

• Fig. 6.28 Cryptogenic organising pneumonia in a 70-year-old man with chronic consolidation. The appearances had been unchanged for several weeks despite multiple courses of antibiotics.

• Fig. 6.29 Cryptogenic organising pneumonia. There is a wedge-shaped pleurally based patch of consolidation containing an air bronchogram. The diagnosis was confirmed following a percutaneous needle biopsy.

• Fig. 6.31 Bronchial atresia. There is a well-defined opacity in the right lower lobe surrounded by a patch of emphysematous lung (arrowheads).

• Fig. 6.32 Complete collapse of the left lung. A newborn child with complex cyanotic heart disease. The tip of the endotracheal tube (arrow) is beyond the carina (asterisk) and down the right bronchus, causing collapse of the left lung and compensatory hyperinflation of the right lung which has herniated across the midline (arrowheads).

• Fig. 6.33 Complete collapse of the left lung due to a left hilar tumour. (A) The chest radiograph demonstrates deviation of the trachea and shift of the mediastinum to the left. Air-soft-tissue interfaces are seen due to herniation of the right lung across the midline (arrowheads). (B) CT scan demonstrates herniation of both the retrosternal lung and the azygo-oesophageal reflection. The oesophagus contains a small amount of air (arrow).

• Fig. 6.34 Right upper lobe collapse. (A) PA projection. Note how lesser fissure is drawn upward, and often curved, toward the apex and mediastinum. (B) Right lateral view. Lesser fissure also displaced upward. Note some forward displacement of greater fissure above the hilum.

• Fig. 6.35 (A) PA film shows a mass (white arrowhead) above the right hilum, and elevation of the horizontal fissure (black arrowheads). There is compensatory hyperinflation of the right lower lobe. (B) Lateral film shows anterior displacement of part of oblique fissure (arrowheads). (C) CT scan of right upper lobe collapse in a different patient (images on mediastinal window settings.)

• Fig. 6.35 (A) PA film shows a mass (white arrowhead) above the right hilum, and elevation of the horizontal fissure (black arrowheads). There is compensatory hyperinflation of the right lower lobe. (B) Lateral film shows anterior displacement of part of oblique fissure (arrowheads). (C) CT scan of right upper lobe collapse in a different patient (images on mediastinal window settings.)

• Fig. 6.36 Right middle lobe collapse. In both projections the lesser fissure fissure is drawn downward. In the PA view (A) the fissure finally merges with the mediastinum and disappears. Note in the lateral view (B) that the lower part of the greater fissure may be displaced forward.

• Fig. 6.37 Right middle lobe collapse. (A) PA film shows loss of definition of the right heart border indicating loss of aeration of the middle lobe. (B) A lateral film shows partial collapse of the middle lobe evident as a wedge-shaped opacity (arrows).

• Fig. 6.39 Right lower lobe collapse. (A) Normal preoperative film. (B) Following coronary artery bypass surgery there is right lower lobe collapse with depression and medial rotation of the hilum, elevation of the right hemidiaphragm and hyperinflation of the right upper lobe.

• Fig. 6.40 Left lower lobe collapse. No fissure is visible in the PA projection. The lateral view shows that the greater fissure is displaced posteriorly as in collapse of the right lower lobe. The upper part of the fissure may also be drawn downward as well as backward.

• Fig. 6.41 (A) Sixty-six-year-old man with squamous cell carcinoma of the left lower lobe. The oblique fissure is displaced posteriorly (black arrows).The left hemidiaphragm is obscured by the collapsed lobe, but the position of the stomach bubble (white arrows) indicates that the left hemidiaphragm is elevated. (B) Postoperative film of patient with aortic valve replacement. The shadow of the collapsed left lower lobe (black arrowheads) is seen through the shadow of the heart (white arrowheads). (C) Fifty-seven-year-old man with oat cell carcinoma occluding the left bronchus (arrow). The left lower lobe is collapsed, obscuring the left hemidiaphragm. The mediastinum is shifted to the left, and part of the hyperinflated right lung has herniated across the midline (arrowheads).(D) Left lower lobe collapse demonstrated on CT. There is mixed density within the collapsed lung, probably due to fluid-filled bronchi.

• Fig. 6.41 (A) Sixty-six-year-old man with squamous cell carcinoma of the left lower lobe. The oblique fissure is displaced posteriorly (black arrows).The left hemidiaphragm is obscured by the collapsed lobe, but the position of the stomach bubble (white arrows) indicates that the left hemidiaphragm is elevated. (B) Postoperative film of patient with aortic valve replacement. The shadow of the collapsed left lower lobe (black arrowheads) is seen through the shadow of the heart (white arrowheads). (C) Fifty-seven-year-old man with oat cell carcinoma occluding the left bronchus (arrow). The left lower lobe is collapsed, obscuring the left hemidiaphragm. The mediastinum is shifted to the left, and part of the hyperinflated right lung has herniated across the midline (arrowheads).(D) Left lower lobe collapse demonstrated on CT. There is mixed density within the collapsed lung, probably due to fluid-filled bronchi.

• Fig. 6.42 Lingula and left upper lobe collapse in a man with carcinoma at the left hilum. (A) PA film shows hazy left heart border, indicating loss of aeration of the lingula. A mass is present in the aortopulmonary window (arrowhead). (B) Lateral film shows collapse-consolidation of the lingula, with anterior displacement of the lower part of the oblique fissure (arrowheads). The upper part of the oblique fissure (arrows) is thickened, but in normal position. (C) Five weeks later the left upper lobe has collapsed. A hazy opacity covers most of the left hemithorax. Vessels in the hyperinflated left lower lobe can just be seen through the haze, and the aortic knuckle is obscured (arrowhead). (D) Lateral film shows that the oblique fissure is now displaced anteriorly (arrows).

• Fig. 6.42 Lingula and left upper lobe collapse in a man with carcinoma at the left hilum. (A) PA film shows hazy left heart border, indicating loss of aeration of the lingula. A mass is present in the aortopulmonary window (arrowhead). (B) Lateral film shows collapse-consolidation of the lingula, with anterior displacement of the lower part of the oblique fissure (arrowheads). The upper part of the oblique fissure (arrows) is thickened, but in normal position. (C) Five weeks later the left upper lobe has collapsed. A hazy opacity covers most of the left hemithorax. Vessels in the hyperinflated left lower lobe can just be seen through the haze, and the aortic knuckle is obscured (arrowhead). (D) Lateral film shows that the oblique fissure is now displaced anteriorly (arrows).

• Fig. 6.43 Left upper lobe collapse. (A) The greater fissure does not become visible in the PA projection. When the degree of collapse is fairly complete the lobe shows a uniform loss of translucency (this may be due to accompanying consolidation), which increases in density as the degree of collapse increases. Vessel markings seen through this opacity are those in the overexpanded lower lobe. (B) In the lateral view, initially the fissure moves bodily forward, the lingula remaining in contact with the diaphragm. With increasing collapse the lingula retracts upward, and the bulk of the upper lobe moves posteriorly, and becomes separated from the sternum by aerated lung. This is usually overexpanded lower lobe, though occasionally a portion of the right lung may herniate across the midline.

• Fig. 6.44 Left upper lobe collapse due to squamous cell carcinoma. (A) PA film shows typical upper zone haze, through which is seen the elevated and enlarged left hilum, and vessels of the hyperinflated lower lobe. The contour of the aortic knuckle is indistinct, but the descending aorta is sharply outlined. (B) Lateral film shows the collapsed left upper lobe between the anteriorly displaced oblique fissure (arrow heads) and part of the hyperinflated lower lobe. (C) CT demonstration of left upper lobe collapse. Calcified lymph nodes due to previous tuberculosis are visible.

• Fig. 6.44 Left upper lobe collapse due to squamous cell carcinoma. (A) PA film shows typical upper zone haze, through which is seen the elevated and enlarged left hilum, and vessels of the hyperinflated lower lobe. The contour of the aortic knuckle is indistinct, but the descending aorta is sharply outlined. (B) Lateral film shows the collapsed left upper lobe between the anteriorly displaced oblique fissure (arrow heads) and part of the hyperinflated lower lobe. (C) CT demonstration of left upper lobe collapse. Calcified lymph nodes due to previous tuberculosis are visible.

• Fig. 6.45 Rounded atelectasis in a patient with a history of asbestos exposure. (A) Chest radiograph shows en face pleural plaque on the right with calcified pleural plaques over the dome of the right diaphragm (arrowheads). There is the suggestion of a right infrahilar mass. (B) High resolution CT demonstrates indrawing of the bronchovascular structures into a pleurally based mass. The appearances are typical of rounded atelectasis. There is widespread calcified pleural plaque.

• Fig. 6.46 Air bronchogram. (A) CT shows patent air-filled bronchi surrounded by widespread pulmonary consolidation due to an acute bacterial chest infection. (B) Chest radiograph of a different patient following aspiration of gastric contents demonstrating widespread air-space shadowing containing air bronchograms.

• Fig. 6.47 (A) Right lower lobe consolidation associated with volume loss demonstrated on CT. Note the air-filled bronchi. (B) Ultrasound scan, The air bronchograms are evident as echogenic linear structures (arrows). (C) Fluid bronchograms in a different patient (arrows); arrowheads indicate the position of the diaphragm.

• Fig. 6.47 (A) Right lower lobe consolidation associated with volume loss demonstrated on CT. Note the air-filled bronchi. (B) Ultrasound scan, The air bronchograms are evident as echogenic linear structures (arrows). (C) Fluid bronchograms in a different patient (arrows); arrowheads indicate the position of the diaphragm.

Fig. 6.48 Right upper lobe consolidation in a 6-year-old boy with aortic valve disease. (A) Opacity in the right upper zone obscures the upper mediastinum. (B) The lateral film shows consolidation anterior to the upper part of the oblique fissure (arrows), mostly in the posterior segment of the right upper lobe.

• Fig. 6.49 Right middle lobe consolidation in a 37-year-old man with squamous cell carcinoma of the right middle lobe. (A) PA film shows homogeneous opacity limited by horizontal fissure (arrows) and obscuring the right heart border. (B) Lateral film shows consolidation bounded by horizontal fissure (arrowheads) and lower half of oblique fissure (arrows).

• Fig. 6.50 Right lower lobe consolidation. Pneumonia complicating chronic bronchitis. (A) PA film shows right lower zone shadowing obscuring the diaphragm but not the right heart border (arrowheads). (B) Lateral film shows shadowing with air bronchogram, limited by oblique fissure anteriorly (arrowheads). The left hemidiaphragm is visible (arrows) but the right is obscured.

• Fig. 6.51 Left upper lobe and lingula consolidation. A 70-year-old man with left upper lobe carcinoma. (A) Patchy consolidation obscures the left heart border and aortic knuckle. (B) The consolidation is bounded posteriorly by the oblique fissure (arrowheads).