DAVID SUTTON PICTURES ONLY FOR STUDY

1. 9The Paediatric Chest
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • 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.

4. • 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).

5. • 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.

6. • 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).

7. • 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.

9. • 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.

10. • 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.

11. • 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,

12. • 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.

13. • 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). ??????????

14. • 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.

15. • 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.

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

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

18. • 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.

19. • 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.

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

21. • Fig. 9.19 Pneumocystis pneumonia. Widespread
alveolar shadowing.

22. • 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.

23. • 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.

24. • 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.

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

26. 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.

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

28. • 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.

29. • 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.