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large airway presentation.pptx
- 1. By: Dr. Niranjan B Patil Professor Dept. of Radiodiagnosis D.Y.Patil Medical college and Hospital.
- 2. • The trachea extends from the inferior aspect of the cricoid cartilage to the carina • Measures 10 to 12 cm in length. • Anterior and lateral tracheal walls - hyaline cartilage Posterior - posterior tracheal membrane • The normal transverse internal diameter: 15 and 25 mm -men 10 to 21 mm -women TRACHEA
- 6. Tracheal Bronchus • Congenital bronchial branching anomaly • Ectopic (more frequently) or supernumerary bronchial branch arises from the lateral tracheal wall just above the carina. • Bronchus suis (Pig bronchus)
- 8. Accessory Cardiac Bronchus • Rare: 0.5% of adults • Arises from medial aspect right main bronchus or bronchus intermedius • Directed towards the heart • Usually blind-ending
- 9. Bronchial Atresia Focal obliteration of proximal segmental or subsegmental bronchus • Most patients- Asymptomatic • Imaging diagnosis: • Mucocele (Round, ovoid, Branching structure) • Hyperinflated surrounding lung (key finding) • LUL (64%), RUL, RML, RLL, LLL
- 11. Tracheal Stenosis • Narrowing of the tracheal lumen without airway wall thickening • Mild congenital stenosis asymptomatic • Severe congenital tracheal stenosis becomes symptomatic early during infancy
- 12. POST INTUBATION STENOSIS: hourglass configuration • involves the trachea above the level of the thoracic inlet POST-TRACHEOSTOMY STENOSIS: • begins 1–1.5 cm distal to the inferior margin of the tracheostomy stoma TRACHEAL STENOSIS
- 13. SABER SHEATH TRACHEA • Characterized by an abrupt change in the caliber of the trachea at the thoracic inlet. • Trachea narrows in coronal diameter to about 50% of its sagittal diameter. • Usually occurs in males with COPD • due to abnormal intrathoracic transmural pressures secondary to COPD.
- 15. Trauma
- 17. • Granulomatous (TB, Fungal, WG, Sarcoid) • Polychondritis • Amyloidosis • Papillomatosis • TBO • Ulcerative Colitis • Malignancy CAUSES OF TRACHEAL NARROWING
- 18. RELAPSING POLYCHONDRITIS • Rare inflammatory disease • Affects cartilages of ears, nose, UR tract, joints • Recurrent cartilaginous inflammation followed by fibrosis, calcification • Spares membranous wall • Respiratory tract involved in 50%, recurrent pneumonia
- 20. • Uncommon, older males • Multiple submucosal osteocartilagenous nodules along anterolateral walls • Sparing of membranous wall • Tracheobronchial cartilages are thickened and nodular with luminal narrowing • Ossification within nodules TRACHEOBRONCHOPATHIA OSTEOCHONDROPLASTICA
- 22. Tracheobronchonmegaly / Mounier-Kuhn syndrome • Congenital condition • Defect in smooth muscle and elastic tissue • Diffuse dilatation of trachea and central bronchi • Scalloped/corrugated appearance • Recurrent infections,bronchiectasis Tracheomalacia
- 24. Tracheomalacia • Resulting from weakened tracheal cartilages • Chronic cough,dyspnea,recurrent infections • Excessive expiratoryc ollapse >70% • "Frown sign"
- 27. Granulomatosis with Polyangiitis (GPA) • Granulomatous vasculitis (Wegener's granulomatosis) • Upper and lower RT, kidneys and other organs • Diffuse or focal TB involvement • Narrowing and thickening of airway • Subglottic location most common • Mediastinal adenopathy • Sinusitis
- 29. Amyloidosis • Extracellular deposition of proteinacous fibrils, stain with Congo red • Focal or diffuse thickening • Nodularity/airway obstruction • May calcify • Associated adenopathy • Enhancement of focal lesions
- 32. Sarcoidosis • idiopathic multisystemic granulomatous disease • Involvement of the trachea and main bronchi is rare, whereas abnormalities in the lobar and segmental bronchi are more common • consist of mucosal and submucosal inflammation and noncaseating granulomas, which cause smooth, irregular, or nodular luminal narrowing.
- 33. Bronchiectasis: Definition • Localized irreversible dilatation of bronchial tree • Infection is usually the common pathway in • most cases.
- 34. Bronchiectasis Types of bronchiectasis Cylindrical Bronchiectasis Varicose Bronchiectasis Cystic Bronchiectasis
- 36. Cylindrical Bronchiectasis • Mildest form • Bronchi are thick walled and dilated • Smaller bronchi plugged with secretions • Bronchi have a uniform caliber, do not taper and have parallel walls (tram track sign)
- 37. Varicose Bronchiectasis • Bronchial walls more irregular • Bronchi have a beaded appearance • 6-7 bronchial subdivisions • Bronchiolitis obliterans in smaller airways
- 38. Cystic Bronchiectasis • Most severe type • Bronchi form clusters or air-filled cysts • May have air-fluid levels in dilated bronchi
- 39. Post infectious ABPA (Aspergillus) Pertussis TB Adenovirus Chronic aspiration Chronic obstruction Neoplasm (carcinoid) Foreign body CAUSES OF BRONCHECTASIS
- 40. Impaired host defense and immunity Cystic fibrosis Immotile cilia syndrome (Kartagener's syndrome) Immune deficiencies Bruton's hypogammaglobulinemia Immunoglobulin deficiencies (IgG, sIgA) Congenital Mounier-Kuhn syndrome Cartitage deficiency (Williams-Campbell syndrome) CAUSES OF BRONCHECTASIS
- 41. Plain Radiograph Diagnosis Tram tracks appearance
- 42. Air-fluid levels
- 43. Ring Shadows
- 44. finger in glove Opacity
- 45. CT Findings of Bronchial Dilatation • Increased bronchoarterial ratio • Lack of Bronchial Tapering • Abnormal Bronchial Contours • Visibility of Peripheral Airways • Mucous Impaction and Air-Fluid Levels • Mosaic Perfusion and Air Trapping • Tree-in-Bud • Bronchial Artery Enlargement SPECIFIC FINDINGS NON SPECIFIC FINDING ANCILLARY FINDINGS • Bronchial wall thickening
- 46. signet-ring sign
- 47. Lack of Bronchial Tapering
- 48. Abnormal Bronchial Contours string of pearls sign
- 50. Visibility of Peripheral Airways
- 53. Allergic Bronchopulmonary Aspergillosis • Disease results from a hypersensitivity reaction to Aspergillus growing in airways • Occurs in asthmatics (1-2%) and in patients with CF (10%) • ABPA characterized by: Asthma Infiltrates Blood Eosinophilia Allergy to Ag of Aspergillus • Age 20 - 40 • Aspergillus grows as mycelial plug in proximal airway and immune reaction causes airway damage resulting in bronchiectasis • Unlike other causes of bronchiectasis the distal smaller airways remain intact (no bronchiolitis obliterans)
- 54. Allergic Bronchopulmonary Aspergillosis: CXR • Consolidations • Collapse • Upper lung zone fibrosis • Mucoid impaction("toothpaste shadow" • or“finger in glove") • Bronchiectasis in the perihilar and upper lungzones
- 55. АВРА: СТ Bronchiectasis Upper lobe consolidations, Atelectasis and scarring Mucoid impaction
- 56. • Autosomal recessive • Genetic defect in the structure of the CF transmembrane conductance regulator (CFTR) • Resulting in decreased mucus clearance, mucous plugging of airways, and an increased incidence of bacterial airway infection. Cystic Fibrosis
- 57. Cystic Fibrosis: Radiology Emphysema Barrel chest with flat diaphragms Enlarged hilar shadows Hilar adenopathy from infections Enlarged pulmonary arteries: pulm htn Bronchiectasis Tubular or cystic Most pronounced in upper lungs
- 58. Cystic Fibrosis: Radiology • Atelectasis and focal infiltrates Complications: • Pneumothorax from rupture of a bleb • Massive hemoptysis from hypervascularity due to chronic inflammation
- 62. Dyskinetic Cilia Syndrome • Abnormal ciliary structure and movement • Abnormal mucociliary clearance and chronic infection • Bronchiectasis and sinusitis are common manifestations. • Autosomal Recessive Defect
- 63. KARTAGENAR’s SYNDROME • 50% of CDS have Kartagener's • Characterized by the triad: Situs inversus Paranasal sinusitis Bronchiectasis
- 64. Tracheal Neoplasm Benign : present as small intraluminal nodule • papilloma • hamartoma • lipoma Malignant primary • Squamous cell carcinoma • Adenoid cyctic carcinoma • Mucoepirdermoid • Carcinoid Secondary :due to haematogenous metastasis • Melanoma • Renal carcinoma Direct invasion: Thyroid Carcinoma, Laryngeal Carcinoma, Lung carcinoma
- 65. Malignant Neoplasms • Most tracheal tumors are malignant • Direct invasion by adjacent malignancies - Thyroid, esophagus, lung • Hematogenous metastases - Melanoma, breast, renal,colorectal • Most common primary ca - Squamous cell and adenoid cystic carcinoma
- 66. Squamous cell papilloma • Most common benign tumor • Smoking, M>F • ST intraluminal nodule, non-invasive Hamartoma • 2nd most common • Fat and cartilaginous components (25%) • Slow growth, obstructive changes BENINGN TRACHEAL TUMORS
- 67. Chondroma • Uncommon, middle aged males • Arise inferior surface of cricoid (70%) • Cartilaginous calcification, airway obstruction
- 68. Tracheobronchial Papillomatosis • Viral infection with human papilloma virus • Usually acquired at birth • Juvenile laryngeal papillomatosis usually confined to larynx • Spread to tracheal, bronchi, lungs • Polypoid or sessile masses with vascular core and well differentiated squamous epithelium • Pulmonary nodules and cysts
- 71. Squamous cell Cancer • Generally order male smokers • Irregular/nodular thickening • Airway /bronchial obstruction • Locally invasive • Regional lymph node spread • Hematogenous mets
- 73. Adenoid cystic carcinoma • 4th decade of life, not smoking related • Mass, circumferential or diffuse thickening • Distal trachea most common • Submucosal spread, regional LNs, slow growth
- 75. Mucoepidermoid Tumor • Rare • Mean age 36 years • High or low-grade malignancy • Endobronchial mass in large central bronchus or rarely trachea • Nonspecific appearance
- 77. Broncholithiasis • Calcified peribronchial lymph node • Histoplasmosis or Tuberculosis
- 78. THANK YOU
Editor's Notes
- Extnds from c6 vertebra to T5 VERTREBRA post by band of smooth muscle the posterior tracheal ring the extrathoracic trachea is 2 to 4 cm in length, while the intrathoracic trachea measures 6 to 9 cm in length.
- They contain air and so are of lower density (blacker) than the surrounding soft tissues. The trachea branches at the carina into the left and right main bronchi, which can be followed as they branch beyond the hila into the lungs.Start your assessment of every chest X-ray by looking at the airways. The trachea should be central or slightly to the right at the level of the aortic knuckle.If the trachea is deviated, it is important to establish if this is because of patient rotation or if it is due to pathology.
- HRCT through the normal trachea. The tracheal wall (arrow) is outlined by mediastinal fat externally and usually is visible as a 1- to 2-mm soft tissue stripe. The posterior tracheal membrane usually appears thinner than the anterior and lateral tracheal walls and is variable in shape due to its lack of cartilage.
- On inspiration, the trachea has a rounded appearance. On CT performed during or after forced expiration, the posterior tracheal membrane bulges anteriorly, narrowing and, in some cases, nearly obliterating the tracheal lumen (Fig. 22-3). The mean anterior-posterior diameter of the trachea decreases by 30% to 40% during forced expiration due to anterior bulging of the posterior membrane; the transverse diameter decreases by 10% to 20%.
- i which an. This condition also is known as bronchus suis because it is a normal finding in pigs. us is called “pig bronchus” [1, 8]. Tracheal bronchi are frequently asymptomatic and are incidental imaging findings, but impaired drainage may cause recurrent pneumonia [1, 8]. Endobronchial intubation may occlude a tracheal bronchus, resulting in atelectasis
- An axial lung window computed tomography (CT) image shows an anomalous right upper lobe bronchus (straight arrow) directly arising from the trachea (T). Atelectasis (curved arrow) is present in the medial right upper lobe. B, A frontal three-dimensional (3D) volume-rendered image of the central airways and lungs shows an anomalous right upper lobe bronchus (arrow) directly arising from the trachea.
- genraaly patient with cardiac bronchus are aymtomatic but sometimes they may prresnt with hemoptysis and recurrent infectuions
- It usually presents as a proximal focal ovoid or tubular opacity (finger-in-glove) radiating from the hilum associated with a distal area of hyperlucent lungThe bronchi distal to the atresia become filled with mucus and may form a mucocoele/bronchocoele. The lung distal to the atretic bronchus develops normally but is overinflated due to collateral air drift with air trapping
- Posteroanterior chest radiograph shows hyperlucency (arrows) of left upper lobe due to decreased vascularity and increased air content.Axial CT image shows atretic bronchial segment (arrow) of left upper lobe. Note areas of hyperlucency in lung parenchyma.
- aused by complete or near-complete tracheal ring and an incidental finding sagittal reformation (B) CT images show severe funnel-shaped narrowing of trachea The typical imaging appearance is diffuse, segmental, or funnellike progressive airway stenosis without wall thickening
- oned-down PA chest radiograph (Fig. 17.1A) demonstrates symmetric narrowing of the tracheal lumen. Chest CT (lung window) with axial and coronal reformation (Figs. 17.1B, 17.1C) demonstrates tracheal narrowing CT reformation image shows circumferential hourglasslike narrowing (arrows) of trachea. owing with a reduced coronal diameter and anterior luminal tapering. Surface rendered 3-D image (Fig. 17.1D) of tracheal and central airways shows a tapered area of stenosis in the upper trachea at the level of previous tracheostomy.
- PA chest radiograph shows hourglass-shaped narrowing of the intrathoracic trachea (black arrows). The extrathoracic trachea (white arrows) appears normal. B: In the lateral projection, the tracheal diameter appears normal or increased (arrows).
- A: The extrathoracic trachea is normal. The tracheal cartilage is calcified and well seen. B, C: The intrathoracic trachea at two levels is markedly narrowed from side to side (arrows), associated with deformity of the tracheal cartilage. The sagittal tracheal diameter is increased. The tracheal wall is otherwise normal in appearance.
- axial (A) with coronal reformation (B) chest CT (mediastinal window) of a 42-year-old man with acute stridor after receiving blunt trauma to the trachea during a barroom fight demonstrates a longitudinal fracture through the left thyroid cartilage with adjacent hematoma narrowing the tracheal lumen
- ig. 17.3 Contrast-enhanced chest CT (mediastinal window) of a 39-year-old woman with goiter demonstrates diffuse enlargement of the thyroid gland, which produces extrinsic mass effect on the trachea, with resultant luminal narrowing Coned-down PA chest radiograph of a 62-year-old man with squamous cell carcinoma of the trachea demonstrates severe narrowing of the tracheal lumen
- ct image shows cartilagenous wall diffusly thickend and contains calcification and sparing of post tracheal wall
- diffuse thickening of anterior wall of trachea with calcification and sparing the membranous wall on coronal view lateral cartilagenous wall are diffusely thickend
- axial image showi nodularrity and thcikening of tha anteroior and lateral wall of trachea with some ossification sparing post wall bronchoscopy image showing submucosal nodulairty protruding in the lumen
- Tracheobronchopathia osteochondroplastica. Axial CT image above the aortic arch demonstrates diffuse thickening and calcification of the tracheal cartilage with nodularity that spares the posterior wall. Tracheobronchopathia osteochondroplastica. (A) Coronal CT image shows thickening, nodularity, and calcification of the tracheal cartilage. (B) Coronal CT image at lung windows better demonstrates the marked nodularity of the tracheal wall
- On CT a tracheal diameter of greater than 3 cm (measured 2 cm above the aortic arch) and diameter of 2.4 and 2.3 cm for the right and left bronchi, respectively, determine the diagnosis (Fig. 13-11). Additional findings include tracheal scalloping or diverticula (especially along the posterior membranous tracheal wall)
- coronal image,typical corrugated aapearance of trachea and main bronchi and diffuse dialatation of trachea and main bronchi
- abnormality may be seen in association with a number of disorders including tracheobronchomegaly, COPD, diffuse tracheal inflammation such as relapsing polychondritis, as well as following trauma. Axial CT image obtained during inspiration shows lunate configuration of trachea (arrow). Axial CT image obtained during expiration shows severe collapse with anterior bowing of posterior membrane (black arrow) (“frown” sign). Note associated air trapping (white arrows) in both lungs
- saggital images on insp showing normal configuration of trachea significant collapse of greater than 70% on expiration
- CT CT with inspiratory and expiratory phases is particularly useful in the assessment of tracheomalacia. Inspiratory only CT is unable to make the diagnosis; however, a dilated trachea (>3 cm), especially with posterior bowing of the membranous portion (thus becoming circular) may indicate over-compliance of the trachea and thus suggest the diagnosis. During expiration, collapse of the trachea (dynamic tracheal collapse) is seen, with bowing of the posterior membranous portion anteriorly, creating a crescent shape in the axial plane 1. Typically a decrease of the anterior-posterior diameter by 50% or greater is used as a cut-off
- ass sinusitis with thickeningf maxiary antrum
- CT shows tracheal narrowing associated with concentric thickening of the tracheal wall (arrows). C: At the level of the carina, bronchial wall thickening (arrow) also is seen. D
- tracheal wall axial ct image,in distal trachea,mass like defect seen obstruting the airway n which dense calcifiction is seen reprensting focal mass like amyloid deposition
- axial image showing cartilagenos and membranous thikening of wall of trachea and main bronchi which are densely calcified reprsenting a diffuse form amyloidosis
- circumferantial area of diffuse thiening in proximal trachea causing luminal narrowing
- airway abnormalities Axial CT image shows smooth wall thickening (arrows) of mainstem bronchi.
- bronchetasis occours secondary to infections diameter of bronchus is compared to the accompaying artey
- based on appearnce broncectasis is 3 types
- beacuse of inflammtion damges to airway d loss of cilia
- destruction of distal subdivison of bronchi only 6-7 bronchial sub division are intact With increasingly severe abnormalities of the bronchial wall and increasing bronchial dilatation, the bronchi may assume an irregular, beaded or bulbous configuration
- in which dialated cycstic bronchi seen and get infected
- Plain radiographs are abnormal in 80% to 90% of patients with bronchiectasis,Tram tracks, parallel line shadows representing thickened bronchial walls, are a common finding in bronchiectasis They may be the only finding visible in patients with cylindrical bronchiectasis.
- Cystic bronchiectasis results in multiple, air-filled, cystic lesions, which may be thick or thin walled, and clustered, lobar, patchy, or diffuse in distribution. Multiple air-fluid levels often are seen because of infection or retained secretions
- patient with cystic fibrosis, ring shadows (arrows) indicate bronchiectasis
- Mucous plugs or fluid filling the bronchi sometimes is visible and may aid in recognizing them as dilated. Mucous plugs within dilated bronchi may be visible as oval (“finger in glove”) or branching (“hand in glove”) opacities.
- diameter of a bronchus should measure approximately 0.65-1.0 times that of the adjacent pulmonary artery branch greater than 1.5 indicates bronchiectasis
- , a dilated bronchus may appear larger than the artery 1858 adjacent to it. This is known as the signet-ring sign and indicates that bronchial dilatationThe signet-ring sign is present when a dilated bronchus (large arrows) is associated with a much smaller pulmonary artery (small arrows). Bronchial walls are thick.
- . A dilated bronchus in the right upper lobe (arrows) shows a lack of tapering.
- Bronchiectasis may be classified as cylindrical, varicose, or cystic. Recognition of one of these abnormal contours is diagnostic of bronchial dilatation. A: Varicose bronchiectasis results in irregular bronchial dilatation (arrow). B: Cystic bronchiectasis. Air-fluid levels are visible within the abnormal bronchi (arrows). The dilated bronchi are visible in the lung periphery.
- Cystic bronchiectasis is characterized by the presence of numerous cysts (see Fig. 23.5B). In general, the dilated airways in patients with cystic bronchiectasis are thick walled; however, the cysts may be thin walled. A clear-cut branching appearance of the dilated airways generally is lacking, and it may be difficult to make the distinction from cystic lung disease in some cases. This appearance has been described as similar to a “cluster of grapes.” Air-fluid levels may be seen.
- Visibility of a peripheral airway as an indication of bronchial wall thickening. In a patient with bronchiectasis, a bronchus (arrow) is visible in the peripheral lung. The fact that it is visible indicates that its wall is thickenedIn normal subjects, airways in the peripheral 2 cm of lung are uncommonly seen because their walls are too thin. Peribronchial fibrosis and bronchial wall thickening in patients with bronchiectasis, in combination with dilatation of the bronchial lumen, allow the visualization of small airways in the lung periphery.
- Extensive mucous plugging in bronchiectasis. Numerous dilated, opacified bronchi are visible (arrows)Patients with cystic bronchiectasis may show fluid levels within the abnormal bronchi (see Fig. 23.5B), due to retained secretions and chronic infection.
- The term tree-in-bud refers to the presence of nodular and Y-shaped branching structures, which resemble a budding tree, in the lung periphery (Fig. 23.9; see also Fig. 10.28 in Chapter 10). This appearance generally reflects the presence of dilated, mucus- or pus-filled centrilobular bronchioles (the trunk and branches) associated with small nodular areas of bronchiolar dilatation or peribronchiolar inflammation (the buds at the tips of the branches).
- which leads to abnormal chloride transport across epithelial membranes ,,,secondary bronchiectasis
- CHEST X RAY showing cyctic and tubular shadows,hyperinflation and increaesd lung volume due to air trapping
- latreal view showing hyperinflation and at hila bronchial dialtation is seen
- on Ct,dilated bronchi are seen in the upper lobe
- Radiographs and CT typically show bilateral bronchiectasis with a basal (lower or middle lobe) predominance. Cylindrical bronchiectasis is most common. Appropriate antibiotic
- soft tissue on ct fat attenuation is the key finding
- ct image at cricoid level,wch extends into lumen and significantly narrows it and contains cartilagenous calcification
- from infected mother pulmonary nodules generally manifest as pulmonary nodules an cycts
- ct image showing polypoid mass arising from the lateral and anterior walls of trachea
- A: Concentric thickening of the tracheal wall (arrows) is due to diffuse involvement by papillomas. The tracheal lumen is markedly narrowed. B: Multiple cystic pulmonary lesions may be seen in some patients with tracheobronchial papillomatosis.
- extend into adjacent soft tissue
- Originates from tracheal mucous glands Most common in the upper trachea,often arise from the posterolateral tracheal wall. on frontal and lateral cxr - intraluminal mass on ct polypoid lesion are seen causing obstrution of trachea and thickeing of left lateral wall of trachea
- circumferaential tracheal innvovlement seen,diifuse thickening of trachel wall composing of posterior and lateal wall and extending into ajacent mediastinal fat on coronal view,circumferantial narrowing f trachea by mass extending into the mediastinum
- originates from minor salivary glands lining the tracheao brobchial treaa difficult to diffrentiate from other carcinoma
- a well-defined ovoid or lobulated intraluminal or lung peripheral mass with moderate to marked heterogeneous contrast enhancement may suggest towards the diagnosis 1. mass occurring within the segmental airways and growing wthin the airways at the level of carina polypoid mass extendding into right main bronchus causing obstruvtion and no local invasion
- peribronchial calcified nodal disease erodes into or distorts an adjacent bronchus.Calcified material in a bronchial lumen or bronchial distortion by peribronchial disease results in airway obstruction.