CXR: 'Silhoutte' and other signs

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CXR: 'Silhoutte' and other signs

  1. 1. Interesting chest xray for discussion Prof Magesh kumar unit Dr vijayanand
  2. 2. <ul><li>60 years old gentleman comes with </li></ul><ul><li>c/o cough with sputum 3months </li></ul><ul><li>c/o haemoptysis on &off 3 months </li></ul><ul><li>Chronic smoker </li></ul><ul><li>No h/o prior anti tb therapy </li></ul>
  3. 3. Clinical examination <ul><li>Tracheal shift to Rt </li></ul><ul><li>Movements decreased in R infrascapular, interscapular regions </li></ul><ul><li>Dull note in above areas. </li></ul><ul><li>Breath sounds decreased in intensity in above areas </li></ul>
  4. 6. <ul><li>Differential Diagnosis </li></ul><ul><li>1 Bronchogenic carcinoma </li></ul><ul><li>2 neurogenic tumours </li></ul><ul><li>3 Bronchogenic cyst </li></ul><ul><li>4 lung sequestration </li></ul><ul><li>5 oesophageal lesions </li></ul>
  5. 7. <ul><li>6 neuro enteric cyst </li></ul><ul><li>7 Pharyngo-oesophageal pouch </li></ul><ul><li>8 Aneurysm of descending aorta </li></ul><ul><li>9 Bochdalek hernia </li></ul><ul><li>10 Pancreatic pseudo cyst </li></ul><ul><li>11 Paravertebral mass </li></ul><ul><li>12 Hiatus hernia </li></ul>
  6. 9. <ul><ul><li>Silhoutte sign </li></ul></ul><ul><li>Dr Ben felson in 1950 </li></ul><ul><li>Localisation of lesions by studying diaphragm & mediastinal outlines </li></ul><ul><li>The borders are seen because of adjacent aerated alveoli,diff in radiodensity b/w lung &adjacent structures. </li></ul><ul><li>If air is displaced by disease ,borders are obliterated and lesions are localised </li></ul>
  7. 10. <ul><li>If the border is retained & abnormality is superimposed </li></ul><ul><li>Lesion may lie anterior or posterior </li></ul><ul><li>Obliteration may occur with pleural, chest wall,mediastinal ,pulmonary pathology. </li></ul><ul><li>Silhoutte sign refers to loss of normal appearing interfaces </li></ul>
  8. 11. Silhouette/Structure Contact with Lung Upper right heart border/ascending aorta Anterior segment of RUL Right heart border RML (medial) Upper left heart border Anterior segment of LUL Left heart border Lingula (anterior) Aortic knob Apical portion of LUL (posterior) Anterior hemidiaphragms Lower lobes
  9. 12. DEFINITION: PARTIAL OR COMPLETE LOSS OF VOLUME OF A LUNG OMPLETE LOSS OF A LUNG IS REFERRED TO AS COLLAPSE OR ATELECTASIS
  10. 15. <ul><li>DISPLACEMENT OF INTERLOBAR FISSURES - MOST IMP AND RELIABLE SIGN </li></ul><ul><li>LOSS OF AERATION </li></ul><ul><li>VASCULAR AND BRONCHIAL SIGNS : PARTIALLY COLLAPSED LOBE-CROWDING OF ITS VESSELS. </li></ul>
  11. 16. <ul><li>ELEVATION OF HEMIDIAPHRAGM - MAY BE IN LL-RARE IN OTHERS </li></ul><ul><li>MEDIASTINAL DISPLACEMENT - ULOBE-TRACHEA.LL-HEART. </li></ul><ul><li>HILAR DISPLACEMENT - ELEVATED-UL,DEPRESSED-LL. </li></ul><ul><li>COMPENSATORY HYPERVENTILATION </li></ul>
  12. 17. <ul><li>MINOR FISSURE MOVES UPWARDS WITH CONCAVITY INFERIORLY. </li></ul><ul><li>AN AREA OF OPACITY AGAINST APEX OF MEDIASTINUM. </li></ul><ul><li>TRACHEAL SHIFT TO RIGHT. </li></ul><ul><li>RIGHT HILUM IS ELEVATED. </li></ul><ul><li>GOLDEN SIGN OF S </li></ul>
  13. 18. <ul><li>Golden “ S’’ sign </li></ul><ul><li>Causes – bronchogenic carcinoma, enlarged lymph nodes, metastases. </li></ul><ul><li>Distorted minor fissure , laterally concave inferiorly, medially is convex inferiorly </li></ul><ul><li>Reverse s apearance </li></ul>
  14. 20. <ul><li>Chilaiditi sign </li></ul><ul><li>Rare sign , incidence 0.1% </li></ul><ul><li>Interposition of colon between liver and diaphragm. </li></ul><ul><li>Incidental finding in normal xray </li></ul><ul><li>No symptoms </li></ul><ul><li>Chilaiditi syndrome when it causes pain , torsion of bowel , shortness of breath. </li></ul>
  15. 22. <ul><li>Pneumo peritoneum </li></ul>Perforated peptic ulcer Bowel obstruction Ruptured diverticulum Penetrating trauma Ruptured inflammatory bowel disease (e.g. megacolon ) Necrotising enterocolitis /Pneumatosis coli [2] Bowel Cancer Ischemic bowel Steroid
  16. 23. After laparotomy After laparoscopy Breakdown of a surgical anastomosis Bowel injury after endoscopy Peritoneal dialysis Vaginal insufflation (air enters via the fallopian tubes , e.g. water-skiing, oral sex) Colonic or peritoneal infection From chest (e.g. bronchopleural fistula ) Non-invasive PAP [positive airway pressure ]
  17. 26. <ul><li>MORE OBVIOUS ON LATERAL VIEW . </li></ul><ul><li>ILL DEFINED SHADOW ADJ TO RIGHT HEART BORDER,BECOMES INDISTINCT. </li></ul><ul><li>RT HEART BORDER IS SILHOUTTED </li></ul><ul><li>MINOR FISSURE MOVE DOWNWARDS </li></ul><ul><li>LATERAL VIEW : TRIANGULAR SHAPE WITH APEX AT HILUM. </li></ul>
  18. 28. <ul><li>MAJOR FISSURE WHICH IS NOT NORMALLY SEEN –SEEN IN RLL COLLAPSE. </li></ul><ul><li>OBLITERATION OF DIAPHRAGM </li></ul><ul><li>HEART BORDER CLEARLY SEEN </li></ul><ul><li>CT SCAN-PARASPINAL MASS LIKE APPEARANCE </li></ul><ul><li>NOTE : CONCOMITANT RML AND RLL APPEAR AS-SUBPULMONIC EFFUSION.FISSURE IDENTIFICATION-IMP </li></ul>
  19. 31. <ul><li>LUFT SICHEL SIGN :HYPEREXPANDED SUPERIOR SEGMENT OF LEFT LOWER LOBE INTERPOSITIONED BETWEEN ATELECTATIC UPPER LOBE AND AORTIC ARCH-APPEARANCE OF CRESCENT OF AERATED LUNG . </li></ul><ul><li>OBLITERATION OF LEFT UPPER CARDIAC BORDER </li></ul><ul><li>SHIFT OF RT UL ACROSS MIDLINE </li></ul>
  20. 34. <ul><li>INCREASED RETROCARDIAC OPACITY </li></ul><ul><li>SILHOUTTING LEFT HEMIDIAPHRAGM </li></ul><ul><li>ROTATION OF HEART-FLATTENING OF CARDIAC WAIST-FLAT WAIST SIGN. </li></ul><ul><li>SUPERIOR MEDIASTINUM MAY SHIFT-OBLITERATION OF AORTIC KNOB </li></ul><ul><li>HEART-STRAIGHT LATERAL BORDER- SAIL LIKE SIGN </li></ul>

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