Normal Chest X-ray🗸

• Trachea: Stridor & choking

• Appears as a SLIT in AP view.

• Appears CIRCULAR in lateral view.

Xray

• X-ray on inspiration + expiration should be taken.
• NOTE:
• Pneumothorax → Expiratory X-ray view is taken.

• Normally
• Lungs in inspiration contain air - appears black.
• On expiration, air is expelled out - appears white.

• In FB, if obstruction is on the bronchus:
• On expiration, air is not expelled out.
• Hence remains black.
• Suggests the side of obstruction.

Q. A 2-year-old girl is brought with a sudden onset cough and difficulty in breathing. There is no history of fever. On probing, there was a history of choking while feeding. The x-ray is shown below. What is the diagnosis?

• Ans. Foreign body aspiration

• More radiolucent

• Hyperinflated right lung → Air trapping → Expiratory CXR

• M/c obstructs Right bronchus

• Method of choice for foreign body removal:
• Rigid bronchoscopy
• Flexible bronchoscope is used nowadays

Asphyxial Triad (Mnemonic: CPC)

• Cyanosis

• Congestion of viscera

• Tardeus spots → Petechial hemorrhage

Most vulnerable brain regions to Hypoxia

1. Cortical boundary zones (grey matter)

2. Hippocampus
• CA1 sector (Sommer’s area)
• Subiculum

3. Cerebellar folia

4. Globus pallidus (basal ganglia)

Chest X-ray: 

• Expiratory X-ray view is taken.
• Foreign Body → inspiration + expiration view taken

• Reason: Better contrast between lung and pneumothorax in expiration.

• Absent lung markings,

• mediastinal shift,

• collapsed lung

• Mediastinal shift to the opposite side.

Deep sulcus sign:

• Seen on supine X-ray of pneumothorax.

• Air going into the sulcus is making the sulcus deeper.

Pneumothorax on CT scan:

• Jet black appearance is seen.

• The visceral pleural line is seen.

eFAST: 

• Loss of seashore
• Seashore sign → Normal

• M mode: Barcode/ Stratosphere sign.

• Lung point sign:
• Transition from seashore sign → barcode sign.
• Most specific sign for pneumothorax.

Emergency: 

• Needle thoracocentesis
• Adults: 5th I/C space, mid axillary line
• Children: 2nd I/C space, mid clavicular line

Definitive: 

• Tube thoracocentesis:
• Chest tube in triangle of safety
• 5th I/C space, mid axillary line
• Removal when <100 mL in 24 hours + Completely expanded lungs

• Cover sucking wound:
• 3-sided occlusive dressing (reverses flow of one-way valve)

Pleural Effusion

(Light, REM and PEM)

• IOC - USG.

• Best X-ray view: Ipsilateral decubitus view.

• Light’s criteria for exudative effusion:
1. Pleural fluid protein/serum protein >0.5
2. Pleural fluid LDH/serum LDH >0.6
3. Pleural fluid LDH >2/3rd upper reference limit of normal for serum.

Lordotic view

• AP view with shoulders touching the cassette.

• Done for:
• lung apex.
• right Middle lobe collapse (is seen better).

• MRI is IOC for:
• Pancoast tumor:
• Brachial plexus invasion (Nerves are better visualised in MRI).
• Posterior mediastinal mass:
• Since m.c - Neurogenic tumor.

Button Battery

• On AP view:
• Double ring appearance.

• On lateral view:
• Sloping/ Bevelled edge.

• Corrosive → Alkali → Liquefactive necrosis

• Has to be removed even if the patient is asymptomatic.

Management

• Beyond C6: Patient observation.

• If coin: Impacted at C6: Endoscopic removal.

• Endoscopic removal (D/T corrosive nature → Perforation)



• 1. Battery in esophagus
• Diagnosis ≤ 12 hours:
• Immediate endoscopic removal.
• Diagnosis > 12 hours:
• Consider surgical consult / CT before endoscopic removal.
• 2. Battery not in esophagus
• Symptomatic or magnet co-ingestion:
• Stomach:
• Immediate endoscopic removal.
• Small intestine:
• Consider surgical consult / CT before endoscopic removal.
• Asymptomatic:
• Repeat X-ray after 7–14 days (or sooner if symptoms develop).

Swyer James Mcleod syndrome

• Post bronchiolitis obliterans.

• decreased vessel markings

• Mnemonic: Mcleod syndrome → Makkalkk varunna syndrome

Chest X-ray: 

• Expiratory X-ray view is taken.
• Foreign Body → inspiration + expiration view taken

• Reason: Better contrast between lung and pneumothorax in expiration.

• Absent lung markings,

• mediastinal shift,

• collapsed lung

• Mediastinal shift to the opposite side.

Deep sulcus sign:

• Seen on supine X-ray of pneumothorax.

• Air going into the sulcus is making the sulcus deeper.

Pneumothorax on CT scan:

• Jet black appearance is seen.

• The visceral pleural line is seen.

eFAST: 

• Loss of seashore
• Seashore sign → Normal

• M mode: Barcode/ Stratosphere sign.

• Lung point sign:
• Transition from seashore sign → barcode sign.
• Most specific sign for pneumothorax.

Emergency: 

• Needle thoracocentesis
• Adults: 5th I/C space, mid axillary line
• Children: 2nd I/C space, mid clavicular line

Definitive: 

• Tube thoracocentesis:
• Chest tube in triangle of safety
• 5th I/C space, mid axillary line
• Removal when <100 mL in 24 hours + Completely expanded lungs

• Cover sucking wound:
• 3-sided occlusive dressing (reverses flow of one-way valve)

Investigations

• Stable patients: CECT.

• Unstable patients: 
• Contrast study → Only IOHEXOL
• Barium C/I

Pneumomediastinum X-ray:

• Angel wing sign
• Thymus seen bilaterally

• Spinnaker sail sign
• Separation of thymus from heart due to air in between

• Ginkgo leaf sign
• Air between fibers of pectoralis major
• Pneumomediastinum with subcutaneous emphysema into muscle fibers

Pleural effusion

Pneumomediastinum CECT:

Pleural effusion vs Hydropneumothorax

• Pleural effusion:
• Ellis's curve.
• Blunting of costophrenic angle.

• Hydropneumothorax:
• Horizontal air fluid level.

• Lateral decubitus X-ray
• Done for pleural effusion.
• Fluid comes to the dependant side.

• Pleural effusion signs:
• Most sensitive
• USG (5 - 10 mL) >
• I/L lateral decubitus > Lateral > CXR PA erect > Supine (500 ml)
• On chest X-ray:
• Ellis's curve.
• Blunting of costophrenic angle.
• due to accumulation of fluid.
• On CT scan (in supine):
• Fluid gravitates posteriorly.
• Appears gray in color.

• Most sensitive investigation:
• USG.

Infected pleural effusion (empyema)

• Empyema causes thickening of surrounding pleura:
• Split pleura sign.

Localisation of Pathologies

• Respiratory Epithelium Types

Location	Epithelium Type
Nasal mucosa till Proximal bronchiole	Pseudostratified ciliated columnar epithelium
Terminal bronchiole	Ciliated cuboidal epithelium • No goblet cells • Epithelium change • No hyaline cartilage from here
Respiratory bronchiole	Non-ciliated cuboidal epithelium
Alveolus	Simple squamous epithelium

• Air bronchogram sign:
• Differentiate between parenchymal and extra parenchymal pathologies.
• Seen when:
• The lungs are white.
• The bronchi is patent (containing air - appears black).
• Seen in intraparenchymal pathologies:
• Consolidation.
• Hyaline membrane disease.
• Pulmonary edema
• Absent in
• Mediastinal mass
• Pleural effusion

Consolidation vs Collapse

• Dilatation of bronchi.

• Normally, bronchus tapers down peripherally.

• In Bronchiectasis
• no tapering → bronchi remain parallel
• Tram track sign
• Signet ring sign:
• Vessel adjacent to the dilated bronchi.

• Bronchiectasis associated with situs inversus
• Kartagener's syndrome

Klebsiella Pneumonia:

• Bulging fissure sign:
• Horizontal fissure is curved.

Pneumatocele:

• Cavity filled with air.
• Staphylococci
• PCP (HIV +)
• Pneumatocele + ground glass opacity → perihilar region.

Pneumocystis Carinii Radiology

TB Radiology

• Fibrocavitary TB:
• Generally unilateral or asymmetrical.
• Bulky right hilum due to enlarged hilar lymph nodes.

Miliary TB:

 

• Due to hematogenous spread of infection.

• Also seen in
• Histoplasmosis
• Healed varicella
• hemosiderosis
• silicosis
• small metastasis

• His (Histoplasmosis) chicken () iron () thinn → cancer () vann → He joined military (Miliary)

Tree in bud sign: (3a)

• Seen in TB.
• Due to endobronchial spread of infection.
• Centrilobular nodules

• CT scan showing Mediastinal Lymph nodes: (3b)
• They are necrotic lymph nodes,
• hence not enhancing.
• Only margins of lymph nodes will enhance
• Ring / Peripheral enhancing lymph nodes.

• Necrotic lymph nodes and pleural effusion - TB.

TB Meningitis

Conglomerate lesions

• with necrotic tuberculomas

Thick and enhanced meninges.

• Basal exudates.

On MR Spectroscopy

• Lipid peak is seen

Hydrocephalus

• Dilated ventricles

MR Spectroscopy

• Creates a graph of chemical metabolites.

Condition	Maximum Peak
Normal brain	NAA
Tumor	Choline
Tuberculosis	Single lipid peak + basal exudates
Neurocysticercosis	Multiple amino acid peaks.

• Water lily sign:
• Lesion with air fluid level,
• i.e. Spherical cyst and membranes floating in the fluid level.

• Other Signs:
• Rising sun sign.
• Serpent sign.
• Cumbo sign.
• Meniscus sign.

Aspergillus lungs:

• A fungus with septate and acute angle branching hyphae.

• Can cause:
• Allergic Bronchopulmonary aspergillosis (ABPA).
• Aspergilloma.
• Angio invasive aspergillosis.

ABPA:

• Dilated central bronchi filled with mucous - Finger in glove sign.

Aspergilloma:

• Seen when there is a pre existing cavity in the lung.

• Air crescent sign or monod sign.

• Prone CT to confirm aspergilloma:
• fungal ball is mobile
• comes to the dependent position.

Angio Invasive Aspergillosis:

• Central infarct surrounded by GGO - Halo sign.

• i.e. white consolidation surrounded by ground glass opacity.

• Seen in immunocompromised patients.

• Voriconazole

Mucormycosis lungs

• Also called: Black fungus

• Reverse HALO sign (Atoll sign) → centre dark, periphery light

 

• Reverse halo sign on CT

• Neutropenia

• Immunocompromised

• Hyphae: Aseptate, Right angle, Broad, ribbon-like

• Culture:
• Lid-Lifters (SDA)
• May be negative d/t Hyphal fragility (killed by tissue homogenisation)

• Lid lift cheyyumbo mukki povum

• Treatment
• Surgical resection
• Amphotericin B +/- Posaconazole
• Mucus pasha pole - Posaconazole

• Negative Staining Group:
• Blastomyces, Mucorales, Cryptococcus
• Banglore Medical College

• Types: Fungal ball, Allergic fungal rhinosinusitis

• Seen in immunocompetent and immunocompromised

• Cause: Aspergillus

• Peanut butter discharge

• Mnemonic: HIV AIDS → Kuninj bent cheythapo sinusitis vann

• Bent and Kuhn criteria for AFRS:
• Major Criteria
• Mnemonic: Mr KUHN
• Test Mucus
• Eosinophilic Mucin
• KOH Fungal smear: Positive

---

• CT scan:
• Hazy sinuses + Heterogeneous opacities
• Double density sign / Serpiginous sign
• Gray mucous with white fungal matter





---

• Endoscope
• Nasal polyps → Ethmoidal polyps more associated
• Serum
• Uno → 1 → Type 1 hypersensitivity (↑IgE levels)
• Minor Criteria
• Mnemonic: CURE AF
• no major features like culture, asthma
• Charcot–Leyden crystals
• Unilateral predominance
• Radiological Bony erosion
• Serum Eosinophilia
• Asthma
• Fungal culture: Positive

• Treatment:
• FESS
• Endoscopic surgical drainage, along with drainage and ventilation.
• Steroids
• Pre- and post-operatively.
• Antifungal therapy: Itraconazole.

• CT scan:
• Hazy sinuses + Heterogeneous opacities
• Double density sign / Serpiginous sign
• Gray mucous with white fungal matter

• History of woody injury (+)

• Types:
1. Invasive aspergillosis
2. Invasive mucormycosis

Mucormycosis Nose

• aka Phycomycosis

• Angioinvasive

• Presents with blackish eschar

• Fungal thrombus causes tissue necrosis

• MRI shows Black turbinate sign

• Biopsy
• Foreign body granuloma
• Gomori’s Methanamine Silver stain + PAS positive

• IOC: Contrast enhanced MRI.

• CT: Bony spread.

• Spread: Blood.

Treatment:

• Extensive debridement of tissue.

• Liposomal form of Amphotericin B (lyophilised form is nephrotoxic).

M/c HRCT finding:

• Bilateral Multifocal peripheral/ subpleural GGO
• Typical → CORADS 5 (highly suspicious).

Popcorn Calcification:

• Seen in pulmonary hamartoma.

• NOTE: Pop corn in brain → Cavernoma

• Mnemonic: Eating Hamara popcorn in a cave

• Military (Miliary) people
• get TB
• Laugh (Loeffler’s)
• Heal by eating chicken (healed varicella)
• make History (Histoplasmosis)

• Presentation:
• Usually a female patient
• dry cough, shortness of breath
• associated with connective tissue disorder.

• M/c type
• Idiopathic pulmonary fibrosis

• IOC - HRCT.
• UIP/IPF pattern
• Honeycombing pattern +
• Basal Lower lobe dominance +
• Traction bronchiectasis
• Ni thanna (Nintendanib) Feni done (Pirfenidone) ayi → lung fibrosis ayi (IPF)



• TGF α → KGF α → Menetriers disease
• TGB β → KGF β → drink Feni
• Ninte Dani → PD Girl Friend (PDGF)

Crazy pavement appearance:

• Interlobular septal thickening is seen with ground glass opacity.

• no air filled cavities are seen.

• Seen in Pulmonary alveolar proteinosis >>> COVID 19

• Mnemonic: Crazy Pappu (PAP) in pavement

Cystic Bronchiectasis

• Some of these dilated bronchi contain mucus.

• Bronchi appears as cysts.

• Bunch of grape appearance.

• Mnemonic: Sarcoidosis → Nun showing ass → Some put garland (1,2,3 garland) → some throw egg (egg shell) → some buy her galaxy () → Broker () her deal → she has a panda () and a lamb (lambda)

Chest X-ray:

• Mediastinal mass (B/l hilar lymphadenopathy)

• 1-2-3 pattern/ Garland sign

• Scadding staging

Later phase:

CT chest:

• Fissural nodularity and bronchovascular thickening.

• Galaxy sign or Pawnbroker sign.

• (lesions in lung parenchyma).

Gallium scan: (not done currently)

• Panda sign (parotid, lacrimal, salivary gland involvement),

• Lambda sign (hilar lymphadenopathy).

NOTE: Panda sign on MRI brain

• Wilson's disease.

Facial Palsy causes summary

• Most common cause:
• Idiopathic > Traumatic

• Iatrogenic facial palsy:
• Occurs during mastoidectomy
• Mastoid segment affected

Causes of B/L facial Nerve (diplegia):

Condition	Features
Sarcoidosis	ㅤ
Melkersson Rosenthal Syndrome	Triad: • Recurrent facial nerve palsy • Swelling of lips • Fissured tongue Melkerson → Rose koduthitt french kiss cheyth (lips - tongue)
GBS	• Albumino-cytological dissociation • Earliest sign: Distal areflexia. • Bladder and bowel spared. • Bilateral ascending symmetrical flaccid paralysis. • Brighton Criteria for GBS

• Occupational lung disease - M/c shipyard industry.

• Mnemonic: Asbestos → Holly leaf → comet tail

• M/c radiological finding:
• Calcified pleural plaques - Holly leaf sign.
• Base of lung/Diaphragmatic pleura is affected.

• On CT:
• Comet tail sign:
• Rounded opacity
• vessels pulled towards it
• seen in round atelectasis.
• The white opacity seen along the pleura are the plaques.

• Can give rise to Mesothelioma.

• History: Smoker with hemoptysis.

• IOC: CT.

• Gold standard: CT guided biopsy.

• To assess metastasis: PET CT.

• Spiculated margins are suggestive of malignancy.

Cannonball mets

• B/L circular, similar sized structures.

• M/c primary malignancies
• CRESP
• Colorectal Ca
• Prostate Ca
• Endometrial Ca/ Choriocarcinoma Ca
• RCC
• Synovial CA

• Canon ball hit ur groin → bleeding from urethra (RCC, Prostate), vagina (endometrial carcinoma) and anus (colorectal cancer)

• M.c cause of respiratory distress is a preterm neonate

• Basic defect: deficiency of mature surfactant

Congenital Diaphragmatic Hernia

• Absence of the pleuroperitoneal membrane.

• Leads to persistence of the pleuroperitoneal canal (Bochdalek foramen)

• M/c → Left > right

• Clinical Features:
• Scaphoid abdomen with respiratory distress.

Diagnosis:

• Prenatal detection can be done.
• scaphoid abdomen

• Bowel gas shadows are present in the thorax

• Diaphragmatic outline is not clearly visible

• Heart shadow is not visualized due to mediastinal shift

Complications

• 1st most common cause of death:
• Pulmonary hypoplasia
  (due to reduced space for lung development)
• scaphoid abdomen
• respiratory distress and
• features of mediastinal shift

• 2nd most common cause of death:
• Pulmonary hypertension (PPHN).
• Managed with inhaled nitrates.

Management (Mx)

• Best ventilation: IPPV (Intermittent Positive Pressure Ventilation).

• ExUtero Intrapartum Treatment Procedure (EXIT)
• Airway is ensured before the infant is separated from Placenta
• Also done in Laryngeal atresia, Stenosis, Teratoma, Hygroma, Oral tumors

• Resuscitation: 
• with Bag and mask ventilation C/I

• If there is severe respiratory distress
• Intubation and bag and tube ventilation needs to be done

• Surgical Management (Sx):
• Circular incision around the diaphragm.
• Bowel reduced back into abdominal cavity.
• Mesh placed to reinforce the repair.

Eventration of diaphragm

• Similar to CDH but not a true hernia.

• Thinning of pleuroperitoneal membrane