x ray approach for pediatrics and diagnosis

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1. READING OF XRAY AND RADIOGRAPHIC PICTURE OF COMMON PAEDIATRIC CONDITIONS Moderator: Dr Shree Krishna G N Presenter: Dr Swathi O N

2. Introduction Points to be known before reading a X-ray Interpretation of CXR Particular Pediatric points Neonatal X-rays Respiratory system Cardiovascular system Bone disorders Case scenarios

3. How tissue appears on X-ray: AIR & FAT absorb relatively less radiation Consequently radiolucent – black and dark grey images respectively SOFT TISSUES Composed mainly of water Appear as shades of grey BONE Absorb much more X-radiation radiopaque – images are white

4. Points to be known before reading CXR

5. PA / AP view ?? Cassette Direction of x-ray beam Direction of x-ray beam Routine OPD Stable patients Unstable patients ( supine AP) ICU patients (portable) Trauma ward, head injury Neonates

6. Magnification on AP CXR : Does it matter ? A false impression of cardiac, mediastinal and /or aortic enlargement is seen.

7. PA or AP view ?? PA VIEW AP VIEW Clavicles Seen over the lung fields Seen above the apex of lung field Scapula Inner borders seen away from the lung fields Inner borders seen over the lung fields Cardia No Apparent cardiomegaly + Lungs Anatomical shape of lung visualized Costophrenic and cardiophrenic angles are clearly seen Lung volume is reduced Costophrenic and cardiophrenic angles give false appearance of pleural effusion Diaphragm Lowest level Highest level

8. For easy identification Portable is always AP. Ribs are horizontal Spine is very prominent PA view Ribs are more oblique Heart shadow more prominent than that of spine

9. Phase of respiration: Inspiration or Expiration ?? Dome of diaphragm corresponds to anterior end of 5 th -6 th rib – GOOD INSPIRATORY FILM Fewer than 5 anterior ribs - UNDER INFLATION / EXPIRATION More than 6 anterior ribs - HYPERINFLATION Posterior ribs in younger children Adequate inspiration : 8 th – 9 th posterior rib is visible Hyperinflation > 9 posterior ribs Poor inspiration < 8 posterior ribs 1 2 3 4 5 6

10. With under inflation as in expiratory film, the 3 rd or 4 th rib crosses the diaphragm. This makes normal lungs appear opaque and a normal heart appears enlarged. 1 2 3 4

11. Penetration : Under or Over exposed ?? Cardiac shadow is opaque, with little or no visibility of thoracic vertebrae. Lungs appear much whiter. Cardiac shadow becomes more radiolucent. Lungs appear more darker. Proper penetration: Just able to distinguish the intervertebral spaces through the heart shadow

12. Patient rotation: Does it matter ? Inner clavicular ends should be at the same distance from the midline (vertical line through center – vertebral bodies T1-T5 ) Rotation to that side is present when one of the clavicles is further away from the midline. In children, when clavicular ends are difficult to locate, use the anterior rib ends

13. Potential problems: Rotation to right – manubrium sterni / superior vena : usually prominent Rotation to left – aortic arch appear enlarged This can simulate a mediastinal mass / dextrocardia .

14. INTERPRETATION OF CXR Lateral Frontal

15. Interpreting a lateral CXR : Lungs appear blacker as we go inferiorly Heart, aorta, inferior vena cava Right and left main pulmonary arteries Trachea and bronchi Rapidly exclude / confirm most equivocal abnormalities seen on frontal projection Whether pathology is anterior or posterior Which lobe

16. Interpreting a frontal CXR : Airway Bones & soft tissue Cardiovascular Diaphragm Extra pulmonary/ effusions Lung fields Gastric bubble Hilum & mediastinum A-B-C-D-E-F-G-H approach

17. A : Airway Trachea and bronchi – branching at carina Trachea passes to right of aorta May be slightly off midline to the right

18. Clavicles Ribs Sternum Spine – lower cervical & thoracic Scapulae & humerus if visible B : Bone & soft tissues

19. Thick soft tissue due to obesity may obscure some underlying structures such as lung markings Breast tissue may obscure the costophrenic angles Lucencies within the soft tissue may represent gas Soft tissue

20. 1.Supraclavicular fossae (enlarged nodes) 2.Lateral chest wall (emphysema) 3. Under diaphragm ( pneumoperitonium )

21. Subcutaneous tissue – edematous With evidence of pleural effusion of right side 3 rd spacing by fluid Calcified lymph node in left axilla -TB U/l increase in soft tissue density – Cellulitis / necrotizing fascitis

22. C : Cardiovascular - CTR CTR assessed on a PA CXR obtained in full inspiration. a (CR+CL) – max transverse diameter of heart b (T) – max internal diameter of thorax. Cardiomegaly: if a / b > 50% ,in adults. > 55%, in infants > 57% , in newborns As a generalization, CTR >60% in an infant or newborn is considered as cardiomegaly. Microcardia : CTR < 40%

23. Heart borders: Right border: Edge of right atrium Left border: (L) ventricle + (L) auricle Anterior border: Right ventricle Posterior border: Left ventricle Right ventricle lies anteriorly and therefore doesn't have a border on the PA view RV LV LA

24. Orientation of cardia : Left atrium is the most posterior structure. Left atrial appendage can be seen as a small outpouching just below the pulmonary trunk. Right atrium form the right heart border. Left ventricle is seen on the left side posteriorly to RV forming left heart border. Right ventricle is the most anterior structure and is situated behind the sternum.

25. Aortic knuckle Aortic knuckle represents left lateral edge of aorta – as it arches backwards over left main bronchus Contour – descending thoracic aorta – seen in continuation of aortic knuckle Displacement or loss of contours – can indicate - disease in adjacent lung: consolidation - aortic aneurysm

26. Aorto pulmonary window Located between aortic knuckle and left pulmonary artery Space where abnormal enlargement of mediastinal lymph nodes seen

27. Pulmonary artery Deoxygenated blood – from right ventricle into main pulmonary artery From main PA into left PA and right PA – passes the hilum of lung

28. The lower lobe pulmonary arteries extend inferiorly from the hilum. They are described as little fingers as each has the size of a little finger. On the right side the little finger will be visible in 94% of normal CXRs and on the left side in 62% of normal.

29. D : Diaphragm: On PA & AP CXR – both domes are well defined Right dome –usually higher due to elevation by the liver. Look for any pathological variations in relation to diaphragm - air under diaphragm - flattened diaphragm (disease in adjacent lower lobe) - loss of diaphragm definition - elevated hemi diaphragm

30. E : Effusion (pleura) : Pleura and pleural spaces will only be visible when there is an abnormality present. Like pleural thickening, fluid or air in the pleural space.

31. Clinical types of pleural collection Air: pneumothorax Pus: empyema or pyothorax Serous: hydrothorax Blood: hemothorax Chylous : chylothorax Empyema is usually due to underlying pneumonia. Staphylococcal empyema rapidly develops within 24 hrs

32. Blunting of CP angle + (a). Approx 200-300ml (b). Approx 2 L (c). Approx 5 L with mediastinum shifted to normal side Encysted pleural effusion – fluid between 2 layers of pleura lining horizontal fissure

33. Sub pulmonic effusion Fluid has pooled between visceral & parietal pleura at the base of lung. Normally Highest point of dome - center. But in subpulmonic effusion, highest point is situated laterally. Gastric bubble is widely separated from the superior margin of diaphragm >7mm).

34. Blunting of CP angle+ Parapneumonic effusion with effusion in minor fissure too May resolve or turn into an empyema

35. F : Lung fields – zones Lungs – assessed & described by dividing them into – UPPER, MIDDLE & LOWER zones Each zone is compared with its opposite side

36. Lung fields – lobes

37. H : Hilum & mediastinum Consists primarily of major bronchi & PA,PV Hilar point – angle formed where upper and lower pulmonary vessels meet. Left hilum – at same level or higher than the right.

38. Hilar Lymphadenopathy On a PA view it is not clear whether HILAR ENLARGEMENT is d/t dilated vessels / enlarged lymph nodes. Lateral view shows round opacities where no vessel is expected, confirming the presence of hilar lymphadenopathy, may be sarcoidosis.

39. Mediastinum Aortic arch - first convexity on the left side of the mediastinum. Pulmonary artery – next convexity on the left, and the branches should be traceable as it fans out through the lungs. Lateral margin of SVC – lies above the right heart border.

40. Particular Pediatric points : THYMUS Thymus shadow visible at birth Different shapes & sizes Involutes between the ages of 2-8 yrs THYMIC SAIL SIGN If in doubt – USG thorax – thymus never compress the structures in mediastinum

41. THYMIC SAIL SIGN: thymic tissue producing a triangular projecting shadow PSEUDOPNEUMONIA SIGN: slight rotation may mimic pneumonia of upper lobe. NOTCH SIGN: Normal thymic silhouette blends with cardiac silhouette with a notch at its interface.

42. Neonatal CXR When to order for a neonatal CXR ?? For evaluating the initial cause of respiratory distress For suspected cardiac or pericardial disease To check position of endotracheal tube, umbilical lines For evaluating the cause of worsening respiratory distress

43. HMD Typically, FINE RETICULO-GRANULAR pattern / diffuse “GROUND GLASS” appearance, which is b/l & symmetrical in distribution Presence of air bronchogram especially extending peripherally White out lungs

44. MAS Coarse nodular opacities Air trapping and hyper-expansion from airway obstruction. Acute atelectasis Diffuse chemical pneumonitis Pneumothorax, pneumomediastinum can happen as complications.

45. TTNB Fluid in the fissures Perihilar streaking Hyperinflation of the lungs Pleural effusions Mild Cardiomegaly

46. Esophageal atresia CXR reveals lucency over the cervical and upper thoracic spine due to blind ending pouch of esophagus filled with air Coiling of infant feeding tube A complete gasless abdomen is hallmark of esophageal atresia without fistula. Fluoroscopic examination with barium helps in presurgical evaluation. TYPES A – Isolated esophageal atresia B – Atresia with proximal fistula C – Atresia with distal fistula D – Atresia with double fistula E – Isolated fistula (H type)

47. CDH Neonate presents with acute respiratory distress with a scaphoid abdomen. Bowel sounds are audible on the herniated hemithorax . mediastinal shift to opposite side ipsilateral hemithorax contains bowel loops filled with gas ipsilateral lung is hypoplastic .

48. Duodenal atresia – double bubble sign

49. Hirchsprung disease Plain X ray reveals dilated bowel loops with an absent rectal gas shadow. Barium enema demonstrates reduced caliber rectum & sigmoid - SAW TOOTH APPEARANCE, with transition point seen at the junction sigmoid & descending colon. Rectal biopsy is Gold standard showing absence of ganglionic cells in submucosal & myenteric plexuses. Anorectal manometry

50. Lines & tubes in NICU: UVC A UVC tip position is acceptable as long as it is not in the liver nor in the heart. Preferred position of catheter tip: in the IVC approximately at the level of T8-T9 vertebrae i.e 0.5-1 cm above the level of diaphragm IVC RA

51. Wrong position: potential complications Tip in the heart: cardiac arrhythmia valvular injury pericardial perforation resulting in effusion Tip in a pulmonary artery: pulmonary infarction Tip in portal venous system: portal vein thrombosis hepatic necrosis

52. UAC High UAC - tip is well above the origins of coeliac axis(T12), SMA(T12-L1) & renal arteries(L1-L2) bet T6 & T9 Low UAC – tip is well below the origins of same arteries & above the aortic bifurcation(L4-L5) bet L3 & L4

53. Wrong position : potential complications Tip in the arch of aorta – head vessels are at risk of thrombosis. Tip between T12 & L2 – the major arterial branches of the aorta are at risk of thrombosis.

54. Identification of UVC & UAC

55. ET Tube placement ET tube has an opaque line in the side of it, making it clearly visible on a plain x ray. Optimum position of the tip is in the MID TRACHEA i.e in between the vocal cords and carina. Radiologically the tip should lie just above the carina – T4 vertebra. If the clavicles are visible, then the tip of ETT should lie just below the medial ends of the clavicles

56. ETT in the right main bronchus has caused complete consolidation of the non ventilated left lung ETT in esophagus Air filled stomach is seen

57. CXR R : Rotation I : Inspiration P : PA view E : Exposure Search for pathology A-B-C-D-E-F-G-H approach Respiratory system:

58. Frontal X-ray – white shadows in lung Lung consolidation (pneumonia): NO LOSS OF LUNG VOLUME most common cause Lobar collapse: VOLUME LOSS EVIDENT Whiteness is because – it has no air within it & mucus secretions back up and collect in alveoli

59. Viral etiology: BRONCHIOLITIS Infection occurring in children up to two years of age Respiratory syncytial virus. Bronchioles are narrowed by the inflammatory exudate and the narrowing causes air trapping Bronchiolitis typically shows : a. Over-expansion (air trapping) of the lungs b. Peribronchial cuffing(i.e. bronchial wall thickening) beyond inner 1/3 rd of lung c. Small areas of linear collapse / peripheral atelectasis. Rule of thumb: If the CXR shows poor expansion of the lungs, i.e. they are not over-inflated…this suggests that the infant does not have bronchiolitis.

60. Viral LRTI with atelectasis mimicking Pneumonia Segmental atelectasis, single or multiple, u/l or b/l, because of combined effect of mucosal inflammation, endo bronchial secretions and mucus plugs may result in bronchial obstruction and may mimic pneumonia. Clue for viral diagnosis: there will be rapid clearing of respiratory distress symptoms usually in < 24hrs, as it is often due to rapid dislodgement of mucus plug.

61. A child presented with acute onset of fever of 102 F, marked respiratory distress and mild cyanosis. D1 of adm , Viral LRI with atelectasis mimicking pneumonia Peribronchial infiltrates,viral parahilar infiltrates Patchy consolidation at right lower lobe D2 of adm , peribronchial infiltrate persists, Pneumonic patch disappeared. Such a rapid clearing is not possible with bacterial pneumonia

62. Hilar adenopathy: varying degrees of hilar adenopathy from nil to well circumscribed lymph node may be seen. Pneumonitis: inflammatory extension and mucus exudation may cause either alveolar or insterstitial pneumonitis. Alveolar infiltrate can be nodular, fluffy, patchy or consolidative and at times it may be difficult to differentiate from similar infiltrates produced by bacterial infections Interstitial pattern is characterized by streaky or reticular infiltrate coursing through the lungs or radiating from prominent hilar regions into parenchyma – SHAGGY HEART appearance Parahilar , parabronchial infiltrate with hilar adenopathy TYPICAL of VIRAL LRTI

63. Lobar & Broncho pneumonia Homogenous opacity throughout much or most of a lobe May show an air bronchogram Pneumococcus Klebsiella Scattered and diffuse nodular & linear opacities Klebsiella E.coli Pseudomonas Staph aureus Pneumococcus Anaerobes Bacterial spectrum: Clinically evident symptomatic pneumonias with normal CXR, can be seen as there is a usual delay period of up to 12hrs from the onset of symptoms to appearance of a radio graphically demonstrable infiltrate . LUNG CONSOLIDATION: often used to describe pneumonic changes on a CXR

64. Silhouette sign An intrathoracic lesion touching a border of the heart, aorta or diaphragm will obliterate that border on the CXR. An intrathoracic lesion not anatomically contiguous with a border will not obliterate that border. Lobe Adjacent structure RUL Ascending aorta RML Right heart border RLL Right diaphragm LUL Aortic knob Left heart border (bordered by lingual) LLL Left diaphragm Descending aorta Silhouette – meaning the outline of a solid object The term silhouette sign is a deliberate misnomer- which actually refers to loss of part of the silhouette

65. 4 patients present with cough & fever Silhouette sign tells us that there is consolidation in: Left lower lobe – as the left dome of diaphragm is blurred. Lingular segment of upper lobe –as the left heart border is blurred. Middle lobe – as the right heart border is blurred. Right lower lobe – as right dome of diaphragm is blurred.

66. Absence of silhouette sign: Consolidation in the left lung but the left heart border is sharp & clear Left lower lobe pneumonia but not lingular segment of upper lobe Consolidation in the right lung but the right heart border is sharp & clear Right lower lobe pneumonia but not middle lobe.

67. Key findings of pneumonia on the X-ray are: Ill-defined homogenous opacity obscuring vessels Silhouette sign: loss of lung/ soft tissue interface Air- bronchogram Extension to the pleura or fissure, but not crossing it No volume loss

68. Lobar pneumonia Homogenous ill defined opacity silhouetting the right cardiac border RIGHT MIDDLE LOBE PNEUMONIA Homogenous ill defined opacity not silhouetting the right cardiac border RIGHT LOWER LOBE PNEUMONIA

69. Broncho pneumonia Scattered and diffuse nodular & linear opacities

70. Bacterial pneumonia -homogenous opacity Viral pneumonia – parahilar & parabronchil infiltrates

71. Pneumonia – a six week rule There is no need to rush to repeat the CXR if pt is clinically well or improving. In approximately 73% of patients, CXR will be clear at six weeks.

72. Lobar Collapse Affected lobe is usually white Volume loss will be evident W hiteness is because: (a) the affected lung tissue occupies a smaller volume, (b) it has no air within it, and (c) mucus secretions back up and collect in the alveoli Consolidation also appears as white area on CXR but with NO LOSS OF LUNG VOLUME

73. Likely cause of a collapsed lung by presentation a. post surgical / in the intensive care unit : Mucus plug or incorrect position of an endotracheal tube b. Asthmatic pt : Mucus plug c. Toddler/ young child: inhaled foreign body d. primary TB e. viral LRTI

74. Lobar collapse – general features Evidence of volume loss : displacement of trachea or mediastinum, elevation of dome of diaphragm decreased spacing between ribs. Evidence of over-inflation of adjacent unaffected lobes Vessels in the over-expanded lobes are widely separated compared with the opposite normal lung

75. Collapse – right lower lobe Classic triangular shadow with evidence of volume loss – displacement of trachea Medial aspect of right dome of diaphragm is obscured.

76. Collapse – left lower lobe Triangular density is superimposed over the heart Medial aspect of left dome of diaphragm is obscured

77. Collapse – middle lobe Blurring of the right heart border Evidence of volume loss- displacement of trachea

78. Collapse – right upper lobe A mucus plug causing collapse of right upper lobe in an asthmatic child

79. Veil like density covers much of left hemithorax – lack of aeration – collapsed upper lobe. Left heart border is obscured – in whole or in part. Left hilum is elevated LUFTSICHEL sign may be present- cresentric lucency around left side of aortic knuckle – overexpanded apical segment of left lower lobe positioning itself between the collapsed upper lobe and aortic arch. Collapse – left upper lobe

80. Mimics - Collapse Right upper lobe : AGYGOS FISSURE Middle lobe : depressed sternum Right lower lobe : epicardial fat pad Left lower lobe : hiatus hernia

81. Depressed sternum in a patient of PECTUS EXCAVATUM, a congenital deformity of the ribs & sternum, silhouettes the right cardiac border mimicking a middle lobe pneumonia. Pectus excavatum can be confirmed on lateral CXR.

82. A large epicardial fat collection could be misinterpreted as consolidation or collapse – within the right lower lobe.

83. Increased density within the lung can be ??

84. Single lung visualized CXR of a well growing older child presenting for respiratory ailment: had mild tachypnea An acutely ill neonate with respiratory distress , CXR post PDA clipping AGENESIS ATELECTASIS

85. Pulmonary Agenesis Confirm by : flexible scopy / CT Chest/ ECHO – size of pulmonary vessel Clue: Intercostal spaces are very much narrowed in agenesis unlike in atelectasis Not in respiratory distress unlike atelectasis

86. Bilateral hyperinflation Darker – more air Anterior end – 8 th rib seen Bronchovascular marking present (air is within the lung) Diaphragm – flattened Rectangular box like lung parenchymal shadow – asthma under poor control

87. Unilateral hyperinflation - Obstructive Darker – more air Bronchovascular markings present Diaphragm – flattened Common cause – FB Differentiate from Congenital lobar emphysema

88. Congenital lobar emphysema Results from a bronchial obstruction affecting a lobe of lung May be a structural occlusion – bronchial atresia Commonly seen in left upper lobe Air enters the lobe via the canals of lambert and pores of kohn (collateral air drift) but cannot exit. Consequently the lobe gradually distends. c/f : few present in neonatal period, m/c ly symptoms occur between 1-6 months of age, dyspnea & cyanosis. CXR : Hyperlucent left upper lobe, small triangular collapsed lower lobe mediastinal shift to right

89. Congenital lobar emphysema Left lung – darker than the right Collapse of left lower lobe Herniation of left upper lobe crossing the midline Mediatinal shift + Mid zone – more darker Collapse of right upper & lower lobe : Congenital middle lobe emphysema

90. Localized air trapping : CPAM Large multicystic mass in the left hemithorax with mediastinal shift as a result of CPAM

91. Foreign body aspiration (trachea) M/c ly inhaled FB : peanut May produce any one of three appearances a. Normal CXR : this is not necessarily reassuring. If a strong clinical suspicion persists then urgent referral for bronchoscopy b. area of collapse c. air trapping because the bronchial blockage has caused a ball valve effect. The affected lung appears darker & larger.

92. Complete Collapse of right side following FB inhalation Inhaled peanut lodged in right main bronchus. Right lung – darker and larger Following a rapid expiration, CXR shows severe air trapping in right lung with displacement of the mediastinum

93. Foreign body ingestion (coin in esophagus) Child may be asymptomatic but erosion of the mucosa by a coin can cause an abscess or mediastinitis. There is no danger to the child if the coin has passed into the stomach or the intestine A radiograph of abdomen represents unjustified radiation exposure. If the CXR is normal, then the parents can be reassured that the coin has passed into the gut, will cause no harm and will be excreted within next few days.

94. FB impaction usually occurs at 3 sites At the cervical esophagus At the level of arch of aorta At the gastro-esophageal junction

95. FB : Ingested vs Aspirated Frontal CXR: esophaheal – En -face, airway – sagittal Lateral CXR to be done to confirm. Coin / disk battery ? Disk battery can be identified by the distinctive double circle enhancement at the edge of circular radio opaque object

96. Aspiration Right lung is most frequently involved as the right main bronchus directly takes off from principle bronchus. In the recumbent position, superior segment of right lower lobe and posterior segment of right upper lobe are the most dependent segment of lung. In erect posture, basal segment of lower lobe is most dependent. In small infants, who are fed in lying posture are prone for right upper lobe involvement.

97. In hydrocarbon aspiration, pulmonary changes are absent for the first 6-12 hrs. Hydrocarbon being lipid solvent, destroys surfactant and leads to micro atelectasis of the alveoli. CXR findings: fine perihilar opacities, b/l basilar infiltrates atelectasis

98. Lung abscess They are commonly due to complications of pneumonias or chronic bronchial obstruction with suppuration. The features are thick walled lesions Regular or irregular in outline Round or oval in shape Air fluid levels are significant

99. Air fluid level + LUNG ABSCESS With left upper lobe pneumonia Lung abscess can also present at the base of lung

100. Air trappings in the chest Pneumomediastinum Air can enter the mediastinum as a result of different pathological processes – rupture of alveoli, trachea or bronchi or any esophageal tear. The air commonly extends into the neck.

101. Air may get collected subpleurally along the diaphragm producing : CONTINUOUS DIAPHRAGM SIGN A lucent black halo surrounding the heart. Streaks of air in the neck or in the soft tissues of chest wall. Air around the PA : black ring appearance “RING AROUND THE ARTERY SIGN” Thymic “ ANGEL WING SIGN” or “SPPINAKER SAIL SIGN” in young children and neonates represents normal thymus surrounded by mediastinal air. CXR appearances

102. Pneumothorax Increased size and lucency of the involved hemithorax . Contralateral shift of the mediastinum Absence of bronchovascular markings on affected side. Unaltered volume and lucency of the affected chest on expiration.

103. Tension pneumothorax 2 cardinal features to look for The ipsilateral dome of diaphragm is nearly always depressed and flattened. Mediastinum and heart – pushed to opposite side. A medical emergency

104. Tension pneumothorax or not ?? In tension pneumothorax, the dome of diaphragm is depressed or flattened and mediastinum is displaced to left side. In pneumothorax, mediastinal shift will be seen but the dome of diaphragm is neither depressed or flattened.

105. Typical baseline asthmatic chest The presentation are widespread overaeration , parahilar peribronchial prominence, bronchial cuffing, hilar adenopathy. The picture may almost mimic that of viral LRTI and the only clue is recurrence of episodes and occurrence at times may be without fever.

106. Other findings include Long thin cardiac silhouette- elongated small heart Prominent pulmonary artery possibly due to acute pulmonary hypertension

107. READING OF XRAY AND RADIOGRAPHIC PICTURE OF COMMON PAEDIATRIC CONDITIONS Moderator: Dr Shree Krishna G N Presenter: Dr Swathi O N

108. Occasionally the azygos vein reaches the superior vena cava by passing through right upper lobe trapping a segment of upper right lobe and creating an azygos fissure Which appears as a white shadow on X ray Right upper lobe collapse mimicked by AZYGOS FISSURE

109. RDS – can be graded based on CXR findings as , Grade 1 : lung show fine reticulo granular pattern Grade 2 : widespread air bronchogram become visible Grade 3 : confluent alveolar shadowing Grade 4 : complete white lung fields with obscuring of cardiac shadow

110. CT Ratio Cardiomegaly: if a / b > 50% ,in adults > 55% in children >60% in an infant or newborn

111. Cardiac evaluation of Newborn X-ray Position : situs solitus , levocardia Cardiac size Specific chamber enlargement Pulmonary vascularity : Plethora Oligemia Venous / arterial hypertension Cardiovascular system

112. Situs solitus – Viscera are in their normal positions i.e liver on right, stomach & spleen on left, 3-lobed lung is on the right, 2 lobed lung on the left, right atrium on the right & left atrium to the left Situs inversus – abdominal organs & lung lobation are reversed, RA to the left & LA to the right : mirror image of situs solitus . 1. Position : Situs

113. Situs indeterminus or heterotaxia - visceroatrial situs cannot be readily determined. 2 major variations are ASPLENIA syndrome / right isomerism/ bilateral right sidedness : liver – centrally located spleen – absent 2 morphologic right lungs POLYSPLENIA syndrome/ left isomerism/ b/l left sidedness : multiple small spleens absence of intrahepatic portion of IVC 2 morphologic left lungs Heterotaxia syndromes are usually associated with severe CHD .

114. Liver is transverse, stomach is on the right, Asplenic neonate with right isomerism

115. Cardiac shadow : Usually levocardia - 2/3 rd to left & 1/3 rd to right. Dextrocardia – predominant cardiac shadow on right with apex pointing to right. - base to apex axis is to right.

116. Situs solitus levocardia Prevalence of CHD less than 1% Situs solitus dextrocardia Prevalence of CHD 90%

117. Situs inversus levocardia Prevalence of CHD 100% Situs inversus dextrocardia Prevalence of CHD less than 5%

118. Dextrocardia without associated situs inversus & Levocardia in the presence of situs inversus Have higher prevalence of CHD.

119. 2. Specific chamber enlargement Right atrial enlargement: Right heart border becomes more convex RA occupies more than 3 intercostal spaces Distance from midline to right hear border > 4cm With RVH: Severe PS, severe PAH, large ASD Without RVH: Ebstein anomaly, Tricuspid atresia

120. Left atrial enlargement Only left atrial appendage forms part of left heart border. LA can enlarge in any direction. Prominent left atrial appendage on left heart border. Elevation of left bronchus Splaying of left & right bronchi with the widening of carinal angle. “SHADOW ON SHADOW” appearance extending to right heart border

121. Double density / shadow on shadow sign LAE seen in PDA, VSD, MR, MS

122. Left ventricular enlargement Normal apex is formed by LV . LV forms the left heart border In LVE, Left heart border displaced downwards & outwards Rounding of cardiac apex Depression of left hemidiaphragm Elongation of long axis of LV Seen in large PDA, large VSD, AVSD with sever MR, dilated cardiomyopathy

123. Right ventricular enlargement Apex displaced upwards & laterally. Upturned apex: apex elevated from the diaphragm. RV apex without cardiomegaly: TOF, PAH, VSD,PS With cardiomegaly: ASD with eisenmenger syndrome, VSD with PAH, TAPVC

124. 3. Pulmonary vascular patterns Normal vascularity Increased vascularity or plethora Decreased vascularity or oligemia Pulmonary venous hypertension pattern Pulmonary arterial hypertension pattern Uneven or asymmetrical pattern

125. Normal vascularity Symmetric Gradual tapering towards peripheral lung fields Diameter of RDPA is equal to trachea In peripheral lungs pulmonary vessels and accompanying bronchi are of equal size

126. Plethora Uniformly enlarged vessels at hilum and within lung fields Dilated tortuous vessels extending to lateral 3 rd of lung fields Diameter of RDPA more than the size of trachea Diameter of peripheral pulmonary artery more than adjacent bronchus Seen in L – R shunts : ASD/ VSD/ PDA

127. Pulmonary oligemia Small size of pulmonary vessels at hilum and lung fields Seen in TOF, Critical PS, Severe PAH, tricuspid atresia

128. Pulmonary venous hypertension Compared to adults, PVH is less commonly found in infants & young children. Normally upper lobe veins are less prominent than lower lobe veins due to gravity effect. In early PVH, there is equalization of the venous vascularity.

129. PCWP Xray findings 5-12 mm hg normal > 12 mm hg Equalization of upper & lower lobe veins > 15 mm hg Kerley lines Interstitial edema > 18 mm hg Perihilar distribution of fluid occurs > 25 mm hg Frank pulmonary edema Cotton wool / bat wing app Seen in Obstucted TAPVC, HLHS, MS,Acute MR

130. Cephalization Inverted moustache sign Stag antler sign

131. Kerley A lines: linear opacities extending from periphery to hilum, due to distension of anastomotic channels between peripheral & central lymphatics Kerley B lines : short horizontal lines situated perpendicular to the pleural surface at lung base, due to edema of interlobular septa.

132. Short horizontal lines situated perpendicularly to the pleural surface at lung base, due to edema of interlobular septa.

133. Pulmonary arterial hypertension PAH associated with congenital heart disease is currently the most common in children. CXR features Prominent pulmonary artery RVH Pulmonary oligemia

134. ASD A small shunt across the ASD : Normal appearing CXR Patients with significant shunts : -Cardiomegaly d/t RA RV enlargement -Prominent pulmonary artery -Increased pulmonary vascularity

135. VSD Cardiomegaly d/t LA, LV & RV enlargement Increased pulmonary vascularity Degree of cardiomegaly & pulmonary plethora directly relate to the magnitude of L-R shunt.

136. PDA A small shunt PDA : Normal appearing CXR Patients with significant shunts : Cardiomegaly d/t LA LV & ascending aorta enlargement Increased pulmonary vascularity

137. Typical X-ray findings like Boot shaped heart Egg on side Figure of 8 or snowman Takes 2-3 weeks to develop

138. Newborn with respiratory distress and cyanosis with Spo2 of 70% Situs solitus levocardia Cardiomegaly + RV apex –apex upturned RAE – convex right heart border Narrow base Pulmonary plethora TGA – EGG ON SIDE APPEARANCE

139. Newborn with respiratory distress and cyanosis with Spo2 of 70% Situs solitus levocardia Cardiomegaly + RV apex –apex upturned No RAE wide base may be d/t right arch Pulmonary oligemia TOF – BOOT SHAPED HEART

140. Newborn with severe respiratory distress and cyanosis Situs solitus Cardiomegaly ? white washed lungs + OBSTRUCTED TAPVC This may mimic HMD. Differentiating findings are Absolutely normal sized heart Air bronchogram seen in HMD

141. Situs ?, levocardia Cardiomegaly + Dilated PA, RAE with small aorta Pulmonary plethora UNOBSTRUCTED TAPVC – FIGURE OF 8 app Figure of 8 appearance takes 3-6 months to develop. The upper part of 8 is formed by SVC on right & vertical vein on left. The lower half is formed by RA on right & LV on left. THYMIC ENLARGEMENT CAN MIMIC FIGURE OF 8 APPEARANCE

142. Newborn with severe respiratory distress and cyanosis Situs solitus levocardia Gross Cardiomegaly + ,heart occupying > 80% of thoracic diameter. ballooned RA Pulmonary oligemia EBSTEIN’S ANOMALY

143. Situs solitus levocardia Cardiomegaly - minimal prominent aorta normal Pulmonary vascularity COARCTATION OF AORTA – FIGURE OF 3 SIGN 3 sign : due to dilatation of aorta & subclavian artery proximal to CoA & post stenotic dilatation of descending aorta. Rib notching in 3 rd – 8 th ribs, posteriorly d/t dilatation of posterior intercostal arteries. Evident only after 4-6yrs.

144. Bone & metabolic diseases Rickets Scurvy

145. Rickets

146. Rickets Widened wrist Bony prominence above the wrist, resulting from fraying of lower end of radius and ulna Normal child Child with rickets showing metaphyseal fraying & cupping of distal radius & ulna

147. Widening of growth plate: d/t decreased calcification -earliest & specific radiological change - Hallmark of rickets -Best seen at the knees, which is the most active growth plate. Fraying – edge of metaphysis loses its sharp border. Fraying is d/t irregular attempts to mineralize the cortex. Cupping – edge of metaphysis changes from a convex or flat surface to a more concave surface. Cupping is d/t stress placed on the soft unmineralized bone matrix & is related to degree of activity of child, being more pronounced in radius and ulna at wrist in crawling babies.

148. Craniotabes : excess osteoid deposition in frontal & parietal regions with posterior flattening of skull d/t supine posture of infant, squared configuration of skull. Frontal bossing is d/t excess bone laid down without calcium Bending of bones especially lateral bowing of tibiae occurs in advanced rickets / windswept deformity Rachitic rosary: bulbous enlargement of costochondral junction.

149. Types of rickets Vit D deficiency – “classical rickets” caused by low endogenous vitamin D. Vit D dependent : type 1 is due to 1 alpha hydroxylase deficiency type 2 is due to a mutation in vitamin D receptor Vit D resistant – defect in tubular absorption of phosphate – x-linked hypophosphatemic rickets.

150. Scurvy Rickets involves failure of mineralization while osteoid formation is normal. Scurvy is a disorder of osteoid formation. Osteoblasts form osteoid for which vitamin C is important. Scorbutic rosary Gingival lesions Perifollicular petechiae

151. Radiological features: Dense zone of provisional calcification is seen since bone mineralization is normal – WHITE LINE OF FRANKEL WIMBERGER’S SIGN – sclerotic ring surrounding the epiphyses. SCORBUTIC ZONE / ZONE OF TRUMMERFELD – represents the lucent area on the metaphyseal side of the white line

152. 4. PELKAN’S SPUR – zone of provisional calcification extends beyond the margins of the metaphysis resulting in periosteal elevation & marginal spur formation. 5. Subperiosteal hemorrhages. Large subperiosteal hemorrhage with areas of calcification seen along the shaft of right femur

153. Osteomyelitis Within 72hrs of onset of symptoms of osteomyelitis, plain radiographs of involved site shows f/o Tissue edema : displacement of the deep muscle planes from adjacent metaphysis. Lytic bone changes – not visible on radiographs until 30-50% of bony matrix is destroyed. Tubular long bones donot show lytic changes for 7-14 days after onset of infection. Radiographs in children with possible osteomyelitis – important to exclude other possible causes like fractures of presenting symptoms & signs. Osteopenia & trabecular destruction in radius

154. The earliest sign to appear on x-ray is periosteal reaction i.e subperiosteal new bone formation at metaphysis 7-10daysto appear.

155. Case scenarios A 2 yr old boy presented with high fever, cough, lethargy, o/e tachypnea and grunting + & rhonchi + in the right side of chest.

156. A : trachea in midline, normal B : no fractures, no soft tissue pathology C : normal, no cardiomegaly D : highest point of dome is at the center E : CP angles are sharp, no effusion F : abnormality found in right middle lobe G: gastric shadow seen H : normal It’s a well exposed, CXR AP view taken in inspiration with no rotation.

157. A homogenous opacity, silhouetting the right cardiac margin is seen in the right lower zone, with air bronchogram & no signs of volume loss. Likely to be right RIGHT MIDDLE LOBE PNEUMONIA

158. An intubated neonate in the NICU develops worsening of respiratory distress, lower oxygen saturation and diminished breath sounds on right. C hest x-ray is ordered. It’s a well exposed, CXR AP view, with no rotation. A : trachea cant be assessed B : no fractures, no soft tissue pathology C : cannot assess D : depressed right dome of diaphragm E : air in the pleural space F : collapsed and compressed right lung Mediatinum : shifted to left

159. Hyperlucent right pleural space with collapsed & compressed right lung with mediastinal shift to left & depressed right dome of diaphragm. Likely to be RIGHT TENSION PNEUMOTHORAX.

160. References: IAP textbook of Pediatric Radiology, TM Ananda Kesavan , S Venkateswaran Nelson textbook of pediatrics – 21 st edition Ghai essential pediatrics -9 th edition The Chest x-ray : A survival guide , GERALD DE LACEY AIIMS protocols in Neonatology 2 nd edition Manual of Pediatric emergencies & critical care, Suchitra Ranjit