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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5790_Библиотеки_им_академика_М_И_Перельмана.pdf
6.3 Pathology of Chest Wall
• Large space-occupying lesions, tumours or lymph node enlargement visible
• Anatomy of large vessels addressed with echocardiography
195
6.2.6.3 Posterior Mediastinum
Diffi cult to visualise by US
Usually anterior access supplemented by posterior paravertebral access
Used for assessing tumours, particularly neuroblastoma
6.2.7 CDS
Except for assessment of vessels, CDS not very useful in normal situation
Indications for chest CDS for DDx in pathology mostly of the lung: e.g. abscess
or necrosis, tumour vascularisation, vascular malformations, suspected particularly
peripheral pulmonary artery embolism (PAE, resemble triangular subpleural pneumonic areas without depictable vascularistion), etc.
6.3 Pathology of Chest Wall
6.3.1 Aplasia, Variations of Ribs
Quite common, cartilaginous part nicely assessed by US, wide range of rib
anomalies:
• 3DUS reconstructions improve understanding and visualisation (see Fig. 1.34 )
• Plain fi lm: US complements plain fi lm
6.3.2 Congenital Malformations
Vascular malformations (lymphangioma, haemangioma), other soft tissue masses
– see below:
• Refl ect typical US appearance elsewhere (see Chaps. 4 , 8 , and 11 )
6.3.3 Traumatic Changes
Fractures of ribs and sternum: see musculoskeletal US (Chap. 11 ):
• Particularly in cartilaginous parts and sternum
– US may be superior to plain fi lm, where these structures are diffi cult to assess
if not signifi cantly displaced
NOTE : Follow entire structure in longitudinal and axial sections to detect any sur-
face interruption/irregularity.
196
ab
Fig. 6.4 Chest wall lipoma: ( a ) Chest wall lipoma: well-defi ned subcutaneous mass (+ +), fat-like
intermediate density echoes. ( b ) Below lipoma mass, structures of chest wall can be appreciated:
muscle and ossifi ed ribs (shadowing)
6 Ultrasound of the Chest
Often some reactive focal subperiosteal haematoma:
• Without history, differentiation from osteomyelitis diffi cult
• Particularly if bilateral, multiple, of different age – NAI should be considered.
Additional fi ndings:
• Complicated haemorrhagic pleural effusion, atelectasis
• Haematoma: seen in all chest wall spaces, usually no indication for imaging – only
in unclear cases, complicated course, suspicion of infection (DDx: seroma, etc.)
6.3.4 Chest Wall Tumours
6.3.4.1 Lymphangioma (veno-lymphatic vascular malformation)
US fi nding : Multicystic space occupying lesions with echogenic septae
• Spontaneous haemorrhages with fl uid-fl uid levels often present (see Fig. 4.12 )
• CDS: potentially some vessels within septae
6.3.4.2 Lipoma
US fi nding : Usually slightly inhomogeneous, echogenic mass, sharp margins (Fig. 6.4 )
6.3.4.3 Fibroma/Neurofibroma
US fi nding : Usually sharp margin, hyperechoic or inhomogeneous
6.3.4.4 Other Tumours
Rare; e.g. rhabdomyosarcoma or Ewing sarcoma (Fig. 6.5 ):
• Sometimes diffi cult to differentiate from myositis ossifi cans, particularly Askin
tumour.
US fi nding : No specifi c sonographic features
6.3.5 Breast
Breast US: In childhood of limited importance
Neonates : Transient physiologic swelling, cystic duct ectasia and cysts seen
• Secondary infection with abscess formation and haematoma may occur (Fig. 6.6a )
6.3 Pathology of Chest Wall
Fig. 6.5 Chest wall tumour – Askin tumour/
Ewing sarcoma. Extended fi eld of view US
demonstrates large chest wall tumour with
calcifi ed part (dorsal shadow) arising from
partially destructed rib – i.e. Ewing sarcoma
197
a
b
c
Fig. 6.6 Breast US in childhood: ( a ) Neonatal breast abscess – huge collection with membrane
and adjacent soft tissue reaction (hyperechoic, swelling) after neonatal mastitis; note plenty US gel
to facilitate transducer coupling to tissue without interposing air. ( b ) Impressive cystiform duct
ectasia in a breast feed infant. ( c ) Asymmetric prominent breast tissue at onset of pubarche in
11-year-old girl
( Pre -) puberty cysts, tubular duct ectasia, fi broadenoma, infl ammatory formations
(Fig. 6.6b ):
• Overall appearance varies with age and maturation (Fig.
6.6c )
• Most pathological entities do not differ from typical US appearance in adults
Additional application of breast US in childhood: Assessment of sexual maturation,
documenting presence and size of breast tissue
• In girls with suspected hormonal or genetic pathology
• In boys with gynaecomastia
– In some centres proof of signifi cant breast tissue necessary for treatment
decision
NOTE : Breast carcinoma extremely rare in childhood.
CDS : Can be helpful for assessment of superfi cial tumours or vascular malformations
and other pathology described in respective chapters
198
6 Ultrasound of the Chest
6.3.6 Role of US and Additional Imaging
US : Supplementary tool in clinically equivocal situation, follow-up
Additional Investigations :
• Suspicion of tumour – depending on oncology protocols – plain fi lm, CT/MRI
• Assessment of osseous structures: plain fi lm, rarely CT
• Mammography: rarely indicated, and only in/after puberty
6.4 Pathology of Pleural Space
6.4.1 Pleural Effusion
Defi nition : Some fl uid in between two pleural sheets of varying aetiology:
• Cardiac, infl ammation, trauma, tumour, etc.
• Most common pleural change, most common indication for chest US
US fi ndings :
Simple pleural effusion : Unechoic fl uid without septae (Fig. 6.7 )
Complicated effusion : Fluid contains fl oating echoes, septae, complex nature
(Fig. 6.8 ):
• Depends on haemorrhage, chronicity and recurrence, empyema, etc.
• Defi nite diagnosis of underlying entity not achievable by US
NOTE : Quantifi cation of pleural effusion limited. If US used for follow-up
(to determine increase or decrease of amount of fl uid) – use standardised views
and positioning:
• Possibly in sitting or upright position
• US aspect changes signifi cantly with posture – with redistribution of fl uid,
depending on position
6.4.2 Empyema
Defi nition and US fi ndings : Complex effusion with multiple septae which may
contain vessels (Fig. 6.8b ):
• Some space-occupying component
• May compress adjacent lung – often associated with or even caused by
pneumonia, atelectasis and abscess
( a ) CDS : Peripheral and Septal Hyperaemia
DDx : Any other complex fl uid, most important entities:
• Subphrenic/subpulmonic abscess, lung abscess (may exist concurrently)
• Complex pericardial effusion
• Haemorrhagic bronchogenic cyst
• Complex echinococcal/hydatid cyst
• Thoracic lymphangioma
• Ventral meningocele (usually clear fl uid, posterior mediastinum)
• Duplication cyst
6.4 Pathology of Pleural Space
a
c
199
b
Fig. 6.7 Simple pleural effusion: ( a ) Axial view: Small amount of simple pleural effusion (+ +)
in pleuritis: the little amount of effusion better visualised on US than on plain fi lm. Note pleural
thickening. ( b ) Sagittal dorsal view in upright sitting child for standardised assessment: simple
pleural effusion – height (+….+) can be measured. ( c ) Axial view through liver, transducer tilted
cranially: bilateral simple pleural effusions in a neonate – US cannot differentiate kind and entity
(e.g. chylothorax)
ab
Fig. 6.8 Complicated pleural effusion and empyema: ( a ) Axial intercostals view with sector
transducer: complex fl uid with fl oating echoes in complicated pleural effusion, lung compressed
and not aerated; US does not allow for differentiation of entity (e.g. haemorrhage versus
infl ammation). ( b ) Axial section: Complicated effusion with cystic areas in pleural empyema;
NOTE : Atelectasis of adjacent pneumonic lung
200
a
b
6 Ultrasound of the Chest
c
Fig. 6.9 Pleural tumours: ( a , b ) Pleural metastasis, particularly well seen with pleural effusion.
( c ) Sagittal view, sector transducer, infant with adrenal carcinoma: tumour has invaded through
diaphragm into thoracic cavity
6.4.3 Other Pleural Pathology
Thickening of pleura: after surgery/infl ammation
Space-occupying lesions/tumours of pleura: extremely rare in children
• Few entities reported:
– Pleural mesothelioma, pleural carcinosis, infi ltration by metastases
– Penetration from pulmonary as well as abdominal tumours (Fig. 6.9 )
– No specifi c US fi ndings
6.4.4 Role of Imaging
Role / Value of US :
• More sensitive than plain fi lm or even CT for detection of minimal pleural
effusions – gold standard for diagnosis and follow-up
6.5 Pathology of Diaphragm
ab
Fig. 6.10 Pleural drainage/puncture: ( a ) Puncture needle ( arrow ) entering pleural space. ( b ) Tip of
chest drain ( arrow ) visualised in some residual effusion with sedimentation after pleural haemorrhage
201
• Ideal complementary imaging tool for assessing equivocal opacities on plain fi lm
• May guide diagnostic/therapeutic aspiration/drainage (Fig. 6.10 )
• Applicable at bedside, in ICU/NICU, ER, etc.
Additional / Complementary Imaging :
• Plain fi lm, particularly in initial diagnosis, considered compulsory
• In complex situations CT, fl uoroscopy, MRI, scintigraphy and biopsy
6.5 Pathology of Diaphragm
6.5.1 Diaphragmatic Hernia
Defi nition : Defect of diaphragm with potential displacement of abdominal
structures into chest
US fi ndings :
• Gap in diaphragm: discontinuity may be diffi cult to visualise
• Indirect sign: abnormal shape, displacement of abdominal structures into
chest:
– Particularly intestinal structures fi lled with fl uid (Fig. 6.11 )
– Hiatal/Bochdalek hernia: fi ll stomach/intestines by liquid feed
– Without structural herniation: diffi cult to differentiate diaphragmatic
eventration versus hernia, particularly on right side (liver covering defect,
usually in fi brous part) (Fig. 6.11c )
NOTE : Differentiation of small gap from eventration of diaphragm may be impossible; same applies to reliable “exclusion” of diaphragmatic hernia.
202
a
c
Fig. 6.11 Diaphragmatic hernia: ( a ) Paramedian sagittal section in a neonate with diaphragmatic her-
nia – fl uid-fi lled stomach reaches up into left chest through defect, which is only partially covered by
liver. ( b ) Axial transhepatic view tilted cranially behind liver muscular remnants of diaphragm seen –
but dorsally, liver parenchyma and intestinal loops herniated into right thoracic cavity. ( c ) Diaphragm
“bump” (eventration) on an axial oblique transhepatic/abdominal view tilted cranially
b
6 Ultrasound of the Chest
6.5.2 Diaphragmatic Motion Disturbance
Changes in diaphragmatic mobility easily seen:
• Documented by video loops or M-Mode (see Fig. 6.1 )
• Correlation with respiratory manoeuvres: allows differentiation of relaxation
from palsy or reduced mobility (e.g. secondary to pneumonia or trauma):
– Diaphragmatic palsy – paradoxical motion
– Relaxation – absent or minimal motion, but symmetric during respiratory
cycle
NOTE : Assessment of diaphragmatic palsy should always be performed without
positive pressure ventilation (will mask abnormal motion).
6.5.3 Role and Potential of Imaging
US : primary tool in assessment of suspected diaphragmatic pathology
Additional imaging : plain fi lm, fl uoroscopy, cross-sectional imaging
• Only in equivocal situations
6.6 Lung Pathology
ab
Fig. 6.12 Pneumonia. Two typical images of pneumonia – with more or less perceived sonoaero-
bronchogram and reactive pleural effusion
6.6 Lung Pathology
6.6.1 Pneumonia
Defi nition : Infl ammatory change of various reasons
• US appearance not specifi c in terms of aetiology
US fi ndings (Fig. 6.12 ):
• Liver-like aspect of fully non-aerated lung tissue, some mass effect
• More or less echogenic stripes with tree-like appearance (sonographic air
bronchogram):
– Potentially change with respiration
– Depend on amount of fl uid in bronchial structures
DDx : Dys-/Atelectasis, infarction, other infi ltration
203
6.6.2 Lung Abscess
Defi nition : Complication of infection and/or aspiration
US fi ndings : Seen if access possible (through pneumonic lung, etc.) (Fig. 6.13 ):
• As any abscess elsewhere: complex cystic mass with membrane-like wall
• Potentially fl uid-fl uid or fl uid-air levels
CDS : No central vascularisation, well-vascularised hyperaemic capsule
• Potentially bronchial/pleural arterial supply particualrly with long history
DDx : Other complex cyst, necrosis (may be indistinguishable) and haemorrhage
204
6 Ultrasound of the Chest
a
b
c
Fig. 6.13 Lung necrosis and abscess. Three conglomerating lung abscesses: Depicted on gray
scale ( a ) without perfusion on CDS ( b ). aCDS reveals more conspicuously vascularised and
non- perfused necrotic areas ( c )
6.6.3 Atelectasis
Defi nition : Area of hypoinfl ation, if completely non-ventilated = atelectasis, if some
areas show residual ventilation = dystelectasis
US fi ndings : Similar to pneumonia – liver-like appearance of lung tissue, without
any central air echoes, collapsed aspect with concave surface (Fig. 6.14 ):
• Potentially bronchial/vascular structures can be discriminated as tubular
bands
• If residual air in central bronchi, sonographic air bronchogram seen:
– Similar to pneumonia