Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5795_Библиотеки_им_академика_М_И_Перельмана.pdf
238
M. Riccabona
Table 12.1 (continued)
Lung sliding Sliding of lung
surface, best
documented by
video clip
Pleural line White line,
underneath chest
wall, visceral +
parietal pleura.
DDx: peripheral
dystelectasis (use
HR Tdx)
Normal ventilation
Thick line, irregular;
possibly + effusion
(thin line = normal)
Quad sign Fluid surrounded
Ring-down
artefact
Seashore sign Lung sliding,
Shred sign Deeper incomplete
Sinusoid sign On M-mode: lung
Tissue sign “Hepatisation” =
by four borders
(pleural line, rib
shadow, lung)
Condensed or
grouped B-lines
If very dense =
“lung rockets”
documented by
M-mode
set of lines due to
irregular borders
moves in a sinusoid
pattern with
breathing
liver-like US
appearance of
non-ventilated lung
parenchyma
Seen in effusions
similarities with “bat
sign”
1–3 normal
>3 = pathology
Normal ventilation
Soft tissue “mass”,
atelectasis, subpleural
consolidation, etc.
M-mode pattern of e.g.
effusion with
unimpaired respiratory
motion
For example, in
pneumonia, total
atelectasis, tumour, etc.
12 Ultrasound oftheChest
Table 12.1 (continued)
White lung So many B-lines
that cannot be
differentiated and
entire lung is
echogenic
Adapted from “Bildgebung des Thorax bei Neugeborenen und Kleinkindern” (Riccabona M, Beer
M, Mentzel HJ. eds): Chapter 4, Sonograe des Früh- und Neugeborenen-, bzw. Säuglingsthorax,
Tab. 1. Springer 2019, p.35; Some US images courtesy of B.Coley, Cincinnati, Ohio, USA
Severe hypoination/no
aeration: (I/A)RDS, if
only basal “wet lung”,
“white lung” during
ECMO, etc.
239
12.2.6 Mediastinum
12.2.6.1 Anterior Mediastinum/Thymus
Mainly Thymus (Fig.12.3):
• Physiologically large in neonates, then eventually regresses.
• Shape and size variable.
• Echogenicity: hypoechoic, mixed, with some septa (“dot-dash pattern”).
• Behaviour of soft tissue: not compressing or displacing other structures, particu-
larly vessels.
• Size of thymus difcult to assess, reliable age-related normal values not available.
• CDS: some internal vascularity.
Value of US:
• Differentiate from other mediastinal or chest masses (unclear opacication on
chest lm).
• Demonstrate normal echogenicity and behaviour in relation to surrounding
structures of a large thymus.
• Additionally: ideal acoustic window to deeper structures (vessels, middle and
posterior mediastinum, hilar area and oesophagus, etc.).
Note Large thymus at unusual age may point at diffuse inltration or thymus
hyperplasia; inltration and tumours will cause increased stiffness and thus subsequent impression or displacement of surrounding structures or crossing vessels.
12.2.6.2 Middle Mediastinum
Contains—among others—large vessels, trachea, potential nodes may be visualised
by US (Fig.12.4):
• Particularly feasible in neonates and infants.
• Large space-occupying lesions, tumours or lymph node enlargement visible.
• Anatomy of large vessels addressed with echocardiography.
240
Fig. 12.3 Thymus: (a) Anterior mediastinum, axial section, linear transducer: Large neonatal
thymus, serving as window to deeper structures such as the great vessels. Note non-ossied sternum with central ossication centre. (b) Sagittal section, anterior and middle mediastinum, linear
transducer in trapezoid format, paramedian view: Large neonatal thymus. Note anechoic nonossied parts of ribs and large, uncompressed vessels; behind one can see a feeding tube in the
oesophagus. (c) Left anterior mediastinum, axial section, sector transducer: Enlarged thymus with
inhomogeneous echogenicity in nodular-patchy fashion in a child with Hodgkin lymphoma. (d)
Right anterior mediastinum, axial section, linear transducer in trapezoid format: US in mediastinitis, abscess-like pseudotumourous inammatory lesions with nodular appearance in the
mediastinum
M. Riccabona
Fig. 12.4 Middle mediastinum: vessels and
lymph nodes. Parasternal (jugular) sagittal view,
sector transducer: thoracic aortic arch,
supra-aortic vessels, two enlarged mediastinal
lymph nodes (dotted circular lines)
12 Ultrasound oftheChest
241
12.2.6.3 Posterior Mediastinum
Difcult to visualise by US.
Usually anterior access supplemented by posterior paravertebral access.
Used for assessing tumours, particularly neuroblastoma.
12.2.7 (Colour) Doppler Sonography
Except for assessment of vessels, CDS not very useful in normal situation.
Indications for chest CDS mostly for DDx in pathology, mostly of the lung:
e.g. abscess or necrosis, tumour vascularisation, vascular or other malformations,
suspected particularly peripheral pulmonary artery embolism (PAE, resemble triangular subpleural pneumonic areas without depictable vascularisation), etc.
12.2.8 Contrast Enhanced US (ce-US)
CEUS and ce-US can be used in the paediatric chest, though presently (still?) offlabel—sometimes helpful, also depending on quality of equipment and if relevant
ndings with therapeutic consequence can already be seen without US contrast agents.
Indications for iv.-CEUS are assessment of necrotic areas in pneumonia, whereas
the intracavitary application of the US contrast agent (ce-US) via drain may help in
assessing empyema or connections between uid-lled compartments (see
Fig.12.10d, e).
12.3 Pathology ofChest Wall
12.3.1 Aplasia: Variations ofRibs
Quite common, cartilaginous part nicely assessed by US, wide range of rib
anomalies:
• 3DUS reconstructions improve understanding and visualisation (see respective
chapter).
• Plain lm: US complements plain lm.
12.3.2 Congenital Malformations
Vascular malformations (lymphangioma, haemangioma), other soft tissue masses—
see below:
• Reect typical US appearance elsewhere (see respective chapters).
242
M. Riccabona
12.3.3 Traumatic Changes
Fractures of ribs and sternum: see chapter on musculoskeletal US.
• Particularly in cartilaginous parts and sternum
– US may be superior to plain lm, where these structures are difcult to assess
if not signicantly displaced.
Note Follow entire structure in axial and longitudinal sections to detect any surface
interruption/irregularity.
Often some reactive focal subperiosteal haematoma:
• Without history, differentiation from osteomyelitis difcult.
• Particularly if bilateral, multiple, of different age—NAI should be considered.
Additional Findings
• 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,
myositis ossicans, etc.).
12.3.4 Chest Wall Tumours
12.3.4.1 Lymphangioma (Venolymphatic Vascular Malformation)
US Finding
Multicystic space-occupying lesions with echogenic septae.
• Spontaneous haemorrhages with uid–uid levels often present.
• CDS: potentially some vessels within septae.
12.3.4.2 Lipoma
US Finding
Usually slightly inhomogeneous, echogenic mass, sharp margins (Fig.12.5).
12.3.4.3 Fibroma/Neurofibroma
US Finding
Usually sharp margin, hyperechoic or inhomogeneous.
a
12 Ultrasound oftheChest
243
b
cd
Fig. 12.5 Chest wall US: (a) Chest wall lipoma: well-dened subcutaneous mass (+ +), fat-like
intermediate density echoes. (b) Below lipoma mass, structures of chest wall can be appreciated:
muscle and ossied ribs (shadowing). (c, d) Thoracic inlet syndrome: compression (arrow) of the
subclavian vein (c), with secondary subclavian and axillary vein thrombosis (i.e. mass in vessel, no
ow on CDS) (d)
Fig. 12.6 Chest wall tumour—Askin
tumour/Ewing sarcoma. Extended eld
of view US demonstrates large chest wall
tumour with calcied part (dorsal shadow)
arising from partially destructed rib
12.3.4.4 Other Tumours
Rare; e.g. rhabdomyosarcoma or Ewing sarcoma (Fig.12.6):
• Sometimes difcult to differentiate from myositis ossicans, particularly
Askin tumour.
US Finding
No specic sonographic features.
12.3.5 Breast
Breast US In childhood of limited importance (see also chapter small part US).
244
M. Riccabona
Neonates Transient physiologic swelling, cystic duct ectasia and cysts seen.
• Secondary infection with abscess formation and haematoma may occur
(Fig.12.7b).
(Pre-)puberty cysts, tubular duct ectasia, broadenoma, inammatory formations
(Fig.12.7c):
• Overall appearance varies with age and maturation (Fig.12.7a, d).
• 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 signicant breast tissue necessary for treatment
decision.
Note Breast carcinoma extremely rare in childhood.
CDS Can be helpful for assessment of supercial tumours or vascular malforma-
tions and other pathology described in respective chapters.
a
c
Fig. 12.7 Breast US in childhood: (a) Normal breast tissue. (b) Neonatal breast abscess—huge
collection with membrane-like border and adjacent soft tissue reaction (hyperechoic, swelling)
after neonatal mastitis; note plenty of US gel to facilitate transducer coupling to tissue without
interposing air. (c) Impressive cystiform duct ectasia in a breast feed infant. (d) Asymmetric prominent breast tissue at onset of pubarche in 11-year-old girl
d
b
12 Ultrasound oftheChest
245
12.3.6 Miscellaneous Other Applications
Other potential applications in “lumps and bumps” of chest wall addressed in chapter on musculoskeletal and small part US.
Additionally vascular queries may arise—e.g. thoracic inlet/outlet syndrome
(Fig.12.5c, d).
12.3.7 Role ofUS andAdditional Imaging
US Supplementary tool in clinically equivocal situation, follow-up.
Additional Investigations
• Suspicion of tumour—depending on oncology protocols—plain lm, CT/MRI.
• Assessment of osseous structures: plain lm, rarely CT.
• Mammography: very rarely indicated, and only in/after puberty.
12.4 Pathology ofPleural Space
12.4.1 Pneumothorax
Detection by US is possible and benecial for patients in the emergency department
(ER) and on ventilation support (NICU, ICU, etc.).
US Findings
• To-and-fro motion during respiration in real-time US with B-mode (visceral
pleura or parietal pleura) “gliding” or “sliding” sign and M-mode “seashore”
sign (see also Table12.1).
• Additional ndings: lung point, absence of B-lines and absence of lung pulse.
• Pneumothorax directly beneath the US transducer: no sliding sign in B-mode
and “stratosphere” sign on M-mode (see Fig.12.21e and Table12.1).
False-positive ndings from hyperextended hyperinated lung (COPD,
Note
severe asthma, air trapping, aspiration with focal emphysema/hyperination, etc.).
12.4.2 Pleural Effusion
Denition
Some uid in between two pleural sheets of varying aetiology:
• Cardiac, inammation, trauma, tumour, etc.
• Most common pleural change, most common indication for chest US.
246
M. Riccabona
US Findings
Simple pleural effusion: Unechoic uid without septae (Fig.12.8).
Complicated effusion: Fluid contains oating echoes, septae, complex nature
(Fig.12.9):
– Depends on haemorrhage, chronicity and recurrence, empyema, etc.
– Denite diagnosis of underlying entity not achievable by US.
Note Quantication of pleural effusion limited. If US used for follow-up (to deter-
mine increase or decrease of amount of uid)—use standardised views and
positioning:
• Possibly in sitting or upright position.
• US aspect changes signicantly with posture—with redistribution of uid,
depending on position.
12.4.2.1 Empyema
Denition and US Findings
Complex effusion with multiple septae which may contain vessels (Fig.12.9b):
• Some space-occupying component.
• May compress adjacent lung—often associated with or even caused by pneumo-
nia, atelectasis and abscess.
(a)CDS Peripheral and septal hyperaemia.
ce-US Via a pleural drain US contrast agent can be instilled to observe connections
between the various compartments, e.g. for monitoring during brinolytic therapy;
non-communicating compartments may need a separate drain.
Fig. 12.8 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 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)
12 Ultrasound oftheChest
Fig. 12.9 Complicated pleural effusion and empyema: (a) Axial intercostals view with sector
transducer: complex uid with oating echoes in complicated pleural effusion, lung compressed
and not aerated; US does not allow for differentiation of entity (e.g. haemorrhage versus inammation). (b) Axial section: Complicated effusion with cystic areas in pleural empyema; NOTE:
Atelectasis of adjacent pneumonic lung
247
DDx Any other complex 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 uid, posterior mediastinum).
• Duplication cyst.
• Cystic extasia of the lymphatic duct (Fig.12.10d, e).
12.4.3 Other Pleural Pathology
Thickening of pleura: after surgery/inammation.
Space-occupying lesions/tumours of pleura: extremely rare in children.
• Few entities reported:
– Pleural mesothelioma, pleural carcinosis, inltration by metastases.
– Penetration from pulmonary as well as abdominal tumours (Fig.12.10).
– No specic US ndings.
12.4.3.1 Role ofImaging
Role/Value of US
• More sensitive than plain lm or even CT for detection of minimal pleural effu-
sions—gold standard for diagnosis and follow-up.
• Ideal complementary imaging tool for assessing equivocal opacities on plain lm.