Bild 11
- How is the chest rotated?
(Click here for the answer) Left: the more you see ventral ribs, the more it is an LAO projection! Calc.1 is far dorsal.
Middle: typical pa projection. "2” is the dorsal border of the calcification.
Right: ribs seem to fall from medial to lateral. The lateral shape of ribs is ring-like. This is typical for RAO projection (of a left hemithorax). – "3” is a calcification far ventral.
12. Diagnosis is pneumothorax.
Bild 12
- What can we actually see of the two pleural leaves and the pleural gap in a healthy individual?
(Click here for the answer) When healthy, we don’t see anything of the pleural leaves or pleural gap. Only when the gap is extended (as it is here by air or liquid), will it be visualized. There is even a great contrast between a
compression of the lungs (positive summation-effect) and
pneumothorax (negative summation-effect).
The visceral pleura thus forms a well visible silhouette; here it is marked by black dots.Im Holländischen gibt es ein sehr gutes Wort für den Pneumothorax:
"klaplong". Das Wort hilft die "radiodiagnostiek" zu verstehen. Die Lunge (überzogen vom Lungenfell) klappt durch ihre elastischen Kräfte zusammen. Das kann sie aber nur wenn Luft zwischen Lungenfell und Rippenfell eingedrungen ist.
Normalerweise befindet sich in diesem Raum nur ein hauchdünner Flüssigkeitsfilm. Der kann sich nicht ausdehnen und hindert die Lunge am "zusammenklappen". Im Gegenteil, sie muss den Bewegungen des Brustkastens folgen und sich auffüllen oder verkleinern.
Bild 13
- Diagnosis? Why is this image modality insufficient?
(Click here for the answer) Pneumothorax (in Nederlands: Klaplong).
If this diagnosis still seems difficult for you, it is necessary to repeat the case shown in picture 12.
The clinical question is: does the patient (urgently) need a pleural drainage to ventilate the left lung? In order to answer this, we need to see the whole thorax and assess whether the heart and mediastinum have been shifted to the right.
"Tension-pneumothorax" requires prompt action!
14. These both have an expanded pleural space in common. In one case the space contains air, and in the other an effusion. Characteristic of the effusion is the homogeneous shadowing close to the thoracic wall.
Bild 14
- What difference may we draw between an effusion and a soft tissue process (e.g. mesothelioma or peripheral bronchial carcinoma)?
(Click here for the answer) Pleural effusions are often characterized by form mutability depending on body position. The next picture shows the change between prone and supine. Sonography is even more important here; it shows the transonic fluid and its deformation depending on body - and diaphragmal position (respiration). In CT contrast medium intravenously gives direct evidence of tissue perfusion. Tumours will enhance, effusion will not.
Bild 15
- Is there a definite rule as to how the picture changes in the prone position, or in the side-position with a horizontal beam?
(Click here for the answer) Unfortunately not. Pleural adhesions can sometimes prevent a typical shift of effusion.