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Pediatric Radiology:Normal inspiratory and expiratory chest

苏苗赏 副主任医师 温州医科大学附属第二医院 儿内呼吸科
2009-05-28 3519人已读
苏苗赏 副主任医师
温州医科大学附属第二医院

 

胸部影像分析已成为呼吸科医生必需掌握的一门技术。在疾病的早期发现、诊断、治疗、判断预后以及医学科学研究中发挥重要作用。工作之余常常关心一些有关的学习资料。愿意与志同道合的同事一起探讨这方面的知识和进展情况。

Fig. 3.1. Normal inspiratory chest 温州医科大学附属第二医院儿内呼吸科苏苗赏
a Frontal examination reveals a normal lung volume. The criteria for a normal lung volume are: ( a ) less than one-third of the heart is projected below the hemidiaphragm; ( b ) the diaphragm is rounded, and the sixth or seventh anterior rib (ar) intersects the diaphragm; and ( c ) the lungs are air-filled (black). This is a properly positioned, nonrotated film as evidenced by (1) comparative anterior ribs equidistant from the pedicles ( p ), (2) medial aspects of the clavicles (cl) symmetrically positioned, (3) the carina approximates the right pedicles (arrow), and (4) no difference in aeration between the two sides. The film was taken with the patient erect, as shown by the air–fluid level in the stomach (arrowhead)
b Lateral examination confirms normal aeration of the lungs. Note that the vertebral bodies (vb) get blacker as we go from superior to inferior. The patient is slightly rotated as you can see the ribs on each side (arrows)
Fig. 3.1. 正常吸气相胸片
a 胸部正位片示正常肺容积。正常肺容积的标准有: ( a ) 不到1/3的心脏影于膈肌下方; ( b ) 膈肌呈圆形隆起,且第6或第7根肋骨前方(ar)于膈肌影相交汇;并且( c )肺充气良好(呈黑色)。 一张适当位置,非旋转的胸片是通过以下几个方面判断的:(1)从椎骨上比较各前肋之间间距相等(P),(2)锁骨的内侧面(cl)呈对称分布,(3)气管隆凸靠近右侧胸椎(箭头处),还有(4)两侧的充气影应该是相同的。 通过胃泡的气液面(△)可以看出这张片子是患儿竖直立拍的。
b 侧位片检查也可证实肺的正常充气。注意这个脊柱部分(vb)从上部到下部渐渐变黑。 如果你发现有一侧的肋骨时(箭头处,说明拍片时患儿有稍稍的旋转。
Fig. 3.2. Expiratory chest


Fig. 3.2. Expiratory chest
a Frontal film taken during expiration, i.e., ( a ) more than one-third of the heart projects below the diaphragmatic margins (below the dotted line), ( b ) hemidiaphragms are domed, and the fourth anterior rib ( ar ) crosses the diaphragmatic margin, and ( c ) the lungs are not as well aerated. The patient is rotated, as shown by ( a ) asymmetric comparable ribs in relationship to the pedicles and ( b ) asymmetric position of the clavicles – note the right end of the clavicle (cl) is quite laterally positioned
b Expiratory lateral film shows no posterior air spacebehind the heart (compare this to Fig. 3.1)
c–e These three films are in varying degrees of inspiration:
c is an optimal inspiration; d is acceptable but less than average with the 5th anterior rib at the diaphragm; e shows complete expiration with almost a white-out of the lungs. It is important to appreciate the degree of inspiration so one can make an accurate determination of any pathology
Fig. 3.2. 呼气相胸片
a 呼气相正位片 :( a ) 有超过1/3的心脏影位于膈膜边缘以下(在虚点线下方), ( b ) 膈肌呈穹型隆起并且第4肋影前方( ar )于膈膜边缘相交汇,并且( c )肺通气不佳。患儿拍片位置有点旋转,可以通过( a )椎骨旁的肋骨不对称和( b )锁骨的位置不对称判断出来-注意锁骨的右侧末端位置偏了许多。
b 与图3.1的侧位片相比较,这张片上在心影的后方没有后面的气体空间。
c-e 这是三张不同程度的吸气相胸片图
c这是张理想的吸气相胸片
d 这张还可以接受,但是不到第5肋就于膈面相交了。
e 这是张完全的呼气相,肺影几乎呈乳白色了。
对一张胸片进行吸气程度的评价是很重要的,以至我们可以对肺部病变进行准确的判断。

Fig. 3.3. Hyperexpanded chest radiograph

Fig. 3.3. Hyperexpanded chest radiograph
a Frontal view. The entire heart is projected above the diaphragm, the hemidiaphragms are flattened, and the lungs are quite black – yet the film is not overexposed.You know this because you can see the pedicles of the spine behind the heart and the peripheral vasculature (arrow)
b Lateral view.The hemidiaphragms are obliquely oriented (arrow), and there is a large air space ( a ) both behind and in front of the heart. Remember: hyperexpansion is involuntary and is caused by air trapping. It must be seen on both frontal and lateral projections
c, d Comparable drawings of the hyperexpanded lungs

Fig. 3.3. 过渡扩张的胸片影
a 正位片。心影完全位于膈肌上方,膈肌呈平直的,肺影完全呈黑色,当然这张片子没有过渡曝光啦 。你了解这些是因为我们可以看到心影后方的脊椎椎弓和周围血管影( 箭头 )。
b 侧位片。我们可以看到膈肌有膈倾斜面(箭头处),并且在心脏前方及后方均有一较大的空间(a) Remember: hyperexpansion is involuntary and is caused by air trapping. It must be seen on both frontal and lateral projections记住:肺过度扩张常是无意识的,是屏气的结果。它必须要通过正位片和侧位片来观察。
c、d 过度扩张肺对照示意图
Fig. 3.4. The rotated chest


Fig. 3.4. The rotated chest
a Schematic drawing demonstrates the signs of rotation – asymmetric clavicles, differences in aeration (not shown), heart projected over one hemithorax and not the other, asymmetric ribs when relating the anterior rib to the pedicle
b Rotated chest as in a.Note the child has an opacity (arrow) in the lower right lung field. To which side is the child rotated? (Answer in Appendix 2)
c Schematic drawing of the rotated lateral film. The ribs are visible and not the spinous process
d Lateral radiograph of child in b, showing these findings and the posterior opacity (arrow)
e Another rotated child with all of the abnormalities described above. To which side is this child rotated? ( Answer in Appendix 2 ).
The patient in b is rotated to the left. The heart is appreciably in the left hemithorax, and the left side of the chest is relatively elongated, as compared to the right.Note the opacity in the right lower chest field ( arrow ). The reverse is true in e
Fig. 3.4. The rotated chest 旋转不对称的胸片
a 示意图描绘出旋转不对称的特征– 不对称的锁骨,充气不均匀(未显示),心影于一侧横膈上方而另一侧仍有遮挡,在计算椎弓两旁的前肋时会发现肋骨的不对称。
b同图片a似的旋转不对称的胸片:注意这个患儿在右侧肺野的下方有一块不透明区(箭头处)。问这个患儿是朝哪一侧旋转的呢?(答案见附2)
c 旋转的侧位片示意图。肋弓可见但棘突未现。
d 这张是b患儿的侧位片,我们可以看到这些表现,还可见一后部半透明区(箭头处)
e这是另一张侧位旋转的儿童胸片,有着上面所提及的所有异常描述。请问这张胸片中患儿朝哪侧侧旋。(见附2)
图片b中的患儿偏向左侧。心脏稍偏左膈,并且左侧肺部与右侧相比显的相对有些拉长。注意在右肺下野有一半透明区(箭头处)。图e正好相反。
Fig. 3.5. Effect of patient position and the tube target distance

Fig. 3.5. Effect of patient position and the tube target distance
a Patient in supine position, with approximately 46 in. ( ca 1.2 m ) between the X-ray tube and the film. Upper-lobe vessels ( arrow ) are equal in size to those of the lower lobe ( arrow ). The heart is magnified. There is a central venous catheter in place
b Patient is erect and 6 ft ( ca 1.8 m ) from the X-ray tube. It is difficult to see the upper lobe vessels, but the lower lobe vessels are easily seen
Fig. 3.5. 患儿体位与距离发射管的距离对放射片的影响
a患儿呈卧位,X-线发射管离胶片的距离大约为46英寸(1.2米)。肺上叶的血管影(箭头处)与下叶血管影大致一致。这张片上,心影是放大的。我们在其中可以看到中心静脉导管。
a 这张片上患儿为直立着的,大约离发射管6英尺(大约1.8米)。我们很难看到肺上叶血管影,但下部的血管影仍清悉易见。
Fig. 3.6. Tube–film distance and magnification


Fig. 3.6. Tube–film distance and magnification
Fig. 3.6. 管-片距离与影像放大之间的联系
Fig. 3.7. Adequacy of exposure


Fig. 3.7. Adequacy of exposure
a This is an entirely black film, showing that there has been too much exposure (overexposure) and all of the X-ray beams have passed through the patient to hit the cassette or film and none were absorbed by the patient
b This is an underexposed examination. The film is white, and you can barely see the surgical sutures (arrow) in the sternum and cannot see the spine at all
c This is a (overexposed) frontal examination; a properly exposed examination is seen in Fig. 3.1.Note how on the poorly exposed film the pedicles can be seen ( arrow), but you cannot see peripheral lung markings
Fig. 3.7. 适当的曝光
a 这是张完全的黑片,表示曝光过度,所有的X-线都穿过患儿射击到暗盒和胶片上,而患儿身体未吸收任何x-线
b 这是张未充分曝光的片子。片子泛白,你很难看到胸骨处的缝合材料(箭头处),并且脊骨也很难看清。
c 这也是一张曝光过度的片子,适当的曝光检查片我们可参考图3.1。注意在曝光不充分的片子上我们可以看到脊弓,但周边肺标志是看不清的。
Fig. 3.8.


Fig. 3.8. On the properly exposed films, you can see both the pedicles ( p ) and the peripheral lung markings (arrow). Is the film up correctly? (See Appendix 2)
The film is reversed ( right to left ) according to markers! p, pedicle; white arrows on anterior ribs; black arrows on vessels in base of lung. Remember, the heart and liver are transparent
Fig. 3.8.在曝光适当的片子上,我们是可以同时辨认出脊弓(p)和外缘肺标志(箭头处)的。这张片子正确么?(见附二)
这张片子是反的,我们根据标记可看出左右颠倒的。p:脊椎弓;白箭头于前肋上,黑箭头为肺底部血管影,心脏和肝脏均为透明的。
Fig. 3.9. Traps


Fig. 3.9. Traps
Nonfusion of spinous process. On this supine film of a 6-month-old infant, the spinous processes ( arrow ) of the thoracic vertebrae are not fused at multiple levels
Fig. 3.9. 陷阱
未完全融合的棘突。在这张6月儿仰卧位片上,我们可以看到多个平面上胸椎的棘突(箭头处)未完全融合。

 

Fig. 3.10. Sternal ossification centers


Fig. 3.10. Sternal ossification centers
As you can tell by the ribs, this patient is quite rotated. There is a nasogastric tube in the esophagus.You should note multiple rounded bony structures projecting over the heart in the right hemithorax ( arrows ). These are the sternal ossification centers,which because of rotation are clearly visible
Fig. 3.10. 胸骨骨化中心
如果你辨认下肋骨,你会发现患儿位置有些偏转。我们还可见一根鼻胃管在食道中,我们可以发现在右侧胸廓心脏前方有多个圆形的骨性结构(箭头处)。这些是胸骨的骨化中心,在稍旋转侧位上可以容易看到。

Fig. 3.11. This neonate has respiratory distress

Fig. 3.11. This neonate has respiratory distress
a Frontal radiograph shows the endotracheal tube in the appropriate position ( arrow ).However, see the lateral film
b On this lateral radiograph, the endotracheal tube is in the esophagus (white arrow); the airway ( black arrow ) is anterior. Whenever there is a question of unexplained respiratory distress, a lateral film may be helpful, particularly in an intubated patient
Fig. 3.11. 一呼吸窘迫患儿
a在胸部正位上可见气管插管(箭头处)在正确的部位。但是我们再看看侧位片。
b在侧位片上,我们发现气管插管在食道内(白箭头),而气道(黑箭头)在前方。当我们发现难以解释的呼吸窘迫时,一张侧位片也许有很大帮助,尤其是气管插管患儿。
Rule No.1: On every chest film, read the abdominal portion as you would read an abdominal film.
规则一:在阅读每一张胸片时,要像你阅读腹部片一样观察腹腔脏器的位置。
Fig. 3.12. Can you find the abnormality? (Look at the films; then read on)

Fig. 3.12. Can you find the abnormality? (Look at the films; then read on)
a Film of a 12-month-old boy.No, the film is not labeled incorrectly. The patient has dextrocardia and abdominal situs inversus
b Correct position of the film
c An 11-year-old girl with blunt abdominal trauma.Free air is seen below the diaphragm.The “diaphragm” extends across the midline – an impossibility. This is the “continuous diaphragm sign.”Note how you can see both sides of the diaphragm. The patient was in a motor vehicle accident and had a perforated bowel
d A lateral radiograph of a sickle cell patient with a large heart.Most importantly, did you see the gallstones?
Fig. 3.12. 你可以发现异常么?(请先阅片再看说明)
a这是张12个月的男孩正位片。哦,这张片标反了。该病人为右位心和内脏反位。
b正确位置的胸片
c这是一位 11岁腹部钝挫创伤的女孩。可见膈肌下方游离气体。“膈膜”延伸横穿过中线,当然这是不可能的。这是“膈膜连续征”。要注意观察两侧的膈膜。该患儿为摩托车事故所致外伤,并发肠穿孔。
d这是一张镰刀细胞贫血患儿的侧位片,我们可见心脏增大,更重要的是你发现胆结石了么?
Fig. 3.13.


Fig. 3.13. This 13-year-old girl presented with fever and pain
Can you detect the abnormality on this chest film? Did you look at the bones? There is destructive process of the right humerus (dark spots with periosteal reaction) consistent with osteomyelitis in this sickle cell patient. There is a catheter entering from the left side extending into the right atrium for intravenous therapy
Fig. 3.13. 一13岁高热伴疼痛患儿
你能在此片中发现异常么?你注意到骨头了么?在这个伴有骨髓炎的镰刀状细胞贫血的病人中我们可以看到右侧肱骨(呈黑点状的骨膜反应)破坏过程 。有一根导管从左胸进入到右心房行静脉治疗。
Fig. 3.14.


Fig. 3.14. A 9-year-old boy with a cough
Frontal chest film reveals the heart and lungs to be normal, but there is something missing – the clavicles. This patient has cleidocranial pubic dysostosis
Fig. 3.14.9岁咳嗽患儿
在胸部正位片上心影与肺影均正常,但是不要漏了锁骨。这是一个锁骨发育不全的患儿。
Fig. 3.15.


Fig. 3.15. A 17-year-old boy with a cough
On the frontal film ( a ) the heart is large. See the sclerosis ( white spots ) in the right humerus ( arrow ) and the abnormal vertebrae ( T8, T9 ) ( arrows ),which have decreased height in their midportion. On the lateral view ( b ), the cortical end plates of most of the thoracic vertebrae are depressed. This patient has sickle cell anemia, and the depressed end plates ( arrows ) are due to infarctions. These are called “H” vertebrae ( look like old Lincoln cabin log toy pieces ) and are typical of sickle cell disease
Fig. 3.15. 一17岁咳嗽患儿
在正位片上(a)心影增大。注意右侧肱骨(箭头处)上的硬化灶(白色点状物),还有异常中段高度减少的的椎骨(T8,T9)。在侧位片上(b)多处胸椎的椎间盘皮质端变薄。该患儿有镰刀状细胞贫血,椎间盘变薄(箭头处)是感染的原因所致。这就是所谓的镰刀状细胞贫血缩特有的“H”型椎骨。
Fig. 3.16.


Fig. 3.16. This 12-year-old presented with café au lait spots and scoliosis
Aside from the obvious right large mediastinal mass superiorly there are ribbon-like irregularities of the left fourth through sixth ribs. The combination of the mediastinal mass, rib changes, and café au lait spots suggests a diagnosis of neurofibromatosis. The chest mass is either an anterior meningocele or a neurofibroma. The ribs are wavy secondary to dystrophic bone and hypertrophied intercostal tissue in the subcostal groove. The film is photographed for bone detail and lung markings are lost in this exposure
Fig. 3.16. 一12岁咖啡牛奶色素斑并脊柱侧凸患儿
除了那个大的右侧纵隔上部肿块外,我们可见左侧第4到第6肋骨呈不规则的带状。纵隔肿块、肋骨改变加上牛奶咖啡斑支持多发性神经纤维瘤诊断。
肋骨呈带带状波动是由于骨病变及肋下凹槽内肋间组织 增生肥大所致。在这张片子上由于曝光骨细节改变和肺特征改变未能显现出来。
Fig. 3.17.

Fig. 3.17. A 6-month-old infant with fever of unknown origin
A 6-month-old infant with fever. The frontal chest film shows a soft-tissue swelling of the right shoulder. This patient has osteomyelitis of the right humerus ( arrow ). Compare this to the normal left humerus
Fig. 3.17. 6个月FUO患儿
这是个6个月高热患儿。胸部正位片上可见右侧肩部一增大的软组织。该患儿右肱骨骨髓炎(箭头处),我们可以和正常左肩做比较。
Rule No. 2: Knowledge of anatomy is the key to the correct radiographic diagnosis.
规则二:良好的解刨知识是正确阅片诊断的关键
Fig. 3.18.


Fig. 3.18. Choanal atresia. In this newborn baby there is bony connection between the vomer and the lateral palatine bone. All these bones have fused and this is bony choanal atresia (arrows)
Fig. 3.18. 鼻后孔闭锁。在这个新生儿我们可见在犁骨与侧颚骨间为骨性连接。所有这些均为骨性融合,这是个先天性鼻后孔闭锁(箭头处
Fig. 3.19.


Fig. 3.19. The normal airway, lateral view. ( From [ 1 ] with permission )
Fig. 3.19. 正常气道侧位片
Rule No.3: The airway should be visible on all normal chest films.
规则三:在所有正常的胸片上都应该看到气道。
Fig. 3.20.


Fig. 3.20. Normal (and almost normal) lateral neck examinations in a 2-year-old, an 8-year-old, and a 10-year-old
a This 2-year-old is in the neutral position.Using our basic concept of looking at the entire film, we note that the sella turcica ( s ) is normal. The patient has adenoid tissue ( a ) , which should be present by 6 months of age, and also palatine tonsils ( t ). The patient has abundant air in the hypopharynx and one can see the retropharyngeal soft tissue space (behind the hypopharynx and in front of the spine) is quite normal. The vallecula at the base of the tongue ( v ) , hyoid bone (arrow), epiglottis (arrowhead), and the laryngeal ventricle are normal. There is buckling of the proximal trachea as expected in this age group
b A 9-year-old child in which we see similar anatomy, perhaps better defined. The adenoid tissue ( a ) is somewhatlarger and is encroaching upon the nasal air passage.
rp, retropharyngeal space; lv, laryngeal ventricle.
The palatine tonsils are also large
c A 10-year-old child. The sella ( s ) is normal. The adenoids ( a ) do not narrow the nasal air passage (normal)
Fig. 3.20. 2岁、8岁、10岁正常儿颈部侧位片
a这是个2岁儿童正常部位图。用我们基本的概念来阅读全片。我们可以注意道蝶鞍(s)是正常的。患儿有腺样体(a),这在6个月以内的儿童是正常的,还可见到扁桃体(t)。该患儿在下咽部有大量的气体,我们可以看到在下咽部后方和脊骨前方之间的咽后软组织间隙。会咽谷由舌头(v)、舌骨(箭头处)、会咽(△)及喉腔组成,均正常。在这个年龄组可以见到近端气道的弯曲。
b 在这张9岁儿童的片子上我们可以见到同样的结构且更易辨认。此腺样体(a)较大,阻塞了鼻气道。
rp,咽后间隙; lv, 喉腔.这个患儿的扁桃体也很大。
c 这是个10岁患儿的片子。蝶鞍是正常的。腺样体正常,没有阻塞鼻气道。
Fig. 3.21.


Fig. 3.21. Schematic drawings of the frontal airway during various phases of respiration and phonation
A, quiet breathing; B, phonation;
C, closed glottis. ( From [ 1 ] with permission )
Fig. 3.21. 各种呼气及发声时气道正位片示意图
A, 平静呼吸时;B, 发声时
C, 声门关闭时
Fig. 3.22.


Fig. 3.22. Three frontal radiographs ( a – c ) corresponding to the schematic view in Fig. 3.21:
a quiet breathing,
b phonation,
c closed glottis
Fig. 3.22. 示图Fig. 3.21对应的3副正位片( a – c )
a 平静呼吸,
b 发声时,
c 声门关闭时
Fig. 3.23.

 


Fig. 3.23. A 1-year-old boy with stridor
a Frontal radiograph shows the lungs to be of normal volume and the heart of normal size. The thoracic airway is clearly demonstrated, but there is a linear opacity within the airway in the cervical region
b Magnification high-kV film showing the foreign body. A piece of eggshell was later removed. ( From [2] with permission )
c–e Three views of a magnification high-kV technique in a 1-yearold with stridor. There is narrowing and penciling of the airway ( arrow ) on all films. This was a fixed change, but on clinical followup several weeks later the patient was not longer stridorous and the airway appeared normal. This represents inflammatory changes (laryngotracheobronchitis – croup)
Fig. 3.23.一岁喘鸣患儿
a正位片上肺容积与心影正常。胸廓气道清晰,但其中颈部气道中可见一线型半透明区。
b高压放大片上可见一异物。一片蛋壳随后取出。
c–e一岁喘鸣患儿的3张高电压放大片。我们在所有的片子上可以看到狭窄线样的气道(箭头处)。说明这个变化是固定的,但随后几周随访观察患儿不再喘鸣,且气道片表现正常。这说明这是一个炎症改变(喉气管支气管炎哮喘
Fig. 3.24.

Fig. 3.24. What anatomical abnormality can you see in these two separate examinations –
a a lateral chest film and
b a lateral neck film in another child? (Answer in Appendix 2)
Airway abnormalities
a Acute epiglottis. This is a 3-year-old with respiratory distress. The lateral chest is normal, but the lateral neck shows an enlarged epiglottis and aryepiglottic folds
b Laryngeal papillomatosis. This 12-year-old has multiple growths in the airway. It is not black like the hypopharynx but rather mottled gray
Fig. 3.24.在这两张片上你能发现什么解刨异常么?
a侧位胸片。
b另一患儿的侧位颈部片
气道异常
a 急性会咽炎。这是位3岁的呼吸窘迫患儿。侧位胸片正常,但侧位颈部可见增大的会咽和杓会厌襞。
b 喉乳头状瘤病。这是位12岁气道反复增大的患儿。它呈斑片灰色,不像下咽部那么黑。
Fig. 3.25. A 6-month-old infant with cough

Fig. 3.25. A 6-month-old infant with cough
a Frontal radiograph shows the carina pushed to the left. There is a bulge on the right side of the airway. Can you see a normal aortic arch on the left? This is a right aortic arch to the right of the trachea with a right descending aorta ( arrow ) to the right of the spine. This child has congenital heart disease, tetralogy of Fallot.Many children ( approximately one-third ) with this disease have a right aortic arch
b Normal buckling of the airway in an infant
Fig. 3.25. 6个月咳嗽患儿
a 正位片上气管隆凸被推向左侧。可见气道右侧一个膨出。你可以在左侧看见正常的主动脉弓么?该患儿有先天性心脏病,为法洛四联症。许多法洛四联症患儿(大约1/3)都表现为右主动脉弓。
b这是一个正常幼儿的正常气道弯曲。
Fig. 3.26. Mediastinum


Fig. 3.26. Mediastinum
Anterior, the space in front of the heart and great vessels;
middle, the space between the anterior and posterior mediastinal components, including heart, airway, esophagus, and lymph nodes;
posterior, everything behind a line connecting the midportion aspects of the vertebrae, including the vertebrae, neural elements, and paraspinal lymph tissue. ( See “Masses and Pseudomasses” for masses typical of these areas. ) Some definitions begin the posterior mediastinum with the anterior aspect of the vertebral body
Fig. 3.26. 纵隔
前纵隔,为心脏和大血管前方空间;
中纵隔,前纵隔和后纵隔间的空间,包括心脏、气道、食管及淋巴结;
后纵隔, 为脊柱椎骨中断间连线的后方,包括椎骨、神经节、脊柱旁淋巴组织。

Fig. 3.27. Thymus

Fig. 3.27. Thymus
a Frontal radiograph shows all the parameters of a film taken during expiration. If you are not acquainted with these criteria, you may interpret this film as showing an infiltrate in both lungs. (See Table 3.1 and Fig. 3.2 for criteria establishing that the film is taken during expiration.) Note that the spinous processes are not fused
b With a good inspiratory effort, same child shows that the “infiltrate” is really thymus which is quite prominent on the right. Notice the thymic sail sign (arrow).
c In this rotated film, one can see the effect of the thymus in the right upper thorax. A nasogastric tube is in the stomach
d A more rotated film shows again how the thymus can masquerade as a parenchymal opacity. This patient has a central vascular line in the right atrium
Fig. 3.27. 胸腺
a在正位片上可以看到所有呼气的指征.如果你不能获得所有的这些特征(根据图3.1和图3.2上呼气相特征),你就可以解释这张片子为双肺浸润.大家注意该患儿的脊柱突起未完全融合.
b 但是在好的吸气相上,同一患儿的胸片上我们看到浸润处实际为胸腺影,在右侧更为突出.大家注意这是典型的胸腺飘帆影(箭头处)
c 在稍稍偏转的片子上,我们可以看到胸腺影在胸廓右前方.一根鼻胃管插于胃中.
d更加旋转的正位片上可见胸腺更像是一个伪装的肺浸润实变影.该患儿有一中心静脉插管于右心房内.
Fig. 3.28.


Fig. 3.28. Normal contrast-enhanced CT of the mediastinum (axial projection).Remember the vessels in the heart “light up”
a Most cephalic section reveals the sternum anteriorly.The superior vena cava (S) and innominate vein ( I ) are clearly visible. The left subclavian artery is seen ( arrow )
b A next lower section shows the aortic arch on the left side ( A )
c Proceeding inferiorly, the descending aorta ( D ) is noted.Note the nonenhanced thymus of triangular shape anteriorly.This occurs in children over 5 years of age. Before 5 years of age, the thymus is rectangular
d A section through the main pulmonary artery ( P ) and its right ( RP ) and left ( LP ) branches. This section is just below the carina and the left main-stem bronchus is seen above the descending aorta ( D )
e This section is at the level of the left atrium ( LA )
f A section showing the ventricular septum ( S ) and both ventricles
g The most cephalic section of the liver showing the joining of the hepatic veins ( HV ) to the interior vena cava ( C )
Fig. 3.28.正常纵隔轴位的对比-增强CT影.记住心脏中的血流信号是高亮的.
a大部分的截面多为胸骨在前方.其中上腔静脉(S)和无名静脉(I)清晰可见.左侧锁骨下静脉也可见到(箭头处).
b接下来的一个截面可见左侧的主动脉弓.(A)
c 再往下的一个截面,可见到主动脉弓的降部(D).注意前方三角形的不太明显的胸腺影.这是一个5岁以上的儿童.在小于5岁的儿童上胸腺为矩形.
d 此截面穿过肺主动脉(P),及其左右分支(RP,LP).此截面正于气管隆凸下方,且在主动脉弓降支(D)上方可见左主支气管
e此截面为左心(LA)房水平
f在此截面上可见室间隔(S)和两侧心室
g在大部分头侧的肝脏截面可以见到肝静脉(HV)汇入中心静脉(C)
Fig. 3.29. MR of the mediastinum



Fig. 3.29. MR of the mediastinum (axial, coronal, and sagittal sections).Remember: black is flowing blood
a The cephalic-most section reveals the rectangular, homogeneous thymus anteriorly beneath the sternum and in front of the aortic arch ( A ). The vertebral body ( V ) and dural sac ( arrow ) are seen posteriorly on all the sections
b The next section is at the level of the main pulmonary artery ( P ) . This patient has coarctation of the aorta.
Note the small descending aorta
c The next caudad plane is at the level of the left atrium ( LA )
d Section through four chambers of the heart
e Most anterior coronal section showing thymus ( T ) and right atrium ( RA )
f Next posterior section through the ascending aorta ( AA )
g, h Section through the trachea ( T ) and left atrium ( LA )
i Posterior section showing the vertebral bodies
j Oblique midline sagittal section showing the aortic arch (AA). See the discrepancy between the aortic arch and proximal descending aorta
k Static sagittal scan of a cine MR imaging with the computer-enhanced blood appearing white.Note the descending aorta ( arrow )
Fig. 3.29. 纵隔MRI像(轴位、冠状位及矢状位)记住:黑色为流动的血液
a在头侧大部分的截面上可以看到在胸骨的前下方和主动脉弓前方(A)呈矩形质地均一的胸腺。在所有的层面的后方都可见到椎体(V)和硬膜囊(箭头处)。
b在下个截面为肺主动脉水平(P)。此患者有主动脉缩窄,大家注意其细小的主动脉降支。
c 在下一尾侧平面为左房水平(LA)
d 此截面横穿心脏4个心腔。
e 大部分冠状位切片上可见到胸腺(T)和右心房(RA)
f 下一个后面的截面穿过升主动脉弓(AA)
g, h 截面横穿气管(T)及左心房(LA)
i再向后的一个截面可见脊椎体。
j 侧斜的中线矢状位截面上可见主动脉弓(AA)。在此我们可见主动脉弓与邻近的降主动脉不一致。
k 一张动态MRI的矢状位静态扫描影,通过电脑增强血流影(显为白色)。注意主动脉弓降段(箭头处)
Fig. 3.30. Mediastinal and pericardial air

Fig. 3.30. Mediastinal and pericardial air
a Frontal examination shows air ( black ) in both shoulders ( arrows ), axilla, chest wall, and in the mediastinum. There is separation of the aortic knob from the pulmonary artery ( arrowhead ). In this instance, there is both air in the mediastinum, as seen in the shoulders, and air in the pericardium, as seen by the separation of the pulmonary artery and aorta
b Lateral view shows air ( arrow ) anterior to the heart and in the mediastinum
Fig. 3.30. 纵隔及心包积气
a正位片检查可见双侧肩部(箭头处)、腋窝、胸壁及纵隔气体(呈黑色)。我们可见到主动脉隆凸与肺动脉分离(△处)。在这个病例中,我们可看到同肩部一样,纵隔也有积气,当看见肺动脉和主动脉的分离征表明有心包积气。
b 侧位片上可见在纵隔内心脏前方的气体(箭头处)。


Rule No. 4: A mass must be seen in two planes. If the heart is really large, it must appear large in two planes, both frontal and lateral.
规则四:一个肿块必须在2个平面上看到。如果心脏真的增大,那么必须在2个平面(正位片及侧位片上)观察均增大。


Fig. 3.31. Evaluation of cardiac enlargement on lateral film


Fig. 3.31. Evaluation of cardiac enlargement on lateral film
a Frontal view of the chest shows the heart to be enlarged. There are indistinct vessels. These two findings suggest congestive heart failure
b The trachea and carina are easily seen on the lateral film
c, d Using the carinal line ( c ) or the anterior tracheal line ( d ) demonstrates cardiomegaly. In this instance, both parameters are seen – the heart extends behind the imaginary line and the line hits the spine above the diaphragm
e Normal anterior tracheal line
Fig. 3.31. 侧位片上的心脏增大影
a 在正位片上可见增大的心影,并有模糊的血管影,这两点说明这是个充血性心衰的患儿。
b 侧位片上气管及气管隆凸清晰可见。
c, d 运用气管隆凸线( c ) 或主气管前线( d )来证实心脏增大。在这个患儿中,我们可见上面两个指征都说明了心脏增大,心影超出了假想线的后方,且气管前线延伸与脊柱相交。
e 正常的气管前线。


Fig. 3.32. Moguls (bumps along heart border)



Fig. 3.32. Moguls (bumps along heart border)
a Schematic drawing of the impression of various vascular and cardiac structures in the mediastinal silhouette
b, c A young child with pericardial effusion. This was diagnosed by echocardiography. The plain film, however, is revealing in that the cardiac silhouette is large but none of the normal moguls are seen.Note how far back the cardiac silhouette is on the
lateral view
Fig. 3.32. Moguls (心缘隆起)
a 纵隔轮廓中各种血管及心脏结构形态的示意图。
b, c 这是个心包渗出的患儿,由超声心动图检查确诊。在平片上我们可见心脏轮廓增大,但是未见正常的轮廓隆起。在侧位片上心脏轮廓非常的far back。


Fig. 3.33.


Fig. 3.33. What is the unusual dilatation ( arrow ) above the right main-stem bronchus?
In this 4-year-old asymptomatic girl, a bulge was noted at the junction of the right main-stem bronchus and trachea ( arrow ). It did not pulsate, nor did it affect the esophagus. It was not seen on the lateral film.At ultrasonic examination, the intrahepatic vena cava was found to be atretic, leaving just an infrarenal vena cava. The mass is the azygos vein,which returns blood from the abdomen to the heart. This condition is called azygous continuation of the inferior vena cava
Fig. 3.33. 这张片中右主支气管上的异常凸起物是什么?
这是一个4岁的无任何症状的女孩,此凸起物位于右主支气管和主气管汇和处。它即不搏动也没有累及气管。在侧位片上看不见。通过超声检测,肝内腔静脉闭锁,仅存有下腔静脉。我们所见的凸起物为奇静脉影,腹部的血液从此回流入心。这种情况叫azygous continuation of the inferior vena cava(我的理解是腔静脉肝段缺如而与奇静脉吻合,经上腔静脉从右上方注入共同心房) 。


Fig. 3.34.Vascular ring



Fig. 3.34.Vascular ring
a Plain film examination shows a mass ( m ) to the right of the airway with the carina to the left of midline
b Barium swallow in the frontal projections shows the impression on the right and left side of the esophagus ( arrows )
c Coronal MR reveals two circles, one to the right and one to the left of the trachea ( t ). These circular impressions are the right and left arches
d A more posterior coronal MR section shows the two arches joining and descending. This is a double aortic arch
e Another child with a double aortic arch. The carina ( c ) is over the left pedicles
f The lateral film shows anterior bowing of the trachea ( arrow )
g Lateral film of a barium swallow in this child showing the mass impression behind the esophagus and causing slight bowing and narrowing of the airway
Fig. 3.34.血管环
a正位平片 检查可见一肿块(m)位于气管隆凸气道右侧并向中线左侧凸出。
b正位片上钡餐检查可见食管左右侧的压迹(箭头处)。
c冠状位MRI可见两个环状结构,分别于气管(t)左右两侧。这两个环状结构显示为左右主动脉弓。
d在更后部一点的MRI片上显示出两个主动脉弓汇和并向下延伸。这是个双主动脉弓畸形。
e 这是另一位双主动脉弓患儿。气管隆凸(c)与左侧椎弓重合。
f 侧位片上可见气管向前弓形隆起。(箭头处)
g侧位片上患儿吞钡检查可见食管后方的肿块压迹,且影响导致气管的稍稍狭窄和弓状改变。


Fig. 3.35. Relationship between the esophagus and the trachea


Fig. 3.35. Relationship between the esophagus and the trachea
a Normal lateral esophagram.Note the trachea and esophagus and their relationship
b Lateral view of a child with esophageal stricture
c Lateral view after most of the barium has passed into the stomach.Note how the dilated esophagus ( now filled with air ) bows and compresses the trachea ( arrow )
Fig. 3.35. 食管-气管的关系
a正常食管侧位片。注意食管与气管的位置及其联系。
b一食管狭窄患儿侧位片。
c 大部分钡餐已通过并进入胃腔后的侧位片图。注意扩大的食管(现在充满着空气)弓状隆起并压迫气管(箭头处


Rule No. 5: An esophagram must be performed on any child with unexplained respiratory disease.
规则五:在所有不能解释的肺疾病同时需要行食管检查。


Fig. 3.36. Enlarged mediastinal and hilar nodes


Fig. 3.36. Enlarged mediastinal and hilar nodes
This 8-month-old had tuberculosis. There is enlargement of the right hilum and the right bronchus is narrowed by multiple mediastinal nodes
Fig. 3.36. 纵隔及肺门淋巴结肿大
这是一位结核患儿。我们可见右侧肺门影增大且由于多个纵隔淋巴结导致右支气管狭窄。


Fig. 3.37. Lobar and fissure anatomy


Fig. 3.37. Lobar and fissure anatomy
Fig. 3.37. 肺叶裂解刨


Fig. 3.38. Anatomy as seen on high-resolution CT

 


Fig. 3.38. Anatomy as seen on high-resolution CT
This shows the ability of CT to visualize small structures within the lung. (From [2] with permission)
Fig. 3.38. 高分辨CT上肺叶结构
CT可见的肺叶支气管细微结构


Fig. 3.39. High-resolution CT.

Fig. 3.39. High-resolution CT. This is the anatomy of the secondary pulmonary lobule
a Anatomy of the secondary pulmonary lobule
b Normal appearance in an isolated lung preparation ( arrows, pointing to small bronchus ). ( a, b from [ 3 ] with permission )
c Normal appearance in a 10-year-old child
d High-resolution CT in a teenager with hypogammaglobulinemia and lymphoid interstitial pneumonitis.Note the effects on the secondary lobule
Fig. 3.39. 高分辨CT. 肺叶二级支气管结构
a 二级支气管解刨结构
b这是个正常的独立的肺段标本结构(箭头处为小支气管)。
c 正常10岁儿童肺CT表现
d 这是位10岁低丙种球蛋白血症及淋巴样间质性肺炎患儿的高分辨CT片。请注意其肺叶二级结构的改变。


Fig. 3.40.


Fig. 3.40. A 3-year-old who started choking after eating peanuts
a Inspiratory frontal film has subtle changes: the right lung is hyperexpanded and blacker than the left, although there is no mediastinal shift
b Expiratory film reveals that air did not leave the right lung; it remains trapped during the expiratory phase of respiration. The mediastinum is shifted to the left ( the left lung has gone through expiration properly )
c Two days after a peanut was removed from the right main-stem bronchus the expiratory film shows no difference in aeration
Fig. 3.40. 这是位进食花生后哽咽的3岁患儿
a 这张吸气相正位胸片影上可见到细微改变:右肺膨胀且较左肺影黑,但没有纵隔移位。
b呼气相上可见右肺仍然呈充气状,而纵隔偏向左侧(左肺影由于呼气相有所减少)。
c 在花生从右主支气管取出2天后,这张呼气相片上双侧肺通气无差异。


Rule No. 6: In unilateral hyperexpansion of the lungs, you must see how the air moves. Air must move in and out of each lung.Mediastinal position is critical to this determination.
规则六:在一个单侧的肺扩张中,你必须看到气体如何移动。气体必须在各个肺叶中进出移动。纵隔的位置对此判断很重要。


Fig. 3.41. Lobar collapse.

Fig. 3.41. Lobar collapse. Note the shifts of the various fissures. The blackened area and arrows denote the position of collapse as opposed to the standard position seen in Fig. 3.37
a Right upper lobe collapse
b Right middle lobe collapse. The heart margin is obliterated
c Right lower lobe collapse
d Left upper lobe collapse. The major fissure moves anteriorly
e Left lower lobe collapse
Fig. 3.41. 肺叶塌陷. 注意各种裂隙影的改变。与图3.37标准位置相对应,黑色区域和箭头为各肺叶塌陷的部位
a 右上肺叶塌陷
b 右肺中叶塌陷, 心脏外缘影是消失的。
c 右下肺叶塌陷
d 左上肺叶塌陷, 主裂隙向前移位。
e 左下肺叶塌陷


Fig. 3.42. Examples of lobar collapse



Fig. 3.42. Examples of lobar collapse
a Frontal film showing right upper lobe collapse with elevation of the minor fissure ( arrow )
b, c Frontal radiograph showing obscuration of the right heart border, collapse of the middle lobe, and shift of the mediastinum toward the right. The lateral film shows the wedge-shaped collapse overlying the heart
d, e Right lower lobe collapse. The right heart border is maintained but, as seen on the lateral film, the opacity is posterior and the major fissure is depressed posteriorly ( arrow ). The heart margin is normal
f, g Left upper lobe collapse.Note that the heart margin is quite irregular and not well seen. The major fissure ( arrow ) is anteriorly displaced and there is opacity anteriorly
h Left lower lobe collapse. The heart is no longer transparent and the major fissure is shifted medially and denotes an area of opacity from the spine to visualization of the fissure ( arrows )
Fig. 3.42. 肺叶塌陷图例
a 正位片上可见右上肺叶塌陷,并伴有次要裂隙上抬。
b, c在正位片上可见右侧心缘消失,右肺中叶塌陷,纵隔右偏。在侧位片上可见心影前方的楔状塌陷影。
d, e右下肺叶塌陷图。心影右缘仍然存在,但是在侧位片上,不透明区在后方,且主裂隙向后压迫(箭头处)。心影缘是正常的。
f, g左上肺塌陷。注意其心缘影不规则并模糊不清。主裂隙(箭头处)向前压迫,并可见前方的不透明区。
h左下肺塌陷。心影不再透明,主裂隙向中间偏移,我们可见脊柱旁裂隙不透明区。


Rule No. 7: The heart and liver are transparent organs.
规则七:心脏和肝脏均为透明的脏器。


Fig. 3.43. The heart and liver are transparent organs

Fig. 3.43. The heart and liver are transparent organs
a A 2-year-old with fever and cough. One can see vessels through the liver and through the most left lateral contour of the heart ( arrows ) .However, medially, there is a large opacity consistent with a left lower lobe pneumonia (asterisk)
b, c A 3-year-old with fever and tachypnea. There is a subtle opacity behind the left heart on the frontal film. The lateral film, however, shows a large opacity ( arrow ) posteriorly making the vertebral body look whiter than the ones above. This is a good sign on the lateral that there is opacity
d The same child at follow-up examination: note how black the vertebrae appear without the lower lobe opacity
Fig. 3.43. 心脏和肝脏是透光的气管
a 这是个2岁发热咳嗽的患儿。我们可见肝面的血管影,且透过大部分心缘左侧弧面影(箭头处)。我们还可见到在靠中间部位有个大的不透明区存在,为左下肺炎表现(星号处)。
b, c 这是一位发热呼吸急促的患儿。我们在正位片上可见一个心影左侧后方一隐约的不透明区。在侧位片上,明显可见一后方一大的不透明区(箭头处),使得此处的脊椎显得较上方白些。这个不透明区在侧位片上有很好的显示。
d 这是同一个患儿的随访结果:注意在没有下肺叶不透明区的影响,其脊椎的黑白程度。


Fig. 3.44. Unusual pulmonary opacities

Fig. 3.44. Unusual pulmonary opacities
a Round pneumonia. The frontal chest film shows a right upper lobe rounded opacity that might, at first glance, be mistaken for a tumor or metastasis.Antibiotic therapy resulted in a subsequent normal examination
b Another child with a right lung round opacity. This too proved to be a round pneumonia. Most round pneumonias are caused by streptococcal organisms
c Loculated pleural fluid. This child had unexplained fever and cough for 2 weeks after antibiotic therapy for pneumonia. Chest films show an elliptical density on the right.Note how it conforms to the position of the minor fissure. This is characteristic of a loculated effusion (in this case, infected fluid) in the fissure
d Lateral film of another child with loculated pleural fluid in the posterior portion of the major fissure
Fig. 3.44. 异常的肺部不透明区
a 圆形环状肺炎。在此正位片上可见右上肺叶区一圆形不透明区,猛的一看,很容易误诊为肿瘤或转移灶。而在抗生素治疗后复查,不透明区消失,肺影正常。
b这是另一患儿的右肺圆形实变影的胸片.这也被证实为圆形肺炎实变.大部分圆形肺炎是由链球菌感染而引起的.
c 包裹性间隔腔胸膜积液.这是一位在抗生素治疗肺炎2周后仍明不原因发热伴咳嗽的患儿.胸片检查可见右侧一椭圆性质密影.注意它与此肺裂沟的位置正好相符合.这正是肺裂小室积液的特征(在这个例子里为炎症感染性液体).
d另一包裹性胸膜积液患儿的侧位片,我们可见在主肺裂后部的的包裹性胸膜积液.


Fig. 3.45. A 16-month-old with cough

Fig. 3.45. A 16-month-old with cough
a Frontal chest radiograph shows the mediastinum shift to the right and bowel loops compressing the left lower lung
b Barium was given, confirming the intrathoracic location of the stomach and small bowel.At surgery there was an intact diaphragm, but it was very thin, consistent with a large eventration.When the eventration is this large, it acts as a mass causing the same symptoms as a diaphragmatic hernia
Fig. 3.45. 一16个月咳嗽患儿
a正位片检查可见纵隔右移,且肠曲压迫左下肺
b钡餐检查证实胃与小肠凸入胸廓内.手术证实为大的腹腔脏器凸入胸廓,但之间仍有一实质性的膈膜存在,但异常菲薄.但腹腔脏器凸入巨大时,它的表现和膈疝是一样的.


Fig. 3.46. Mediastinal mass

Fig. 3.46. Mediastinal mass
a This 10-year-old has a widened mediastinum.He is too old to have a large thymus and, in fact, has an enlarged right hilum with paratracheal adenopathy ( arrow ). The subcarinal region is also “too white”when compared to the rest of the heart
b Lateral roentgenograph opacity the density in the middle mediastinum – a common presentation for a lymphoma ( arrows ). There is contrast material in the esophagus
Fig. 3.46. 纵隔肿块
a 这是一纵隔增宽的10岁患儿,他这么大了,此处不可能为胸腺.实际上这是一个由于气管旁肿块而引起的肺门增大(箭头处).在气管隆凸下方的位置与心影相比显得要白一些.
b 侧位片可见中纵隔处不透明的实变影,这是淋巴瘤的常见特征(箭头处).这与食管形成鲜明的对比.


Fig. 3.47. Metastatic lung disease

Fig. 3.47. Metastatic lung disease
a Scout film prior to CT in this 3-year-old who had a Wilms’ tumor removed 7 months previously. There are multiple rounded opacities in the chest
b CT reveals multiple lung metastases
Fig. 3.47. 肺转移性病
a 此为一3岁wilms瘤手术7膈月后的CT片随访.我们可见胸片上多个圆形的不透明实变影.
bCT证实为多发性肺部转移.


Fig. 3.48. Pleural effusion

Fig. 3.48. Pleural effusion
a, b Erect frontal ( a ) and lateral ( b ) view of a patient with nephrotic syndrome who is 5 years old. The silhouette sign is present as the left heart margin is obscured.Note the distance between the stomach and the apparent diaphragm on the left side ( arrows ). The diaphragm should be closely applied to the stomach and therefore this could not be diaphragm but is fluid beneath the lung and above the diaphragm – a subpulmonic effusion. There is another cardinal sign of subpulmonic effusion
on the right side. The highest point of the diaphragm is quite lateral (arrowhead). This is the shape of the bottom of the lung and there is fluid below the lung and above the hemidiaphragm. On neither side do we really see the diaphragm. It is important to note that the usual pleural reaction is an opacity tracking along the lateral chest wall. There is a very small lateral component on the right side and a much larger lateral component on the left side. The lateral view shows separation of the stomach and diaphragm as well as opacity posteriorly
a,b此为一5岁肾病综合症患儿,在其正位片( a )上我们可见其侧影轮廓上心脏左缘模糊不清。注意左侧胃和所谓的膈肌之间的距离。作为膈肌应该与胃上界紧密接近的,因此这不是膈肌而是位于肺下部膈肌上方的液体-肺下渗出。对于肺下渗出另一个基本的表现就是在右侧的肺下渗出。膈肌的最高点偏向外侧(△)。这就是肺下界的形态,液体于肺下方于膈肌上方之间,两侧我们均不能看到真正的膈肌。必须重视的是通常的胸膜反应常为一沿着胸侧壁的不透明影。该患儿右侧较轻左侧较重。在侧位片上我们也可以看到胃与膈肌之间的下方不透明区。


Fig. 3.49. Empyema


Fig. 3.49. Empyema
a Chest radiograph in this 32-month-old with fever and respiratory signs reveals a large right opacity with a convex appearance toward the lung ( arrows ). This opacity has an elliptical type configuration and suggests a mass or a loculated effusion
b Decubitus film with left side down ( see fluid level in stomach ) shows the opacity does not move
c CT was performed to show the split pleural sign. There is enhancement of the parietal and visceral ( arrow ) pleura with low-density fluid between them. This is infected loculated fluid
Fig. 3.49. 脓胸
a这是一32个月发热并呼吸体征阳性患儿的片子,我们发现一个位于右侧凸向肺部的大块不透明区(箭头处)。这个不透明区呈椭圆形,说明此为一个实性肿块或局部渗出。
b在左侧卧位片(通过胃内的液平)上可见这块不透明区没有随体位改变而移动
c通过CT检查可见胸膜分裂征
在个增强了的胸膜壁层和脏层中(箭头处),其中可见低密度的液体位于其中。这是个感染了的腔隙液体。


Fig. 3.50.

Fig. 3.50. A child with acute onset of respiratory distress. (See Appendix 2)
A child with onset of acute respiratory distress.Frontal ( a ) and lateral ( b ) films.Did you notice the white, linear density along the right heart border? The child aspirated a pin and it was removed endoscopically from the right main-stem bronchus
Fig. 3.50. 急性呼吸窘迫患儿
该患儿为急性呼吸窘迫发作患儿。在正位片( a )及侧位片( b )你可否注意到沿着右心外缘的白色线样致密影?该患儿吸入一大头针,后来通过内景从右主支气管内取出。


Fig. 3.51.

Fig. 3.51. Chronic lung disease. (See Appendix 2)
A 6-year-old with a cough. Frontal examination ( a ) reveals a large density extending to the left paraspinal line behind the heart. The heart is no longer transparent. The borders of the density are convex laterally, suggesting an extrapleural mass. On the lateral view ( b ) the mass is difficult to see. The vertebral bodies are whiter inferiorly than they are superiorly, indicating the mass is in the posterior aspect of the hemithorax. This was a ganglioneuroblastoma
Fig. 3.51. 慢性肺疾病。(见附2)
一6岁咳嗽患儿。正位片检查( a )上可见一大的致密影,扩大到心脏后方的脊椎左旁。心影不再透明状。其致密影的边界向一侧凸出,说明这是一个胸膜外的肿块。在侧位片上( b )肿块不很难看清。片中可见脊椎椎体的下方影像较上方白,说明肿块在单侧胸的后方。这是一个神经节成神经细胞瘤。


Fig. 3.52.

Fig. 3.52. A child with wheezing. (See Appendix 2)
A child with wheezing. The frontal radiograph ( a ) shows the distal trachea pushed to the left and effaced; the carina is not adjacent to the right pedicles. The lateral film (b ) reveals the airway bowed forward and slightly narrowed. The frontal view of a barium swallow ( c ) shows the right and left indentations on the esophagus. The lateral view ( d ) reveals a bulge behind the esophagus and some narrowing and bowing of the airway. The patient has a vascular ring, specifically a double aortic arch
Fig. 3.52.喘鸣患儿。(见附2)
一喘鸣患儿。正位片上( a )可见气管远端被累积并推向左侧;气管隆凸不能接近右侧椎弓。侧位片( b )上。发现气道向前弯曲并有轻度的狭窄。正位片钡餐检查( c )中可见食管左侧及右侧的压迹。其侧位片上( d )可见一个食管后方的膨出及气道的一些狭窄和弯曲。该患儿有一血管环,为双主动脉弓特定表现。

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苏苗赏 副主任医师

温州医科大学附属第二医院 儿内呼吸科

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