The Macklin effect describes one of the pathophysiological processes of pneumomediastinum in blunt chest trauma. The Macklin effect accounts for ~40% of severe blunt traumatic pneumomediastinum. Exclusion of tracheobronchial and oesophageal causes of pneumomediastinum is mandatory to exclude con...
Thickening of bronchovascular bundles is a chest CT imaging feature that can be observed in a number of entities.
Conditions that can result in bronchovascular bundle thickening include:
sarcoidosis - see pulmonary manifestations of sarcoidosis 1
classical condition to giv...
The third mogul sign can be seen on frontal chest radiograph in the presence of left atrial enlargement. It refers to an extra mogul or bump along the upper left cardiac silhouette just below the left main bronchus.
The third mogul sign commonly represents the enlarged left atrial appendage, pa...
Thoracentesis, commonly known as a pleural or chest tap, is a procedure where excess pleural fluid is drained from the pleural space for diagnostic and/or therapeutic reasons. Ultrasound-guided thoracentesis performed by radiologists has been shown to have fewer complications than blind thoracen...
Thoracic actinomycosis refers to an uncommon indolent infection caused principally by the genus Actinomyces (higher prokaryotic bacteria belonging to the family Actinomyceataceae).
While it is rare in general, the thoracic form actinomycosis may constitutes ∼15% of the total burde...
Thoracic air leak syndrome (TALS) is an uncommon late complication in haematopoetic stem cell transplant recipients with chronic graft verses host disease. These patient led to develop features of thoracic air-leakage (i.e. spontaneous pneumomediastinum, spontaneous pneumothorax, pneumopericardi...
Thoracic anatomy encompasses the anatomy of all structures of the thoracic cavity.
This anatomy section promotes the use of the Terminologia Anatomica, the global standard for correct gross anatomical nomenclature.
Thoracic aortic aneurysms are relatively uncommon compared to abdominal aortic aneurysms. There is a wide range of causes, and the ascending aorta is most commonly affected. CTA and MRA are the modalities of choice to image this condition.
The term aneurysm is used when the axial d...
There are a number of causes and mimics of thoracic aortic dilatation.
post-stenotic dilatation, e.g. bicuspid aortic valve
thoracic aortic aneurysm
atherosclerosis (usually descending thoracic aorta)
Thoracic aortic injury is the most common type of traumatic aortic injury and is a critical life-threatening, and often life ending event.
Approximately 80% of patients with thoracic aortic injury die at the scene of the trauma. In those who make it to hospital, clinical...
The differential for thoracic aortic stenosis includes:
aortitis (especially Takayasu arteritis)
Williams syndrome: supravalvular aortic stenosis
congenital rubella syndrome: supravalvular aortic stenosis
The thoracic cage refers to the skeleton of the thorax:
thoracic vertebral column
12 pairs of ribs
The thoracic duct is the main lymphatic channel for the return of chyle to the venous system. It drains lymph from both lower limbs, abdomen (except the convex area of the liver), left hemithorax, left upper limb and left face and neck.
The thoracic duct is the superior continua...
Pleural-thoracic empyema (commonly referred simply as an empyema) or pyothorax refers to an infected purulent and often loculated pleural effusion, and is a cause of a large unilateral pleural collection. It is a potentially life-threatening condition requiring prompt diagnosis and treatment.
Thoracic endometriosis is an uncommon location for endometriosis and the main cause of catamenial pneumothorax.
Most often occurs in the third and fourth decades of life 3.
Symptoms may include:
catamenial pleuritic chest pain
catamenial haemoptysis: whe...
Thoracic (or pulmonary) histoplasmosis refers to pulmonary manifestations from infection with the organism Histoplasma capsulatum which is an organism endemic to El Salvador but can be found widely in other parts of North, Central and South America. It can have variable clinical and radiographic...
High resolution CT (HRCT) of the lungs has specific terminology relating to pulmonary anatomy with which one needs to be comfortable.
secondary pulmonary lobule
interlobular septal thickening
Thoracic lymph nodes are divided into 14 stations as proposed by the International Association for the Study of Lung Cancer (IASLC) 1, principally in the context of oncologic staging.
highest mediastinal nodes: low cervical, supraclavicular, and sternal notch nodes
Thoracic myelolipomas are extremely rare entities; only ~3% of myelolipomas are thought to occur in the thorax. When do occur in the thorax they can manifest as
mediastinal myelolipoma: most occur in the posterior mediastinum
intrapulmonary myelolipoma (much less common)
As with my...
Thoracic outlet syndrome (TOS) refers to a group of clinical syndromes caused by congenital or acquired compression of the brachial plexus or subclavian vessels as they pass through the superior thoracic aperture.
Clinical presentation will depend on the structure compre...
The thoracic plane, also known as the transthoracic plane or the plane of Ludwig is an artificial horizontal plane used to divide the mediastinum into the superior mediastinum and the inferior mediastinum.
It is defined as a horizontal line that runs from the manubriosternal joint (sternal angl...
A handy mnemonic to remember the structures found at the level of the thoracic plane (also known as the plane of Ludwig) is:
C: cardiac plexus
L: ligamentum arteriosum
A: aortic arch (inner concavity)
P: pulmonary trunk
T: tracheal bifurcation (carin...
The thoracic spine sign on lung ultrasound is an indirect indicator of the presence of a pleural effusion or haemothorax. It represents the visualisation of the vertebral bodies in the thoracic cavity above the diaphragm which are usually not seen unless there is a fluid collection.
Thoracic splenosis refers to autotransplantation of splenic tissue into the pleural space which typically occurs after trauma. It may occur in approximately 18% of patients with combined diaphragmatic and splenic injuries and is more common after penetrating injuries.
Splenic tissue ...
Thoracoabdominal sign, a variation of the silhouette sign, is a frontal chest radiograph sign which helps to localize a thoracic lesion.
Since the posterior costophrenic sulcus is more caudal than the anterior lung, a thoracic lesion must be posterior if its caudal end is visible below the dome...
The thoracoepigastric vein provides a communication between the superficial epigastric vein and the lateral thoracic vein as it ascends superficially on anterolateral chest and abdominal wall. It, therefore, drains into both the superior vena cava via the axillary vein and the inferior vena cava...
Thoracoliths are rare, calcified pleural-based nodules that are almost always incidental findings. They are usually considered mobile, and more common on the left.
The exact aetiology is unknown and theories include 1,2:
calcified fibrin body
degenerated pleural lipoma
Thoracoplasty is a surgical procedure that was originally designed to permanently collapse the cavities of pulmonary tuberculosis by removing the ribs from the chest wall 1-3 . The resection of multiple ribs, allows the apposition of parietal to the visceral or mediastinal pleura. Until supplant...
Thymic carcinoid tumour refers to a carcinoid tumour arising in the thymus. It is the most common histologic type for a neuroendocrine tumour of the thymus.
Affected patients are typically in the fourth or fifth decades of life. There is a recognised male predominance with M:F rat...
Thymic carcinoma is part of the malignant end of thymic epithelial tumours.
Patients are typically 50 to 70 years of age at presentation 9.
The incidence of paraneoplastic syndromes is thought to be low. At least 10 different histologic variants have been described 4. ...
Thymic cysts are cysts that occur within, or arise from, the thymus.
Thymic cysts are uncommon lesions and are estimated to account for approximately 1-3% of all anterior mediastinal masses 4. Approximately 50% of congenital thymic cysts are incidentally discovered during the firs...
Thymic epithelial tumours are rare tumours arising from thymus in anterior mediastinum of middle age patients. However, they are still the most common primary neoplasm of the thymus and anterosuperior mediastinum. This article discusses thymomas, invasive thymomas and thymic carcinoma.
Thymic hyperplasia is a disorder whereby there is hyperplasia of the thymus gland.
Thymus hyperplasia can be subdivided into two forms:
true thymic hyperplasia
Both true thymic hyperplasia and lymphoid hyperplasia manifest as diffuse symmetric enlargement of...
The thymic notch sign represents the normal thymus in a newborn on a frontal chest radiograph. Interruption of the cardiac silhouette forms a notch, which may be seen on either side, but more frequently is seen on the left side.
The thymic sail sign represents a triangular-shaped inferior margin of the normal thymus seen on a neonatal frontal chest radiograph. It is more commonly seen on the right side, but can also be bilateral. It is seen in 3-15% of all cases. This sign should not be confused with the spinnaker sail ...
Thymolipoma is a rare, benign anterior mediastinal mass of thymic origin, containing both thymic and mature adipose tissue.
Thymolipomas comprise ~5% (range 2-9%) of all thymic neoplasms, but are less common than a mediastinal lipoma of non-thymic origin. There is no recognised s...
The thymus is a T-cell producing lymphoid organ in the anterior mediastinum that plays a role in the development of the immune system, particular the maturation of T-cells. It typically has a retrosternal location and hence can mimic retrosternal pathology.
It is relatively large...
Tietze syndrome refers to a benign costochondritis accompanied by hypertrophy of the costal cartilages.
The exact incidence of occurrence is not known. It is seen most commonly in the 2nd to 5th decades of life. Both sexes are affected equally.
It is characterised as a...
Tissue tropism is a phenomenon by which certain host tissues preferentially support the growth and proliferation of pathogens. This concept is central to the radiological evaluation of infectious disease.
As infections that display tissue tropism will thrive in certain tissue locati...
Total repair of tetralogy of Fallot is a corrective surgical procedure that involves closure of the ventricular septal defect (VSD) and relief of right ventricular outflow tract (RVOT) obstruction.
Most patients with tetralogy of Fallot (TOF) undergo elective surgical repair between ...
The trachea, known colloquially as the windpipe, connects the upper respiratory tract to the lungs via the tracheobronchial tree, enabling gas exchange.
The trachea is a tube-shaped structure consisting of 15-to-20 D-shaped cartilage rings anterolaterally bridged by annular ligam...
Primary tracheal and endobronchial lesions are generally rare and can be either malignant or benign. The majority of these lesions are malignant.
primary malignant endobronchial lesions
squamous cell carcinoma: commonest malignant lesion in tr...
Tracheal atresia (TA) is an extremely rare anomaly and refers to a congenital absence of the trachea.
There may be a greater male predilection 5.
Tracheal atresia falls under the spectrum of laryngeal-tracheo-bronchial atresia which in turn results either from an obstr...
A tracheal bronchus (with some variations also known as a pig bronchus) is an anatomical variant where an accessory bronchus originates directly from the supracarinal trachea. The latter term (pig bronchus or bronchus suis) is often given when the entire upper lobe (usually right side) is suppli...
Tracheal buckling is a normal finding in young infants when it is more flexible. There is typically deviation of the trachea anteriorly and to the right (up to 90°) and any other configuration (i.e. to the left or posteriorly) should raise the possibility of underlying pathology.
Tracheal calcification, or tracheobronchial calcification, is a benign radiological finding of the middle aged and elderly and is usually of no clinical significance.
Patients are generally asymptomatic.
Long-term warfarin therapy may be associated with trache...
A tracheal diverticulum is usually an incidental finding. Occasionally it may mimic pneumomediastinum, so called pseudopneumomediastinum.
It may be congenital or acquired. The acquired form is thought to be due to prolonged increased intraluminal pressure, e.g. due to a chronic cough...
The differential for tracheal masses can be rather wide.
For a single mass consider:
direct invasion from adjacent organ (lung, thryoid,esophagus)
distant metastsis ( such as melanoma)
squamous cell carcinoma: commonest primary tracheal malignancy 2 ~50 %
Tracheal stenosis is usually acquired following intubation or tracheostomy. Inflammation and pressure necrosis of the tracheal mucosa most commonly occur at either the tracheostomy stoma or at the level of the tube balloon. Acute post-intubation stenosis results from mucosal oedema or granulatio...
Tracheal wall thickening may have several causes. For diagnostic purposes, tracheal thickening may be categorized by length of airway involvement in order to narrow the differential diagnoses. Note that some etiologies may be associated with either focal or diffuse pattern of involvement.
Tracheal webs occur as a thin layer of tissue that narrows the tracheal lumen. They do not completely obstruct the trachea.
The incidence of congenital tracheal is 1:10,000 births.
Some patients will be asymptomatic. Symptomatic patients can present with a ...
Tracheobronchial amyloidosis refers to tracheal and/or bronchial involvement in amyloidosis. It is sometimes classified as a subtype of pulmonary amyloidosis.
It is a rare manifestation with some reports suggesting less than 100 published cases around the time of writing 5.
Tracheobronchial branching anomalies can be seen as an isolated finding or accompanying heterotaxy syndromes, pulmonary sling, and conditions associated with pulmonary underdevelopment (agenesis and aplasia), including the scimitar syndrome.
Abnormal branching patterns include:
right sided iso...
Tracheobronchial injury is a serious but uncommon manifestation of chest trauma. It is usually a fatal injury with only a small percentage of patients making it to hospital. Given the magnitude of force required to injure the major airways, there are often multiple chest injuries and other body ...
Tracheobronchial papillomatosis refers to the occurrence of multiple squamous cell papillomas involving trachea and bronchi. It is an unusual manifestation of recurrent respiratory papillomatosis (RRP), itself a rare condition where HPV-associated papilloma form along the aerodigestive tract 8.
A tracheo-bronchial stent is a device used in the treatment of symptomatic airway compression.
This device is inserted under bronchoscopic guidance in patients with external compression from mediastinal based malignancy, for example lung or oesophageal cancers. It may also be used in the treat...
The tracheobronchial tree is the branching tree of airways beginning at the larynx and extending inferiorly and peripherally into the lungs as bronchioles. The luminal diameter decreases as the branching increases more peripherally into the lungs. The walls of the airway down to the level of the...
Tracheobronchopathia osteochondroplastica (TO) is a very rare idiopathic non-neoplastic tracheobronchial abnormality.
The estimated prevalence on routine bronchoscopy can be up to 0.7%. It typically affects those in the 5th to 6th decades and there may be a male predilection 4.
Tracheomalacia, or sometimes described as tracheobronchomalacia, is a common incidental finding on imaging of the chest of older patients and manifests as an increase in tracheal diameter as well as a tendency to collapse on expiration. Generally, more than 70% collapse of the trachea during exp...
A dilated trachea has numerous causes, and in almost all cases represents tracheomalacia (increased size and increased compliance).
As is almost always the case, various diameters have been used. Typical figures include >26 mm in men, >23 mm in women or >3 cm for both genders.
Although many of...
Tracheo-oesophageal fistula is a pathological communication between the trachea and oesophagus.
It can be broadly classified into two types:
congenital tracheo-oesophageal fistula
acquired tracheo-oesophageal fistula: from malignancy/tuberculosis
Traction bronchiectasis refers to an aetiological sub type of bronchiectasis where there is irreversible dilatation of bronchi and bronchioles within areas of pulmonary fibrosis or distorted lung parenchymal architecture.
It can arise from a number of underlying causes which result i...
Tram-track sign may be used in chest radiography or CT to denote the thickened non-tapering (parallel) walls of cylindrical bronchiectasis.
It should not be confused with other tram-track signs elsewhere in the body.
Transfusion related acute lung injury (TRALI) is defined as non-cardiogenic pulmonary oedema temporally related to transfusion therapy.
It tends to occur within 6 hours after a blood transfusion and requires exclusion of other alternative diagnoses such as sepsis, volume overload.
Transient tachypnoea of the newborn (TTN), also known as retained fetal fluid or wet lung disease, presents in the neonate as tachypnoea for the first few hours of life, lasting up to one day. The tachypnoea usually resolves by within 48 hours.
TTN is one of the commonest causes ...
A transudate is a collection of fluid that has a relatively low specific gravity and protein concentration. They occur secondary to increased hydrostatic pressure or reduced colloid oncotic pressure:
left ventricular failure (increased hydrostatic pressure)
hypoalbuminaemia (decreased colloid ...
The transverse cervical artery, also known as the cervicodorsal trunk, is 1 of the 4 branches of the thyrocervical trunk (off the first part of the subclavian artery).
It is a short artery that bifurcates into the superficial and deep branches, both which course superficially and laterally acro...
Trapped lung, also known as unexpandable/unexpanded lung, is a term used where there is non-expandable lung after fluid removal, often thoracentesis. It is similar to but not entirely synonymous with the term lung entrapment, which is a similar condition but caused by active pleural disease rath...
Trauma CT thorax review areas are useful to reduce the potential for error, which is higher than usual given the larger number of images requiring review, and the often present time pressures and the potential presence of numerous concurrent injuries (see CT polytrauma).
Using some standard re...
Tree-in-bud sign or pattern describes the CT appearance of multiple areas of centrilobular nodules with a linear branching pattern. Although initially described in patients with endobronchial tuberculosis, it is now recognised in a large number of conditions.
The triangle of safety is an anatomical region in the axilla that forms a guide as to the safe position for intercostal catheter (ICC) placement. With the arm abducted, the apex is the axilla, and the triangle is formed by the:
lateral border of the pectoralis major anteriorly
lateral border o...
Triple-rule-out CT (TRO CT) angiography may be ordered in the setting of acute chest pain to examine the thoracic aorta and the coronary and pulmonary arteries. The protocol helps exclude life-threatening causes of acute chest pain, especially if atypical, or if alternative causes to acute coron...
Tuberculomas or tuberculous granulomas are well defined focal masses that result from Mycobacterium tuberculosis infection and are one of the more severe morphological forms of tuberculosis. Tuberculomas most commonly occur in the brain (see: CNS tuberculosis) and the lung (see: pulmonary tuberc...
Pulmonary manifestations of tuberculosis are varied and depend in part whether the infection is primary or post-primary. The lungs are the most common site of primary infection by tuberculosis and are a major source of spread of the disease and of individual morbidity and mortality.
A general d...
This is a basic article for medical students and other non-radiologists
Tuberculosis (TB) is a non-bacterial multisystem infection that often affects the lungs. It may be a primary tuberculous infection, secondary infection or appear as chronic scarring. TB may also be seen on a chest x-ray as ...
Tuberculous adrenalitis is the result of adrenal mycobacterium tuberculosis (TB) infection. Its incidence has decreased in the western world with the declining incidence of tuberculosis.
As the tuberculous infection causes destruction of the adrenal cortex, primary adrenal insufficie...
Tuberculous empyema is a chronic, active infection of the pleural space characterised by thick rind of pleura with thick and irregular calcification of both parietal and visceral pleura usually surrounding a loculated pleural fluid which contains a large number of tubercle bacilli 1. This could ...
Tuberous sclerosis (TS), also known as tuberous sclerosis complex or Bourneville disease, is a neurocutaneous disorder (phakomatosis) characterised by the development of multiple benign tumours of the embryonic ectoderm (e.g. skin, eyes, and nervous system).
Tuberous sclerosis has...
Tulip bulb sign refers to the characteristic appearance of annuloaortic ectasia as seen on CT angiography.
There is symmetric dilatation of the three sinuses of Valsalva, with extension into the ascending aorta and effacement of the sinotubular junction.
It is seen especially in Marfan syndro...
There are many tumour-like conditions of the pleura. These are non-malignant entities that on imaging may mimic a pleural tumour.
Tumours of the chest wall are varied, some of which are found most often in this region. They can be divided into benign and malignant tumours and into those which arise in the ribcage and those of soft tissue density.
Benign tumours include 1,3-4:
A tumour-to-tumour metastasis, also known as a collision tumour, is a rare metastatic process in which a primary malignant tumour ('donor') metastasises to another tumour ('recipient'), most commonly a benign tumour such as a meningioma.
Tumour-to-tumour metastasis is considered v...
The twelfth rib is an atypical rib. It is the shortest rib, and one of two floating ribs.
The 12th rib has a single facet on its head for articulation with the T12 vertebra. It has a short neck and no tubercle. It also lacks a costal groove and angle. internal surface ...
Typical ribs are those numbered 2 to 10 with ribs 1, 11 and 12 considered atypical.
A typical rib is long and flat. They contain a:
Ribs have a rounded, smooth superior border. The inferior border is thin and sharp.
The term unfolded aorta refers to the widened and 'opened up' appearance of the aortic arch on a frontal chest radiograph. It is one of the more common causes for apparent mediastinal widening and is seen with increasing age.
It occurs due to the discrepancy in the growth of the ascending aorta...
A unifocalisation procedure is a corrective surgical technique used in patients with complete pulmonary artery atresia with major aortopulmonary collateral arteries (MAPCAs). In this technique, the collateral vessels supplying blood from the aorta directly to the lungs are brought into continuit...
Mnemonics for a unilateral hyperlucent hemithorax include:
C: contralateral lung increased density, e.g. supine pleural effusion
A: air, e.g. pneumothorax
W: wall, e.g. chest wall mass, mastectomy, polio, Poland syndrome, surgical re...
Unilateral hypertranslucent hemithorax has many potential causes. It may be the result of rotation away from an optimal position or because of pathology.
A unilateral hypertranslucent hemithorax may be caused by the positioning of the patient. Rotation away from the radiation beam alt...
Unilateral pulmonary artery atresia (UPAA) or unilateral absence of the pulmonary artery (UAPA) is a variant of pulmonary artery atresia.
The estimated prevalence is around 1 in 200,000 young adults. The reported frequency on the right side is slightly greater for some reason 10....
Unilateral pulmonary oedema represents only 2% of cardiogenic pulmonary oedema with predilection for the right upper lobe and is strongly associated with severe mitral regurgitation 1, 2. It is hypothesised that the regurgitation jet is directed towards the right superior pulmonary vein thus pre...
Unilateral pulmonary vein atresia is a type of pulmonary vein atresia.
The condition usually present in infancy or childhood with recurrent episodes of pneumonia and/or haemoptysis. Presentation in adulthood does occur but is uncommon.
It results from failure ...
The upper and lower lobe distribution of certain bilateral pulmonary pathologies can be recalled using the following mnemonics:
upper lobe or apical predominance: CASSET HPP or SET CAP
lower lobe or bibasilar predominance: BAD RASH
C: cystic fibrosis
A: ankylosing spo...
Distribution of bronchiectasis can help in narrowing the differential diagnosis. Upper lobe bronchiectasis is typically seen in:
Rarely it may be seen with non tuberculous mycobacterial infection (e.g. MAC infection 2)
When in mid-upper lobes also consid...