PLEURAL DISEASES
DR FLORA [Link]
The pleura
• is composed of visceral and parietal serous membranes. The lungs and
interlobar fissures are invested in the visceral pleura, whereas the
parietal pleura lines the ribs, diaphragm, and mediastinum.
• The visceral and parietal pleura are continuous with one another as they
are reflected around the hilum and the inferior pulmonary ligament.
• Inferiorly, the parietal pleura is situated within the costophrenic sulcus.
• The area between the two pleural layers forms a “potential space,”
which can be enlarged when filled with fluid, cells, or air. Normally, there
is approximately 1 to 5 mL of pleural fluid within this space
• CT can detect smaller amounts of pleural fluid than can chest
radiography .
• In addition, CT enables determination of whether fluid is loculated,
the extent and localization of loculated fluid for purposes of drainage,
assessment of pleural morphology (irregular thickening and focal
masses suggest malignancy),
Can you see the pleura?
Imaging Modalities
• Plain radiography
• Ultrasound, Ultrasound guided procedures
• Computed Tomography
• Magnetic Resonance Imaging
• PET-positron emission tomography
• Plain radiography-usually initial investigation
• Ultrasound-pleural effusion, guiding pleural procedures
• CT
• MRI
• PET-assessment of response to therapy
Pleural diseases
• Pneumothorax
• Pleural effusion
-Empyema
-Hemothorax, Pyothorax,Chylothorax
• Pleural Tumors
• Pleuritis-inflammation of pleura
Pneumothorax
• What is pneumothorax? Is pathological accumulation of air in the
pleural space
• Causes:
-Spontaneous-no underling lung dis, underlying lung dis (COPD,
Tumours, Infections
-Traumatic –penetrating chest trauma
-displaced rib fracture with rupture of visceral pleura
-Iatrogenic –lung biopsy, thoracocentesis,pleural biopsy,Positive
pressure ventilation, chest opaerations
Tension pneumothorax
• Life threatening emergency caused by continuous entrance and
entrapment of air into the pleural space (one way valve is formed, air
is trapped with each inspiration and cant leave)
• Patient has dyspnoea, increased resp rate, sharp chest pain,
distended neck veins
• Commonly follows traumatic chest injury or individuals breathing
through mechanical [Link] no reason found.
Chest x-ray findings Tension Pneumothorax
• Is accompanied by mediastinal and tracheal shift away from the
pneumothorax.
• Radiolucency
• Treatment: needle decompression
2 days later
CT-pneumothorax
Tension pneumothorax
Pleural Effusion
• Definition: fluid in the pleural space
• develop when there is excess pleural fluid produced, diminished resorption of
fluid from the pleural space, or both.
• Can be blood, pus, chyle
• The appearance of an effusion depends on the patient’s position at the time of
the radiologic examination and on the mobility of the effusion.
• In an upright person, fluid collects mainly in the lower pleural space, as long as
it is freely mobile, creating a homogeneous opacity with a curvilinear upper
border that is sharply marginated and concave to the lung.
• Fluid can collect in the fissures, creating a “pseudotumor” that conforms to the
edges of the fissures and resolves with clearing of lung edema (
Common causes
• Infection
• Neoplasm
• Cardiovascular disease (congestive heart failure)
• Cirrhosis
• Hypoproteinemia
• Pancreatitis
• Uremia
• Subdiaphragmatic abscess
• Trauma (hemothorax, chylothorax)
• Occupational (asbestos)
• Collagen vascular disease (systemic lupus erythematosus)
• Hypothyroidism (often with pericardial effusion)
• Pulmonary embolism
• Can be detected by Ultrasound
CT
Chest xray
Empyema- collection of pus in the pleural cavity
Radiological signs of pleural effusion
• Blunting of costophrenic angles
• Meniscus sign
• If large shift of mediastinum to opposite side.
Hydronpneumothorax
Causes of pleural masses (1)
Tumors
• pleural tumors
• solitary fibrous tumor of the pleura (pleural fibroma)
• mesothelioma
• localized mediastinal malignant mesothelioma
• metastatic pleural disease, particularly from adenocarcinomas, e.g.
• bronchogenic adenocarcinoma
• breast cancer
• ovarian cancer
• prostate cancer
• gastrointestinal adenocarcinoma
• renal cell carcinoma
• lymphoma: pleural lymphoma
• invasive thymoma
• lipoma
Causes of Masses (2)
• loculated fluid (on plain film)
• pleural effusion (pleural pseudotumor)
• empyema
• hemothorax
• mass related to ribs or chest wall, e.g. Ewing sarcoma of chest wall, Askin
tumor
• mass related to the intercostal nerve
• intercostal nerve neurilemmoma
• splenosis - thoracic splenosis
• infection including tuberculosis
• References
Pleural tumors
• Maybe Benign or Malignant
• Primary or secondary (metastasis from other sites in body)
• Primary tumours:
-mesothelioma
-Lymphoma
Secondaries:
Metastasis –lung Ca, Breast Ca, Ovarian Ca, gastric Ca,
Invasive tumours-pericardial tumours
Features on Plain Radiographs
• Obtuse angles with lateral chest wall
Chest wall Mass
Diseases of chest wall
• Has muscles, bones, joints and soft tissues
• May be congenital , developmental,trauma,infectious, inflammatory,
soft tsiisue and bone tumors
Pulmonary mass
• SOLITARY MASS-commonest cause of pulmonary mass over 3cm is
carcinoma.
• Other casues of solitary mass-granulomas-tb,fungal infection,benign
tumors,solitray metastasis.
• Dx confirmed by percutaneous fine needle biopsy.
