US in the Diagnosis of Pediatric Chest Diseases1
(CME Available in print version and on RSNA Link)
Ok Hwa Kim, MD,
Woo Sun Kim, MD,
Min Jung Kim, MD ,
Jin Young Jung, MD and
Jung Ho Suh, MD
1 From the Department of Radiology, Ajou University Hospital, 5 Wonchon-Dong, Paldal-Gu, Suwon 442-749, Kyonggi-Do, South Korea (O.H.K., M.J.K., J.Y.J., J.H.S.); and the Department of Radiology, Children's Hospital, Seoul National University, Seoul, South Korea (W.S.K.). Recipient of a Magna Cum Laude award for a scientific exhibit at the 1998 RSNA scientific assembly. Received March 11, 1999; revision requested May 10; final revision received January 7, 2000; accepted January 10. Address reprint requests to O.H.K. (e-mail: kimoh@madang.ajou.ac.kr).
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Figure 1. Transducer positions for imaging intrathoracic structures. A = supraclavicular, B = suprasternal, C = transsternal, D = parasternal, E = intercostal, F = subxiphoid, G = transdiaphragmatic.
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Figure 2. Sonographic air bronchogram in pneumonic consolidation. Intercostal oblique US scan of the left lower lobe shows echogenic lung containing bright dots and linear or branching structures (arrow), which represent air bronchograms. A small, hypoechoic pleural effusion (P) defines the boundary of the lung.
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Figure 3. Sonographic air bronchogram in passive atelectasis as a sequela of pneumonia and empyema. Transverse US scan of the left lower lobe shows conglomerated, parallel-running bright lines (black arrows) within echogenic lung, an appearance that represents an air bronchogram in atelectatic lung. A thick and echogenic rind of pleura (white arrows) denotes adhesive pleural thickening.
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Figure 4. Sonographic fluid bronchogram in mucoid impaction in a 7-year-old boy. Chest radiography showed an oval area of increased opacity in the left lower lobe, which persisted for 1 month despite antibiotic therapy. The question was whether this area of increased opacity represented a true lung mass, parenchymal consolidation, or a posterior mediastinal mass. Transverse US scan of the left lower lobe obtained with the patient in the prone position shows an echogenic mass containing branching, hypoechoic, tubular structures (arrows), which represent bronchi filled with fluid or mucus; this appearance is reflective of parenchymal consolidation. Bronchoscopy showed tubular collections of impacted mucus in dilated left lower lobe bronchi.
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Figure 5. Normal pulmonary vessel in consolidated lung. Transverse color US scan shows branching pulmonary vessels within an echogenic area of consolidation. Anechoic pleural fluid (P) with a color band (fluid color sign) represents an effusion with floating debris.
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Figure 6a. Round area of pneumonia in a 5-year-old boy. (a) Chest radiograph shows a masslike area of increased opacity in the right upper lobe. The lesion is attached to the chest wall. (b) Transverse US scan obtained with the patient in the prone position shows an echogenic mass containing a branching pattern of bright echoes; this is a typical sonographic air bronchogram. (c) Follow-up chest radiograph obtained 1 week later shows regression of the consolidation with pneumatocele formation.
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Figure 6b. Round area of pneumonia in a 5-year-old boy. (a) Chest radiograph shows a masslike area of increased opacity in the right upper lobe. The lesion is attached to the chest wall. (b) Transverse US scan obtained with the patient in the prone position shows an echogenic mass containing a branching pattern of bright echoes; this is a typical sonographic air bronchogram. (c) Follow-up chest radiograph obtained 1 week later shows regression of the consolidation with pneumatocele formation.
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Figure 6c. Round area of pneumonia in a 5-year-old boy. (a) Chest radiograph shows a masslike area of increased opacity in the right upper lobe. The lesion is attached to the chest wall. (b) Transverse US scan obtained with the patient in the prone position shows an echogenic mass containing a branching pattern of bright echoes; this is a typical sonographic air bronchogram. (c) Follow-up chest radiograph obtained 1 week later shows regression of the consolidation with pneumatocele formation.
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Figure 7a. Intralobar pulmonary sequestration in a 2-year-old girl. (a) Chest radiograph shows an area of increased opacity in the left lower lobe with pleural effusion. US was performed to guide pleural tapping. (b) Longitudinal US scan of the left lung base shows echogenic lung containing multiple cysts. SP = spleen. (c) Transverse color US scan obtained with a subxiphoid approach shows an anomalous vessel (arrow) arising from the aorta (A) and supplying the mass (M).
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Figure 7b. Intralobar pulmonary sequestration in a 2-year-old girl. (a) Chest radiograph shows an area of increased opacity in the left lower lobe with pleural effusion. US was performed to guide pleural tapping. (b) Longitudinal US scan of the left lung base shows echogenic lung containing multiple cysts. SP = spleen. (c) Transverse color US scan obtained with a subxiphoid approach shows an anomalous vessel (arrow) arising from the aorta (A) and supplying the mass (M).
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Figure 7c. Intralobar pulmonary sequestration in a 2-year-old girl. (a) Chest radiograph shows an area of increased opacity in the left lower lobe with pleural effusion. US was performed to guide pleural tapping. (b) Longitudinal US scan of the left lung base shows echogenic lung containing multiple cysts. SP = spleen. (c) Transverse color US scan obtained with a subxiphoid approach shows an anomalous vessel (arrow) arising from the aorta (A) and supplying the mass (M).
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Figure 8a. Cystic adenomatoid malformation in a 13-year-old boy. (a) Chest radiograph shows patchy infiltration with small cystic areas in the left lower lobe. (b) Longitudinal US scan of the left lower lobe shows a honeycomb appearance with numerous small cysts within echogenic lung. This appearance is similar to that of pulmonary sequestration (see Fig 7b). (c) Cut section from the left lower lobe shows tiny cystic spaces containing fluid (arrows). The diagnosis of type II cystic adenomatoid malformation was established.
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Figure 8b. Cystic adenomatoid malformation in a 13-year-old boy. (a) Chest radiograph shows patchy infiltration with small cystic areas in the left lower lobe. (b) Longitudinal US scan of the left lower lobe shows a honeycomb appearance with numerous small cysts within echogenic lung. This appearance is similar to that of pulmonary sequestration (see Fig 7b). (c) Cut section from the left lower lobe shows tiny cystic spaces containing fluid (arrows). The diagnosis of type II cystic adenomatoid malformation was established.
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Figure 8c. Cystic adenomatoid malformation in a 13-year-old boy. (a) Chest radiograph shows patchy infiltration with small cystic areas in the left lower lobe. (b) Longitudinal US scan of the left lower lobe shows a honeycomb appearance with numerous small cysts within echogenic lung. This appearance is similar to that of pulmonary sequestration (see Fig 7b). (c) Cut section from the left lower lobe shows tiny cystic spaces containing fluid (arrows). The diagnosis of type II cystic adenomatoid malformation was established.
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Figure 9a. Pulmonary blastoma in a 3-year-old girl. (a) Chest radiograph shows total opacification of the right hemithorax with contralateral shifting of the heart. The question was whether this appearance represented a massive effusion or a huge mass. (b) Transverse US scan shows a huge echogenic mass (arrows) with a central anechoic portion. An unexpected finding was the near absence of pleural effusion (P). (c) Contrast material-enhanced CT scan shows a huge mass with a necrotic portion replacing the whole right hemithorax.
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Figure 9b. Pulmonary blastoma in a 3-year-old girl. (a) Chest radiograph shows total opacification of the right hemithorax with contralateral shifting of the heart. The question was whether this appearance represented a massive effusion or a huge mass. (b) Transverse US scan shows a huge echogenic mass (arrows) with a central anechoic portion. An unexpected finding was the near absence of pleural effusion (P). (c) Contrast material-enhanced CT scan shows a huge mass with a necrotic portion replacing the whole right hemithorax.
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Figure 9c. Pulmonary blastoma in a 3-year-old girl. (a) Chest radiograph shows total opacification of the right hemithorax with contralateral shifting of the heart. The question was whether this appearance represented a massive effusion or a huge mass. (b) Transverse US scan shows a huge echogenic mass (arrows) with a central anechoic portion. An unexpected finding was the near absence of pleural effusion (P). (c) Contrast material-enhanced CT scan shows a huge mass with a necrotic portion replacing the whole right hemithorax.
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Figure 10a. Simple pleural effusion with floating debris. (a) Chest radiograph shows an ill-defined area of increased opacity in the left lower lobe. (b) Longitudinal US scan of the left lower lobe shows a large amount of hypoechoic fluid containing swirling particles, an appearance indicative of a simple effusion amenable to aspiration. The subpulmonic location of the fluid is well visualized between the spleen (SP) and an echogenic area of lower lobe consolidation (L).
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Figure 10b. Simple pleural effusion with floating debris. (a) Chest radiograph shows an ill-defined area of increased opacity in the left lower lobe. (b) Longitudinal US scan of the left lower lobe shows a large amount of hypoechoic fluid containing swirling particles, an appearance indicative of a simple effusion amenable to aspiration. The subpulmonic location of the fluid is well visualized between the spleen (SP) and an echogenic area of lower lobe consolidation (L).
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Figure 11. Complicated pleural effusion with fibrin bands. Transverse US scan shows anechoic fluid containing mobile echogenic bands. This type of fluid collection is amenable to thoracentesis.
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Figure 12a. Complicated pleural effusion with multiple loculi. (a) Intercostal oblique US scan shows thickening of the visceral and parietal pleura (arrows). The pleural space is filled with profusely septated fluid, which has a honeycomb appearance. This type of fluid collection is not really amenable to thoracentesis. (b) CT scan obtained on the same day shows a rind of hypoattenuating pleural effusion. The multiloculated nature of the effusion is not visualized.
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Figure 12b. Complicated pleural effusion with multiple loculi. (a) Intercostal oblique US scan shows thickening of the visceral and parietal pleura (arrows). The pleural space is filled with profusely septated fluid, which has a honeycomb appearance. This type of fluid collection is not really amenable to thoracentesis. (b) CT scan obtained on the same day shows a rind of hypoattenuating pleural effusion. The multiloculated nature of the effusion is not visualized.
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Figure 13a. Adhesive pleural thickening and fibrosis in a child with empyema. One week after thoracotomy, no more fluid was drained. (a) Chest radiograph shows a bandlike, pleural area of increased opacity along the left lateral chest wall. The question was whether this finding represented fluid that could be drained by repositioning the thoracotomy tube. (b) Transverse US scan shows thick, echogenic plaque filling the pleural space. In this situation, thoracotomy is no longer effective.
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Figure 13b. Adhesive pleural thickening and fibrosis in a child with empyema. One week after thoracotomy, no more fluid was drained. (a) Chest radiograph shows a bandlike, pleural area of increased opacity along the left lateral chest wall. The question was whether this finding represented fluid that could be drained by repositioning the thoracotomy tube. (b) Transverse US scan shows thick, echogenic plaque filling the pleural space. In this situation, thoracotomy is no longer effective.
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Figure 14a. Opaque hemithorax due to massive pleural effusion caused by pleural metastases in a 4-year-old boy. (a) Chest radiograph shows complete opacification of the right hemithorax. (b) Longitudinal US scan shows a massive pleural effusion containing echogenic masses (M). The patient had undergone left nephrectomy due to Wilms tumor, and the echogenic masses were metastases.
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Figure 14b. Opaque hemithorax due to massive pleural effusion caused by pleural metastases in a 4-year-old boy. (a) Chest radiograph shows complete opacification of the right hemithorax. (b) Longitudinal US scan shows a massive pleural effusion containing echogenic masses (M). The patient had undergone left nephrectomy due to Wilms tumor, and the echogenic masses were metastases.
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Figure 15a. Normal but prominent thymus simulating a mediastinal mass in a 5-month-old boy. (a) Chest radiograph shows a masslike area of increased opacity on the left side of the superior mediastinum. (b) Transverse US scan inclined to the left shows a normal left thymic lobe (T) with a round configuration. A = aorta.
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Figure 15b. Normal but prominent thymus simulating a mediastinal mass in a 5-month-old boy. (a) Chest radiograph shows a masslike area of increased opacity on the left side of the superior mediastinum. (b) Transverse US scan inclined to the left shows a normal left thymic lobe (T) with a round configuration. A = aorta.
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Figure 16a. Apical pulmonary consolidation mimicking a prominent thymus in a neonate with mild respiratory distress. (a) Chest radiograph shows a homogeneous area of increased opacity in the left upper lobe. The question was whether this area of increased opacity represented a normal but prominent thymus or a mediastinal mass or lung lesion. (b) Transverse US scan shows a triangular region of echogenic lung (L), which is sharply separated from a normal thymus (T). ST = sternum.
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Figure 16b. Apical pulmonary consolidation mimicking a prominent thymus in a neonate with mild respiratory distress. (a) Chest radiograph shows a homogeneous area of increased opacity in the left upper lobe. The question was whether this area of increased opacity represented a normal but prominent thymus or a mediastinal mass or lung lesion. (b) Transverse US scan shows a triangular region of echogenic lung (L), which is sharply separated from a normal thymus (T). ST = sternum.
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Figure 17a. Herniation of the thymus into the anterior chest wall due to a manubrial defect. (a, b) Photographs show a neonate with an intermittently bulging mass (arrow in b) during crying. (c) Transverse US scan of a typical neonate shows the normal configuration of the ventral margin of the thymus (T), the manubrium (M), and assorted ribs (R). Manubrial ossification produces posterior acoustic shadowing through the midportion of the thymus. A = aorta. (d) Transverse US scan of the neonate with the bulging mass shows the thymus (T) herniating through a manubrial defect (arrows). The posterior acoustic shadowing produced by manubrial ossification is not seen. Assorted ribs (R) are widely separated. A = aorta.
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Figure 17b. Herniation of the thymus into the anterior chest wall due to a manubrial defect. (a, b) Photographs show a neonate with an intermittently bulging mass (arrow in b) during crying. (c) Transverse US scan of a typical neonate shows the normal configuration of the ventral margin of the thymus (T), the manubrium (M), and assorted ribs (R). Manubrial ossification produces posterior acoustic shadowing through the midportion of the thymus. A = aorta. (d) Transverse US scan of the neonate with the bulging mass shows the thymus (T) herniating through a manubrial defect (arrows). The posterior acoustic shadowing produced by manubrial ossification is not seen. Assorted ribs (R) are widely separated. A = aorta.
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Figure 17c. Herniation of the thymus into the anterior chest wall due to a manubrial defect. (a, b) Photographs show a neonate with an intermittently bulging mass (arrow in b) during crying. (c) Transverse US scan of a typical neonate shows the normal configuration of the ventral margin of the thymus (T), the manubrium (M), and assorted ribs (R). Manubrial ossification produces posterior acoustic shadowing through the midportion of the thymus. A = aorta. (d) Transverse US scan of the neonate with the bulging mass shows the thymus (T) herniating through a manubrial defect (arrows). The posterior acoustic shadowing produced by manubrial ossification is not seen. Assorted ribs (R) are widely separated. A = aorta.
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Figure 17d. Herniation of the thymus into the anterior chest wall due to a manubrial defect. (a, b) Photographs show a neonate with an intermittently bulging mass (arrow in b) during crying. (c) Transverse US scan of a typical neonate shows the normal configuration of the ventral margin of the thymus (T), the manubrium (M), and assorted ribs (R). Manubrial ossification produces posterior acoustic shadowing through the midportion of the thymus. A = aorta. (d) Transverse US scan of the neonate with the bulging mass shows the thymus (T) herniating through a manubrial defect (arrows). The posterior acoustic shadowing produced by manubrial ossification is not seen. Assorted ribs (R) are widely separated. A = aorta.
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Figure 18a. Mediastinal lymphangioma involving the thymus in a 7-day-old neonate with mild respiratory distress. (a) Chest radiograph shows a full and enlarged mediastinal silhouette. (b) Transverse US scan shows multiple cysts replacing the whole thymus, which is a typical finding of cystic lymphangioma. The septa and the multicystic nature of the lesion were not demonstrated at subsequent MR imaging. ST = sternum.
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Figure 18b. Mediastinal lymphangioma involving the thymus in a 7-day-old neonate with mild respiratory distress. (a) Chest radiograph shows a full and enlarged mediastinal silhouette. (b) Transverse US scan shows multiple cysts replacing the whole thymus, which is a typical finding of cystic lymphangioma. The septa and the multicystic nature of the lesion were not demonstrated at subsequent MR imaging. ST = sternum.
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Figure 19. Enlarged thymus due to leukemic infiltration (acute lymphoblastic leukemia, T-cell type). Transverse US scan obtained with a suprasternal approach shows a lobulated thymic contour (arrows) with heterogeneous echotexture (see Fig 15b).
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Figure 20a. Langerhans cell histiocytosis of the thymus in a 1-year-old boy. (a) Chest radiograph shows widening of the anterosuperior mediastinum with a fuzzy margin. (b) Inclined transverse US scan obtained with a parasternal approach shows heterogeneous echotexture of the thymus (short arrows). The thymus contains discrete echogenic nodules (long arrows), which represent calcifications. A = aorta, S = superior vena cava. (c) Contrast-enhanced CT scan obtained at the level of the aortic arch shows an anterior mediastinal mass containing irregular hypoattenuating areas and punctate calcifications.
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Figure 20b. Langerhans cell histiocytosis of the thymus in a 1-year-old boy. (a) Chest radiograph shows widening of the anterosuperior mediastinum with a fuzzy margin. (b) Inclined transverse US scan obtained with a parasternal approach shows heterogeneous echotexture of the thymus (short arrows). The thymus contains discrete echogenic nodules (long arrows), which represent calcifications. A = aorta, S = superior vena cava. (c) Contrast-enhanced CT scan obtained at the level of the aortic arch shows an anterior mediastinal mass containing irregular hypoattenuating areas and punctate calcifications.
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Figure 20c. Langerhans cell histiocytosis of the thymus in a 1-year-old boy. (a) Chest radiograph shows widening of the anterosuperior mediastinum with a fuzzy margin. (b) Inclined transverse US scan obtained with a parasternal approach shows heterogeneous echotexture of the thymus (short arrows). The thymus contains discrete echogenic nodules (long arrows), which represent calcifications. A = aorta, S = superior vena cava. (c) Contrast-enhanced CT scan obtained at the level of the aortic arch shows an anterior mediastinal mass containing irregular hypoattenuating areas and punctate calcifications.
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Figure 21a. Mediastinal tuberculous lymphadenopathy in a 6-month-old boy with coughing and fever. (a) Chest radiograph shows an ill-defined area of increased opacity in the right upper lobe, which persisted despite antibiotic therapy. Obvious narrowing of the right intermediate bronchus may suggest mediastinal lymphadenopathy, but the question was whether the area of increased opacity represented pneumonic consolidation. (b) Transverse US scan obtained with a right parasternal approach shows multiple enlarged, hypoechoic lymph nodes (N) and a partly compressed brachiocephalic vein (BV). (c) Contrast-enhanced CT scan obtained at the level of the aortic arch (A) and brachiocephalic vein (B) shows markedly enlarged, conglomerated nodes with central low attenuation and peripheral rim enhancement, which reflect caseous necrosis. Note the compression of the brachiocephalic vein (arrow).
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Figure 21b. Mediastinal tuberculous lymphadenopathy in a 6-month-old boy with coughing and fever. (a) Chest radiograph shows an ill-defined area of increased opacity in the right upper lobe, which persisted despite antibiotic therapy. Obvious narrowing of the right intermediate bronchus may suggest mediastinal lymphadenopathy, but the question was whether the area of increased opacity represented pneumonic consolidation. (b) Transverse US scan obtained with a right parasternal approach shows multiple enlarged, hypoechoic lymph nodes (N) and a partly compressed brachiocephalic vein (BV). (c) Contrast-enhanced CT scan obtained at the level of the aortic arch (A) and brachiocephalic vein (B) shows markedly enlarged, conglomerated nodes with central low attenuation and peripheral rim enhancement, which reflect caseous necrosis. Note the compression of the brachiocephalic vein (arrow).
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Figure 21c. Mediastinal tuberculous lymphadenopathy in a 6-month-old boy with coughing and fever. (a) Chest radiograph shows an ill-defined area of increased opacity in the right upper lobe, which persisted despite antibiotic therapy. Obvious narrowing of the right intermediate bronchus may suggest mediastinal lymphadenopathy, but the question was whether the area of increased opacity represented pneumonic consolidation. (b) Transverse US scan obtained with a right parasternal approach shows multiple enlarged, hypoechoic lymph nodes (N) and a partly compressed brachiocephalic vein (BV). (c) Contrast-enhanced CT scan obtained at the level of the aortic arch (A) and brachiocephalic vein (B) shows markedly enlarged, conglomerated nodes with central low attenuation and peripheral rim enhancement, which reflect caseous necrosis. Note the compression of the brachiocephalic vein (arrow).
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Figure 22a. Incidentally discovered ganglioneuroblastoma in a 1-year-old boy. (a) Chest radiograph shows a juxtaphrenic paravertebral mass (arrow). (b) Transverse US scan obtained with a subxiphoid approach shows an egg-shaped hypoechoic mass (arrows) containing echogenic dots attached to a vertebra (V). Subsequent CT showed that the hyperechoic dots were calcifications.
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Figure 22b. Incidentally discovered ganglioneuroblastoma in a 1-year-old boy. (a) Chest radiograph shows a juxtaphrenic paravertebral mass (arrow). (b) Transverse US scan obtained with a subxiphoid approach shows an egg-shaped hypoechoic mass (arrows) containing echogenic dots attached to a vertebra (V). Subsequent CT showed that the hyperechoic dots were calcifications.
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Figure 23a. Incidentally discovered neurenteric cyst in a 13-year-old girl. (a) Chest radiograph shows a well-defined mass. The question was whether the mass was in the lung or the mediastinum. Subtle thoracic scoliosis is seen. (b) Transverse US scan shows a fluid-filled cyst attached to a vertebra (V). On the basis of the location and cystic nature of the lesion, a diagnosis of posterior mediastinal enteric or neurenteric cyst was suggested.
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Figure 23b. Incidentally discovered neurenteric cyst in a 13-year-old girl. (a) Chest radiograph shows a well-defined mass. The question was whether the mass was in the lung or the mediastinum. Subtle thoracic scoliosis is seen. (b) Transverse US scan shows a fluid-filled cyst attached to a vertebra (V). On the basis of the location and cystic nature of the lesion, a diagnosis of posterior mediastinal enteric or neurenteric cyst was suggested.
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Figure 24a. Osteomyelitis of a rib in a 10-day-old neonate. (a) Chest radiograph shows a masslike area of increased opacity in the middle of the left lung. (b) Longitudinal US scan obtained along a rib shows a focal area of punched-out bone destruction (solid arrows), with a large anechoic mass (open arrows) projecting toward the lung. US-guided aspiration of the anechoic area yielded pus, and the diagnosis of staphylococcal osteomyelitis was established.
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Figure 24b. Osteomyelitis of a rib in a 10-day-old neonate. (a) Chest radiograph shows a masslike area of increased opacity in the middle of the left lung. (b) Longitudinal US scan obtained along a rib shows a focal area of punched-out bone destruction (solid arrows), with a large anechoic mass (open arrows) projecting toward the lung. US-guided aspiration of the anechoic area yielded pus, and the diagnosis of staphylococcal osteomyelitis was established.
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Copyright © 2000 by the Radiological Society of North America.
