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Aspiration Diseases: Findings, Pitfalls, and Differential Diagnosis¹

¹ From the Department of Radiology, Hospital de Sant Pau, Universidad Autónoma de Barcelona, Avda San Antonio Maria Claret 168, Barcelona 08125, Spain. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received April 1, 1999; revision requested May 7 and final revision received December 20; accepted December 22. Address reprint requests to T.F. (e-mail: 19429tfc@comb.es).

View larger version (111K): [in a new window]   Figure 1.   Tracheoesophageal fistula in a 3-day-old infant with respiratory difficulty after feeding. Barium esophagogram clearly depicts a fistula between the trachea and the midesophagus (arrowhead). Opaque contrast material is seen filling the bronchi of the right lower lobe.

View larger version (106K): [in a new window]   Figure 2.   Postradiation pulmonary-esophageal fistula in a 65-year-old man with advanced esophageal carcinoma. Contrast-enhanced fluoroscopic image from a barium study reveals a fistula between the esophagus and the lung parenchyma. Note the retrograde alveolar filling by contrast material.

View larger version (101K): [in a new window]   Figure 3.   Obstructive air trapping in a 6-year-old boy. Expiratory chest radiograph demonstrates a metallic foreign body in the right lower lobe bronchus (arrowheads). Air trapping is seen in the right lower lobe.

View larger version (115K): [in a new window]   Figure 4.   Obstructive atelectasis in a 10-year-old boy who had aspirated vegetable matter. Posteroanterior chest radiograph shows complete collapse of the left lung. A posteroanterior chest radiograph obtained after bronchoscopic removal of the aspirated material (not shown) appeared normal.

View larger version (133K): [in a new window]   Figure 5.   Foreign body aspiration in an asymptomatic 13-year-old boy. CT scan shows a pulmonary mass in the right lower lobe with surrounding ground-glass attenuation due to bloody intraalveolar material. The aspirate proved to be vegetable matter at surgery.

View larger version (115K): [in a new window]   Figure 6.   Pseudotumoral left hilar mass in a 52-year-old man with hemoptysis. CT scan shows a large, solid mass in the left hilar region associated with left lower lobe collapse. A bronchogenic carcinoma was suspected. Surgery revealed a pistachio nut surrounded by a significant chronic inflammatory reaction.

View larger version (100K): [in a new window]   Figure 7a.   Acute aspiration pneumonia (Mendelson syndrome) in a 68-year-old man who had undergone surgery for intestinal obstruction. (a) Anteroposterior chest radiograph obtained less than 2 hours after surgery demonstrates a focal consolidation in the right lower lobe, a finding that is consistent with aspiration pneumonia. (b) Anteroposterior chest radiograph obtained 24 hours later shows the development of extensive bilateral air-space consolidation, a finding that is typical of acute pulmonary edema.

View larger version (112K): [in a new window]   Figure 7b.   Acute aspiration pneumonia (Mendelson syndrome) in a 68-year-old man who had undergone surgery for intestinal obstruction. (a) Anteroposterior chest radiograph obtained less than 2 hours after surgery demonstrates a focal consolidation in the right lower lobe, a finding that is consistent with aspiration pneumonia. (b) Anteroposterior chest radiograph obtained 24 hours later shows the development of extensive bilateral air-space consolidation, a finding that is typical of acute pulmonary edema.

View larger version (92K): [in a new window]   Figure 8.   Near drowning in a 46-year-old man. Anteroposterior chest radiograph obtained in the intensive care unit shows diffuse, bilateral pulmonary edema.

View larger version (149K): [in a new window]   Figure 9.   Acute fire-eater pneumonia in a 21-year-old man who had aspirated petroleum during a performance. Posteroanterior chest radiograph shows ill-defined nodular areas of increased opacity in both lower lobes (arrows).

View larger version (135K): [in a new window]   Figure 10a.   Lipoid pneumonia in a 56-year-old man with cough and fever who had undergone laryngectomy. (a) Posteroanterior chest radiograph demonstrates a loculated pleural collection and bilateral, ill-defined parenchymal areas of increased opacity. (b) Chest CT scan (lung window) shows ground-glass attenuation in the left lower lobe. (c) CT scan (mediastinal window) demonstrates segmental consolidation with fat attenuation values (-40 HU) in the right lower lobe (arrows). (Courtesy of Josep M. Mata, MD, Unidad Diagnóstica Alta Tecnología, Sabadell, Spain.)

View larger version (116K): [in a new window]   Figure 10b.   Lipoid pneumonia in a 56-year-old man with cough and fever who had undergone laryngectomy. (a) Posteroanterior chest radiograph demonstrates a loculated pleural collection and bilateral, ill-defined parenchymal areas of increased opacity. (b) Chest CT scan (lung window) shows ground-glass attenuation in the left lower lobe. (c) CT scan (mediastinal window) demonstrates segmental consolidation with fat attenuation values (-40 HU) in the right lower lobe (arrows). (Courtesy of Josep M. Mata, MD, Unidad Diagnóstica Alta Tecnología, Sabadell, Spain.)

View larger version (117K): [in a new window]   Figure 10c.   Lipoid pneumonia in a 56-year-old man with cough and fever who had undergone laryngectomy. (a) Posteroanterior chest radiograph demonstrates a loculated pleural collection and bilateral, ill-defined parenchymal areas of increased opacity. (b) Chest CT scan (lung window) shows ground-glass attenuation in the left lower lobe. (c) CT scan (mediastinal window) demonstrates segmental consolidation with fat attenuation values (-40 HU) in the right lower lobe (arrows). (Courtesy of Josep M. Mata, MD, Unidad Diagnóstica Alta Tecnología, Sabadell, Spain.)

View larger version (134K): [in a new window]   Figure 11.   Exogenous lipoid pneumonia in a 54-year-old woman with mild dyspnea. Thin-section (2-mm-collimation) CT scan through the lung bases (lung window) shows patchy areas of increased attenuation and thickened interlobular septa in both lower lobes. Note the characteristic crazy-paving pattern. (Reprinted, with permission, from reference 5.)

View larger version (113K): [in a new window]   Figure 12.   Postaspiration necrotizing bronchopneumonia in a 53-year-old alcoholic man. CT scan demonstrates confluent alveolar areas of increased attenuation in the right lower lobe with associated cavitation (arrowheads) and pleural effusion. A small focus of aspiration is also visible in the left lower lobe.

View larger version (151K): [in a new window]   Figure 13a.   Periodontal disease in a 42-year-old alcoholic man with fever, putrid sputum, and pyorrhea. (a) Posteroanterior chest radiograph shows bilateral, ill-defined, rounded areas of increased opacity with associated cavitation (arrowhead). (b) Thin-section CT scan demonstrates multiple solid as well as cavitary nodules. Note the presence of thick-walled cavities surrounded by ground-glass attenuation.

View larger version (158K): [in a new window]   Figure 13b.   Periodontal disease in a 42-year-old alcoholic man with fever, putrid sputum, and pyorrhea. (a) Posteroanterior chest radiograph shows bilateral, ill-defined, rounded areas of increased opacity with associated cavitation (arrowhead). (b) Thin-section CT scan demonstrates multiple solid as well as cavitary nodules. Note the presence of thick-walled cavities surrounded by ground-glass attenuation.

View larger version (125K): [in a new window]   Figure 14.   Squamous cell carcinoma in a 58-year-old man who had undergone laryngectomy. Frontal radiograph shows a cavitary lesion in the posterior segment of the left upper lobe. A presumptive diagnosis of pulmonary abscess was made. Response to appropriate antibiotic therapy was poor, and surgery was performed. At histologic analysis, a cavitated squamous cell carcinoma was diagnosed.

View larger version (135K): [in a new window]   Figure 15a.   Lentil aspiration pneumonia in a 54-year-old man with esophageal stricture. (a) Posteroanterior chest radiograph shows basilar, 3-5-mm pulmonary nodules. Biapical pleuroparenchymal areas of increased opacity are also seen, findings that are consistent with radiation changes. (b) CT scan through the upper lungs demonstrates scattered, poorly defined pulmonary nodules up to 10 mm in diameter. (c) CT scan through the lung bases shows diffuse, 1-3-mm centrilobular nodules and branching areas of increased attenuation with a "tree-in-bud" appearance. (Reprinted, with permission, from reference 40.)

View larger version (126K): [in a new window]   Figure 15b.   Lentil aspiration pneumonia in a 54-year-old man with esophageal stricture. (a) Posteroanterior chest radiograph shows basilar, 3-5-mm pulmonary nodules. Biapical pleuroparenchymal areas of increased opacity are also seen, findings that are consistent with radiation changes. (b) CT scan through the upper lungs demonstrates scattered, poorly defined pulmonary nodules up to 10 mm in diameter. (c) CT scan through the lung bases shows diffuse, 1-3-mm centrilobular nodules and branching areas of increased attenuation with a "tree-in-bud" appearance. (Reprinted, with permission, from reference 40.)

View larger version (116K): [in a new window]   Figure 15c.   Lentil aspiration pneumonia in a 54-year-old man with esophageal stricture. (a) Posteroanterior chest radiograph shows basilar, 3-5-mm pulmonary nodules. Biapical pleuroparenchymal areas of increased opacity are also seen, findings that are consistent with radiation changes. (b) CT scan through the upper lungs demonstrates scattered, poorly defined pulmonary nodules up to 10 mm in diameter. (c) CT scan through the lung bases shows diffuse, 1-3-mm centrilobular nodules and branching areas of increased attenuation with a "tree-in-bud" appearance. (Reprinted, with permission, from reference 40.)

View larger version (133K): [in a new window]   Figure 16a.   Aspiration bronchiolitis in a 68-year-old man with Zenker diverticulum. (a) CT scan demonstrates a large, posterior esophageal diverticulum in the superior mediastinum. Note the characteristic air-fluid level. (b) CT scan obtained at a lower level demonstrates multiple patchy, ill-defined parenchymal areas of increased attenuation. Note the reticular pattern of the posterobasal lesions.

View larger version (144K): [in a new window]   Figure 16b.   Aspiration bronchiolitis in a 68-year-old man with Zenker diverticulum. (a) CT scan demonstrates a large, posterior esophageal diverticulum in the superior mediastinum. Note the characteristic air-fluid level. (b) CT scan obtained at a lower level demonstrates multiple patchy, ill-defined parenchymal areas of increased attenuation. Note the reticular pattern of the posterobasal lesions.

View larger version (111K): [in a new window]   Figure 17.   Diffuse aspiration bronchiolitis in a 61-year-old woman with achalasia and recurrent aspiration of foreign particles. Thin-section CT scan shows multiple diffuse centrilobular areas of increased attenuation with a characteristic tree-in-bud appearance. Esophageal dilatation with an air-fluid level is also seen.

View larger version (122K): [in a new window]   Figure 18a.   Gastric aspiration and constrictive bronchiolitis in a 68-year-old woman with achalasia. (a) Posteroanterior chest radiograph shows a hyperlucent zone in the right lower lobe with associated volume loss and a reduced number of lung vessels (arrowheads). (b) Prone expiratory CT scan shows decreased attenuation in the right lower lobe. The size and number of vessels are reduced. These findings are consistent with the presence of bronchiolar inflammatory disease with air trapping.

View larger version (119K): [in a new window]   Figure 18b.   Gastric aspiration and constrictive bronchiolitis in a 68-year-old woman with achalasia. (a) Posteroanterior chest radiograph shows a hyperlucent zone in the right lower lobe with associated volume loss and a reduced number of lung vessels (arrowheads). (b) Prone expiratory CT scan shows decreased attenuation in the right lower lobe. The size and number of vessels are reduced. These findings are consistent with the presence of bronchiolar inflammatory disease with air trapping.