Mediastinal shift to the affected side. Median Shadow Offsets

Part 2.

Displacement of the trachea or mediastinal shadow

The trachea can be retracted or displaced, usually only three pathological processes are the cause of this (with two it is displaced, with one it is delayed). With an effusion in the right pleural cavity, the trachea and mediastinum will be displaced to the left - to the healthy side (Fig. 2). We will see the same thing with a left-sided tension pneumothorax - the mediastinum will be shifted to the right, since the air sharply increases the pressure in the left pleural cavity (Fig. 3).

Figure 2. Right-sided pleural effusion

Figure 3. Left-sided tension pneumothorax with shear
mediastinum to the right (the collapsed lung is indicated by the arrow)

Figure 4. Atelectasis of the lower lobe of the left lung (arrow)
with mediastinal shift to the left

On the other hand, if there is a collapse of the lung tissue, for example, on the left, then the collapsed lung will pull the trachea and mediastinum along with it to the left - that is, to the diseased side (Fig. 4). Many pathological processes (for example, compaction of the lung tissue, non-tensioned pneumothorax, and others) have practically no effect on the position of the mediastinum. If you see a shift in the mediastinum, then you need to think about three conditions (pleural effusion, tension pneumothorax and atelectasis) and look for signs of them.

Increasing the size of the shadow of the heart

Figure 5. Left ventricular failure

The most common cause of an increase in the size of the shadow of the heart is congestive heart failure, so look for signs of left ventricular failure in the picture (Fig. 5):

Strengthening of the lung pattern due to veins, especially in the upper sections
Kerley's lines of type B. These are thin horizontal lines in the peripheral regions of the lungs, which are typical of volume overload of the interstitium.
The roots are enlarged and look like "butterfly wings".
Reduced transparency of the lung tissue - in severe pulmonary edema, fluid is not only in the interstitium, but also in the alveoli, so you will see "spotty" shading and possibly an air bronchogram (that is, against the background of shading of the lung tissue, transparent bronchi filled with air are visible.

Left ventricular failure with normal heart size occurs in a few conditions - this is acute myocardial infarction (sudden development of left ventricular failure) or with cancerous lymphangitis.

Enlargement of the roots of the lungs

This may be a sign of the pathology of any structure located in the roots of the lungs.

Figure 6. Idiopathic pulmonary hypertension.

Figure 7. Cancer of the left main bronchus (arrow)

Figure 8. Bilateral zoom lymph nodes
lung roots (arrows) due to sarcoidosis

Pulmonary artery - e.g. pulmonary arterial hypertension due to pathology mitral valve, chronic thromboembolism pulmonary artery or primary pulmonary hypertension (Figure 6)
The main bronchus is the central lung cancer (Fig. 7).
Swollen lymph nodes - caused by infection, such as in tuberculosis, metastases lung tumors, lymphoma, or sarcoidosis (Figure 8).

№1. What is the maximum allowable dose for HD patients per year?

No. 2. What are the total doses used in the radical treatment of malignant tumors of low radiosensitivity.

№3. What x-ray symptoms are typical for multiple myeloma?

1. Multiple rounded destructions in flat bones*.

2. Widespread diffuse osteoporosis.

3. Multiple periosteal reactions.

4. Penetrating sequesters.

5. Multiple swellings in short tubular bones.

No. 4. What changes can be observed on the radiograph in the initial period of development of rheumatoid arthritis?

1. Linear periostitis.

2. Narrowing of the x-ray joint space.*

3. Small marginal destruction in the area of the articular surfaces.

4. All of the above x-ray symptoms.

5. Usually no change.

№5. A sign of slit-like enlightenment at the upper pole of a rounded, clearly defined shadow is typical for:

1. Decaying peripheral cancer

2. Solitary air cyst complicated by inflammation

3. Tuberculomas

4. Echinococcal cyst*

№6. What radiological symptoms are typical for a stomach polyp?

1. Fold convergence

2. Filling defect with a niche in the center

3. Round filling defect with a smooth contour*

4. Symptom of breakage of folds at the border with filling defect.

№7. Is darkening typical for lobar pneumonia in the infiltration phase?

1. Heterogeneous

2. Low intensity

3. Focal

4. Intense*

№8. The shift of the shadow of the mediastinum towards the lesion is typical for:

1. Exudative pleurisy

2. Croupous pneumonia

3. Cirrhosis of the lung *

4. Hydropneumothorax

5. Pneumothorax

№9. In what disease is calcification observed along the edge-forming contours of the heart?

1. Mitral stenosis

2. Myocarditis

3. Adhesive pericarditis*

4. Hydropericardium.

№10. What early radiation reactions from the skin are acceptable during radiation therapy?

1. Skin atrophy,

2. Erythema*

3. Radiation fibrosis of the subcutaneous tissue,

4. Wet radioepidermitis

5. Dry radiodermatitis*

№11. What bone landmarks make it possible to more reliably judge the position of the kidneys?

2. Upper edges of the ilium

3. Transverse processes of the bodies of the lumbar vertebrae*

4. M obvious process.

No. 12. Which method of X-ray examination allows better assessment of the functional state of organs chest?

1. Fluoroscopy*

2. Radiography

3. Tomography

4. Bronchography

№13. Diagnosis on the Hounsfield scale is used in the method:

2. Linear tomography

4. Computed tomography.*

No. 14. What is the total focal dose in the treatment of degenerative diseases of the osteoarticular apparatus (arthritis, osteochondrosis)?

No. 15. What methods radiodiagnosis should be done first of all to a patient with acute renal colic?

1. Panoramic fluoroscopy of the abdominal cavity

2. X-ray *

5. Retrograde pyelography

№1. What radiographic symptoms are typical for the prespondylitis (stage I) phase of spinal tuberculosis?

1. Wedge-shaped deformation of bodies 2-3 X vertebrae that are close to each other.

2. Foci of destruction in the vertebral body and a decrease in the height of the intervertebral disc. *

3. Shadow of the swell abscess at the level of the affected 3-4 X vertebrae.

4. Destruction in the vertebrae and the formation of kyphosis at the level of the lesion.

№2. What method of x-ray examination of the colon is most effective for detecting tumors?

Tight filling of barium suspension

Double contrast *

Oral examination of the colon with barium suspension

Oral examination of the colon with water-soluble drugs.

Number 3. What method of radiation diagnostics allows to study the morphological features of the ureters

Excretory urography

Scintigraphy

Retrograde pyelography*

№4. Benign lung tumors are characterized by:

1. Multiplicity of lesions

2. Sharp contours*

3. Increase in size in a short period of observation

4. Enlargement of broncho-pulmonary lymph nodes

No. 5. What lymph nodes can be seen on x-ray:

1. Bronchopulmonary

2. Paratracheal

3. Tracheobronchial

4. Everyone is visible

5. All invisible *

№6. What is the best technique to study an aneurysm or narrowing of the aorta?

1. Radiography

2. Tomography

3. X-ray kymography

4. Angiography *

№7. You suspect that the shadow on the x-ray is patchy. Which radiologistscal methods of radiation diagnostics allow you to confirm or reject yourassumption?

Bronchography

Tomography*

Magnetic resonance imaging

Angiography

CT scan.*

№8. What method of radiation diagnostics is most often used to study patients with nodular goiter?

1. Radiography in 2 projections

2. Thermography

5. Angiography

No. 9. What is the maximum allowable dose for BD patients per year?

№10. Which of the following tumors is the most radiosensitive?

1. Skin melanoma

2. Squamous cell carcinoma of the tonsil

3. Malignant mediastinal lymphoma*

4. Adenocarcinoma of the stomach

5. Osteosarcoma

No. 11. Which of the proposed methods of long-distance therapy is best used in the treatment of central lung cancer?

1. Interstitial

2. Single field static

3. Multifield static*

4. Tangential

No. 12. What total doses are used in the radical treatment of malignant tumors with high dose radiosensitivity:

1. 15-20 Gy per hearth

№13. Which of the following shadows is non-uniform?

basal
segmental
spherical
annular*.

№14. What disease causes usuration of the lower contours of the ribs?

1. Mitral defect

2. Mitral valve insufficiency

3. Non-closure of the interventricular septum

4. Coarctation of the aorta *

№ 15. Mediastinal shift to the healthy side is observed when:

1. Acute pneumonia

2. Lung cancer

3. Exudative pleurisy *

4. Fibrothorax

№ 1. Specify which of the X-ray signs is not typical for malignant bone tumors?

1. Destruction

2. Visor-like periostosis

3. Heterogeneous bone structure

4. Spiculous periostosis

5. Linear periostitis *

№ 2. Effusive pleurisy is characterized by:

№3.

1. Bleeding

2. Penetrations

3. Perforations;

4. Malignancy*

5. Cicatricial deformity.

No. 4. What causes the horizontal level of fluid in the pleural cavity?

1. The amount of liquid

2. The nature of the effusion

3. The presence of gas in the pleural cavity *

4. Pleural adhesions.

№5. What is not aboutThe main purpose of preliminary preparation before intravenous urography:

Removal of gases from the intestines

Removal of feces from the intestines

Elimination of soreness of the study *

№6. A jerky displacement of the mediastinal organs with a deep breath in the direction of the lesion is observed with:

1. Atelectasis*

2. Cirrhosis

3. Lobar pneumonia

4. Exudative pleurisy

№7. A thick-walled solitary cavity with a wavy inner and outer contour without content is characteristic of:

1. Abscessing pneumonia

2. Decaying peripheral cancer *

3. Festering cyst

4. Echinococcus with partial emptying

No. 8. The lower border of the oblique interlobar fissure on the right?

1. Anterior 4 ribs

2. Anterior section 5 ribs

3. Anterior section 6 ribs *

4. Anterior section 7 ribs

№9. What method of radiation diagnostics allows studying the liver parenchyma?

1. Ultrasound *

2. Radiography in 2 projections

3. Angiography

4. Tomography

№10. What bone tumor is characterized by the appearance of "cauliflower"?

1. Osteogenic sarcoma

2. Ewing's sarcoma

3. Osteochondroma *

4. Compact osteoma

5. Hemangioma

№11.

1. Small

2. Medium

3. Large *

4. The esophagus does not deviate

№12. The structure of the pathological shadow in the lung in differential diagnosis:

Doesn't matter

Only relevant in combination with shadow sizes

It has a very relative meaning.

Significant.*

№13. Name the lines morphological symptoms stomach ulcer?

1. Symptom of the inflammatory shaft

2. Symptom "niche" *

3. Symptom "index finger"

4. Symptom "trefoil"

№14. Kfocal changes in the liver, with an anechoic structure, do not include:

2. Abscess

3. Tumor with areas of necrosis

4. Hemangioma.*

№15. Why are conventionally small total doses of 0.3-1.0 Gy used in radiation therapy?

1. Treatment of tumors with high radiosensitivity

2. Treatment of acute inflammatory diseases *

3. Treatment of eczema

4. Treatment of arthrosis of the knee joint.

№1. What X-ray sign is not typical for osteoma?

3. Bone formation with visor periostosis.*

4. Significant compaction of the bone in the area of the tumor.

5. Bone formation on a wide base without periosteal reaction.

№2. What method is used to study the external fistula in pleural empyema?

1. Fistulography *

2. Bronchography

4. Tomography

5. Radiography in 2 projections.

№3. K Which symptom is most characteristic on a plain radiograph of the abdominal cavity, with a thin intestinal obstruction?

1. Clowber's bowls of the central parts of the abdominal cavity *

2. Absence of gas along the colon

3. Limiting the mobility of the domes of the diaphragm

Presence of free gas under diaphragm domes

Small horizontal levels mainly along the periphery of the abdominal cavity.

№4. Which kidney shadow is located higher on urograms?

3. Both kidneys are located on the same level.

№5. an elliptical displacement of the mediastinal organs with a deep breath in the direction of the lesion is observed with:

1. Atelectasis*

2. Cirrhosis

3. Lobar pneumonia

4. Exudative pleurisy

No. 6. The upper border of the oblique interlobar fissure on the right?

1. 1 thoracic vertebra

2. 2nd thoracic vertebra

3. 5th-6th thoracic vertebra

4. 3-4 thoracic vertebra *

№7. At what defect the left ventricle is often not enlarged in size?

1. Coarctation of the aorta

2. Ventricular septal defect

3. Mitral stenosis *

4. Stenosis of the aortic valve

№8.

radiography

fluorography

X-ray with fluorescent screen*

fluoroscopy with URI.

№9. In what projections is an image obtained with CT:

1. Frontal

2. Horizontal

3. Sagittal

4. Axial

5. In all projections *

№10. What is the maximum allowable dose for patients in the categoryHELLin year?

No. 11. Which of the following tissues is the most radiosensitive?

1. Central nervous system

2. Gastric mucosa

3. Red bone marrow*

5. Bladder mucosa

№12. Which of the proposed methods is better to use in the treatment of basilioma (basal cell carcinoma) of the skin?

1. telegammatherapy

2. intracavitary

3. close-focus X-ray therapy*

4. megavolt long-distance therapy

№13. What does tissue radiosensitivity depend on?

1. from the volume of tissue

2. from the blood supply

3. on the degree of cell differentiation*

4. on the rate of growth (division) of cells

No. 14. Blackout in croupous pneumonia?

1. Ring-shaped

2. Triangular

3. Low intensity

4. Heterogeneous

5. Intense *

№fifteen. "A three-layer "ulcerous niche in the stomach indicates:

1. Perforation

2. Malignancy

3. Penetration *

4. Bleeding

5. Scarring of the ulcer.

№1. What X-ray sign is typical for osteogenic sarcoma?

1. Bone formation with a clear contour.

2. Bone formation of a spongy structure with a wavy contour.

3. Bone formation with visor periostosis. *

4. Bone formation on a wide base without periosteal reaction.

№2. effusion pleurisycharacterized by:

1. The presence of air in the pleural cavity

2. Displacement of the mediastinal organs to the affected side

3. The presence of intense uniform darkening in the lower sections *

4. Depletion of the lung pattern on the opposite side

№3. What complication is not typical for duodenal ulcer?

1. Bleeding

2. Penetrations

3. Perforations

4. Malignancy *

5. Cicatricial deformity.

№4. When is antegrade pyelography used?

If retrograde pyelography is not possible*

With persistent bending of the ureter

In violation of the excretory function of the kidneys

If there is a reaction to the introduction of iodine-containing contrast agents

With unstable bending of the ureter.

№5. Multiple rounded well-defined shadows in the lower lobes of the lungs 1-3 cm in size are characteristic of:

1. Tuberculosis

2. Metastasis* 3. Pneumonia

4. Pneumoconiosis

No. 6. At the level of which rib is the horizontal interlobar fissure located?

1. Clavicle

2. 2nd rib

3. 6th rib

4. 4th rib *

№7. In what disease is the deviation of the esophagus along the arc of a small radius observed?

1. Open ductus arteriosus

2. Mitral stenosis *

3. Aortic insufficiency

4. Effusive pericarditis

№8. The greatest radiation load on the body is exerted by:

1. Radiography

2. Fluorography

3. Fluoroscopy with fluorescent screen*

4. Fluoroscopy with URI.

№9. What kindmethods X-ray diagnostics do not use x-rays:

Computed and linear tomography

Bronchography

1. Reducing the size of the liver with the presence in its structure of a hyperechoic formation with dorsal enhancement behind

2. The presence of an anechoic formation with clear, even contours and an acoustic shadow behind

3. Presence of an anechoic mass with a capsule, septa, or intracavitary inclusions*

4. The presence of a hypoechoic formation of a deforming organ contour, with blood flow during Doppler sonography.

No. 11. What is the maximum allowable dose for category B persons per year?

No. 12. What methods of dosimetry are biological?

1. Scintillation

2. Ionization

3. Method for determining lethal doses*

4. Photographic film

5. Method for determining the number of chromosome aberrations*

№13. What methods of radiation therapy are used mainly for the treatment of non-tumor diseases?

1. Contact radiation therapy

2. Interstitial radiotherapy

3. Remote X-ray therapy*

4. Megavolt radiation therapy.

No. 14. What are the total doses used in the radical treatment of malignant tumors of high dose radiosensitivity:

1. 15-20 Gy per hearth

№15. Direct action of ionizing radiation is -

1. Biosubstrate ionization*

2. Damage to the biosubstrate due to the direct action of radiation

3. Damage to the biosubstrate by the products of water radiolysis.

No. 1. What periosteal reaction is typical for osteogenic sarcomas?

1. Fringed periostitis

2. Spiculous periostosis *

3. Layered periostitis

4. Periosteal reaction is usually not observed.

5. Linear periostitis

№2. X-ray examination for liver diseases begins with:

2. Overview of the liver

3. MRI

5. Fluoroscopy

Number 3. Decompensated stenosis of the gastric outlet is characterized by:

Enhanced peristalsis

Fold atrophy

Rapid evacuation

Enlargement of the stomach in volume. *

No. 4. What radiographic features are most characteristic of chronic osteomyelitis?

1. Linear periostitis

2. Visor periostosis

3. Osteosclerosis *

4. Spotted osteoporosis

5. Penetrating sequestration*

6. Spiculous periostosis

№5. What kidney contrast technique is most often complicated by pyelorenal reflux?

Retrograde pyelography*

Intravenous urography with long-term compression of the ureters

Intravenous urography without compression of the ureters.

№6. In favor of peripheral lung cancer, the following state of the contour of the rounded shadow testifies:

1. Sharply defined, smooth

2. Unevenly wavy, bumpy *

3. Calcified

No. 7. Darkening with bronchopneumonia?

1. Uniform

2. Ring-shaped

3. Intense

4. Low intensity *

№8. What is the radius of the arc deviation of the contrasted esophagus characteristic of mitral valve insufficiency?

1. Small

2. Medium

3. Large *

4. Double

№9. X-rays are:

Directional electron flow

Electromagnetic shortwave radiation*

Mechanical oscillation of medium particles

Variable electric field.

№10. What X-ray signs are typical for hydropneumothorax:

2. Enlightenment

3. Mediastinal displacement

4. All of the above *

No. 11. What is the maximum allowable dose for people in category B per year?

3. 10 mSv *

No. 12. Which of the following tissues is the least radiosensitive?

1. Intestinal mucosa

2. Gastric mucosa

3. Red bone marrow

5. Connective tissue *

№13. Combined is a method of treating tumors using:

1. Various methods of radiotherapy*

2. Surgical and radiation methods

3. Radiation and chemotherapy

4. Surgical method and chemotherapy

№14. In what phase of cell division is the cell most radiosensitive?

1. Synthetic

2. Presynthetic

3. Mitosis*

4. Postsynthetic

№15. The "stump" of the lobar bronchus is observed when:

1. Lung cancer *

2. Lobar pneumonia

3. Bronchoectatic disease

4. Infiltrative tuberculosis

Mediastinal displacement, developing slowly, gradually, causes very little or no disturbance of cardio-vascular system. It is very important that the degree of mediastinal displacement in early period after pneumectomy was minimal, especially in elderly and frail patients.
About mediastinal displacement it is best to judge by x-ray or transillumination, for which it is necessary to subject patients to such a study in bed from the 2nd day after the operation.

In the first hours after the operation, the rate of fluid accumulation and the amount of air remaining in the pleural cavity after the wound is closed influence. The first depends on the thoroughness of hemostasis at the end of the operation, and the second depends on the inhalation or exhalation phase, during which the pleural cavity was finally closed.
With the anterior approach, the phase in which the pleural cavity closes is less important than with the posterior and posterolateral approaches.

After the deaf closing wounds, due to the accumulation of fluid in the pleural cavity, increased pressure is created, which leads to a shift of the mediastinum to the healthy side. Therefore, in the early days, it is necessary to control intrapleural pressure not only by X-ray transillumination, but also by a manometer using pleural puncture. If the manometer indicates an increase in pressure in the pleural cavity, it is necessary to pump out such an amount of fluid and air that the pressure becomes negative, approximately equal to 4-6 mmHg.
Under severe negative pressure it is necessary to pump up a little air to equalize the pressure in both pleural cavities.

We made sure that in the first 24-48 hours after pneumectomy, a large amount of fluid often accumulates in the pleural cavity, requiring pumping out. Underwater drainage in such cases is very dangerous, therefore, at the end of pneumectomy, after careful hemostasis, we sew up the pleural cavity tightly and pump out fluid from the pleura as necessary by punctures.

By using manometer we check the intrapleural pressure and, making sure that there is a sharply positive or sharply negative pressure, we either pump out the pleural contents or add air there. Even with a smooth flow, we inject penicillin into the pleural cavity at 200,000-300,000 units, and recently at 500,000 and up to 1,000,000 daily or every 1-2 days for 7-30 days, without pumping out the fluid.
With this or that complication, in particular in the formation of a bronchial fistula, we act according to the rules set out in the chapter on complications.

Some authors with aseptic course operations do without drainage, in case of violation of asepsis during the operation or in case of uncertainty in the tightness of the bronchial suture, the operation is completed by the imposition of a closed underwater drainage.

We can't count it's correct. In the presence of antibiotics, even a clear infection in the wound and in far from always ends with suppuration of the pleura, which resists infection much better than subcutaneous tissue. Most of the empyema that we observed in our clinic were not primary, but secondary from a festering surgical wound and especially from infected costal cartilages, which resist infection very poorly.
Introduction antibiotics(penicillin and streptomycin) into the pleural cavity both at the end of the operation and in the postoperative period by punctures is a good preventive measure against infection of the pleura.

Drainage is the same if it's worth it for a long time, itself is the entry gate for infection. Through the drainage, blood and plasma accumulating there flow out of the pleural cavity, which serve as a material for filling the pleural cavity in the postoperative period. The absence of this fluid leads to a very sharp displacement of the mediastinum and a rise in the diaphragm, which causes a violation of the normal activity of the heart and abdominal organs - primarily the stomach.

If after pneumectomy when coughing through the drainage, not only pleural fluid, but also air will come out, then the negative pressure formed in the pleural cavity, which has come on sharply, will lead to an acute displacement of the mediastinum and a rise in the diaphragm, and therefore, not only to the displacement of the heart, but also to the bending of the vessels with all the ensuing consequences for a patient weakened by a severe operation.

Figure 2. Right-sided pleural effusion with mediastinal shift to the left

Figure 3. Left-sided tension pneumothorax with mediastinal shift to the right (the collapsed lung is indicated by the arrow)

Figure 4. Atelectasis of the lower lobe of the left lung (arrow) with mediastinal shift to the left

Increasing the size of the shadow of the heart

Figure 5. Left ventricular failure

The most common cause of an increase in the size of the shadow of the heart is congestive heart failure, so look for signs of left ventricular failure in the picture (Fig. 5):

Strengthening of the lung pattern due to veins, especially in the upper sections

Kerley's lines of type B. These are thin horizontal lines in the peripheral regions of the lungs, which are typical of volume overload of the interstitium.

The roots are enlarged and look like "butterfly wings".

Reduced transparency of the lung tissue - in severe pulmonary edema, fluid is not only in the interstitium, but also in the alveoli, so you will see "spotty" shading and possibly an air bronchogram (that is, against the background of shading of the lung tissue, transparent bronchi filled with air are visible.

Left ventricular failure with normal heart size occurs in a few conditions - this is acute myocardial infarction (sudden development of left ventricular failure) or with cancerous lymphangitis.

Enlargement of the roots of the lungs

This may be a sign of the pathology of any structure located in the roots of the lungs.

Figure 6. Idiopathic pulmonary hypertension.

Figure 7. Cancer of the left main bronchus (arrow)

Figure 8 Bilateral hilar lymph node enlargement (arrows) due to sarcoidosis

Pulmonary artery - for example, pulmonary arterial hypertension due to mitral valve disease, chronic pulmonary embolism, or primary pulmonary hypertension (Figure 6)

main bronchus - central cancer lung (Fig. 7).

Swollen lymph nodes - caused by infection, such as tuberculosis, lung tumor metastases, lymphoma, or sarcoidosis (Figure 8).