PLEURAL DISESASES

Anatomy
• The pleura is the serous membrane which
covers the surface of the lung and lines the
inner surface of the chest wall
• The two layers of pleura are closely applied to
each other, being separated by thin layer of
lubricating pleural fluid
• The parietal pleural and the visceral pleural
over the periphery of the lung are not
normally visible radiographically
 Disease of the pleura
Disease of the pleural can be divided for
convenience into;
• Inflammatory (serofibrinous pleuritis,
suppurative pleuritis – empyema and
Hemorrhagic pleuritis
• Non inflammatory pleural effusion
(hydrothorax, Hemothorax and chylothorax)
• Neoplasm
– Primary or secondary (metastases)
 Pleural effusion
Increased accumulation of pleural fluid occurs
under five settings
• ed hydrostatic pressure as in CCF
• ed vascular permeability as in pneumonia
• ed oncotic pressure as in nephrotic
syndrome, cirrhosis of the liver
• ed intra pleural negative pressure as in
atelectasis
• ed lymphatic drainage as in mediastinum
carcimatosis
 Pleural fluid
• Fluid accumulates in the pleura space may be
transudate, exudate, pus, blood or chyle
• Hemothorax; bleeding into the pleura space is
almost always secondary to open or closed
trauma to the chest
• Chylothorax; May develop secondary to
damage or obstruction of thoracic lymphatic
vessels
 Radiological appearance of the pleural
fluid
• Free fluid; pleural fluid casts a shadow of
density of water or soft tissue on the chest
radiograph
• Small effusions may thus seen earlier on the
lateral film than on the frontal film, but it is
possible to identify effusions of only few
millimeters using decubitus views with
horizontal beam
• Typically free fluid opacity has a fairly well
defined, concave upper edge, is higher
laterally than medially and obscure the
diaphragmatic shadow
• Frequently fluid will track into the pleural
fissure
• A massive effusion may cause completely
radiopacity of hemithorax
Normal chest radiograph
 PA chest radiograph

Right pleural
effusion with well
defined meniscus
Fluid in the pleural fissure
 PA chest radiograph – massive pleural
effusion

Massive left pleural

effusion with
mediastinum
displacement to the
right
 PA chest radiography

Left massive
/large pleural
effusion with well
defined meniscus
The underlying lung will have retracted
towards its hilum, and the space
occupying effect of the effusion will
push the mediastinum towards the
opposite side
• Atypical distribution of pleural fluid is
quite common
– Lamellar effusions are shallow
collections between the lung surface
and the viscera pleura
– Subpulmonary pleural effusion (large
effusions accumulate between the
diaphragm and under surface of the
lung
 Chest X-ray showing Lamellar effusion
Grossly widened superior
mediastinal shadow,
bilateral lamellar pleural
effusions, effusion in the
right oblique fissure. Right
lamellar effusion appears
contiguous with the
widened superior
mediastinal shadow.
 Subpulmonic pleural effusion
There is a large right
basal pleural
effusion. The fluid
lies in a
subpulmonic
location. The left
pleural space is
clear.
• Loculated fluid
– Encapsulated fluid in the pleura space
– Fluid can may become loculated in one or
more of the interlobar fissure
Fluid collecting in the horizontal fissure
produces a lenticular, oval or round shadow
• Empyema
• May be suspected on plain film by the
spontaneous appearance of a fluid level
in pleural effusion, but best diagnosed by
CT
Chest radiograph showing loculated pleural
effusion
• Obliteration of left
costophrenic angle with
a wide pleural based
dome shaped opacity
projecting into the lung
noted tracking along
the CP angle and lateral
chest wall suggestive of
loculated pleural
effusion
 Pneumothorax
• Is the presence of air in the pleural cavity. Air
enters this cavity through a defect in either the
parietal or the visceral pleura
– Etiology;
1. Spontaneous pneumothorax (is the commonest
type, and typically occurs in young men, due to
rupture of congenital pleural bleb
2. Traumatic pneumothorax e.g. penetrating chest
wound, rib fracture , pleural biopsy etc.
3. Therapeutic
 Pneumothorax cont…
• Pneumothorax is commonly associated with;
– Emphysema
– Tuberculosis
– Asthma
 Radiological appearance
• A small pneumothorax in a free air in
pleural space in an erect patient collects
at the apex. The lung apex retracts
towards the hilum and on a frontal chest
film the sharp white line of the visceral
pleura will be visible, separated from the
chest wall by the radiolucent pleural
space, which is devoid of lung markings
A pneumothorax is
visible in the right lung,
beyond which there are
no lung markings. A
slight shift of the heart
and mediastinum toward
the left side indicates a
tension pneumothorax.
 Tension pneumothorax

Tension pneumothorax; May lead to

massive displacement of the
mediastinum, kinking of great veins and
acute cardiac and respiratory
embarrassment
 Large tension pheumothorax
Large right
pneumothorax, marked
contralateral shift of the
mediastinum,
hyperinflation, obvious
flattening of the right
hemidiaphragm
(suggesting some degree
of tension), and
pulmonary contusion
• Radiologically the ipsilateral lung may be squashed
against the mediastinum, or herniate across the
midline, and ipsilateral hemidiaphragm may be
depressed
• Complications;
– Hemopneumothorax or
– Pyopneumothorax
– Hydropneumothorax (associate with fluid
level)
• In small pneumothorax fluid level may be the most
obvious radiological sign
There is a large right
hydropneumothorax with
collapse of the underlying
lung and displacement of
the mediastinum towards
the left.
Chest X-ray on admission:
the air–fluid level in the
posterior aspect of the
right chest
 Bronchopleural fistula
• Is communication between the
airway and the pleural space
Causes include
1. Pneumonectomy complications
2. Carcinoma of the bronchus
3. Ruptured lung abscess
 Chest PA

Bronchopleural
fistula
 Pleural thickening
• Blunting of costophrenic angle is due to
localized pleural thickening and usually
results from a previous episode of
pleuritis.

• Bilateral apical pleural thickening is a

fairly common findings. Its etiology is
uncertain
• More extensive unilateral pleural
thickening is usually the result of previous
thoracotomy or pleural effusion

• Bilateral pleural plagues are common

manifestation of asbestos exposure, and
more occasionally pleural thickening
• PA chest X-ray examination:
The thick, fibrotized,
calcified stripe-like shadow
of the left visceral pleura
can be seen (arrows). The
middle shadow is mildly
shifted to the right.
 Diffuse pleural thickening
Chest radiograph of a
man with a strong
history of asbestos
exposure, progressive
dyspnea, and a
restrictive picture on
pulmonary function
testing
 Pleural Calcification
• Unilateral pleural calcification is likely
therefore likely to be the result of previous
empyema, hemothorax or pleurisy

• Bilateral calcification occurs after asbestos

exposure and in some other
pneumoconioses, or occasionally after
bilateral effusions
 Bilateral calcifications
This this radiograph shows
the typical appearance of
pleural plaques, secondary
to previous asbestos
exposure. In this
radiograph, the plaques
are calcified, but this is
not always the case.
 Unilateral calcification
Chest x-ray
demonstrates ill-defined
opacities over both mid
and lower zones. Over
the diaphragmatic
domes, linear regions of
calcification are noted.
 Pleural tumors
Primary neoplasms of the pleura are rare
• Benign tumor of the pleural include local
mesothelioma (or fibroma) and lipoma
• The commonest malignant disease of the
pleural is metastases.
– The most frequently metastases arise from
primary neoplasms of lung and breast
 Radiographic appearance
• Pleural fibroma/mesothelioma
– Well defined lobulated mass adjacent to the
chest wall, mediastinum, diaphragm or a
pleural fissure
– The mass may be small or occupy most of
the hemithorax
– Sub pleural lipomas
Appear as well rounded masses ad may
change shape with respiration
 Mesothelioma
• There are two types of the mesothelioma
– Benign mesothelioma
– Malignant mesothelioma
• Benign mesothelioma (called pleural fibroma)
is localized growth that it is often attached to
the pleural surface by a pedicle
– These tumors doses not usually produce a pleural
effusion
Benign Mesothelioma not associated with
pleural effusion
PA CXR LT Lateral CXR
Chest Axial CT – Benign mesothelioma
 Malignant mesothelioma
• Malignant mesothelioma (is usually due
to prolonged exposure to asbestosis dust,
particularly crocidolite
– The usual appearance is nodular pleural
thickening around all or part of a lung
– Pleural effusion may be present
– The effusion may obscure the pleural
masses
 Malignant mesothelioma with pleural
effusion
• (A) Baseline unilateral left
pleural effusion; (B) after 3
months, more diffuse pleural
thickening and pleural masses;
(C) after 5 months, further
ipsilateral volume loss of the
left hemithorax with elevation
of the ipsilateral
hemidiaphragm, ipsilateral
mediastinal shift, and
narrowing of the intercostal
spaces; (D) after 8 months,
contralateral spread of disease
• Malignant mesotheliomas are rare tumors that
arise from either the viscera or parietal pleural
• Up to 90% reported mesotheliomas are
asbestos related.
• There is long latent period of 25 to 45 years
for the development of asbestos-related
mesothelioma
• Mesothelioma also arise in peritoneum,
pericardium, turnica vaginalis and genital tract
 Summary
• Conventional CXR remains as the initial
investigation of choice for patients with suspected
pleural disease.
• U/S adds significant value in the identification of
pleural fluid and pleural nodularity, guiding pleural
procedures and, increasingly, as “point of care”
assessment for pneumothorax, but is highly
operator dependent.
• CT scan is the modality of choice for further
assessment of pleural disease:
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• Imaging plays an important role in the
diagnosis and subsequent management of
patients with pleural disease.
• The presence of a pleural abnormality is
usually suggested following a routine chest x-
ray, with a number of imaging modalities
available for further characterization.
• The most commonly employed radiologic
method in diagnosis of pleural diseases is
conventional chest radiograph.
• The commonest chest- X-Ray findings are the
presence of pleural effusion and thickening.
• Small pleural effusions are not readily
identified on posteroanterior chest
radiograph.
• However, lateral decubitus chest radiograph
and chest ultrasonography may show small
pleural effusions..