Chest Radiology Practice Questions

Q: To visualize vascular sling causing tracheal or external airway compression, which of the following would you best prefer?

CT. ***Correct: CT (CT Angiography)*** - **CT angiography is the gold standard** for diagnosing vascular rings and slings causing airway compression - Provides **excellent spatial resolution** with multiplanar and 3D reconstruction capabilities to clearly demonstrate the anatomical relationship between anomalous vessels and the trachea/bronchi - **Fast acquisition time** minimizes motion artifacts, particularly important in pediatric patients who are the typical population affected by vascular slings - Superior for **surgical planning** due to detailed visualization of vascular anatomy and the exact site and degree of airway compression - More readily available and cost-effective compared to MRI for this specific indication *Incorrect: MRI* - While MRI provides excellent soft tissue contrast and avoids ionizing radiation, it has **longer acquisition times** leading to increased risk of motion artifacts, especially in children - Lower spatial resolution compared to CT for vascular structures - May be used as a **complementary modality** when radiation avoidance is critical or for follow-up imaging, but not the first-line preferred modality *Incorrect: Catheter angiography of aorta and pulmonary artery* - **Invasive procedure** with associated risks including vascular injury, bleeding, and contrast reactions - Provides excellent vascular detail but **no information about airway compression** or surrounding soft tissue structures - Reserved for cases requiring **intervention** (embolization, stent placement) or when non-invasive imaging is inconclusive - Has been largely replaced by non-invasive CTA for diagnostic purposes *Incorrect: PET-CT* - Primarily assesses **metabolic activity**, used for oncology staging, infection, and inflammatory conditions - **Not indicated** for structural vascular anomalies or their anatomical relationships to airways - Does not provide the necessary vascular or airway detail for evaluating vascular slings

Q: All are radiological features of mitral stenosis except:

Oligemia of upper lung fields. ***Oligemia of upper lung fields*** - This is **NOT a feature of mitral stenosis** and is therefore the correct answer to this EXCEPT question. - Mitral stenosis causes **cephalization of pulmonary blood flow** (also called upper lobe blood diversion), which means **increased vascularity** in the upper lung fields, not oligemia (decreased blood flow). - Due to pulmonary venous hypertension, there is redistribution of blood flow from the lower lobes to the upper lobes, making the upper lobe vessels appear **more prominent**, not oligemic. - **Oligemia** (reduced blood flow) is the opposite of what occurs in mitral stenosis. *Straight left border of heart* - This is a **characteristic feature** of mitral stenosis. - Results from enlargement of the **left atrial appendage**, which straightens the normally concave left heart border. - Creates a distinctive silhouette on PA chest X-ray due to left atrial pressure overload. *Pulmonary hemosiderosis* - This is a **feature of chronic severe mitral stenosis**. - Occurs due to recurrent microhemorrhages from chronically congested pulmonary capillaries. - Hemosiderin-laden macrophages (heart failure cells) accumulate in the alveoli. - May present as fine reticulonodular opacities on chest X-ray. *Lifting of left bronchus* - This is a **classic feature** of mitral stenosis with significant left atrial enlargement. - The enlarged left atrium pushes the **left main bronchus** upward, best seen on lateral chest X-ray. - The angle between the main bronchi increases (normally 60-70°, may exceed 90° in severe cases).

Q: Which of the following conditions is most commonly associated with eggshell calcifications?

Silicosis. **Silicosis** - **Eggshell calcifications** in hilar lymph nodes are a **pathognomonic finding** for silicosis. - This condition is caused by the inhalation of **silica dust**, leading to fibrotic changes in the lungs. *Sarcoidosis* - Characterized by **non-caseating granulomas** and can cause hilar lymphadenopathy, but typically does not manifest as eggshell calcifications. - More commonly associated with **bilateral hilar lymphadenopathy** that is symmetric and often resolves spontaneously. *Aspergillosis* - Primarily a **fungal infection** that can cause various lung manifestations, including aspergillomas and invasive aspergillosis. - Does not typically lead to **eggshell calcifications** of the lymph nodes. *Pulmonary artery hypertension* - Involves **elevated pressures in the pulmonary arteries** and is not associated with calcifications of lymph nodes. - Often manifests with **right heart enlargement** and specific vascular changes on imaging.

Q: Best diagnostic aid for bronchiectasis is

CT scan. ***CT scan*** - **High-resolution computed tomography (HRCT)** is considered the **gold standard** for diagnosing bronchiectasis due to its ability to visualize airway dilation and wall thickening with high detail. - CT scans can accurately identify the characteristic **"signet ring" sign** (dilated bronchus adjacent to a pulmonary artery) and **lack of bronchial tapering**. *Bronchoscopy* - While useful for evaluating the airways for obstruction, performing biopsies, or obtaining samples for microbiology, **bronchoscopy** is not the primary diagnostic tool for bronchiectasis itself. - It may be indicated in cases where the cause of bronchiectasis is unclear or to rule out endobronchial lesions. *X-ray* - A **chest X-ray** can show non-specific findings such as increased bronchial markings or cystic shadows, but it is **not sensitive or specific enough** to reliably diagnose bronchiectasis. - **Early or mild cases** of bronchiectasis are often missed on a plain chest X-ray. *Bronchography* - **Bronchography**, an older technique involving the injection of contrast material into the airways, was once used for diagnosing bronchiectasis but has largely been **replaced by HRCT**. - It is an **invasive procedure** with potential complications and poorer resolution compared to modern CT imaging.

Q: The 'water lily sign' is characteristic of which condition?

Hydatid cyst of lung. ***Hydatid cyst of lung*** - The **'water lily sign'** in an **echinococcal cyst** (hydatid cyst) occurs when the **endocyst** ruptures and collapses, detaching from the pericyst. - This detached membrane floats within the cyst fluid, creating a characteristic appearance on imaging that resembles a water lily. *Aspergilloma lung* - An **aspergilloma (fungus ball)** is typically seen as a mobile mass within a pre-existing cavitary lesion, often associated with a **crescentic lucency (air crescent sign)**. - It does not present with the specific appearance of floating membranes seen in the 'water lily sign'. *Tuberculosis* - **Tuberculosis (TB)** in the lung can cause various imaging findings, including **cavitation**, consolidation, and nodules. - However, it does not typically produce the 'water lily sign', which is specific to parasitic cysts. *Silicosis* - **Silicosis** is a pneumoconiosis characterized by **multiple small nodules** in the upper lung fields and can lead to **progressive massive fibrosis**. - Its imaging findings are distinct and do not include the 'water lily sign'.

Q: Ring sign with dilated bronchi on CXR is a feature of

Bronchiectasis. ***Bronchiectasis*** - The "ring sign" on a Chest X-Ray (CXR) is characteristic of **bronchiectasis**, representing the cross-sectional view of a **dilated bronchus**. - **Bronchial wall thickening** and dilation create this appearance, often accompanied by **"tram lines"** (parallel lines corresponding to longitudinal views of dilated bronchi). *Asthma* - CXR in asthma is often normal but may show signs of **hyperinflation** or **bronchial wall thickening** in severe cases. - It does not typically present with the "ring sign" of permanently dilated bronchi. *Bronchiolitis* - This condition primarily affects the **small airways (bronchioles)** and is common in infants. - CXR findings typically include **hyperinflation**, **peribronchial thickening**, and **atelectasis**, but not dilated bronchi forming ring signs. *Candidiasis* - Pulmonary candidiasis is a fungal infection that can cause various CXR findings like **infiltrates**, **nodules**, or **cavities**. - It does not typically lead to bronchial dilation or the characteristic "ring sign" seen in bronchiectasis.

Q: The following are direct signs of lung collapse seen on a chest X-ray, which one of the following is NOT a direct sign?

Mediastinal shift. ***Mediastinal shift*** - While mediastinal shift can occur with lung collapse, it is an **indirect sign** caused by the volume loss in the affected hemithorax, pulling the mediastinum towards the collapsed lung. - Direct signs refer to changes observed *within* the collapsed lung tissue itself, such as increased density or displaced structures, whereas mediastinal shift is a secondary effect. *Crowding of the vessels* - This is a **direct sign** of lung collapse, as the pulmonary vessels become compacted due to the loss of lung volume. - The vessels appear closer together and more prominent in the area of collapse. *Loss of aeration* - This is a **direct sign** of lung collapse, as air is expelled or resorbed from the affected lung tissue, leading to increased opacity. - The collapsed lung appears denser and whiter on the X-ray compared to normally aerated lung. *Displacement of the fissure* - This is a **direct sign** of lung collapse, as the interlobar fissures are pulled towards the collapsed lobe due to volume loss. - The displacement of the fissure indicates the location and extent of the collapse.

Q: Kerley-B lines are seen when pulmonary venous pressure is what?

20 mmHg. ***20 mmHg*** - **Kerley B lines** indicate **interstitial edema** due to elevated **pulmonary venous pressure**, typically occurring when pressure exceeds 18-20 mmHg. - This level of pressure signifies early fluid transudation into the **interstitium**, making these lines visible on chest X-ray. *5 mmHg* - A pulmonary venous pressure of 5 mmHg is considered **normal** or within a healthy range. - At this pressure, there would be **no fluid transudation** into the interstitium, hence no Kerley B lines. *10 mmHg* - A pressure of 10 mmHg is still within the **normal or borderline normal range** for pulmonary venous pressure. - It is **insufficient** to cause the significant interstitial edema required for the formation of Kerley B lines. *40 mmHg* - A pulmonary venous pressure of 40 mmHg indicates **severe pulmonary edema**, often leading to **alveolar edema**. - At this high pressure, there would likely be diffuse, widespread opacities and **"bat wing" appearance**, not just isolated Kerley B lines.

Q: Which of the following conditions is most commonly associated with miliary mottling in the lungs?

Pulmonary tuberculosis. ***Pulmonary tuberculosis*** - **Miliary mottling** on chest X-ray is a classic radiographic feature of **miliary tuberculosis**, which results from hematogenous dissemination of *Mycobacterium tuberculosis* to the lungs. - The term "miliary" refers to the resemblance to **millet seeds**, with characteristic **1-3mm uniformly distributed micronodules** scattered diffusely throughout both lung fields. - These small, diffuse nodules represent widespread tiny **granulomas** formed in response to the disseminated bacilli. - **Miliary TB is the prototype condition** for true miliary mottling pattern. *Sarcoidosis* - While sarcoidosis can cause lung nodules, they are typically larger and more concentrated in the **perihilar regions** and upper lobes, often presenting as **lymphadenopathy** and discrete nodules rather than diffuse miliary patterns. - The nodules in sarcoidosis are **non-caseating granulomas**, but their distribution and size usually differentiate them from miliary tuberculosis. *Histiocytosis X* - **Pulmonary Langerhans cell histiocytosis (Histiocytosis X)** typically presents with a combination of **cysts and nodules**, predominantly in the upper and middle lung zones. - The radiological appearance is often described as **stellate nodules** and multifocal cysts, which is distinct from the fine, diffuse pattern of miliary mottling. *Pulmonary metastasis* - **Pulmonary metastases** usually appear as discrete, well-defined nodules or masses of varying sizes, often referred to as "**cannonball lesions**" if large, and are typically scattered unevenly throughout the lungs. - The metastatic lesions are generally larger and fewer in number compared to the fine, widespread micronodules seen in miliary mottling.

Question 1

To visualize vascular sling causing tracheal or external airway compression, which of the following would you best prefer?

Accepted Answer

CT

Answer

MRI

Answer

Catheter angiography of aorta and pulmonary artery

Answer

PET-CT

Question 2

All are radiological features of mitral stenosis except:

Accepted Answer

Oligemia of upper lung fields

Answer

Straight left border of heart

Answer

Lifting of left bronchus

Answer

Pulmonary hemosiderosis

Question 3

Which of the following conditions is most commonly associated with eggshell calcifications?

Accepted Answer

Silicosis

Answer

Sarcoidosis

Answer

Aspergillosis

Answer

Pulmonary artery hypertension

Question 4

Best diagnostic aid for bronchiectasis is

Accepted Answer

CT scan

Answer

Bronchoscopy

Answer

X-ray

Answer

Bronchography

Question 5

The 'water lily sign' is characteristic of which condition?

Accepted Answer

Hydatid cyst of lung

Answer

Aspergilloma lung

Answer

Tuberculosis

Answer

Silicosis

Question 6

A 70-year-old male presented with complaints of breathlessness and exhibited abnormal bronchial breath sounds on examination. What is the most probable diagnosis based on the provided X-ray image?

Accepted Answer

Metastasis

Answer

Pulmonary TB

Answer

Bronchogenic carcinoma

Answer

Sarcoidosis

Question 7

Ring sign with dilated bronchi on CXR is a feature of

Accepted Answer

Bronchiectasis

Answer

Asthma

Answer

Bronchiolitis

Answer

Candidiasis

Question 8

The following are direct signs of lung collapse seen on a chest X-ray, which one of the following is NOT a direct sign?

Accepted Answer

Mediastinal shift

Answer

Crowding of the vessels

Answer

Loss of aeration

Answer

Displacement of the fissure

Question 9

Kerley-B lines are seen when pulmonary venous pressure is what?

Accepted Answer

20 mmHg

Answer

5 mmHg

Answer

10 mmHg

Answer

40 mmHg

Question 10

Which of the following conditions is most commonly associated with miliary mottling in the lungs?

Accepted Answer

Pulmonary tuberculosis

Answer

Sarcoidosis

Answer

Histiocytosis X

Answer

Pulmonary metastasis

Chest Radiology — MCQs

Chest Radiology — MCQs

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