Case Challenges: Thoracic

Introduction to Challenge Cases: Lines, Tubes, Devices, and Other Surprises

This is the topic for my challenge cases, lines, tubes, devices, and other surprises.

And this is really one of my, in many ways, one of my favorite topics, both in chest radiology as well as abdominal radiology, mainly because it's sort of simple, but you only have to be determined to look for these and make the right diagnosis often very important for many reasons.

Challenge Case Number One: Misplaced Feeding Tube

This is an 88-year-old male involved in MVA.

And you remember, we are looking for lines and tubes.

And I'm gonna scroll through the study.

He does have a lot of lines and tubes, so maybe sort of hard to decide which one you want to follow.

There are lots of other findings, but just look at the lines and tubes already here, there is something abnormal regarding lines and tubes.

That sounds like it was too easy a case.

Okay, keep looking, keep looking. It's not done yet.

Alright. And in case you didn't see the right line to look at which line is the one or a single incidental finding that needs to be addressed ASAP, the feeding tube.

If we look at the coronals, always a good thing to do. Doesn't take more than another few seconds. If you scroll through it fast and we can see the feeding tube adjacent to the ET tube, going straight into the right main bronchus and then into the right lower lung, and then perforate through the pleura and go up into the pleural space.

Easy to, it's very easy when we look at it like this, but you can see the patient has probably a diaphragmatic rupture.

And if we go up here, maybe his spleen is sort of rotated.

He's got a chest tube.

He's got so much going on, lots of important findings, other findings or those rib fractures that may perforate his pleura.

Maybe some extravasation, really easy to overlook.

Practice for Reviewing Lines and Tubes

A good practice that I adhere to many years is I start with the lines and the tubes always, mainly because again, they could be you'd see Foley catheters within the prostatic urethra, and the patient might be intubated and not be able to mention it and so on and so forth.

Before I look at the anatomy and the pathology, I always look at the lines and tubes. It's really worthwhile.

Complications of Inadvertent Feeding Tube Placement

And a few words about this complication and inadvertent placement of a feeding tube that perforates into the pleural space.

Again, a good clue to look at already at the level of the trachea.

It's a rare complication, but as you can see, it's not unheard of for the clinicians.

They often won't suspect it in a patient who is intubated because the cuffed ET tube or tracheostomy tube often gives them false assurance that this cannot happen.

Possible complication of misplaced NG tubes, or of course, pneumonia as bad as septic shock, pulmonary perforation as we see in this case.

And a hydro pneumothorax.

And a good routine for the clinicians, if they're in doubt, is to always get a chest radiograph prior to initiation of feeding, not after, however, I guess they should first have the doubt regarding it.

Or alternatively, it should be maybe a routine chest x-ray in a patient that has just received one of those feeding tubes.

Recent Case of Feeding Tube Perforation

And this is a recent case, I was on chest that morning.

You can see it's a different patient, no doubt that the feeding tube is in the wrong location.

Here again, perforated through the pleural space.

And there is a large pleural effusion.

This is the following morning after the insertion of the NG tube, the feeding tube.

And you can see that he did get a plain film of the abdomen the evening before.

Always a bedtime, I guess, to get these.

And this was not read until after the x-ray was read the following morning, which is probably not something that we should try to avoid.

The reason I put this is mainly to show that the right lung base here and the pleural space were completely clear before they started feeding him.

Again, how could this be avoided if they would not feed him before they make sure a radiologist has looked at this study and seen where the tip of the feeding tube is.

And I'll just scroll quickly back and you can see the significant difference between the right base, the evening before and the morning after.

More Lines and Tubes: Mediport with Clot

Okay, more lines with tubes and what, and where is the problem?

A bit more subtle. Patient with a mediport, one more time.

Anybody lines and tubes Clot, there is a clot adjacent to the, I'm gonna show it again.

In the exhales, it's hard to see, even though it's not so small.

Again, I'm going to say that one more time. It's good to look at the coronals, sagittals, whatever you need, because look how obvious it is.

So it'll really protect you and then enhance your practice if you do look at, if you have them available.

And they're often generated now by the scanners, if not the techs generate them immediately.

And if you scroll through this, you really have to, you have to either look away or, it's really simple and straightforward, large thrombus in the SVC here.

Complications of Central Venous Catheters

Central venous catheters, of course, play a huge role in medicine especially in oncology, and patients have these indwelling for long periods of time.

Often complications can occur at the insertion. Acute ones.

And the most frequent one would be pneumothoraces and hemorrhage.

However, when there are long term indwelling catheters, they have additional different risks.

And these are mainly infection and thrombosis.

And just remember that despite the routine flushing of these, almost half of them will result in thrombosis of the blood vessels.

And this markedly, of course, increases the risk of infection.

However, only one third of these clots are probably about 10% will end up being symptomatic, but still, it's a large enough percentage for us to look for them actively.

In any patient that has an contrast enhanced ct, we see the line, we should actively search for the clot or any other pathology that's associated with it.

Look for the pe. If you see, if you've seen one of these thrombi, of course, look for the PE as well.

And some studies show that almost all central venous catheters are very fast. They obtain like a fibrin sheath around them.

And over one month thrombi are very common around those catheters.

PE again, not very frequent, still an important cause for additional morbidity and mortality.

Risk factors are, of course, those patients are in additional risk except for the indwelling catheter, because of their malignancy chemotherapy is, et cetera, low dose warfarin.

Coumadin is not too routinely done in those patients.

Just something to remember.

Problematic IJ Line Perforating into the Esophagus

And another problematic line that I'm gonna show you, it's an infrequent finding, but try to look at any catheter you're looking from the insertion all the way down, not only where it ends or where it starts.

And this was an attempt to get the IJ line into the right location.

And you can see that it perforates into the esophagus.

And it might not have been the first attempt because you can see that there are many small areas of extra around it.

And again, it sort of looks very straightforward. It probably is. But when you scroll through this study, this is much more impressive than this tiny little dot that we can sort of overlook.

And you can see the fluid filled esophagus.

I wonder if that's because they've been administering some wonderful medicines through this.

Complications of Left Internal Jugular Central Line

A few words about this left internal jugular central line that's perforating into the esophagus.

This would probably be again, in the earlier category of the insertion.

Pneumothoraces, almost 2% of the cases hematomas as we saw in this case.

And misplacement. This patient happened to have both, maybe even a pneumothorax.

Most complications that are associated with central lines are associated with subclavian lines and internal jugular.

In contrast, femoral or intraosseous that are done more frequently with children. Children almost have very low or pro in this one series published about 10 years ago. No complications associated with this.

IJ and subclavian lines look carefully for a pneumothorax, look carefully for hematoma.

Next Case: Pectus Excavatum Prosthesis

Next case is again, this is probably more of a surprise rather than lines, tubes.

And this is a young woman, and that's the only image.

And that's a simple question. Implant. It's an implant. It's a prosthesis.

You can all see that she has a quite severe pectus excavatum look at the deviation of the heart, the compression on the right atrium, right ventricle.

And this is indeed a prosthesis for sort of confusing the first minute I looked at it because it looked just as if part of her ventricle maybe had somehow migrated out there.

They have sort of the very same appearance.

And I had to scratch my head for a minute.

Treatment Options for Pectus Excavatum

Pectus excavatum is a very common congenital anomaly.

The depressed sternum, it's much more common, by the way, than pectus carinatum.

We don't see that as frequently and much more common in males, not too infrequent.

And as they with the growth of adolescence, it becomes much more pronounced.

And there are two options for treatment.

One would be a very extensive thoracic surgical correction.

And if patient has reached the adult age and does not really want this kind of surgical intervention, the custom made silicone implants as we see in this case, and it's a good alternative for the surgical intervention.

Next Case: Left Atrial Appendage Clip Device

Next case. This is a device that has been in use, I guess throughout the last few months.

I see many of them, but they I think they're quite new in the market.

I wonder if everybody knows this.

This patient has, as you can see in a ICD pacemaker, but the device that I'm gonna scroll through in a moment is the one that we see right here.

This is part of the pacer, of course, and we are not looking at the other incidental findings.

Now, only the device, coronary calcifications.

And I'm gonna scroll through the sagittals.

And this is the device, This is how it looks on a chest plane film and on the lateral.

Anybody familiar with this device?

Electrodes? No, not electrodes.

It's, so it's actually put there on purpose.

It's sort of easy if you see where is it located, do you think?

This is the left atrium, right?

And this would be The appendage. Exactly.

This is a left atrial appendage clip, and it's apparently a new device because I haven't seen them before, like maybe, I think I've seen them on the last six months.

I see at least once a day.

Maybe there is a trial that goes on, but it's worthwhile being acquainted with these.

Purpose and Procedure for Left Atrial Appendage Clip

This is how they look, and they are used for in patients that have atrial fibrillation, mainly to avoid the morbidity and mortality that's associated with tiny thrombi.

As you all know, left atrial append. The left atrial appendage is a good source for slow flow and the formation of thrombi.

And the left atrial appendage is the origin of up to 90% of embolic strokes in patients who do have atrial fibrillation.

The exclusion is believed to be helpful in avoiding such complications.

It's done in surgery.

It's not a simple procedure, however, it's supposed to be safe, effective, and durable.

Patients do undergo a thoracotomy for that.

Case of Left Atrial Appendage Thrombus

This is a 90-year-old patient that has a large left atrial appendage thrombus, as you can see here.

And he presented with an iliac embolus.

You can see the left atrium is enlarged.

It usually is associated left.

Left atrial enlargement with mitral insufficiency or stenosis.

And then the left atrial appendage also enlarges.

This patient is only 40 years old, and you can see he's got severe mitral stenosis and a huge appendage thrombus.

Really, very frequently associated with emboli, both in both directions upwards and towards the lower limbs.

Next Case: Identifying Dentures Postmortem

The next case, this is the hint, and you sort of have to figure out, it's never too late for what?

This again falls under the lines, tubes, devices, other surprises.

Do we have a courageous volunteer?

I'm gonna show you a little bit more. These two, The young lady that sat behind me, you knew all the cases and nobody knows you did.

I know, but because I heard you, but you want to try maybe what, what's wrong with this?

There is this high density, right?

Somebody has it, right? Dentures. Dentures, yes. What?

It's never too late to identify dentures and why it's not too late.

What's all the air mortem? It's postmortem. Exactly.

Story of the Cadaver Case at Tel Aviv University

This is actually a very interesting case that made my day, practically my month, I think because I was, as Dr. Feder mentioned, I'm associated to the Tel Aviv University, and they have started teaching anatomy with the cadaver being scanned prior to the dissection.

This happened to be my table with my students.

I did the horrible mistake of telling them that I was at the same room 30 years earlier.

I completely lost my credential at that moment.

They looked at me as if I was supposed to be one of the cadavers.

But then I completely regained all their appreciation, I think because when I looked at the scan, I said, and it was the thoracic day, I said, this is so strange.

There is something, it was very hard for me to be sure if it's in the pulmonary artery, because you can see there are so many streak artifacts.

And I looked at that, and you can see by the way, that it's, the hands are on the body because they're not raised.

And I said, there must be something metallic within her either main bronchus.

I couldn't really make the diagnosis that it was dentures.

Few minutes later, they came out with this five teeth dentures in the, our table was the most successful table that day.

And I think all the 10 students in that corner, they're all gonna be radiologists thanks to this case.

We couldn't tell if that happened while she was intubated or before that we didn't have that information.

But the nice thing about it was that when I looked through the study, I told them in addition that I believe she must have been diabetic because of all the calcification that you'll see in a moment that she's had bariatric surgery.

Look again at the calcification that she'd had cholecystectomy again, severe atherosclerotic disease.

You can see that here. And that she has had her leg amputated because of her diabetes.

And I think they almost fainted from that.

They thought it was so amazing that I could tell all of that just by looking at the CT scan.

It was a rewarding experience.

I'm not going back there because I won't be as successful the next time.

Aspiration of Teeth and Dental Restorations

A few words about that.

Metallic objects can sort of, for a strange reason, be easily overlooked by us.

Aspiration of teeth and dental restoration is a recognized yet infrequent incident, and we should be aware of it.

Main reasons for us to see these are maxillofacial traumas, dental treatment procedures, patients who are intoxicated or demented patients.

This is a nice, 2011 reference that was looking at the frequency of dentures or other dental devices in almost 1400 patients and found that 0.5, not so few have aspirated a foreign body and it lodged in their airway either because of intubation or trauma.

Cases of Aspirated Dental Objects

This is a nice case from a recent patient at Stanford.

You can see the nice metallic object here with the subsequent atelectasis of the right lower lobe, and he had severe facial trauma and another patient who happened to have also PE so we could easily be distracted by the pe, think this is some sort of maybe a tube and shouldn't be there.

Right-sided PE and a tooth in the left bronchus and different patient that showed us that she can even swallow it.

This one, she never complained about that when we talked to her.

She said, oh, two weeks ago it disappeared.

Similar appearance, something to keep in mind.

These are all cases that I've seen firsthand, not given to me by anybody.

If you practice long enough, you'll definitely see them.

Last Case: Swallowed Batteries

This patient, again, has line tubes, but she does have other surprises too.

A 30-year-old female arrives at Stanford.

She's intubated, and she's got NG tube.

As you can see, they're properly positioned.

I'm showing these in order for you to not look at them anymore.

And then as we go down, you can see she's got breast implants and the NG tube is well positioned.

And since the chest always contains the abdomen, and I told you that my mentor always told me, look underneath the diaphragm, I do that and I really respect her to this day very much.

And I sort of look through this and I tell the fellow next to me that I think she swallowed something and I don't really like it very much.

And she insists that I don't understand the scenario, maybe because of my English, it's a motor vehicle accident.

And I say, I still don't care.

I think that's really wrong. I think these might be, if we look at them, maybe in a different window.

This is always very helpful when you think of metallic structures that shouldn't be there, or you don't know what they are.

And I look at this and I say, oh, I think these are batteries.

And look, I think she's what Dr. Feder calls properly swallower.

And the fellow is much more confident than me.

And she says, oh, I don't think so. You are hallucinating.

I do go over to Dr. Feder who's in the other room, and I say, would you mind looking at this?

And I just scroll through this and he says, oh, these are batteries.

This is end of discussion.

And the patient fortunately goes to endoscopy and they retrieve not more and not less, but eight button batteries.

And what we didn't know when she showed up was that she was a psych patient suffering from schizophrenia.

Psych patient suffering from schizophrenia. So a swallower.

And you can see those other high density objects that you swallowed prior to the MVA and batteries are sort of important to remember, especially if your practice also includes pediatric patients because unlike schizophrenic or other swallowers, they swallow them by mistake.

And they're very common. There are all those little disc batteries that are in every other gadget that we have, right?

Lying around from watches, calculators, and hearing aids.

And it's important to remember they're mainly important when they're impacted in the esophagus.

Not so important as in her case, they're not as urgent when they're already past the esophagus, they won't harm the stomach as much.

In her case, they indeed saw some erosions, but that was probably because there were so many of them.

And again, a good reminder, when you see metallic object, look at this scout film.

It's very helpful. And this was my last case.

Thank you.