0:00

The final category of large airway disorders we will

0:03

discuss are neoplastic disorders.

0:05

I will show you examples of subglottic,

0:07

infantile hemangioma, recurrent respiratory papillomatosis,

0:12

carcinoid tumor muco epidermoid tumor

0:16

and inflammatory myofibroblastic tumor.

0:19

We'll start with a case of subglottic infantile

0:23

Hemangioma.

0:25

We have two axial MRI images,

0:29

T two fat saturation as well

0:31

as T one post contrast fat saturation

0:34

And I wanna scroll down To the subglottic airway.

0:37

There are some additional findings on this patient,

0:39

including a hyperintense enhancing right pro gland,

0:42

but we won't be discussing that today.

0:44

We are instead going to focus on that subglottic airway

0:47

Where we note Subtly that there is a small focus of

0:52

nodular hyperintense signal on the T two

0:56

with corresponding hyper enhancement.

0:59

Although in this patient we've got

1:00

Some motion artifact.

1:02

This is a persistent finding on multiple series

1:05

and multiple planes

1:07

and this corresponded with some prior imaging

1:10

that I'm not showing that included a radiograph,

1:14

a frontal radiograph that included an asymmetric appearance

1:17

Of the sub airway.

1:19

Infantile hemangiomas can occur anywhere in the body,

1:23

but something definitely

1:25

to think about in an infant less than six months old

1:28

who has either croup like symptoms

1:30

but not the right age group for croup

1:32

or sometimes seen on imaging like I mentioned on a

1:35

radiograph with an asymmetric appearance of

1:38

The airway.

1:40

If you find what looks like an infantile hemangioma in the

1:43

subglottic airway, think about syndromes,

1:46

particularly one called faces, P-H-A-C-E-S.

1:51

You don't need to memorize what all of those things are.

1:53

You can always look it up, but it stands

1:55

for posterior fossa, malformation, hemangiomas of the face,

1:59

arterial anomalies, cardiac anomalies, eye anomalies,

2:04

and sternal clefts or supra umbilical ra.

2:07

Again, you don't need To memorize that,

2:08

but do remember that a syndrome can be associated

2:11

with airway hemangiomas.

2:14

This next case is a different patient also

2:16

with a subglottic airway hemangioma,

2:19

but this time on ct,

2:20

as we can see on the axial contrast enhanced image,

2:24

we have a larger focus of enhancement along

2:27

The right poster lateral airway

2:29

Causing narrowing of the airway.

2:31

As we see here on ct, it's important to know

2:35

that this entity exists

2:36

because in these very small patients it would be easy

2:40

to miss them if they're subtle, if you're just racing

2:42

through your study and scrolling through really quickly.

2:45

But if you know this exists

2:47

and if you know the patient is having some sort

2:48

of upper airway symptoms, then keep an eye out

2:52

for potentially small

2:54

focal enhancing nodules in this location.

2:57

Definitely think about a subglottic infantile hemangioma.

3:02

This next case I'm showing you is of an older patient

3:05

who had recurrent respiratory papillomatosis.

3:08

This is caused by benign tumors

3:10

of the aerodigestive tract caused by perinatal transmission

3:13

of HPV most commonly.

3:15

So these patients usually contract HPV from their mother

3:20

during birth.

3:22

This can manifest with AirWave pulmonary

3:24

and GI tract manifestations.

3:27

Rarely these can undergo malignant degeneration.

3:31

The most common finding is actually in the larynx

3:34

where you can see uh, nodules due to the HPV infection,

3:39

but this can spread by endobronchial root

3:43

and end up in the lungs as well.

3:45

In this particular patient,

3:46

we can see in the distal airway a little bit

3:48

of soft tissue nodularity just above the Karina

3:52

and that represents papilloma of this papillomatosis.

3:55

But the more obvious finding in this particular patient is

3:58

the lung involvement.

4:00

We can see multifocal nodular opacities throughout both

4:05

lungs, many of which cavitate,

4:07

and that is a finding that can occur with papillomatosis.

4:11

You can have solid nodules, you can have cavitary nodules,

4:15

and you can have a combination like we see in this patient.

4:18

So important to know that this can be limited

4:20

to the airways, but it also can end up in the lungs

4:23

and so be on the lookout for either finding.

4:26

The next tumor I'm gonna show you

4:29

is an endobronchial lesion.

4:31

I'm gonna start with the coronal CT here.

4:34

Contrast enhanced ct. We have a lot going on,

4:37

but what I'll focus in on first as we sort

4:39

of change the windows a little bit here is this soft tissue

4:43

nodular density within the right main bronchus.

4:46

This is a carcinoid tumor

4:48

and we can see in this particular patient in addition

4:52

to the endobronchial component of the lesion right here,

4:55

causing airway narrowing, it also extends

4:58

beyond the confines of the airway.

5:01

And we can also see associated

5:03

with this lobular soft tissue mass, quite a bit

5:06

of post obstructive atelectasis.

5:10

So carcinoid tumor is a neuroendocrine tumor

5:13

with metastatic potential.

5:14

It can occur in a lot of places,

5:16

but the airways is one of those places.

5:19

We can see calcifications occasionally with these lesions.

5:23

We don't see that here with this patient

5:26

and we can expect to see quite a bit

5:28

of enhancement of the lesion.

5:31

We can see endobronchial lesions like we see in our patient,

5:34

but we sometimes don't see an endobronchial component

5:36

and we instead see a hilar component or a hilar mass.

5:39

Um, and occasionally you can also see solitary pulmonary

5:43

nodules if it's arising further out in the distal airways.

5:47

In our patient, like I mentioned,

5:49

we see post obstructive atelectasis here, quite a bit

5:53

of enhancing atelectatic tissue,

5:55

which I'll also confirm here on the sagittals.

5:58

But in these patients we can also sometimes see air trapping

6:02

bronchiectasis or even mucus plugging in those airways.

6:06

This next patient also has an endobronchial lesion,

6:09

but this is a different lesion.

6:11

Again, we'll start with the coronal here

6:13

and we'll see in that same right bronchus

6:15

that there is an endobronchial soft tissue lesion,

6:18

nonspecific perhaps a little bit less enhancing than the

6:22

carcinoid, and this is a muco epidermoid tumor.

6:25

These can have variable enhancement.

6:27

They also can have calcifications

6:29

In this particular patient.

6:30

We don't see calcifications of the endobronchial lesion,

6:33

but we have quite a bit

6:34

of calcification in surrounding mediastinal

6:37

and hilar lymphadenopathy.

6:40

Give a better demonstration of that lymphadenopathy.

6:43

We'll go to the axials.

6:45

We see the contrast in the vascular structures here,

6:47

and then we have SubCal

6:50

and perihilar calcification as well

6:54

as left perihilar calcification as well.

6:58

Although not seen in this particular patient.

7:00

Uh, we can have post obstructive atelectasis

7:02

and our patient instead, we have more of a post

7:05

obstructive air trapping type picture.

7:08

Our final two cases are two different patients

7:11

with the same entity.

7:13

We'll start with this patient's chest radiograph.

7:17

You can see that there's an obvious density in the left

7:20

lower lung with associated calcification

7:23

or partial calcification of this mass.

7:28

It's important to note in this patient

7:29

that the ribs look pretty normal, they don't look eroded,

7:34

and they also don't look bizarrely shaped or dysplastic.

7:38

The reason I mention that is that there is a rare tumor

7:41

of childhood, uh, called mesenchymal hematoma

7:45

and that can present with a large chest mass

7:48

with calcification, but classically

7:51

has associated bizarre dysmorphic appearance

7:55

of the adjacent ribs in this patient.

7:58

The ribs look pretty preserved.

8:01

This patient went on to get a CT scan with IV contrast,

8:04

and we'll start with the axial image.

8:06

We can see that there's this large soft tissue mass

8:09

occupying much of the left chest with a lot

8:12

of internal calcification,

8:14

as we noted on the chest radiograph,

8:16

and this was an inflammatory myofibroblastic tumor,

8:20

also known as an inflammatory pseudotumor

8:22

or plasma cell granuloma.

8:25

This is a spindle cell tumor

8:26

with intermediate malignant potential.

8:30

It can arise in many different organs in the body, and

8:35

although primary lung tumors are extremely rare in children,

8:38

this is the most common

8:40

of the primary lung tumors in pediatric patients.

8:44

The appearance is variable.

8:45

It can have a heterogeneous enhancing appearance.

8:47

It can have calcifications

8:49

as we see in this particular patient.

8:52

Unfortunately, the prognosis is quite good if there's

8:55

complete surgical resection.

8:57

The final patient I'll show you also has the same diagnosis

9:00

of inflammatory myofibroblastic tumor.

9:04

This is an older child

9:06

and this first radiograph is not in your viewer,

9:09

but I'm showing for your reference.

9:11

They had a procedure for pectus excavatum,

9:14

and this is a pectus bar.

9:16

This was an immediate post procedure radiograph

9:18

with a pneumothorax,

9:19

which is not uncommonly seen immediately

9:22

after a pectus procedure.

9:23

So just keep in mind that this is

9:25

what their chest radiograph looked like.

9:27

Two years later. They were having follow up

9:30

for their pectus surgery and had this radiograph

9:32

and suddenly there's a new dense right chest

9:37

opacity that was not there on the prior, so they went on

9:41

to also get a CT scan.

9:43

We could see in this patient, unlike our prior patient

9:47

that had more of a heterogeneous enhancing appearance,

9:49

this one has a more uniformly hypodense appearance.

9:52

For most of it, there are no calcifications like we saw in

9:56

our prior patient, but this also was the same diagnosis,

10:00

inflammatory myofibroblastic tumor on lung windows.

10:04

We can again see the mass.

10:05

We see a little bit of ectasis of the lung adjacent to it,

10:09

but none of the other findings we saw in our prior patient.

10:12

So this just illustrates the range of appearances

10:15

that this tumor can have.