Tuesday, October 22, 2013

Case review 8: Loculated Hematoma

An elderly man fell from his motorbike 2 weeks ago. He was admitted to hospital and a chest tube was inserted. After a week, he was discharged and consulted his GP who did an x-ray.

X-ray findings
The x-ray showed multiple right rib fractures and fracture mid shaft of his right clavicle.
In addition, there is a homogenous opacity in the right mid upper zone. 
The medial and lower borders are well defined while the upper border is hazy.
The lower border makes an obtuse angle with the lateral chest wall indicating that it is a pleural based lesion. These are strongly suggestive of loculated hematoma. The most likely cause would be complication from his chest tube.
Residual effusion/hematoma is also seen in the lower zone.

Further management

He should be referred back to the hospital as the hematoma may complicates to abscess formation later.

Friday, October 18, 2013

Ultrasound Case Review 2: Breast masses

Elastoscan image


A 34 years old female who has just noticed a newly growing lump in her right breast. She was then called up NR for a breast ultrasound appointment.

Ultrasound findings

The ultrasound showed a rounded, inhomogenous solid lesion detected at 9 o'clock, 6cm distance to nipple. 
The lesion appears isoechoic to surrounding breast tissue with a hypoechoic rim seen and some suspicious extensions beyond the hypoechoic rim.
Intralesional vascularity is also detected. Size of this lesion is 1.13 x 1.08 x 1.21cm. 
Elastoscan demonstrated that the solid lesion is stiff. 
These findings are consistent with BIRADS-4 solid lesion.

Further management

Management of breast masses on ultrasound (BIRADS-4):
  1. Newly or enlarging solid mass with benign features.
  2. Solid mass with suspicious features (irregular shape, microlobulated, ill-defined, non-parallel orientation, sonographic distortion, calcification, and associated with abnormal ducts).
  3. Complex mass (contain both solid and cystic components).

(Harvey, J.A. & March, D.E. (2013). Making The Diagnosis: A Practical Guide To Breast Imaging. Philadelphia: Elsevier Saunders.)

Thursday, October 10, 2013

Ultrasound Case Review 1: Thyroid cysts


  • A 31 years old male was referred from Klinik Dan Pembedahan Mogan for a thyroid ultrasound. He was complaining of painless and sudden onset of right neck swelling for the past one month.
  • Thyroid function test was done by his GP and he was then diagnosed with hyperthyroidism (thyrotoxicosis) with the TSH (thyroid stimulating hormone) of 0.2000mIU/L.

Ultrasound findings

  • The ultrasound revealed the echogenicity for both right and left thyroid glands have increased. 

 Colour doppler examination of Left Thyroid
Colour doppler examination of Right Thyroid

  • The color doppler examination on both right and left thyroid glands appear increased vascularity.
  • A large cystic lesion with internal echoes and mural growth is detected in the middle-lower pole of right thyroid gland, measures 3.17 x 5.05 x 3.62cm. 
  • Peripheral vascularity is detected and intralesional vascularity of the mural growth is also detected. 
  • There is another anechoic cystic lesion with mural growth detected in the upper pole of left thyroid gland, measures 1.76 x 2.82 x 1.26cm. 
  • Septation and peripheral vascularity is detected from the lesion.
  • The findings are consistent with Graves' disease with bilateral complex thyroid cysts.

Wednesday, October 9, 2013

Case review 7: Exostoses in knee x-ray

A 26 years old lady complained to her GP of aching pain in both knees on and off for the last few years. The GP requested for an x-ray to be done.

X-ray findings
 X-ray showed multiple bony projections arising from the medial aspect of his tibias bilaterally as well as medial and lateral aspect of lower femurs. These projections are known as exostoses.

An exostosis (plural: exostoses) is the formation of new bone on the surface of a bone. Some people called it osteochondroma. These are benign growths of bone extending outwards from the surface of a bone. It can occur in any bone. It can be solitary or multiple, sessile or pedunculated.

The number of exostoses and the bones on which they are located vary greatly among affected individuals. The exostoses are not present at birth, but approximately 96% of affected people develop multiple exostoses by the time they are 12 years old. Exostoses typically form at the end of long bones and on flat bones such as the hip and shoulder blade. Once they reach adult height and their bones stop growing, the development of new exostoses also usually stops.

Exostoses can cause chronic pain ranging from mild to debilitating severe, depending on the shape, size, and location of the lesion.
Multiple exostoses can disrupt bone growth and can cause growth disturbances of the arms, hands, and legs, leading to short stature. Often these problems with bone growth do not affect the right and left limb equally, resulting in uneven limb lengths (limb length discrepancy). Bowing of the forearm or ankle and abnormal development of the hip joints (hip dysplasia) caused by exostoses can lead to difficulty walking and general discomfort. 

Multiple exostoses may also result in pain, limited range of joint movement, and pressure on nerves, blood vessels, the spinal cord, and tissues surrounding the exostoses.
Hereditary multiple exostoses is a condition in which people develop multiple exostoses. Exostoses are typically benign; however, in some instances these tumours may become malignant (cancerous). It is estimated that people with hereditary multiple exostoses have a 1 in 20 to 1 in 200 lifetime risk of developing cancerous exostoses (sarcomas).

Thursday, October 3, 2013

Case review 6: Right Upper Lobe collapse


A 28 years old man came for routine medical examination and required for PA chest x-ray.


The chest x-ray showed a triangular opacity in the right apex of the lung (yellow arrow).
The right hemi-diaphragm and right main bronchus are elevated. 
This is consistent with right upper lobe collapse.

Tuesday, October 1, 2013

Case review 5: Intraosseous epidermoid cyst


A 64 year old lady presented with pain and swelling at the tip of her right index finger. She works as a seamstress. An x-ray was done. What do you think?


The x-ray showed a cystic lesion at the distal phalange of her index finger.
This is consistent with intraosseous epidermoid cyst. 
The cause is said to be implantation of the epidermis into the bone. In her case, being a seamstress, she could have poke a needle deep into her finger.
These are benign lesions and a form of pseudotumors (not real tumours). 
The condition can be easily treated by curettage.