question

wet reading

answer

-For stat/ immediate interpretation of xray. - films are interpreted while still dripping with chemicals

question

digital radiography

answer

- the photographic film was replaced by a photosensitive cassette or plate that could be processed by an electronic reader so that the image could be stored digitally.

question

PACS

answer

-Picture Archiving, Communications, and Storage system -it is where studies are maintained on computer servers on which the images could be archived, communicated, and stored

question

CONVENTIONAL RADIOGRAPHY (PLAIN FILMS)

answer

Images produced through the use of ionizing radiation, i.e., x-rays, but without added contrast material like barium or iodine

question

x-ray machine

answer

a source to produce the x-rays

question

film, cassette, or plate

answer

a method to record the image

question

using chemicals or a digital reader

answer

a way to process the recorded image

question

COMPUTED TOMOGRAPHY (CT OR CAT SCANS)

answer

- (1970) - Using a gantry with a rotating x-ray beam and multiple detectors in various arrays (which themselves are rotating continuously around the patient) along with sophisticated computer algorithms to process the data, a large number of two-dimensional, slicelike images could be formatted in multiple imaging planes. - utilize ionizing radiation (x-rays) to produce their images.

question

ULTRASOUND (US)

answer

utilizes acoustical energy above the audible frequency of human hearing to produce images, instead of using x-rays as both conventional radiography and CT scans do.

question

lymphangitic spread

answer

- involves blood-borne spread to the pulmonary capillaries and then invasion of adjacent lymphatics. - An alternative means of lymphangitic spread is obstruction of central lymphatics usually in the hila with retrograde dissemination through the lymphatics in the lung - resemble pulmonary interstitial edema but it tends to be localized to a segment or involve only one lung

question

Ultrasound's transducer

answer

-produces the ultrasonic signal and records it - utilizes no ionizing radiation

question

MAGNETIC RESONANCE IMAGING (MRI)

answer

- utilizes the potential energy stored in the body's hydrogen atoms. The atoms are manipulated by very strong magnetic fields and radiofrequency pulses to produce enough localizing and tissue-specific energy to allow highly sophisticated computer programs to generate 2- or 3-dimensional images - utilize no ionizing radiation and produce much higher contrast between different types of soft tissues than can CT

question

Contrast material (contrast agent)

answer

- usually a substance that is administered to a patient in order to make certain structures more easily visible (frequently referred to simply as contrast). - Dye: the lay term for contrast

question

liquid barium

answer

- most widely used examples of radiologic contrast materials -ORAL : for upper gastrointestinal (UGI) examinations -RECTAL : for barium enema (BE) examinations

question

iodine

answer

administered intravenously for contrastenhanced CT scans of the body

question

" en face"

answer

you look at a lesion directly "head-on", in front

question

Direct extension

answer

- least common form because the pleura is surprisingly resistant to the spread of malignancy through direct violation of its layers. - most likely produce a localized subpleural mass in the lung, frequently with adjacent rib destruction

question

" in profile"

answer

seen tangentially (from the side)

question

air-fluid or fat-fluid level

answer

an interface between two substances of different densities in which the lighter substance rises above and forms a straight-edge interface with the heavier substance below.

question

five basic densities

answer

arranged here from least to most dense - Air - Fat - Soft tissue or fluid - Calcium/ bones - Metal the denser an object is, the more x-rays it absorbs, and the whiter it appears on radiographic images

question

LATERAL CHEST RADIOGRAPH

answer

-A left lateral chest x-ray (the patient's left side is against the film) is of great diagnostic value - part of the standard two-view chest examination together with frontal chest radiograph -used to determine the location; - confirm the presence of disease; and - demonstrate disease not visible on the frontal image

question

FIVE KEY AREAS ON THE LATERAL CHEST X-RAY

answer

The retrosternal clear space The hilar region The fissures The thoracic spine The diaphragm and posterior costophrenic sulci

question

The Retrosternal Clear Space

answer

Lucent crescent between sternum and ascending aorta

question

The Hilar Region

answer

No discrete mass present

question

The Fissures

answer

Major and minor fissures should be pencil-point thin, if visible at all

question

The Thoracic Spine

answer

Rectangular vertebral bodies with parallel end plates; disk spaces maintain height from top to bottom of thoracic spine

question

osteophytes

answer

small, bony spurs that develops on a Degenerated disk that can lead to the narrowing of the disk space.

question

The Diaphragm and Posterior Costophrenic Sulci

answer

Right hemidiaphragm slightly higher than left; sharp posterior costophrenic sulci

question

right hemidiaphragm

answer

we have one diaphragm but we refer the right half of the diaphragm as the right hemidiaphragm - usually visible for its entire length from front to back. - Normally, the right hemidiaphragm is slightly higher than the left.

question

left hemidiaphragm

answer

we have one diaphragm but we refer the left half of the diaphragm as the left hemidiaphragm - seen sharply posteriorly but is silhouetted by the muscle of the heart anteriorly - its edge disappears anteriorly

question

costophrenic angles / sulci

answer

a depression, or sulcus, that surrounds the periphery of each lung and represents the lowest point of the pleural space when the patient is upright - lateral costophrenic sulcus ( On a frontal chest radiograph ) - posterior costophrenic sulcus ( on the lateral radiograph)

question

blunting of the costophrenic angles

answer

When Pleural effusions accumulate in the deep recesses of the costophrenic sulci - 75 cc (or less) to blunt the posterior costophrenic angle on the lateral film -250-300 cc to blunt the lateral costophrenic angles on the frontal film

question

air-fluid or fat-fluid level

answer

an interface between two substances of different densities in which the lighter substance rises above and forms a straight-edge interface with the heavier substance below.

question

five technical factors for adequate reading

answer

• Penetration • Inspiration • Rotation • Magnification • Angulation

question

Penetration

answer

The spine should be visible through the heart -not advisable to read an underpenetrated and overpenetrated films

question

Inspiration

answer

At least eight to nine posterior ribs should be visible

question

Rotation

answer

Spinous process should fall equidistant between the medial ends of the clavicles

question

Magnification

answer

AP films (mostly portable chest x-rays) will magnify the heart slightly

question

five basic densities

answer

arranged here from least to most dense - Air - Fat - Soft tissue or fluid - Calcium/ bones - Metal the denser an object is, the more x-rays it absorbs, and the whiter it appears on radiographic images

question

Angulation

answer

Clavicle normally has an "S" shape and superimposes on the 3rd or 4th rib

question

Pitfalls of underpenetration

answer

Underpenetration can introduce at least two errors into your interpretation 1. left hemidiaphragm may not be visible and it could either mimic or hide true disease in the left lower lung field Sol'n: Look at the lateral chest radiograph for confirmation 2. the pulmonary markings, which are mostly the blood vessels in the lung, may appear more prominent than they really are. You may mistakenly think the patient is in congestive heart failure or has pulmonary f ibrosis Sol'n: Look for other radiologic signs of congestive heart failure and Look at the lateral chest film

question

LATERAL CHEST RADIOGRAPH

answer

-A left lateral chest x-ray (the patient's left side is against the film) is of great diagnostic value - part of the standard two-view chest examination together with frontal chest radiograph -used to determine the location; - confirm the presence of disease; and - demonstrate disease not visible on the frontal image

question

Pitfall of overpenetration

answer

- the lung markings may seem decreased or absent - You could mistakenly think the patient has emphysema or a pneumothorax - and it could render findings like a pulmonary nodule almost invisible Sol'n: Look for other radiographic signs of emphysema or pneumothorax

question

Pitfall: Poor inspiration

answer

- A poor inspiratory effort will compress and crowd the lung markings, especially at the bases of the lungs near the diaphragm. - mistakenly think the study shows lower lobe pneumonia Sol'n: Look at the lateral chest radiograph

question

Pitfalls of excessive rotation

answer

Marked rotation can introduce errors in interpreta-tion: -The hilum may appear larger (sol'n look at the hilum on the lateral chest view) - distort the appearance of the normal contours of the heart and hila - The hemidiaphragm may appear higher on the side rotated away (sol'n Compare the current study to a previous study)

question

Pitfall of excessive angulation

answer

- heart may have an unusual shape, which sometimes mimics cardiomegaly - sharp border of the left hemidiaphragm may be lost, which could be mistaken as a sign of a left pleural effusion or left lower lobe pneumonia. Sol'n: Know how to recognize technical artifacts and understand how they can distort normal anatomy or Consult with a radiologist

question

apical lordotic view

answer

- anterior structures in the chest (like the clavicles) are projected higher on the resultant radiographic image than posterior structures in the chest, which are projected lower -result in angling the x-ray beam towards the patient's head

question

FIVE KEY AREAS ON THE LATERAL CHEST X-RAY

answer

The retrosternal clear space The hilar region The fissures The thoracic spine The diaphragm and posterior costophrenic sulci

question

The Retrosternal Clear Space

answer

Lucent crescent between sternum and ascending aorta

question

two main categories of PARENCHYMAL LUNG DISEASE

answer

Airspace (alveolar) disease Interstitial (infiltrative) disease

question

Airspace (alveolar) disease

answer

- produces a confluent fluffy, cloudlike, or hazy opacities with margins that are fuzzy and indistinct - it can be distributed throughout the lungs, as in pulmonary edema or it may appear to be more localized as in a segmental or lobar pneumonia - air bronchograms or the silhouette sign may be present

question

air bronchogram

answer

- The visibility of air in the bronchus because of surrounding airspace disease - it is a sign of airspace disease

question

What can fill the airspaces besides air?

answer

- Fluid, such as occurs in pulmonary edema - Blood, e.g., pulmonary hemorrhage - Gastric juices, e.g., aspiration - Inflammatory exudate, e.g., pneumonia - Water, e.g., near-drowning

question

silhouette sign

answer

- occurs when two objects of the same radiographic density (fat, water, etc.) touch each other so that the edge or margin between them disappears. - Airspace disease may demonstrate the silhouette sign

question

ACUTE Airspace (alveolar) Diseases

answer

Pneumonia Pulmonary alveolar edema Hemorrhage Aspiration Near-drowning

question

The Hilar Region

answer

No discrete mass present

question

CHRONIC Airspace (alveolar) Diseases

answer

Bronchoalveolar cell carcinoma Alveolar cell proteinosis Sarcoidosis Lymphoma

question

The Fissures

answer

Major and minor fissures should be pencil-point thin, if visible at all

question

Pneumonia

answer

- usually manifests as patchy, segmental, or lobar airspace disease. - Pneumonias may contain air bronchograms. - Clearing usually occurs in less than 10 days (pneumococcal pneumonia may clear within 48 hours

question

The Thoracic Spine

answer

Rectangular vertebral bodies with parallel end plates; disk spaces maintain height from top to bottom of thoracic spine

question

Pulmonary alveolar edema

answer

- classically produces bilateral, perihilar airspace disease sometimes described as having a bat-wing or ANGEL-WING configuration - fluid fills not only the airspaces but also the bronchi themselves, usually no air bronchograms are seen. - clears rapidly after treatment (<48 hours)

question

Aspiration

answer

- tend to affect whatever part of the lung is most dependent at the time the patient aspirates, and its manifestations depend on the substance(s) aspirated - usually occurs in either the lower lobes or the posterior portions of the upper lobes

question

osteophytes

answer

small, bony spurs that develops on a Degenerated disk that can lead to the narrowing of the disk space.

question

Interstitial (infiltrative) disease

answer

- Interstitial disease has discrete reticular, nodular, or reticulonodular patterns. - "Packets" of disease are separated by normal-appearing, aerated lung. - Margins of "packets" of interstitial disease are usually sharp and discrete. - Disease may be focal or diffusely distributed in the lungs. - Usually no air bronchograms are present

question

patterns of presentation of the particles in Interstitial (infiltrative) disease

answer

Reticular interstitial disease appears as a network of lines Nodular interstitial disease appears as an assortment of dots Reticulonodular interstitial disease contains both lines and dots

question

The Diaphragm and Posterior Costophrenic Sulci

answer

Right hemidiaphragm slightly higher than left; sharp posterior costophrenic sulci

question

Pitfall in reading Interstitial (infiltrative) disease

answer

Sometimes, so much interstitial disease is present that the overlapping elements of disease may superimpose and mimic airspace disease on con ventional chest radiographs Sol'n: Look at the periphery, Obtain a CT scan

question

right hemidiaphragm

answer

we have one diaphragm but we refer the right half of the diaphragm as the right hemidiaphragm - usually visible for its entire length from front to back. - Normally, the right hemidiaphragm is slightly higher than the left.

question

RETICULAR Interstitial (infiltrative) Diseases

answer

Idiopathic pulmonary fibrosis Pulmonary interstitial edema Rheumatoid lung Scleroderma Sarcoid

question

NODULAR Interstitial (infiltrative) Diseases

answer

Bronchogenic carcinoma Metastases Silicosis Miliary tuberculosis Sarcoid

question

Pulmonary interstitial edema

answer

- can occur because of increased capillary pressure (congestive heart failure), increased capillary permeability (allergic reactions), or decreased fluid absorption (lymphangitic blockade from metastatic disease) - classically manifests four key radiologic findings: 1. fluid in the fissures (major and minor), 2. peribronchial cuffing (from fluid in the walls of bronchioles), 3. pleural effusions, and 4. Kerley B lines - fluid is in the interstitium of the lung rather than in the airspaces - With appropriate therapy, pulmonary interstitial edema usually clears rapidly (<48 hours)

question

Idiopathic pulmonary fibrosis

answer

- unknown etiology - early stage is a milder form known as desquamative interstitial pneumonia (DIP) - Later in the disease, it is called usual interstitial pneumonia (UIP) - considered the endstage disease along the spectrum of these interstitial pneumonias - Conventional radiographs of the chest may show a fine or, later in the disease, a coarse reticular pattern that is bilaterally symmetrical, most prominent at the bases, subpleural in location and frequently associated with volume loss

question

desquamative interstitial pneumonia (DIP)

answer

- early stage and a milder form of Idiopathic pulmonary fibrosis

question

Usual interstitial pneumonia (UIP)

answer

- later form of Idiopathic pulmonary fibrosis - marked thickening of the interstitium, bronchiectasis, and a pattern of cystic changes in the lung called HONEYCOMBING

question

left hemidiaphragm

answer

we have one diaphragm but we refer the left half of the diaphragm as the left hemidiaphragm - seen sharply posteriorly but is silhouetted by the muscle of the heart anteriorly - its edge disappears anteriorly

question

Rheumatoid lung

answer

- found in some patients with rheumatoid arthritis - three most common manifestations (in order of decreasing frequency): pleural effusions, interstitial lung disease, and nodules in the lung called necrobiotic nodules

question

Bronchogenic carcinoma

answer

- has four major cell types: adenocarcinoma, squamous cell carcinoma, small cell carcinoma, and large cell carcinoma - nodules or masses in the lung are more sharply marginated than airspace disease, producing a relatively clear demarcation between the nodule and the surrounding normal lung tissue

question

Metastases to the lung

answer

can be divided into three categories: hematogenous, lymphangitic and direct extension

question

Hematogenous metastases

answer

- arrive via the bloodstream and usually produce two or more nodules in the lungs, sometimes called cannonball metastases because of their large, round appearance

question

costophrenic angles / sulci

answer

a depression, or sulcus, that surrounds the periphery of each lung and represents the lowest point of the pleural space when the patient is upright - lateral costophrenic sulcus ( On a frontal chest radiograph ) - posterior costophrenic sulcus ( on the lateral radiograph)

question

blunting of the costophrenic angles

answer

When Pleural effusions accumulate in the deep recesses of the costophrenic sulci - 75 cc (or less) to blunt the posterior costophrenic angle on the lateral film -250-300 cc to blunt the lateral costophrenic angles on the frontal film

question

Sarcoidosis

answer

- Mixed Reticular and Nodular Interstitial Disease (Reticulonodular Disease) - In addition to the bilateral hilar and right paratracheal adenopathy characteristic of this disease, about half of patients with thoracic sarcoid also demonstrate interstitial lung disease ( frequently a mixture of both reticular and nodular components)

question

five technical factors for adequate reading

answer

• Penetration • Inspiration • Rotation • Magnification • Angulation

question

Penetration

answer

The spine should be visible through the heart -not advisable to read an underpenetrated and overpenetrated films

question

Inspiration

answer

At least eight to nine posterior ribs should be visible

question

Rotation

answer

Spinous process should fall equidistant between the medial ends of the clavicles

question

Magnification

answer

AP films (mostly portable chest x-rays) will magnify the heart slightly

question

Stages of progression of SARCOIDOSIS

answer

Stage 1: start with adenopathy Stage2: proceed to a combination of both interstitial lung disease and adenopathy Stage 3: progress to a stage in which the adenopathy regresses while the interstitial lung disease remains

question

Angulation

answer

Clavicle normally has an "S" shape and superimposes on the 3rd or 4th rib

question

Pitfalls of underpenetration

answer

Underpenetration can introduce at least two errors into your interpretation 1. left hemidiaphragm may not be visible and it could either mimic or hide true disease in the left lower lung field Sol'n: Look at the lateral chest radiograph for confirmation 2. the pulmonary markings, which are mostly the blood vessels in the lung, may appear more prominent than they really are. You may mistakenly think the patient is in congestive heart failure or has pulmonary f ibrosis Sol'n: Look for other radiologic signs of congestive heart failure and Look at the lateral chest film

question

Hemithorax

answer

...

question

Pitfall of overpenetration

answer

- the lung markings may seem decreased or absent - You could mistakenly think the patient has emphysema or a pneumothorax - and it could render findings like a pulmonary nodule almost invisible Sol'n: Look for other radiographic signs of emphysema or pneumothorax

question

Pitfall: Poor inspiration

answer

- A poor inspiratory effort will compress and crowd the lung markings, especially at the bases of the lungs near the diaphragm. - mistakenly think the study shows lower lobe pneumonia Sol'n: Look at the lateral chest radiograph

question

Pitfalls of excessive rotation

answer

Marked rotation can introduce errors in interpreta-tion: -The hilum may appear larger (sol'n look at the hilum on the lateral chest view) - distort the appearance of the normal contours of the heart and hila - The hemidiaphragm may appear higher on the side rotated away (sol'n Compare the current study to a previous study)

question

Pitfall of excessive angulation

answer

- heart may have an unusual shape, which sometimes mimics cardiomegaly - sharp border of the left hemidiaphragm may be lost, which could be mistaken as a sign of a left pleural effusion or left lower lobe pneumonia. Sol'n: Know how to recognize technical artifacts and understand how they can distort normal anatomy or Consult with a radiologist

question

apical lordotic view

answer

- anterior structures in the chest (like the clavicles) are projected higher on the resultant radiographic image than posterior structures in the chest, which are projected lower -result in angling the x-ray beam towards the patient's head

question

three major causes of an opacified hemithorax

answer

Atelectasis of the entire lung A very large pleural effusion Pneumonia of an entire lung pneumonectomy—removal of an entire lung ( less common)

question

ATELECTASIS OF THE ENTIRE LUNG

answer

- usually results from complete obstruction of the right or left main bronchus - visceral and parietal pleura do not separate from each other in atelectasis, mobile structures in the thorax are "pulled" toward the side of the atelectasis producing a shift (movement) of certain mobile thoracic structures toward the side of opacification

question

two main categories of PARENCHYMAL LUNG DISEASE

answer

Airspace (alveolar) disease Interstitial (infiltrative) disease

question

Airspace (alveolar) disease

answer

- produces a confluent fluffy, cloudlike, or hazy opacities with margins that are fuzzy and indistinct - it can be distributed throughout the lungs, as in pulmonary edema or it may appear to be more localized as in a segmental or lobar pneumonia - air bronchograms or the silhouette sign may be present

question

air bronchogram

answer

- The visibility of air in the bronchus because of surrounding airspace disease - it is a sign of airspace disease

question

What can fill the airspaces besides air?

answer

- Fluid, such as occurs in pulmonary edema - Blood, e.g., pulmonary hemorrhage - Gastric juices, e.g., aspiration - Inflammatory exudate, e.g., pneumonia - Water, e.g., near-drowning

question

silhouette sign

answer

- occurs when two objects of the same radiographic density (fat, water, etc.) touch each other so that the edge or margin between them disappears. - Airspace disease may demonstrate the silhouette sign

question

ACUTE Airspace (alveolar) Diseases

answer

Pneumonia Pulmonary alveolar edema Hemorrhage Aspiration Near-drowning

question

MASSIVE PLEURAL EFFUSION

answer

- the large effusion "pushes" mobile structures away, and the heart and trachea shift away from the side of opacification

question

CHRONIC Airspace (alveolar) Diseases

answer

Bronchoalveolar cell carcinoma Alveolar cell proteinosis Sarcoidosis Lymphoma

question

PNEUMONIA OF AN ENTIRE LUNG

answer

- inflammatory exudate fills the air spaces causing consolidation and opacification of the lung there is neither a pull toward the side of the pneumonia by volume loss nor a push away from the side of the pneumonia by a large effusion - Neither the heart nor trachea shifts -

question

Pneumonia

answer

- usually manifests as patchy, segmental, or lobar airspace disease. - Pneumonias may contain air bronchograms. - Clearing usually occurs in less than 10 days (pneumococcal pneumonia may clear within 48 hours

question

Pulmonary alveolar edema

answer

- classically produces bilateral, perihilar airspace disease sometimes described as having a bat-wing or ANGEL-WING configuration - fluid fills not only the airspaces but also the bronchi themselves, usually no air bronchograms are seen. - clears rapidly after treatment (<48 hours)

question

Aspiration

answer

- tend to affect whatever part of the lung is most dependent at the time the patient aspirates, and its manifestations depend on the substance(s) aspirated - usually occurs in either the lower lobes or the posterior portions of the upper lobes

question

Interstitial (infiltrative) disease

answer

- Interstitial disease has discrete reticular, nodular, or reticulonodular patterns. - "Packets" of disease are separated by normal-appearing, aerated lung. - Margins of "packets" of interstitial disease are usually sharp and discrete. - Disease may be focal or diffusely distributed in the lungs. - Usually no air bronchograms are present

question

patterns of presentation of the particles in Interstitial (infiltrative) disease

answer

Reticular interstitial disease appears as a network of lines Nodular interstitial disease appears as an assortment of dots Reticulonodular interstitial disease contains both lines and dots

question

Pitfall in reading Interstitial (infiltrative) disease

answer

Sometimes, so much interstitial disease is present that the overlapping elements of disease may superimpose and mimic airspace disease on con ventional chest radiographs Sol'n: Look at the periphery, Obtain a CT scan

question

RETICULAR Interstitial (infiltrative) Diseases

answer

Idiopathic pulmonary fibrosis Pulmonary interstitial edema Rheumatoid lung Scleroderma Sarcoid

question

NODULAR Interstitial (infiltrative) Diseases

answer

Bronchogenic carcinoma Metastases Silicosis Miliary tuberculosis Sarcoid

question

Pulmonary interstitial edema

answer

- can occur because of increased capillary pressure (congestive heart failure), increased capillary permeability (allergic reactions), or decreased fluid absorption (lymphangitic blockade from metastatic disease) - classically manifests four key radiologic findings: 1. fluid in the fissures (major and minor), 2. peribronchial cuffing (from fluid in the walls of bronchioles), 3. pleural effusions, and 4. Kerley B lines - fluid is in the interstitium of the lung rather than in the airspaces - With appropriate therapy, pulmonary interstitial edema usually clears rapidly (<48 hours)

question

Idiopathic pulmonary fibrosis

answer

- unknown etiology - early stage is a milder form known as desquamative interstitial pneumonia (DIP) - Later in the disease, it is called usual interstitial pneumonia (UIP) - considered the endstage disease along the spectrum of these interstitial pneumonias - Conventional radiographs of the chest may show a fine or, later in the disease, a coarse reticular pattern that is bilaterally symmetrical, most prominent at the bases, subpleural in location and frequently associated with volume loss

question

desquamative interstitial pneumonia (DIP)

answer

- early stage and a milder form of Idiopathic pulmonary fibrosis

question

Usual interstitial pneumonia (UIP)

answer

- later form of Idiopathic pulmonary fibrosis - marked thickening of the interstitium, bronchiectasis, and a pattern of cystic changes in the lung called HONEYCOMBING

question

Rheumatoid lung

answer

- found in some patients with rheumatoid arthritis - three most common manifestations (in order of decreasing frequency): pleural effusions, interstitial lung disease, and nodules in the lung called necrobiotic nodules

question

Bronchogenic carcinoma

answer

- has four major cell types: adenocarcinoma, squamous cell carcinoma, small cell carcinoma, and large cell carcinoma - nodules or masses in the lung are more sharply marginated than airspace disease, producing a relatively clear demarcation between the nodule and the surrounding normal lung tissue

question

Metastases to the lung

answer

can be divided into three categories: hematogenous, lymphangitic and direct extension

question

Hematogenous metastases

answer

- arrive via the bloodstream and usually produce two or more nodules in the lungs, sometimes called cannonball metastases because of their large, round appearance

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