Chest X-ray Fundamentals on Acquisition and Interpretation.pdf

Chest X-Ray Fundamentals
Dr. Emad Efat
ShebinEl komChest hospital
July 2016

Chest X-ray -Tutorials
1.Chest X-ray -Systematic approach
2.Chest X-ray -Quality
3.Chest X-ray -Anatomy
4.Chest X-ray -Abnormalities
5.Chest X-ray -Tubes

Chest X-ray -Systematic approach
Anatomical structures to check:
1. Trachea and bronchi
2. Hilar structures
3. Lung zones
4. Pleura
5. Lung lobes and fissures
6. Costophrenic angles
7. Diaphragm
8. Heart
9. Mediastinum
10. Soft tissues
11. Bones
12. Below diaphragm and hidden areas

Systematic approach
Anatomical structures to check:

Systematic approach -Patient and image data
Check the patient's identity
Note the image date and time
Note the imageprojection: Check if a posterior anterior
(PA) or anterior posterior (AP) projection was used, and
note if the patient was standing, sittingor supine? Was
the mobile X-ray machine used?
The image annotationsare often useful:
This is a mobilechest X-ray
taken with the patient supine,
at 11.25 amin the resuscitation
room. The patient's name, ID
numberand date of birth are
annotated. Note the side
marker is correct.

Systematic approach -projection
Chest x-ray :
1.P-A view
2.A-P view :for Ambulatory limit
3.Lateral ( Lt/Rt) : forEffusion or
thickening
4.A-P supine
5.Lateral decubitus (Lt/Rt)
6.Lordotic : for Apical lesion
7.Oblique (Rt/Lt;
post/anterior)

Systematic approach -Image quality
Assess the image quality: The chest X-ray should be
checked for rotation, inspiration and penetration
(Mnemonic-RIP-Rest In Peace ).
Comment on the presence of medical artifacts
Can the clinical question still be answered?

Systematic approach -The obvious abnormality
It is often appropriate to start by describing the most
striking abnormality. However, once you have done this,
it is vital to continue checking the rest of the image.
Remember that the most obvious abnormality may not
be the most clinically important.
The elephant in the
image!
If there is an elephant
in the image, don't
ignore it!Describe it
in detail and then use
your system to
continue examining the
image.

Systematic approach -Describing abnormalities
'Shadowing', 'Opacification', 'increased density',
'increased whiteness' are all acceptableterms
'Lesion descriptors' may lead you towards a diagnosis
Be descriptiverather than jumpingto a diagnosis
'Lesion descriptors'
6.PositionAnterior/
Posterior/Lung zone etc.
7.ShapeRound/ Crescentic/etc.
8.EdgeSmooth/
Irregular/Spiculated
9.PatternNodular/
Reticular(netlike)
10.DensityAir/ Fat/Soft tissue/
Calcium/Metal
1.Tissue involved Lung,
heart, aorta, bone etc.
2.SizeLarge/ Small/Varied
3.SideRight/ Left
Unilateral/ Bilateral
4.NumberSingle/ Multiple
5.DistributionFocal/
Widespread

Systematic approach -Describing abnormalities
'Shadows, opacities, densities'
Tissue involved: Lung
Size: Small (>2 cm)
Side: Bilateral
Number: Multiple
Distribution: Widespread
Position: Mainly middle
to lower zones
Shape: Round
Edge: Irregular
Pattern: Nodular
Density: Soft tissue
Diagnosis:
Description helps with diagnosis. Once you have put all the above terms
together, there can only be one diagnosis.
Metastatic disease

Systematic approach -Locating abnormalities
Consider its anterior-posteriorposition.
A lateral view may help, but 3D location may also be
possible on a posterior-anterior (PA) view if you have a
knowledge of chest X-ray anatomyand an understanding
of the 'silhouette' sign.
The 'silhouette' sign:
The silhouette sign is a misnomer !
It should be called the 'loss of silhouette' sign.
Normal adjacent anatomical structures of differing
densities form a crisp 'silhouette,' or contour.
Loss of a specific contour can help determine
the position of a disease process.

Systematic approach -Locating abnormalities
The 'silhouette' sign: Loss of contour of :
1-Left heart borderLinguladisease
2-Hemidiaphragm Lower lobe lung disease
3-Paratrachealstripe Paratrachealdisease
4-Chest wall Lung, pleuralor ribdisease

Systematic approach -Locating abnormalities
The 'silhouette' sign: Loss of contour of :
5-Aortic knuckleAnterior mediastinalor left upper lobe disease
6-Paraspinalline Posterior thorax disease
7-Right heart borderMiddle lobe disease

Systematic approach -Review areas
After a systematic look at the whole chest X-ray, it is worth
re-checking hidden areas that may conceal important
pathology.
Hidden areas:
•Apical zones
•Hilar zones
•Retrocardialzone
•Zone below the
dome of diaphragm

Systematic approach -Interpretation
Whatever the findings are,
they should only be
interpreted in view of the
clinical setting.
Remember to treat the
patient -not the X-ray!
Occasionally there will be
an unexpected finding
(Incidental Finding), which
may need to be considered
with caution, especially if
equivocal or if it does not
fit the clinical scenario.
Posteroanterior (PA) chest
radiograph shows an incidental
findingof a solitary pulmonary
noduleadjacent to the left hilum.

Chest X-ray quality-Inclusion
Check the image for: Inclusion, Projection, Rotation,
Inspiration, Penetration andArtifact.
Check to see if a poor quality X-ray demonstrates a life
threateningabnormality before dismissing it.
Check to see if the clinical question still be answered?
Inclusion:
A chest X-ray
should include
the entire thoracic
cage( first ribs,
Costophrenic
angles, Lateral
edges of ribs ).

Chest X-ray quality -Projection
AP projection :
AP projection image is of
lower qualitythan PA image.
The scapulae are not retracted
laterally and they remain
projected over each lung.
Heart size is exaggerated

Chest X-ray quality -Rotation
Rotation:
The spinousprocesses should lie
half way between the medial
ends of the clavicles
Rotation affects heart size &
shape, aortic tortuosity, tracheal
position and density of lung fields
Rotation can obscure a
pneumothorax. Can also mimic a
mediastinalshift.
Rotation may cause an increase in the transradiancy (blackness)
of the lung on the side to which the patient is rotated.
Rotation will also alter the relative appearance on the hila and
can mimic hilar asymmetry.

Chest X-ray quality -Rotation

Chest X-ray quality -Rotation
Frontal chest x-Ray (CXR) with subject rotated to
the left. Note an enlarged heart and small left
pleural effusion. The left hemithorax is darker
than the right due to the rotation.

Chest X-ray quality -Inspiration & lung volume
Assessing inspiration:
Count ribs down to
the diaphragm.
The diaphragm
should be
intersected by:
the 5th to 7th (right
6th anterior rib)
anterior ribs in the
mid-clavicularline or
The 8th–10th(9th)
posterior ribs . CXR in full inspiration

If the image is acquired in the
expiratory phase or with a
poor inspiratory effort:
1.The lungs are relatively airless
and their density is increased.
2.Increasein lower zone
opacity
3.The hila are compressed and
appear more bulky
4.Exaggerationof heart size
5.Obscurationof the lung
bases.
Chest X-ray quality -Inspiration & lung volume
poor inspiratory effort
full inspiration the same patient

Chest X-ray quality -Penetration
Differential Absorption:
Penetration of the x-ray
beam is dependent on
tissue density
Denser object = Less
beam striking the
film (more
absorption) = whiter
Less dense = More
beam striking the
film = blacker

Chest X-ray quality -Penetration
A well penetrated (exposed) chest X-ray :
The end plates of the lower thoracic vertebral bodies
should be just visible through the cardiac shadow.
The left hemidiaphragm should be visibleto the edge
of the spine.

Chest X-ray quality -Penetration
Good penetration
You should be able to
just see the thoracic
spine through the heart

Chest X-ray quality -Penetration
An under-penetrated film looks diffusely opaque (too
white), structures behind the heart are obscured, and
left lower lobepathology may be easily missed.
An over-penetrated film looks diffusely lucent, the lungs
appear blacker than usual and the vascular markings and
lung detail are poorly seen.

Chest X-ray quality -Artifact
Radiographic artifact
Rotation, incomplete inspiration
and incorrect penetration. Other
radiographic artifact includes
clothingor jewellerynot
removed.
Patient artifact
Poor co-operationwith
positioningor movement. Very
often obesityexaggerates lung
density. Occasionally normal
anatomical structures such as hair
or skin foldscan cause confusion. Hair artifact

Chest X-ray anatomy-Airways
Assessing the airways
Startyour assessment of
every X-ray by looking at the
airways.
The trachea should be central
or slightly to the right.
If the trachea is deviated:
If the patient is rotated, or if
there is pathology.
If the trachea is deviated:
If it has been pushedor
pulledby a disease process.
Thetracheabranchesatthe
carina,intotheleftandright
mainbronchi,andthesecan
oftenbefollowedasthey
branchbeyondthehilaand
intothelungs.

Chest X-ray anatomy -Airways
large left pleural
effusion, and
tracheal shift away
from the effusion
Tension pneumothorax
with tracheal deviation
to right
Tracheal shift to the
right due to thyroid
enlargement
Causes of tracheal deviation:
Ipsilateral(To pull): Collapse and Fibrosis
Contralateral ( To push): Apical mass , Pleural effusion
and Pneumothorax

Chest X-ray anatomy -Hilar structures
The structures contributing to
hilarshadows are:
Major:Pulmonary artery and veins
Minor:Fat, Lymph nodes and
Bronchial walls (not visible unless
abnormal)
Normal Hilum:
Position:Left hilum is slightly
higher than the right hilum, Only in
a minority of cases the right hilusis
at the same levelas the left, but
never higher.
Shape: Concave
Size: Similar on both sides
Density: Almost sameon both sides
Deoxygenated blood (blue
arrow) is pumped upwards out of
the right ventricle (RV) via the
main pulmonary artery (MPA).
This divides into left(LPA) and
right(RPA) which each pass via
the lung hila into the lung tissue

Chest X-ray anatomy -Hilar structures
The hilarpoints: the angle
formed by the descending upper
lobe veins, as they cross behind
the lower lobe arteries
Not everynormal patient has a
very clear hilarpoint on both
sides, but if they are present then
they can be useful in determining
the position of the hila.
Identifymain lower lobe
pulmonary arteries: They
can be compared toa
little fingerpointing
downwards and medially.

Chest X-ray anatomy -Lung zones
The chest radiograph zones:
1.Apical zone: above the
clavicles
2.Upper zone: below the
clavicles and above the
cardiac silhouette (i.e. up to
lower margin of 2nd rib )
3.Mid zone: the level of the
hilarstructures (i.e. from
lower margin of 2ndrib to
lower margin of 4thrib )
4.Lower zone:the bases ( i.e. from 4thrib to diaphragm )

Chest X-ray anatomy -Pleura and pleural spaces
Trace round the entire edge
of the lung where pleural
abnormalities are seen.
Start and end at the hila
Is there pleural thickening?
Is there a pneumothorax?
The lung markings should
be visible to the chest wall
Is there an effusion? The
costophrenic anglesand
hemidiaphragmsshould be
well defined

Chest X-ray anatomy -Pleura and pleural spaces
Costophrenicrecesses and
angles:
The costophrenicangles
are limited views of the
costophrenicrecess
On a frontal view the
costophrenicangles
should be sharp.
The costophrenicangles
consist of the lateral
chest wall and the dome
of each hemidiaphragm.

Chest X-ray anatomy -Lung lobes and fissures
In the right lung there
is an oblique fissure
( of ) and a horizontal
fissure ( hf ) ,
separating the lung into
three lobes -upper,
middle, and lower.
Each lobe has its own
visceral pleural
covering.

Chest X-ray anatomy -Lung lobes and fissures
Theleft lung is
divided into two
lobes, upperand
lower.
These lobes have
their own pleural
covering and these
lie together to form
the oblique (major)
fissure ( of ).

Chest X-ray anatomy -Diaphragm
The hemidiaphragms are not
at the same level on frontal
erectinspiratorychest
radiographs, but are usually
within one rib intercostal space
height (2 cm) of each other.
The left hemidiaphragm is
usually lowerthan the right.
If the left hemidiaphragm is
higher than the rightor the
rightis higher than the left by
more than 3 cm, one of the
many causes of diaphragmatic
elevation should be considered.

Chest X-ray anatomy -Diaphragm
Hemidiaphragms-lateral
view:
The left and right
hemidiaphragms are
almost superimposed on
a lateral view.
Anteriorly the left
hemidiaphragm blends
with the heart and
becomes indistinct.

Chest X-ray anatomy -Heart size and contours
From superior to inferior:
1.Right paratrachealstripe:
made up of right
brachiocephalic veinand SVC
2.Arch of the azygousvein
3.Ascending aorta in older
individuals projects to the
right of the SVC
4.Superior vena cava (SVC)
5.Right atrium
6.Inferior vena cava (IVC)
The normal contours of the heart and mediastinum
(cardiomediastinal contour):
Right cardiomediastinal contour

Chest X-ray anatomy -Heart size and contours
From superior to inferior:
Left paratrachealstripe
Made up of left common
carotid artery, left subclavian
artery and the left jugular vein
Aortic arch +/-aortic nipple
(left superior intercostal vein)
Pulmonary artery
Auricle of left atrium
Left ventricle
The normal contours of the heart and mediastinum
(cardiomediastinal contour):
Left cardiomediastinal contour

Chest X-ray anatomy -Heart size and contours

Chest X-ray anatomy -Heart size and contours
Lateral view:
Anterior cardiomediastinalcontour
From superior to inferior:
1.Superior mediastinum
1.great vessels
2.thymus
2.Ascending aorta
3.Right ventricular outflow track
4.Right ventricle
Posterior cardiomediastinalcontour
From superior to inferior:
1.Left atrium and pulmonary veins
2.Right atrium
3.Inferior vena cava

Chest X-ray anatomy -Heart size and contours
Cardiothoracic ratio:
The cardiothoracic ratio
should be less than 0.5. i.e.
A+B/C<0.5
A cardiothoracic ratio > 0.5
suggests cardiomegaly in
adults
A cardiothoracic ratio > 0.6
suggests cardiomegaly in
newborn.

Chest X-ray anatomy -Heart size and contours
There are several structures in the superior mediastinum
that should always be checked. These include the aortic
knuckle, the aorto-pulmonary window, and the right
para-tracheal stripe.

Chest X-ray anatomy -Heart size and contours
It is a space
located between
the arch of the
aortaand the
pulmonary
arteries.
This space can be
lost as a result of
mediastinal
lymphadenopathy
(e.g. malignancy).
The aorto-pulmonary window:
Aortic knuckle (red arrow) &
Aortopulmonary window (green arrow)

Chest X-ray anatomy -Mediastinum
In lateral CXR, mediastinum divided into :
Superior mediastinum (S): above the
thoracic plane or the plane of Ludwig
(a horizontal line that runs from sternal
angle or angle of Louis) to the inferior
endplate of T4)
Inferior mediastinum: below the plane of
Ludwig
Anterior mediastinum (A): anterior to
the pericardium
Middle mediastinum (M): within the
pericardium
Posterior mediastinum (P): posterior to
the pericardium
In PA view, the mediastinum is that space
between the lungs and pleural surfaces
(yellow lines).

Chest X-ray anatomy -Bones and Soft tissues
Bones:
Ribs(anterior
and posterior)
Claviclesand
shoulders
Sternum
Vertebrae
Shoulder joints
Soft tissues :
Breastshadows
Skinfolds
Muscles
Check for: Symmetry, Deformities, Fractures, Masses, Calcifications
and Lytic lesions.

Chest X-ray anatomy -Lateral view
Interpretation of lateral film

Chest X-ray anatomy -Lateral view
Interpretation of lateral film
The clear spaces
Retrosternal space
Retrotracheal
space
Retro cardiac
Vertebral
translucency
Diaphragm outline
The fissures
The trachea
The sternum

Chest X-ray anatomy -Lateral view
Retrosternal space
Seen as a normal lucency
between the posterior aspect
of the sternum and anterior
aspect of the ascending aorta
This space should be visible
and less than 2.5cm in width.
Can be demonstrated at point
3cm below manibrium sterni
An increased retrosternal
airspace is a reliable sign of
pulmonary emphysema, while
obliterationindicates anterior
mediastinal masse.g.
lymphoma.

Chest X-ray anatomy: Lateral view
Vertebral translucency
The ‘‘spine sign,’’ which
states that the normal
lateral chest film shows
increasing overall lucency
as one looks down the
thoracic vertebral bodies
from the neck to the
diaphragms.
Causes of failure to darken
gradually above the
diaphragms:
Pleural thickening
Lower lobe collapse
Mediastinalmass

Chest X-ray anatomy -Lateral view
Diaphragm outline
Right
hemidiaphragm
continues
anteriorly
left
hemidiaphragm
blendswith the
heart and
becomes
indistinct
Anteriorly.

Chest X-ray anatomy -Lateral view
The fissures

How to speak -Normal CXR
This is chest radiograph, PA view with
normal exposure, no rotationand without
any apparent bonyabnormality. Tracheais
placed centrally& lung fields are clearwith
normal broncho-vescicular markings.
Cardiovascularsilhouette is within normal
limits with normal cardiothoracic ratio.
Mediastinum, costo-phrenic, cardio-phrenic
angles, dome of diaphragm& soft tissue
shadow within normal limits.

Chest X-ray Abnormalities-Trachea
Ensure trachea is visible and in midline
1.Tracheal displacement(discussed previously)
2.Trachea normally narrows at the vocal cords
3.View the carina, angle should be between 60 –100
degrees. Beware of things that may increase this angle,
e.g. left atrial enlargement, lymph node enlargement and
left upper lobe atelectasis
4.Follow out both main stem bronchi
5.Check for tubes, foreign bodies etc.
6.If an endotracheal tube is in place, check the positioning,
the distal tip of the tube should be 5-7cmabove the
carina

Chest X-ray Abnormalities -Trachea

Chest X-ray Abnormalities -Trachea
In this patient, the endotracheal tubeis in the right
mainstembronchus, and the left sided is not being
ventilated. That is why the left side is collapsed

Chest X-ray Abnormalities -The lung hilum
A.Hilar position:
If a hilum has moved, you should try to determine if it has
been pushedor pulled, just like you would for the
trachea.
Theleft hilum must never be lower thanthe right hilum.
Whenever a left hilum appears lower than the right hilum
–look for other evidence suggestive of:
Collapseof either the left lower lobe or of the right
upper lobe
Enlargement of the right hilum

Chest X-ray Abnormalities -The lung hilum
A.Hilar position:
Superiordisplacementand
horizontalizationof the right hilum
(white curved arrow) due to
atelectasisofthe right upper lobe
(black arrows). the hilum (red arrow)
Left lower lobe atelectasis. The blue
arrows point to the edge of a
triangular region of atelectaticleft
lower lobe. Left Hilum displaced
inferiorly. the hilum (red arrow)

Chest X-ray Abnormalities -The lung hilum
B.Hilar enlargement:
May be unilateralor bilateral, symmetricalor asymmetrical

Chest X-ray Abnormalities -The lung hilum
Analyze the enlargement of
hilum (if present):
1. Lymph Node enlargement:
Lobulatedappearance
(lumpy-bumpy opacity )
Presence of calcification
within the mass
indicates usually
tuberculosis.
Egg-shell calcification
indicates silicosis or
sarcoidosis. Calcifiedbilateral hilar
lymphadenopathyin
sarcoidosis

Chest X-ray Abnormalities -The lung hilum
2. Arterial enlargement:
Smoothmargins
In pulmonary arterial
hypertension the
arteries in the outer
two-thirds ofeach
lung are smaller than
those at the hila
(peripheral pruning)
Primary pulmonary hypertension showing
rightheart enlargement and enlargement
of the main pulmonary artery and its right
and leftbranches.

Chest X-ray Abnormalities -The lung hilum
3. Malignancy:
Spiculatedirregular or
indistinctmargins
Hilar enlargement due to
malignant lung lesion is
alsoassociated with
superior mediastinal
lymphadenopathy.Look
at the lung fields (for
presence of tumor) and
bone/ribsfor metastasis.This patient has a bulky right
hilum. This was shown to be
due to a bronchogenic tumour.

Chest X-ray Abnormalities -The lung hilum
C.Hilar density:
May be due to :
A massor calcificationin
the hilum
Dense Hilum Sign:
superimposition of
another abnormal
density (pneumonia or a
mass )in the lungor
mediastinumthat
projects over the hilum
on the frontal image.
Here is increased densityand
enlargementof the right hilum with
a multilobularcontour. The CT
scans show enlarged mediastinal
and righthilar lymph nodes.

Chest X-ray Abnormalities -The lung hilum
Dense Hilum Sign:
On the frontal (PA) image, the left hilum (red arrow)
appears denser than the right hilum (white arrow). This
may be caused by a hilar mass, but not necessarily. The
lateral view shows airspace disease (pneumonia) in the
superior segmentof the left lower lobe (yellow arrow).

Chest X-ray Abnormalities -lung fields
Lung abnormalities:
Abnormal whiteness
(increased density):
Consolidation
Atelectasis
Nodule or mass
Interstitial
Abnormal blackness
(decreased density):
Cavity
Cyst
Emphysema
Assess the lungs by comparing the upper,
middleand lowerlung zones on the left
and right

Chest X-ray Abnormalities -lung fields
Four patterns of
increased density:
Consolidation
Lobar
Diffuse
Multifocal ill-
defined
Atelectasis
Nodule or mass
Solitary Pulmonary
Nodule
Multiple Masses
Interstitial
Reticular
Fine Nodular

lung field abnormalities -Consolidation
The key-findings on the
Ill-defined
homogeneous opacity
obscuring vessels
Silhouette sign: loss of
lung/soft tissue
interface
Air-bronchogram
Extentionto the pleura
or fissure, but not
crossingit
No volume loss
May be Bluntingof
costophrenicangle
X-ray are:

lung field abnormalities -Consolidation
Air bronchogram refers to the phenomenon of air-filled
bronchi(dark) being made visible by the opacification of
surrounding alveoli(grey/white).

lung field abnormalities -Consolidation

lung field abnormalities -Consolidation
Bat's wing appearance:
A bilateral perihilardistribution of consolidation.
Reverse bat's wing appearance:
Peripheralor subpleuralconsolidation

lung field abnormalities -Consolidation
Reverse bat's wing appearance
In Chronic eosinophilic pneumonia

lung field abnormalities -Consolidation
Right Upper Lobe Consolidation:

lung field abnormalities -Consolidation
Right middle Lobe Consolidation:

lung field abnormalities -Consolidation
Right lower Lobe Consolidation:

lung field abnormalities -Consolidation
left upper Lobe Consolidation:

lung field abnormalities -Consolidation
Lingular consolidation:

lung field abnormalities -Consolidation
Left lower lobe consolidation:

lung field abnormalities -Consolidation
Lymphoma: Imaging Findings:
Mediastinal widening due to
mediastinal lymphadenopathy
Parenchymal lung involvement:
Multiplenodules
Consolidationwith an
air -bronchogram
Segmental or lobar
atelectasis
Pleural effusions (Mostly
small, unilateral, and
exudative)
Destructive ribor vertebral
bodylesion
Chest X-ray reveals multiple
scattered consolidation
lesions involving both lungs

lung field abnormalities -Consolidation
Tuberculosis (TB): Primary pulmonary tuberculosis:
Imaging Findings:
Patchy or lobar consolidation
Cavitation(uncommon)
Caseating granuloma
(tuberculoma) which usually
calcifies (known as a Ghon
lesion)
Ipsilateral hilarand
mediastinal(paratracheal)
lymphadenopathy, usually
right sided.
Calcificationof nodes
Atelectasis
Pleural effusions
Chest X-ray shows right upper lobe
and left midzone consolidation
and adenopathy.

lung field abnormalities -Consolidation
Tuberculosis: Post-primary pulmonary: Imaging Findings:
Almost always affect:
1.Posterior segments of the
upper lobes
2.Superior segments of the
lower lobes
Patchyconsolidation
Poorly defined linearand
nodularopacities
Cavitation, Aspergillomas,
fibrosisand Bronchiectasis
pleural effusion
Hilarnodal enlargement
Lobar consolidation,
tuberculomaand miliary TB
Patchybilateral opacificationof the
upper lung lobes with cavitationmost
marked on the left (arrow)

lung field abnormalities -Consolidation
Tuberculoma and Miliary Tuberculosis: Imaging Findings:
Tuberculoma and miliary
tuberculosis are rare
Miliary deposits are seen
both in primaryand post-
primarytuberculosis. It
appear as 1-3 mmdiameter
nodules, which are uniformin
size and uniformly distributed
Tuberculomasare usually
found as singlenodules and
they may include a cavityor a
calcificationwith sharp
margins. They are usually
found in the upper lobes
Miliary Tuberculosis

lung field abnormalities -Consolidation
Aspergillomas:
Mass-likefungus balls of Aspergillusfumigatus, occur in patients
with normal immunity but with pre-existing cavities:
pulmonary tuberculosis
pulmonary sarcoidosis
bronchiectasis
bronchogenic cyst
pulmonary sequestration
Pneumocystis pneumonia (PCP)
associated pneumatocoeles
Imaging Findings: Air crescent sign :
Rounded or ovoidsoft tissue attenuating
masseslocated in a surrounding cavity
and outlined by a crescent of air.
Differential diagnosis (DD); hydatidcyst,
bronchogenic carcinoma and PCP.
Rounded density with an
air crescent

lung field abnormalities -Consolidation
Tuberculosis:Imaging Findings:

lung field abnormalities -Consolidation
Aspiration Pneumonitis and Pneumonia: Imaging Findings:
Chest x-ray shows an
infiltrate, frequently in the
superiororposterior basal
segments of a lower lobe or
the posterior segment of an
upper lobe (The right lower
lobe is the most frequent
location).
Aspiration-related lung
abscess
Interstitialor nodular
infiltrates, pleural effusion,
and other changes may be
slowly progressive.
Typically localized pneumoniain
the right lower lobe.

lung field abnormalities -Consolidation
Consolidation due to Lung infarction:
Hampton’s Hump: consists of a pleural based shallow,
wedge-shaped consolidation in the lung periphery
with the base against the pleural surface

lung field abnormalities -Consolidation
Klebsiella pneumonia (Friedländer’s pneumonia):
Imaging Findings:
Usually involves one of
the upper lobes
Homogeneous,
nonsegmental, lobar
consolidation
Bulging Fissure Sign:
bulging of usually minor
fissurefrom heavy,
exudate ( arrow)
Lung abscess (es)
Pleural effusion (70%)
and/or empyema

Consolidation -Cardiogenic pulmonary edema
Cardiogenic pulmonary edema
Consolidationdue to Congestive Heart Failure (CHF) :

Consolidation -Cardiogenic pulmonary edema
Stage I CHF –Redistribution:
Redistribution of thepulmonary veins. This is know as
cephalization(blue arrow) because the pulmonary veins
of the superior zone dilate due to increased pressure.
An increase in width of the vascular pedicle (red arrows)

Consolidation -Cardiogenic pulmonary edema
The vascular pedicleis bordered on the rightby the
superior vena cava and on the left by the left subclavian
arteryorigin

Consolidation -Cardiogenic pulmonary edema
Stage II CHF -Interstitial edema Characterized by:
1.Kerley’sA lines: extend radially from the hilum to the
upper lobes; represent thickening of the interlobular
septa that contain lymphaticconnections.

Consolidation -Cardiogenic pulmonary edema
2.Kerley’s B lines: are shorthorizontallines situated
perpendicularlyto the pleural surface at the lung base;
they represent edemaof the interlobular septa.

Consolidation -Cardiogenic pulmonary edema
3.Thickeningof the bronchialwalls (peribronchial cuffing)
and as loss of definitionof these vessels (perihilar haze).

Consolidation -Cardiogenic pulmonary edema
4.Fluid in themajoror minor fissure (shown here)
produces thickening of the fissurebeyond the pencil-
pointthickness it can normally attain

Consolidation -Cardiogenic pulmonary edema
Stage III CHF -Alveolar edema Characterized by:
Alveolar edema with
perihilar consolidations
and air bronchograms
( Bat's wingor butterfly
pulmonary opacities )
(yellow arrows)
Pleural fluid (blue arrow)
Prominent azygosvein
and increased width of
the vascular pedicle (red
arrow)
An enlarged cardiac silhouette (arrow heads).

lung field abnormalities -Consolidation
Adult Respiratory Distress Syndrome ( ARDS)
ARDS versus Congestive Heart Failure:
Diffusebilateral
patchy infiltrates
More uniform
opacification
Homogenously
distributed
No cardiomegaly
No cephalization
Usually no pleural
effusion or Kerley
B lines

lung field abnormalities -Consolidation
Bronchopneumonia characterisedby:
Multiple small nodularor reticulonodularopacities which
tend to be patchy and/or confluent.
The distribution is often bilateral and asymmetric, and
predominantly involves the lung bases

lung field abnormalities -Consolidation
Wegener's granulomatosischaracterized by:
Nodules or masslesions, which may cavitate
Fleetingfocal infiltrates (lung consolidation )

lung field abnormalities -Consolidation
It is a congenitalabnormality. A
nonfunctioning part of the lung lacks
communication with the bronchial
treeand receives arterial blood
supply from the systemic circulation.
The plain X-ray often shows a
triangularor oval-shaped, basal,
posteriorlung mass, or, less
commonly, as a cystmore on the left
An infected sequestration may be
associated with a parapneumonic
effusion, and may contain one or
more fluid levels.
Pulmonary sequestration:This is an uncommoncause of lobar
consolidation.
Chest radiograph showing left
lower lobeconsolidation
(arrow)

lung field abnormalities -Consolidation
Eosinophilic pneumonia (EP):
Acute EP : A pattern consistent
with pulmonary edema, with
extensive airspace opacity,
interlobular septal thickening (ie,
Kerley B-lines), and pleural
effusions. The infiltrates are
diffuseand notperipherally
based.
Chronic EP : Nonsegmental
peripheral airspace consolidation
(“photographic negative shadow
of pulmonary oedema” -reverse
bat wingappearance) involving
mainly the upper lobes .
Chronic EP: The chest x-ray
shows bilateralperipheral
patchyinfiltrates with relative
sparing of the lower lobes.

lung field abnormalities -Consolidation
Septic emboli:
Usually present as multipleill-defineddensities, which
are probably consolidations.
In about 50%cavitation is seen.

lung field abnormalities -Interstitial disease
On a CXR the most common pattern is reticular.
The ground-glasspattern is frequently not detected.
The cysticpattern is also difficultto appreciate.
High-resolution computed tomography (HRCT) has the ability
to better define diseases that have similar CXR patterns.
There are many causes. For example:

lung field abnormalities -Interstitial disease

lung field abnormalities -Alveolar vs. Interstitial
Alveolar= air sacs
Radiolucent
Can contain blood,
mucous, tumor, or
edema (“airless lung”)
Interstitial = vessels,
lymphatics, bronchi, and
connective tissue
Radiodense
Interstitial disease:
prominent lung markings
with aerated lungs

lung field abnormalities -Interstitial disease
Linear Pattern:
There is thickeningof the
interlobular septa (contain
pulmonary veinsand
lymphatics), producing
Kerleylines.
DD of KerlyLines:
( Pulmonary edema is the
most common cause, Mitral
stenosis, Lymphangitic
carcinomatosis, Malignant
lymphoma, Congenital
lymphangiectasia, Idiopathic
pulmonary fibrosis, Pneumoconiosis and Sarcoidosis )

lung field abnormalities -Interstitial disease
Reticular Pattern:
Fine "ground-glass" (1-2
mm): e.g. interstitial
pulmonary oedema
Medium "honeycombing"
(3-10 mm): commonly seen
in pulmonary fibrosis
Coarse (> 10 mm):cystic
Spaces caused by
parenchymal destruction,
e.g. usual interstitial
pneumonia, pulmonary
sarcoidosis, pulmonary
Langerhans cell histiocytosis

lung field abnormalities -Interstitial disease
Causes of ReticularPattern:
Pulmonaryedema( heart
failure, fluid overload,
nephropathy )
Infection( viral, mycoplasma,
Pneumocystis, malaria )
Post-infectiousscarring
(tuberculosis, histoplasmosis,
coccidioidomycosis)
Mitralvalve disease
Collagenvascular disorders
Granulomatousdisease
( pulmonary sarcoidosis,
eosinophilicgranuloma )
Drug reactions (e.g.
amiodarone)
Pulmonary neoplasms
( lymphangitis carcinomatosis,
pulmonary lymphoma )
Inhalational lung disease
(asbestosis, silicosis, coal
workers pneumoconiosis,
hypersensitivity pneumonitis,
chronic aspiration pneumonia)
Idiopathic (usual interstitial
pneumonia,
lymphangioleiomyomatosis,
tuberous sclerosis,
neurofibromatosis,
amyloidosis )

lung field abnormalities -Interstitial disease
Nodular pattern:
A nodular pattern consists
of multipleround
opacities, generally
ranging in diameter from
1 mm to 1 cm
Nodular opacities may be:
Miliarynodules: <2 mm
Pulmonary
micronodule: 2-7 mm
Pulmonary nodule:
7-30 mm
Pulmonary mass:
>30mm

lung field abnormalities -Interstitial disease
Causes of Miliaryopacities :
Infection
tuberculosis
fungal (often febrile)
healed varicella pneumonia
viral pneumonitis
nocardosis
salmonella
Miliarymetastases
thyroidcarcinoma
renal cell carcinoma
breast carcinoma
malignant melanoma
pancreatic neoplasms
osteosarcoma
trophoblastic disease
Sarcoidosis
Pneumoconioses
silicosis
coal workers pneumoconiosis
Pulmonary haemosiderosis
Hypersensitivity pneumonitis
Langerhans cell histiocytosis
pulmonary alveolar
proteinosis

lung field abnormalities -Interstitial disease
Causes of Calcifiedpulmonary nodules:
Healed infection
Calcified granulomata, e.g.
Thoracic histoplasmosis
Recovered miliaryTB
Healed varicella pneumonia
Pneumoconioseses
silicosis
coalworker'spneuomconiosis
Pulmonary hamartomas
Metastatic pulmonary calcification
Chronic renal failure
Multiple myeloma
Secondary hyperparathyroidism
Massive osteolyticmetastases
IV calcium therapy
Pulmonary haemosiderosis
idiopathic pulmonary
haemosiderosis
Mitral stenosis
Goodpasturesyndrome
Pulmonary alveolar
microlithiasis
Sarcoidosis
Calcified pulmonary
metastases
Pulmonary amyloidosis
Pulmonary hyalinizing
granuloma
Calcifying fibrous
pseudotumourof lung

lung field abnormalities -Interstitial disease
A reticulonodular
pattern results from a
combination of reticular
and nodularopacities.
A differential diagnosis
should be developed
based on the
predominant pattern.
If there is no
predominant pattern,
causes of bothnodular
and reticular patterns
should be considered.
Causes: the same disorders as reticular patterns
Reticulonodularpattern:

lung field abnormalities -Interstitial disease
Ground-glassappearance
A hazy area of increased
attenuationin the lung with
preserved bronchial and
vascular markings.
Aetiology:
Normal expiration
Partial filling of air spaces
Partial collapse of alveoli
Interstitialthickening
Inflammation
Oedema
Fibrosis
Neoplasm
Perihilarground-glass
appearance in the shape of
bats-wings

lung field abnormalities -Interstitial disease
Cystic lung disease:
A lung cyst is an air filled structure with perceptible wall typically 1 mm
in thicknessbut can be up to 4 mm. The diameterof a lung cyst is
usually < 1 cm.
Aetiology:
Acquired :
Honeycombing in UIP
pattern
Cystic bronchiectasis
Sarcoidosis
Pneumocystis
pneumonia
Pulmonary laceration in
trauma
Primary :
Pulmonary Langerhans cell
histiocytosis
lymphangioleiomyomatosiswith
or without tuberous sclerosis
lymphocytic interstitial
pneumonitis (LIP)
Tracheobronchial papillomatosis
Sjogrensyndrome
Neurofibromatosis

lung field abnormalities -Interstitial disease
Hypersensitivity pneumonitis (HP) -(acute & Subacute):
PCX-ray may be normal
PCX-ray commonly shows
a bilateral diffuse micro nodular
infiltrate, usually dense towards
hila, have a predilection for the
midzonesorlowerzones. An
irregular and linearinfiltrate
may be present in lowerzones.
Acute severe attack : a pattern
of diffuse airspace disease or a
ground-glasspattern mimicking
that of pulmonary edema or,
more rarely, as consolidation.
Bilateralreticulonodular
interstitialinfiltration
secondary to subacute
hypersensitivity pneumonitis.

lung field abnormalities -Interstitial disease
Hypersensitivity pneumonitis (HP) -(chronic):
Pulmonary fibrosis affects
upperzones predominantly,
loss of lung volume.
Reticular pattern and
honeycombing, more severe
in the upperlobes than in the
lower ones
Larger ring shadows 1-4 mm
in diameter are due to bullae,
blebs, cysts, or
bronchiectasis.
Parallel line shadows are
caused by bronchiectasis or
bronchial wall thickening
chronicHP—a pigeon fancier—
shows reticular-nodular
opacification.

lung field abnormalities -Interstitial disease
Sarcoidosis;classified by
chest x-ray into 5 stages :
stage 0: normal chest
radiograph
stage I:hilar or
mediastinal nodal
enlargement only
stage II: nodal
enlargement and
parenchymal disease
stage III: parenchymal
disease only
stage IV: end-stage lung
(pulmonary fibrosis)

lung field abnormalities -Interstitial disease
Radiographic varieties of Sarcoidosis:
Hilar and mediastinallymphadenopathy: Garland triad, also known
as the 1-2-3 signisbilateral hilarand right paratracheal
lymphadenopathy.
Dystrophic calcification of involved lymph nodes: Calcificationcan
be amorphous, punctate, popcorn like, or eggshell.
Parenchymalchanges: including fine nodular; reticulonodular;
acinar(poorly marginated, small to large nodules or coalescent
opacities); and, rarely, focal (solitary nodule or mass).
Mycetomas: in stage IV sarcoidosis and apical bullous disease
In stage IV : when fibrosis supervenes, hilarretraction, decreased
lung volume, and honeycomb lung may be present. Bullous disease,
air trapping and diaphragmatic tenting may also be seen.
Pulmonary hypertension may develop: Prominentmain pulmonary
artery, enlarged rightand left pulmonary arteries, right ventricular
enlargement, and attenuation of peripheral vessels.

lung field abnormalities -Interstitial disease
Can be even normalin patients
with very early disease
In advanced disease:
Decreased lung volumes
Basalfineto coarse
reticulationdue to more
extensive involvement of the
lower lobes
Honeycomb Lung andtraction
bronchiectasis
The major fissure is shifted
inferiorlywhich is best seen on
the lateralchest radiograph.
Usual interstitial pneumonia (UIP):
Plain film features are nonspecific.

lung field abnormalities -Interstitial disease
Usual interstitial pneumonia (UIP):
Honeycombing:
The radiographic appearance of honeycombing comprises reticular
densities caused by the thick walls of the cysts.
Chest radiograph
demonstrates
coarsebibasilar
reticular
interstitial
disease
( honeycomping)
(red arrows)

lung field abnormalities -Interstitial disease
Bronchiectasis:
CXR may be normal
Volume loss
Increased pulmonary markings
Indistinct vessel margins due
to peribronchialfibrosis.
Tramlines: dilated and thickened
airways
Ring shadows: thickenedand
abnormally dilated bronchial walls.
Clusters of cysts in Cystic type
Dextrocardia(Immotile cilia
syndrome)
Mucus plugging (ﬁnger-in-glove)
appearance
Atelectasisordiffuse lung fibrosis
Tram-Tracksign

lung field abnormalities -Interstitial disease
Bronchiectasis:
Cystic bronchiectasiswith
multiple cysticairspaces
Ring shadow ( red arrow) & Tram
lines( yellow arrow)

lung field abnormalities -Interstitial disease
Bronchiectasis: Location:
Allergic bronchopulmonary
aspergillosis–central
Childhood viral infections –
Lower lobe predominance
Mounier-Kuhn syndrome –
First to fourth order bronchi
Mycobacterial aviumcomplex
-Right middle lobe and lingual
Primary ciliarydyskinesia –
Fifty percent associated with
situsinversus, middle lobe,
and lingularpredominance
Cystic fibrosis -Upper lobe,
particularly rightupper lobe
Postprimary mycobacterial
tuberculosis(traction
bronchiectasis) –Apical
and posteriorsegments of
upper lobes
Sarcoidosis (traction
bronchiectasis) –Upper
lobe predominance
Usual interstitial
pneumonitis (commonest
cause of traction
bronchiectasis) -Lower
lobe predominance, worse
peripherally

lung field abnormalities -Interstitial disease
Pneumocystis pneumonia (PCP) -CXR findings:
Bilateral, diffuse, often perihilar,
fine,reticularinterstitial
opacification, which may appear
somewhat granular.
Air-space consolidation
Cysticlung disease, spontaneous
pneumothorax, and isolated lobar
or focal consolidation, particularly
with an upper-lobepredominance.
Miliarynodularity, bronchiectasis,
endobronchiallesions, and
mediastinallymphadenopathy
,which may show calcification
CXR may be normal
Typical bilateral air-space
consolidationof PCPin
acquired immunodeficiency
virus infection.

lung field abnormalities -Interstitial disease
Lymphangiticcarcinomatosis:
The term given to tumourspread
through the lymphaticsof the lung,
and is most commonly seen
secondary to adenocarcinoma e.g.
breast cancer, bronchogenic
adenocarcinoma, colon cancer,
stomach cancer, prostate cancer,
cervical cancer, thyroid cancer, etc.
CXR may be normalor Appears as
reticularor reticulonodular
opacification, often with associated
septal lines (KerleyA and B lines),
peribronchialcuffing, pleural
effusions, and mediastinaland/or
hilarlymphadenopathy
Lymphangitic carcinomatosis.
The radiograph
like in the case of interstitial
pulmonary oedema

lung field abnormalities -Interstitial disease
Silicosis:
1.Acute silicosis (silicoproteinosis):
Large bilateral perihiliarconsolidation
or ground glass opacities.
2.Chronic simple silicosis
(common type ): CXR shows multiple
nodularopacities:
Well-definedand uniformin shape
and attenuation
From 1 to 10mmin diameter
Predominantly located in the upper
lobeand posteriorportion of the lung
Nodules may Calcify
Lymph node enlargement common:
Eggshellcalcification of hilarnodes
(5%), DD: Sarcoidosis
Silicosis features a diffuse
micronodularlung disease
with an upperlobe
predominance

lung field abnormalities -Interstitial disease
Silicosis:
3.Complicated silicosis
(progressive massive fibrosis
(PMF), or conglomerate
silicosis):CXR shows large
symmetricbilateralopacities
that are:
1 cm or more in diameter and
with an irregularmargin
Usually in mid-zoneor
periphery of upper lobes
Compensatory emphysema
occurs in lowerlung fields.
Progressive Massive Fibrosis
(PMF) with scarringand
retraction of hilaupwards.
Progressive Massive Fibrosis. There are
conglomerate soft-tissue densities in
both upperlobes (black arrows) with
linear scarring leading from the lower
lobes (white arrows).

lung field abnormalities -Interstitial disease
Silicosis:
4.Complicated silicosis : Complicated
by tuberculous(Silicotuberculosis),
non-tuberculousmycobacterial, and
fungalinfection, certain autoimmune
diseases, and lung cancer.
Eggshell node calcification in silicosis
Silicotuberculosis, with bilateral
conglomeratedisease. Several
cavitiesare present in the left
upper lobe

lung field abnormalities -Atelectasis
CXR show directandindirectsigns of lobar collapse:
Direct signs include displacement of fissuresand
opacificationof the collapsed lobe.
Indirect signs include the following:
Displacement of the hilum
Mediastinal shift toward the side of collapse
Loss of volume in the ipsilateralhemithorax
Elevation of the ipsilateraldiaphragm
Crowding of the ribs
Compensatory hyperlucencyof the remaining lobes
Silhouettingof the diaphragm or heart border

lung field abnormalities -Atelectasis
Complete atelectasis: Characterized by:
Opacificationof the entirehemithorax
Anipsilateralshift of the mediastinum.

lung field abnormalities -Atelectasis
Right upper lobe collapse:
Increased density in the uppermedial
aspect of the right hemithorax
Elevationof the horizontal fissure
Lossof the normal right medial
cardiomediastinalcontour
Elevationof the right hilum
Hyperinflationof the right middleand
lower lobe result in increased
translucencyof the mid and lower
parts of the right lung
Right diaphragmatic tenting
Non-specific signs :
Elevationof the hemidiaphragm
Crowdingof the right sided ribs
Shiftof the mediastinumand tracheato the right

lung field abnormalities -Atelectasis
Right upper lobe collapse:The Golden S-sign (or reverse
S-sign of Golden): is seen on
PA view and the appearance
is that of right upper lobar
collapse with a central mass
expanding the hilum.
On the lateral projection it is
harder to identify. Elevationof
the horizontal fissure and
upper part of the oblique
fissure may be visible.

lung field abnormalities -Atelectasis
Right middle lobe collapse:
On lateral projection, right
middle lobe collapse is
usually relatively easy to
identify,
Appearing as a triangular
opacity in the anterior
aspect of the chest overlying
the cardiac shadow.
The horizontal fissure is
displacedinferiorly and the
inferior part of the oblique
fissure, displaced
anterosuperiorly.

lung field abnormalities -Atelectasis
Right middle lobe collapse:
On frontal CXR, the findings are more
subtle:
The normal horizontal fissure is no
longer visible (as it rotates down)
Blurring of the right heart border
(silhouette sign) (in atelectasisas
well as consolidation)
Non-specific signs may be subtleor
absent due to the small size of the
right middle lobe :
Elevationof the hemidiaphragm
Crowdingof the right sided ribs
Shift of themediastinum to the right
linear opacities in the lobe suggest that the collapse is chronic
(right middle lobe syndrome), with associated bronchiectasis.

lung field abnormalities -Atelectasis
Right lower lobe collapse:
On frontal CXR, the findings :
Increased opacity (triangularin
shape) at the medial base of the
right lung
Obliterationof the silhouette of
the right hemidiaphragm
The right hilumis depressed
Descending right lower lobe
pulmonary artery is not visualized
Right heart border maintained.
Non-specific signs :
Elevationof the hemidiaphragm
Crowdingof the right sided ribs
Shiftof the mediastinumto right
The collapsed right lower lobe
is a triangularopacity (orange
arrows).The right
hemidiaphragmatic outline is
lost(blue dashed line).

lung field abnormalities -Atelectasis
Right lower lobe collapse:
On lateral projection:
The right
hemidiaphragmatic
outline islostposteriorly
The lower thoracic
vertebrae appear denser
than normal (they are
usually more radiolucent
than the upper
vertebrae)
The collapsed right lower lobe a
triangularopacity (orange arrows).
The right hemidiaphragmatic
outline is lost(blue dashed line).

lung field abnormalities -Atelectasis
Left upper lobe collapse:
Hazyor 'Veil-like' opacificationof
the left hemithorax
Right heart border not visible
The left hemidiaphragmis still
visible
Near-horizontal course of the left
main bronchus
The luftsichelsign (next)
Elevationof the hemidiaphragm
Non-specific signs :
'peaked' or 'tented‘
hemidiaphragm: juxtaphrenic
peak sign
Crowdingof the left sided ribs
Shiftof the mediastinumto left
Left upper lobe collapse: Notice
the ovoid density at the left hilum,
CT confirmed a large left hilar
mass, which occluded the left
upper lobe bronchus

lung field abnormalities -Atelectasis
Left upper lobe collapse:
The luftsichelsign:
In some cases the
hyperexpandedsuperior
segmentof the left lower
lobeinsinuatesitself
between the left upper
lobeand the superior
mediastinum, sharply
silhouetting the aortic
arch and resulting in a
lucencymedially ( red
arrow ).

lung field abnormalities -Atelectasis
Left upper lobe collapse:
On lateral projections:
left lower lobe is
hyperexpandedand
the oblique fissure
displaced anteriorly
(arrows).
Increasein the
retrosternal opacity.

lung field abnormalities -Atelectasis
Left lower lobe collapse:
1.Triangularopacityin the
posteromedialaspect of left lung
2.Edgeof collapsed lung may
create a 'double cardiac contour'
3.left hilum will be depressed
4.lossof the normal left
hemidaphgragmaticoutline
5.lossof the outline of the
descending aorta
6.Non-specific signs indicating
left sided atelectasis :
Elevationof the hemidiaphragm
Crowding of the left sided ribs
Shiftof the mediastinumto left

lung field abnormalities -Atelectasis
Left lower lobe collapse:
7.The flat waist sign refers to flattening of
the contours of the aortic arch and
adjacent main pulmonary artery. It is
seen in severeleft lower lobe collapse
and is caused by leftward displacement
and rotationof the heart.
8.On lateral projection:
The left hemidiaphragmaticoutline is
lost posteriorly
The lower thoracic vertebrae appear
denserthan normal (they are usually
more radiolucent than the upper
vertebrae)

lung field abnormalities -Nodules and Masses
A solitary pulmonary nodule:
Defined as a discrete, well-marginated, roundedopacityless than or
equal to 3 cmin diameter that is completely surrounded by lung
parenchyma, does not touch the hilum or mediastinum, and is not
associatedwith adenopathy, atelectasis, or pleural effusion.

lung field abnormalities -Nodules and Masses
A solitary pulmonary nodule: Differential diagnosis:
Congenital
Arteriovenousmalformation
Lung cyst and Intrapulmonary
Bronchogenic Cyst
Bronchial atresia with mucoid
impaction
Miscellaneous
Pulmonary infarct
Intrapulmonary lymph node
Mucoidimpaction
Pulmonary haematoma
Pulmonary amyloidosis
Fungal infection
Atelectasis
Neoplastic
Malignant
•Bronchogenic carcinoma
•Solitary metastasis
•Lymphoma
•Carcinoid tumours
Benign
•Pulmonary hamartoma
•Pulmonary chondroma
Inflammatory
Granuloma (e.g. TB)
lung abscess
Rheumatoid nodule
Plasma cell granuloma
Round pneumonia

lung field abnormalities -Nodules and Masses
Other causes :
Hyperdensepulmonary mass:
(a pulmonary mass with internal
calcification)
Cavitatingpulmonary mass:
(gas-filledareas of the lung in
the center of the mass. They are
typically thick walledand their
walls must be greater than 2-5
mm. They may be filled with air
as well as fluid and may also
demonstrate air-fluidlevels).
A Pulmonary mass:
It is an area of pulmonary opacificationthat measures more than
3 cm. The commonest cause for a pulmonary mass is lung cancer.

lung field abnormalities -Nodules and Masses
Hyperdense pulmonary mass:
They include:
Granuloma: most common
Pulmonary hamartoma
Bronchogenic carcinoma
Bronchogenic cyst
Carcinoidtumours
Pulmonary metastases
Dystrophic calcification:
Papillary thyroid carcinoma
Giant cell tumourof bone
Synovial sarcoma
Bone forming / cartilage
mineralisation:
Osteosarcoma
Chondrosarcoma
A solitarywell marginated
homogeneous radiodensityis seen in
the right upper zone with focal central
area of increased densitywithin.

lung field abnormalities -Cavities
Pulmonary cavities :
Are gas-filledareas of
the lung in the center
of a nodule, massor
area of consolidation.
They are typically thick
walledand their walls
must be greater than
2-5 mm.
They may be filled with
airas well as fluidand
may also demonstrate
air-fluid levels.

lung field abnormalities -Cavities
Pulmonary cavities:A helpful mnemonicis CAVITY:
I: infection (bacterial/fungal)
Pulmonary abscess
Cavitating pneumonia
Pulmonary tuberculosis
Septic pulmonary emboli
T: trauma -pneumatocoeles
Y: youth (not true "cavity")
Congenital cystic
adenomatoid malformation
(CCAM)
Pulmonary sequestration
Bronchogenic cyst
C: cancer
Bronchogenic carcinoma:
(especially squamouscell
carcinoma)
Cavitatorymetastasis(es):
Squamous cell carcinoma
Adenocarcinoma, e.g.
gastrointestinal tract, breast
Sarcoma
A: autoimmune; granulomas:
Wegener's granulomatosis
Rheumatoid nodules.
V: vascular (both blandand
septicpulmonary embolus)

lung field abnormalities -Cavities
Multicysticmass with airin cysts
CXR in type I( large (2-10 cm)
cysts ) and II(small (< 2 cm)
cysts) CCAM may demonstrate a
multicystic(air-filled) lesion.
Type III ( microcysts) CCAM
appear solid.
Large lesions may cause mass
effectwith resultant, mediastinal
shift, and depressionand even
inversionof the diaphragm.
The cysts may be completely or
partially fluid filled, in which case
the lesion may appear solidor
with air fluidlevels.
Congenital cystic adenomatoid malformation (CCAM):
Multiloculated cystic lesion in
righthemithorax with marked
mediastinal shift to the left.

lung field abnormalities -Cavities
It can be pulmonary10-15% or
Mediastinal65-90%
Usually in the medial1/3 of lungs
With a lower lobe predilection
Mediastinal cysts are visualized as
a mediastinalmass (image 1)
Intrapulmonary cysts usually present
as a solitary pulmonary nodule unless
the cyst contains air.
Cysts are usually fluid filled,
occasionally a communication may
develop following infection or
intervention, resulting in an air-filled
cystic +/-an air-fluid level (image 2)
Bronchogenic cyst: During development a portion of the tracheo
bronchial tree gets separated. CXR:

lung field abnormalities -Decreased density
Unilateral hypertranslucent hemithorax: potential causes:
Pulmonary (ventilation)
Pulmonary emphysema
Congenital lobar emphysema
unilateral bullus/bullae
Compensatory hyperinflation
Airway obstruction e.g.
obliterative bronchiolitis
Swyer-James syndrome
Unilateral lung transplant
Pleura and pleural space
Pneumothorax
Pleural effusion (contralateral)
Mediastinal
Mediastinal fibrosis
Rotation:
Poor patient positioning
Scoliosis
Chest wall defect
Mastectomy
Poland syndrome (absent
pectoralismajor muscle)
Vascular (perfusion)
Pulmonary embolism i.e.
Westermarksign
Congenital heart disease
Shunt (e.g. Blalock-Taussig)
Unilateral absence pulmonary
artery

lung field abnormalities -Decreased density
Pulmonary emphysema:
1.Hyperinflation
Flattened hemidiaphragm(s):
most reliable sign
Increasedand usuallyirregular
radiolucencyof the lungs
Increasedretrosternalairspace
Increasedantero-posterior
diameter
Obtusecostophrenicangle on
posteroanterioror lateral film.
Widely spaced ribs
A narrow mediastinum
Sternalbowing
Low diaphragm

lung field abnormalities -Decreased density
Pulmonary emphysema:
2.vascular changes
Paucity of blood vessels,
often distorted
Pulmonary arterial
hypertension:
Prominenceof the
pulmonary hilum and
enlargement of the main
pulmonary arteries.
Right ventricular
enlargement: encroachment
into the retrosternal space
on a lateral chest film
Pruning of peripheral
vessels

lung field abnormalities -Decreased density
Pulmonary emphysema:
Flat diaphragm are present when the maximum perpendicular
height (red line) from the superior border of the diaphragm to a
line drawn between the costophrenicand cardiophrenicangles in PA
view or between the costophrenicand sternophrenicangles in
lateral view is less than 1.5 cm.

lung field abnormalities -Decreased density
An iatrogenicpulmonary
condition of the prematureinfant
with immature lungs. PIE occurs
almost in association with
mechanical ventilation.
CXR features :
Subtle& often hiddenby other
pathology
linear, oval, and sphericalcystic
air-containing spaces throughout
the lung parenchyma.
Perivascular halos from air
collections
Intra-septal air
Subpleuralcysts
Pulmonary Interstitial emphysema (PIE):
CXR of the infant at 2 days of
age, showing bilateralsevere
PIEand atelectasisof the right
middleandlower lung lobes.

Pleural disease -Pneumothorax
Pneumothorax:
Rotationof CXR can obscurea
pneumothorax . Rotation can
also mimic a mediastinalshift.
Expiratoryimages are thought
to better depicting minimal
(subtle) pneumothoraces.
In erect patients: Pleural gas
collects over the apex .

Pleural disease -Pneumothorax
In the supine position:
The juxtacardiacarea, the
lateralchest wall, and the
subpulmonicregion are the best
areas to search for evidence of
pneumothorax.
The deep sulcus sign: (very wide
and deep costophrenicangle)
An ipsilateralincreased lucency
in the upper quadrant of the
abdomen.
Double Diaphragm Sign: both
the diaphragmatic domeand
anterior portions of the
diaphragm are visualized

Pleural disease -Pneumothorax
Double Diaphragm Sign
of Pneumothorax. Air in
the right hemithorax
displaces both the
dome(white arrow)
and the anterior
costophrenicangle
(yellow arrow) in this
patient with a large,
right-sided
pneumothorax. There is
also a deep sulcus sign
present (red arrow).

Pleural disease -Pneumothorax
A large pneumothorax as
being of greater than 2 cm
width at the level of the
hilum
The volume of a
pneumothorax approximates
to the ratio of the cube of
the lung diameterto the
hemithoraxdiameter
lateral decubitus studies:
Should be done with the
suspected side up
The lung will then 'fall'
away from the chest wall
Rib films are indicated
This chest X-ray shows a large
pneumothorax (P)which is >2 cm
depth at the level of the hilum.

Pleural disease -Pneumothorax
A bullaor thin wall cyst can be
mistaken for loculated
pneumothorax. The pleural
linecaused by pneumothorax is
usually bowed at its center
towards lateral chest wall but
the inner margins of bulla or
cyst is generally concaverather
than convex.
Pneumothoraxwith pleural
adhesionmay simulate bulla or
lung cyst. Differential diagnosis
bycomparison with previous
chest radiography, lateral
decubitousor CT scanning
A chest radiograph shows
Right bullousformation

Pleural disease -Pneumothorax
A skin fold can be mistaken for a pneumothorax. Unlike
pneumothorax, skin folds usually continuebeyond the chest
wall, and lung markings can be seen beyond the apparent
pleural line.

Pleural disease -Pneumothorax
Deep sulcus sign (red arrow) in a supine patient in the ICU.
The pneumothorax is subpulmonic.

Pleural disease -Pneumothorax
Hydropneumothorax:
With the patient upright,
there will be an air-fluid
level in the thoracic cavity
On supineradiographs, a
hydropneumothorax will
be more difficult to see
although a uniform
graynessto the entire
hemithoraxwith the
absenceof vascular
markings suggest the
diagnosis

Pleural disease -Pleural thickening
Best seen at the lung edges where the pleura runs tangentially to
the x-ray beam. Causes:
Unilateral pleural thickening
•Peripheral shadowing on the right
•Loss of right lung volume
•Shadowing over the whole right
lung due to circumferential pleural
thickening
Benign pleural thickening
Recurrent inflammation
Recurrent pneumothoraces
Following a pleural empyema
Complication of haemothorax
Asbestosis & silicosis
Malignant pleural thickening
Primary pleural malignancy
•Mesothelioma
•Primary pleural lymphoma
Pleural metastases
Secondary pleural lymphoma

Pleural disease -Apical pleural cap
In normal asymptomatic individuals, the apical cap is an irregular
densitygenerally less than 5 mm high located over the apex of the
lung.
Apical pleural cap (yellow arrows)
Causes:
Pleural thickening/scarring
Idiopathic: common
feature of advancing age
Secondary to tuberculosis
Radiation fibrosis
Pancoasttumour
Haematoma
Lymphoma
Abscess
Metastases

Pleural disease -Pleural plaques
Asbestos related pleural plaques:
Ill-definedopacities over both
midand lowerzones. Over the
diaphragmatic domes, linear
regions of calcificationare
noted.
Most pleural plaques are
multiple, bilateral, and often
symmetricaland are located in
the mid-portion of the chest wall
between the seventh and tenth
ribs.
Plaques may be calcified(they are
irregular, well-defined, and
classically said to look like holly
leaves), however, most (85-95%)
are not
Visceral pleura, lung apices, and
costophrenic angles are typically
spared.

Pleural disease -Pleural effusion
Pleural effusion is an abnormal
collection of fluidin the pleural space.
Fluid may be (Transudate, Exudate,
Pus, Blood, Chyle, Cholesterol, Urine)
Erect frontal Chest X-ray:
1.Bluntingof costophrenicangle 
2.Bluntingof cardiophrenicangle
3.The diaphragmatic contour is
partially or completely obliterated,
depending on the amount of the
fluid (silhouette sign).
4.Fluidwithin the horizontalor
oblique fissures
5.Concave meniscus seen laterally and
gently sloping medially (horizontal
in case of hydropneumothorax)

Pleural disease -Pleural effusion
Erect frontal Chest X-ray:
6.Massive pleural effusion:
Opacificationof entire hemithoraxand
shiftingof mediastinum to the opposite
side (note: The mediastinalshift can be
less prominent or even absent in the
presence of underlying lung collapse or
contralateral hemithoraxabnormality)
Causes “white-out” lung
Around 5-7 liters of pleural fluid
Generally, the pleural effusion is said to be
massiveif it crosses the anterior border of
the 2
nd
rib. It is said to be moderateif it
crosses the anterior border of the 4
nd
rib
and is said to be mild or small if it is below
that.
Massiveright pleural
effusion (1),
with shiftof mediastinum
towards left (2)

Pleural disease -Pleural effusion
Erect frontal Chest X-ray:
7.Lamellar effusions: Shallow collections between lung
surfaceand visceral pleural sometimes sparing the
costophrenicangle. It represent interstialpulmonary fluid
Bilateral lamellarpleural effusions

Pleural disease -Pleural effusion
Subpulmonic effusion. Note the
increased distance between the air-
filled fundus of the stomach and
the left "hemidiaphragm" (arrow).
Erect frontal Chest X-ray:
8.Subpulmonic effusion:
Unilateralsubpulmonary
effusion is more common
on right side.
Right: appear as a raised
diaphragmwith
flatteningand lateral
displacementof the
dome.
Left: The distance
between the lung and
the stomach bubble will
exceed2 cm

Pleural disease -Pleural effusion
Erect frontal Chest X-ray:
9.Encysted (encapsulated) pleural effusion:
Loculationsecondary to adhesionsafter an infectedor
hemorrhagic effusion.
Peripheralsoft-tissue opacity with smoothobtusetapering
margins

Pleural disease -Pleural effusion
Erect frontal Chest X-ray:
10.Encysted (encapsulated) pleural effusion in the fissure:
Loculatedeffusion in the fissures
appears as a well-defined
ellipticalopacity with pointed
margins.
Pseudotumor/vanishing tumor
(phantom tumor): Loculated
effusion in the fissures ,
secondary to congestive heart
failure, hypoalbuminemia, renal
insufficiency or pleuritis.
Radiologicallysimulating a
neoplasm. It disappears rapidly in
response to the treatment of the
underlying disorder 

Pleural disease -Pleural effusion
Lateral Chest X-ray:
Small effusions appear as
a dependent opacitywith
posterior upward sloping
of a meniscus-shaped
contour.
The opacity obliterates
the underlying portion of
the diaphragmatic
contour (silhouette sign).
Can detect an effusion as
small as 50–75 mL
Note the concave meniscus
bluntingposterior costophrenic
angle.

Pleural disease -Pleural effusion
Supine Chest X-ray:
Due to the effect of gravity, the
pleural fluid is distributed
throughout the posteriorpart of
the pleural during supine
position –this cause the
hemithoraxto appear whiter or
paler grey compared to the
normal side.
Vesselsare often visible through
the shadowing.
It is therefore especially difficult
to identify similarsized bilateral
effusions as the density of the
lungs will be similar.
Requires about 200 ml fluid
Right-sided effusion. a veil-like
increased density of the lower right
hemithorax (blue arrow). Note that the
pulmonary vascular structuresare not
obscured or silhouetted by the vague
density but, rather, are still visible
through it (open arrow).

Pleural disease -Pleural effusion
lateral decubitus Chest X-ray:
A small amount of fluid (10-25 mL) can be depicted on this
projection.
The layering fluid can easily be detected as a dependent, sharply
defined, linear opacity separating the lung from the parietal
pleuraland chest wall, and
the parietal pleura–chest wall margin can be identified as a line
connecting the inner apices of the curvature of the ribs.
Note in the film
on right shows the
findings of sub
pulmonic effusion
(red arrow). In the
lateral decubitus
film fluid layers
along the ribs
(yellow arrow).

Pleural disease -Pleural effusion
Completewhite-out of a hemithorax:
Trachea pulled toward the opacified
side:
Pneumonectomy
Total lung collapse 
Pulmonary agenesis
Pulmonary hypoplasia
Trachea remains central in position:
Consolidation
Pulmonary oedema/ARDS
Pleural mass: e.g. mesothelioma
Chest wall mass: e.g. Ewing sarcoma
Pushed away from the opacifiedside:
Pleural effusion 
Diaphragmatic hernia
Large pulmonary mass

Pleural disease -Pleural effusion
How do you determine the etiologyof effusion from chest x-ray?
Bilateral:considertransudative effusions first. You will need
clinical information.
Bilateraleffusions with cardiomegaly: Congestive heart failure
Bilateralpleural effusions associated with ascites in a alcoholic:
Cirrhosis
Unilateral: mostof them are exudative
Massive unilateral effusion: Malignancy
Pleural effusion with apical infiltrates: Tuberculosis
Pleural effusion with nodes or mass or lytic bone lesions:
Malignancy
Loculatedeffusions are empyemas
Pleural effusion with a missing breast suggesting resection for
cancer: Malignancy
Pleural effusion following chest trauma: Hemothorax
In patients with mediastinal lymphoma: Chylothorax

Chest X-ray Abnormalities-Costophrenic angle
Costophrenic (CP) angle blunting:
On a frontal CXR the costophrenic angles should form acute angles
which are sharp to a point.
Often the term costophrenic "blunting" is used to refer to the
presence of a pleural effusion. This, however, is not always correct
and costophrenic angle blunting can be related to other pleural
disease, underlying lung disease or Lung hyper-expansion.
1-left CP
angle blunting
in effusion
2-bilateral CP
angles
blunting in
emphysema

Elevated hemidiaphragm: If theleft hemidiaphragm is higher
than the rightor the right is higher than the left by more than 3 cm
Can result from:
Above the diaphragm
Decreased lung volume
Atelectasis/collapse
Lobectomy/pneumonectomy
Pulmonary hypoplasia
Diaphragm
Phrenic nerve palsy
Diaphragmatic eventration
Contralateral stroke: usually middle cerebral artery distribution
Below the diaphragm
Abdominal tumour, e.g. liver metastases or primary malignancy
Subphrenicabscess
Distended stomach or colon
Chest X-ray Abnormalities -Diaphragm

Diaphragmatic hernia: defect in the diaphragm can result
from:
Congenital:
Bochdalekhernia: most common, More frequent on left
side, located posteriorlyand usually present in infancy
Morgagnihernia: smaller, anteriorand presents later,
through thesternocostalangles
Acquired:
Traumatic diaphragmatic rupture
Hiatus hernia
Iatrogenic
Chest X-ray Abnormalities -Diaphragm

Morgagni hernia
are: Anteromedial
parasternaldefect,
small, Usually
unilateral, more
often right-sided
(90%)
Chest X-ray Abnormalities -Diaphragm
Bochdalek Hernia : Frontal
viewof the chest shows a
large air-containingand
walled structure in the region
of the left lower lobe (white
arrow). It is originating from
below the diaphragm. Theair-
containing structureis seen
posteriorlyon the lateral view
(red arrow).

Hiatus hernias occur when there is herniation abdominal contents
through the oesophageal hiatus of the diaphragm into the thoracic
cavity. Appears as retrocardiac opacity with air-fluid level
Chest X-ray Abnormalities -Diaphragm
PA and lateral view of hiatal hernia. Can you see the air-
filled "mass" posterior to the heart

Free gas under diaphragm (Pneumoperitoneum): It is a
finding in the chest X-ray seen in case of perforation of
hollow viscus.
Chest X-ray Abnormalities -Diaphragm
CXR shows Minor
opacityin the left
lower zone. Large
volume of free
subdiaphragmatic
gas( yellow arrow).

Chest X-ray Abnormalities -Diaphragm
Chilaiditisyndrome: is a rarecondition in which a portion of the
colonis abnormally located (interposed) in between the liver and the
diaphragm. It is one of the causes of pseudopneumoperitoneum.
Features that suggest a Chilaiditisyndrome (i.e.Chilaiditisign):
Gas between liver and diaphragm
Rugalfolds within the gas suggesting that it is within the bowel.

Cardiophrenic angle lesions:
The more common:
Pericardial fat pad
Pericardial cyst
Morgagni'shernia
Lymphadenopathy
Pericardial fat necrosis
Pericardial lipomatosis
Other less common:
Thymoma
Hydatidcyst
Right middle lobe collapse
Chest X-ray Abnormalities -Diaphragm
Pericardial
cyst: X-ray
shows a well
circumscribed
mass in
contact with
right cardiac
margin.

Cardiomegaly and heart failure:
The heart is enlarged if the cardiothoracic ratio (CTR) is greater than
50%on a PA view. If the heart is enlarged, check for other signs of
heart failure such as pulmonary oedema, septal lines (or Kerley B
lines), and pleural effusions.
Chest X-ray Abnormalities -Heart
CXR shows:
•CardiomegalyCTR= 18/30 (>50%)
•Upper zone vessel enlargement (1)
-a sign of pulmonary venous
hypertension
•Pulmonary oedema(2) -bilateral
increased lung markings (classically
peri-hilarand shaped like bats wings
-more widespread in this case)
•Septal(KerleyB) lines(3)
•Pleural effusions (4)

left atrial enlargement:
The double density sign: Right side of
the dilated left atrium is visible next to
the right heart border (right atrium). It
may extend out beyond the right heart
border, an appearance known as atrial
escape.
Oblique measurement of greater than
7cm(blue arrow).
Convexleft atrial appendage; produces
“straightening” of the left heart border
-normally it is flat or concave.
Splaying of the carina to greater than a
90 degree angle (yellow lines).
Posterior displacement of the left
main stem bronchus on lateral
radiographs.
Chest X-ray Abnormalities -Heart

left ventricular enlargement: CXR shows:
Left heart border is displaced leftward, inferiorly, or posteriorly
Roundingof the cardiac apex
The aorta is prominent
Lateral view: Retrocardiacspace become narrowed or disappeared,
esophageal space disappeaered
Chest X-ray Abnormalities -Heart

Chest X-ray Abnormalities -Heart
If we draw a
tangent line
from the apex
of the left
ventricle to
the aortic knob
(red line) and
measure along
a perpendicular
to that tangent
line (green line)
The distance
between the
tangentand the
main pulmonary
artery (between
two small green
arrows) falls in a
range between
0 mm (touching
the tangent line)
to as much as
15 mm away from
the tangent line
left heart border:

Chest X-ray Abnormalities -Heart
left heart border abnormalities:
The main pulmonary artery may
project beyond the tangent line
(greater than 0 mm). This can occur if
there is increased pressure or
increased flow in the pulmonary
circuit.
The main pulmonary artery may
project more than 15 mm away from
the tangent line. This can occur in
left ventricle enlargementand/or
aortic knob enlargemente.g.
atherosclerosis, aortic incompetence,
and mitral incompetence.

Right atrial enlargement: Features are non-specificbut include :
Right heart enlargement (the right atrium and ventricle cannot be
separately identified on a radiograph) causes filling-in of the
retrosternal clear space and prominence of the right heart border
A prominently convexlower right heart border
Enlarged, globularheart
Narrow vascular pedicle
Chest X-ray Abnormalities -Heart

Right ventricular enlargement: :
Frontal view demonstrates:
Roundedleft heart border
Upliftedcardiac apex
Chest X-ray Abnormalities -Heart
CXR showing right
ventricular
hypertrophy (arrows,
note filling of the
retrosternal space by
an enlarged right
ventricle in the lateral
view) and enlarged
central pulmonary
arteries (arrowhead).
Lateral view demonstrates:
Fillingof the retrosternal
space
Rotationof the heart
posteriorly

Ventricular aneurysm:
A ventricular aneurysm is usually the sequel to a myocardial
infarct, thus cases of calcified ventricular aneurysm are
rare.
Typically the left cardiac border changes shape andbulges.
Chest X-ray Abnormalities -Heart

Ventricular
Pseudoaneurysm:
Itis caused by a
contained
ruptureof the LV
free wall.
A chest
radiograph may
show
cardiomegaly
with an abnormal
bulgeon the
cardiac border.
Chest X-ray Abnormalities -Heart

Pericardial effusion:
It occurs when excess fluid collects in
the pericardial space (a normal
pericardial sac contains approximately
30-50 mL of fluid).
CXR Suggestivebut not usually
diagnostic.
Globular enlargement of the cardiac
shadow giving a water bottle
configuration
Wideningof the subcarinalangle
without other evidence of left atrial
enlargement may be an indirect clue
Chest X-ray Abnormalities -Heart

Pericardial effusion:
lateral CXR may show:
Loss of retrosternalclear space
A vertical opaque line
Produced by pericardial fluid
(yellow arrows) separating a
vertical lucent line directly
behind sternum Produced by
epicardialfat (white arrows)
anteriorly from a similar lucent
vertical lucent line Produced by
pericardial fat (red arrows)
posteriorly; this is known as
the Oreo cookie sign
Chest X-ray Abnormalities -Heart
Real
Oreo
cookies

Pulmonary Arterial Hypertension: Features include:
Elevated cardiac apex due to right ventricular hypertrophy
Enlarged right atrium
Prominentpulmonary outflow tract
Enlargedpulmonary arteries
Pruningof peripheral pulmonary vessels
Chest X-ray Abnormalities -Heart

Transposition of the Great Vessels:
The classic appearance described as an egg on a string sign
Most common cyanotic congenital heart lesion
The aorta arises from the morphologic right ventricle and the
pulmonary artery arises from the morphologic left ventricle
Narrowingof the superior mediastinum on radiographs
Patent ASD, VSD, Foramen ovale, systemic collaterals to sustain life
The right atrial border is convex, and the left atrium is enlarged
CXR Abnormalities -Congenital heart disease

Total Anomalous Pulmonary Venous Return:
Occurs when the pulmonary veins fail to drain into the left atrium
and instead form an aberrant connection with some other
cardiovascular structure
2% of cardiac malformations
SNOWMAN SIGN: resembles a snowman
CXR Abnormalities -Congenital heart disease

Partial Anomalous Pulmonary Venous Return:
Scimitar syndrome
Anomalous pulmonary vein drainsany or allof the lobes of the
rightlung, and empties into the inferior vena cava, portal vein,
hepatic vein, or right atrium
Vein appears like a scimitar, a sword with a curved blade that
traditionally was used by Persian and Turkish warriors.
Hypoplasiaof right lung, hypoplasia of right pulmonary artery, and
anomalousarterial supply of the right lower lobe from abdominal
aorta.
CXR Abnormalities -Congenital heart disease

Tetralogy of Fallot:
10%–11% of cases of congenital heart disease
Components: Ventricular septal defect, Infundibularpulmonary
stenosis, Overriding aorta, Right ventricular hypertrophy
Blood flow to the lungs is usually reduced
The heart has the shape of a wooden shoe or boot(in French,
coeuren sabot)
CXR Abnormalities -Congenital heart disease

Aortic Coarctation:
5%–10% of congenital cardiac lesions
Eccentric narrowing of the lumen of aorta at the level where the
ductusor ligamentumarteriosusinserts anteromedially
Classic radiologic signs:
Figure-of-three sign
Reverse figure-of-three sign
Rib notching on CXR pathognomonic
CXR Abnormalities -Congenital heart disease

Mediastinal abnormalities -Mediastinalwidening
Superior mediastinum:
Should have a width less than 8cm
on a PA CXR.
A widened mediastinum can be
associated with:
APCXR view
Unfolded aortic arch
(not pathological) or a thoracic
aortic aneurysm
Mediastinalmasses
Oesophagealdilatation
Ruptured aorta
Mediastinallipomatosis:
increased deposition of normal
unencapsulatedfat
Unfolded aorta: widened and
'opened up' appearance of
the aortic arch. It is seen with
increasing age

Mediastinal abnormalities -Aortic Dissection
Aortic Dissection: CXR
findings include:
1.Mediastinalwidening; it is
noted in 60%of patients
2.Irregularityof the aortic
contour
3.Double aortic contour
4.Double-calcium sign:
Inward displacement of
atherosclerotic calcification
by more than 10 mm
5.Pleural effusion (more
common on the left side;
suggests leakage)
CXR shows; double density
aortic arch(black/white
arrows), Mediastinal widening,
and Cardiac enlargement

Mediastinal abnormalities -Aortic Dissection
Aortic Dissection:
CXR findings include:
6.Tracheal
displacement to
the right
7.Pericardial effusion
8.Cardiac
enlargement
9.Displacementof a
nasogastric tube
10.Left apical pleural
capping (opacity)
11.Normal CXR in 12%
of patients
CXR shows: rightwarddeviation of thetrachea(red
arrow); left apical pleural capping (blue arrow); aortic
“double-calcium” sign (between white arrows);
depressionof the left bronchus (purple arrow); pleural
effusion(green arrow); widened mediastinum and
loss of the aorto-pulmonary window (not labeled).

Mediastinal abnormalities -Pneumomediastinum
Radiographic features of Pneumomediastinum
Small amounts of air
appear as linearor
curvilinearlucencies
outlining mediastinal
contours and form:
1.Subcutaneous
emphysema
2.Air anterior to
pericardium:
(Pneumoprecardium)
Pneumo-
precardium
subcutaneous
emphysema

Mediastinal abnormalities -Pneumomediastinum
Radiographic features of Pneumomediastinum
3.air around
pulmonary
artery and
main
branches:
ring around
artery sign
4.air outlining
major aortic
branches:
tubular
artery sign
Tubular Artery Sign (Red
arrows)
Ring around artery
sign

Mediastinal abnormalities -Pneumomediastinum
Radiographic features of Pneumomediastinum
5.Continuous diaphragm sign: due to air
trapped posterior to pericardium
6.Spinnaker Sail Sign (angel wing sign) is
seen on neonatal postero-anterior
CXR when thymiclobes are displaced
laterally by air, (Very typical sign in
neonatal age).
Spinnaker Sail
Sign (angel wing
sign)
Continuous diaphragm
sign

Mediastinal abnormalities -Pneumomediastinum
Radiographic features of Pneumomediastinum
NaclerioV sign:
It is seen as a V-shapedair collection.
One limb of the V is produced by
mediastinalair outlining the left
lower lateral mediastinalborder.
The other limb is produced by air
betweenthe parietal pleuraand
medial left hemidiaphragm.
Lateral Chest X-Ray
Retrosternal air
Lateral Decubitus Chest X-Ray
Air will not move with change in position
Neck Films
Air outlining fascialplanes of the neck
Naclerio V sign

Mediastinal abnormalities -Masses
Clues tolocate mass to mediastinum
Masses in the lungMediastinal masses
May contain air
bronchograms
A lung mass abutts
the mediastinal
surface and creates
with lung an acute
angles.
Not contain air bronchograms
The margins with the lung will be obtuse.
Mediastinal lines(azygoesophagealrecess,
anterior and posterior junction lines) will be
disrupted.
There can be associated spinal, costal or
sternalabnormalities.
LEFT: A lung mass abutts the
mediastinal surface and creates
acuteangles with the lung.
RIGHT: A mediastinal mass will
sit in the mediastinum, creating
obtuseangles with the lung.

Mediastinal abnormalities -Masses
Clues to locatemass to mediastinum
LEFT: there is a lesion that has an acuteborder
with the mediastinum. This must be a lung mass.
RIGHT: shows a lesion with an obtuseangle to the
mediastinum. This must be a mediastinalmass.
Localize mass within the mediastinum
In lateral CXR, mediastinumis divided into superiorand Inferior.
Inferior mediastinum is divided into anterior, middle, and posterior

Mediastinal abnormalities -Masses
Some causes of mediastinal masses in adults

Mediastinal abnormalities -Masses
Cervicothoracic sign:
As the anterior
mediastinum ends at the
level of the clavicles, the
upper border of an anterior
mediastinallesion cannot
be visualisedextending
above the clavicles.
Any lesions with a
discernible upper border
above that level must be
located posteriorlyin the
chest,i.e. apical segments
of upper lobes, pleura, or
posterior mediastinum
Anterior
( A )
vs
posterior
( B )
lesion

Mediastinal abnormalities -Masses
Thoracoabdominal sign:
Posterior costophrenic
sulcusextends more
caudally than anterior
basilar lung
Lesion extending
below the dome of
diaphragm must be in
posterior chest
whereas lesion
terminating at dome
must be anterior.
Margin of massis apparent and
below diaphragm, therefore this
must be in the middleor posterior
compartments where it is surrounded
by lung This example is a ‘Lipoma’

Mediastinal abnormalities -Masses
Hilum overlay sign:
When amass arises from
the hilum, the
pulmonary vessels are in
contact with the mass
and as such their
silhouette is obliterated.
If hilarvessels are
sharply delineated it can
be assumed that the
overlying mass is
anterior or posterior
“Hilum overlay” sign. Note that
the vessels of the left hilum
(yellow arrow) can be “seen
through” the mass (red arrows)
projected over the left hilum.

Mediastinal abnormalities -Masses
Hilum convergence sign:
If branches of pulmonary artery converge toward central
mass, is an enlarged pulmonary artery (image A).
If branches of pulmonary artery converge toward heart
rather than mass, is a mediastinaltumor (image B).

Mediastinal abnormalities -Paratrachealstripe
Right paratrachealstripe:
Made up of right tracheal wall,
Paratracheallymph nodes,
adjacent pleural surfaces,
mediastinalfat, right
brachiocephalic vein and SVC
It normally measures less than
4 mm and thickening is
non-specificbut may represent:
lipoma
Paratracheal
lymphadenopathy
Thyroid malignancy,
parathyroid neoplasms
Tracheal carcinoma or stenosis
Pleural effusion or thickening
Widening of the right
paratrachealstripe (arrow)
Abnormal right paratracheal
stripe caused by a large ectopic
parathyroid adenoma

Mediastinal abnormalities -Paratrachealstripe
Left paratrachealstripe:
Made up of pleural surface of
the left upper lobe, tracheal
borderand mediastinalfat.
It is seen less frequently.
It may not be visible if the left
upper lobe contacts the left
subclavianartery or left common
carotid artery.
Abnormal widening may be due:
Pleural effusion
Mediastinal
lymphadenopathy or
malignancy
Mediastinalhaematoma
Widening of the left paratracheal
stripe(arrows), with mass effect
on the trachea. A 47-year-old
patient with metastatic thyroid
carcinoma

CXR Abnormalities -Soft tissue abnormalities
Breast tissue:
left-sided mastectomy:
Increased density
over the right lung
Decreased density
of the left lung
Breast asymmetry
Gynaecomastia:
Mobile AP
Cardiac monitoring
leads
Dense breast tissue
Male patient
Breast cancer:
PA Chest Xray:
Increased soft tissue
densitywith mass
effect projected on
left breast and axilla

CXR Abnormalities -Soft tissue abnormalities
Subcutaneous emphysema:
There is often striated lucenciesin the soft tissues that may outline
muscle fibres. If affecting the anterior chest wall, subcutaneous
emphysema can outline the pectoralismajor muscle, giving rise to the
ginkgo leaf sign.
Large left pneumothorax (white arrow) with mediastinal shift indicating
tension. Left upper lobe cavitating lesion, the lesion which was recently
biopsied. Extensive leftchest wall (yellow arrow), ginkgo leaf sign (red
arrow), and neck surgical emphysema.

CXR Abnormalities -Bones
Bones:
The bones are used as
useful markersof CXR
quality(rotation,
adequacy of inspiration
and CXR penetration).
Plain radiograph may miss
up to 50% of rib fractures
Multiple fractures of the 4th right rib
(yellow arrows), other visible fractures
of 3rd, 5th, 6th and 7th right ribs (red
arrows)
Old rib
fractures:
increased
density (whiter
areas) due to
callus
formation (red
arrows)

CXR Abnormalities -Bones
Bones:
Malignantbone disease may
manifest as either singleor
multiplelesions.
Bones may become denser
(whiter) due to a sclerotic
process (often seen in prostate
cancer), or less dense (blacker)
due to a lyticprocess (as is
often the case in renal cell
cancer).
Primarybone tumours, both
benign and malignant, are
relatively uncommon
Expansile lytic metastasis of right
7th rib from carcinoma thyroid
(red arrow).

CXR Abnormalities -Bones
Bones:
Cervical ribs: are usually bilateral
but asymmetrical. Cervical rib is
usually asymptomatic, but it can
cause thoracic outlet syndrome.
Sclerotic metastases from
carcinoma prostate.
Cervical rib(bilateral) with Cervical
7th transverse process directing
inferiorly

Chest X-ray -Tubes
On a radiograph acquired with
the neck in the neutralposition,
a distance of 5-7 cm above the
carina is generally considered
acceptable for adults.
In most individuals the carina is
located between the levels of
the 5th and 7th thoracic
vertebral bodies. This is an
inaccuratemethod for locating
the carina If the carina is not
clearly visible.
Intubation of a bronchus may
lead to lung or lobar collapse
Endotracheal (ET) tube position:

Chest X-ray -Tubes
Tracheostomy tubes
are positioned so that
their tipsare located
at a midpoint
betweentheupper
end of the tube and
the carina.
It should occupy
one-half to two-thirds
of the tracheal lumen
to minimize airway
resistance.
Tracheostomy Tube:

Chest X-ray -Tubes
Chest X-rays are used to
determine NG tube
position if aspirationof
gastric fluid is
unsuccessful.
The tip of the tube must
be visible below the
diaphragm and on the
left side of the abdomen
-10 cm or more beyond
the gastro-oesophageal
junction.
Nasogastric (NG) tube:

Chest X-ray -Tubes
Catheter positioning:
The tip of a CVC is within the SVC at or just above the level of
the carina(approximately 1-1.5 cm above the level of the carina)
for mostshort-term uses.
Central venous catheter (CVC):
Right
subclavian
vein
catheter
Right
internal
jugular
vein
catheter

Chest X-ray -Tubes
Catheter positioning:
CVCs placed for the purpose of long term chemotherapymay be
placed more inferiorly at the cavo-atrial junction -the junction of
the SVC and right atrium (RA).
Catheters used for haemodialysismay be placed at the cavo-atrial
junctionor even in the RA itself.
Central venous catheter (CVC):
Long term catheter -PICC line:
This peripherally inserted central
catheter (PICC) is correctly located
with its tipat the level of the cavo-
atrial junction-approximately the
height of two vertebral bodies
below the level of the carina

Chest X-ray -Tubes
Catheter positioning:
Left-sided catheters approach the SVC at a shallow angle such that
they may abut the right lateral wall of the SVC. They may need to
be inserted further so the distal end obtains a vertical orientation.
This may mean locating the tipbelow the level of the carina.
Central venous catheter (CVC):

Chest X-ray -Tubes
For treatment of a pneumothorax the tube tipis aimed towards the
upperpleural cavity and for treatment of a pleural effusion towards
the lower part of the pleural cavity
Chest Drains:
Chest
drain -
treatment
for
pleural
effusion
Chest drain
-treatment for
pneumothorax

Thank you

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