Chest x rays

1. Chest Xray - Views

2. PA View

3. AP view The clavicles project too high into the apices. The heart magnified over the mediastinum . The ribs will appear distorted or unnaturally horizontal Pulmonary markings decresed visibility Blunting of costophrenic angles

4. Lateral View Position Seen in : ant mediastinal masses, encysted pleural fluid, post basal consolidation

5. Other Views Decubitus - useful for differentiating pleural effusions from consolidation (e.g. pneumonia) ; Loculated effusions from free fluid in the pleura.

6. Expiratory view and Inspiratory views Demonstrates Air trapping and diaphragm movement Exp : pneumothorax and interstitial shadowing

7. Lordotic view Clavicles projected up Pancoast Tumour

8. Apical View 50 to 60 degrees

9. Oblique view Retrocardiac area Posterior costophrenic angle Chest wall

10. Normal Chest X-Ray

11. Scheme of viewing PA film 1. Request form Name ,age, sex, date, clinical information 2. Technical View Centering, patient position Side Markers Adequate inspiration Exposure/Penetrance 3. Soft tissue and bony cage Subcutaneous emphysema, fractures 4.Trachea Position, Outline 5. Heart and Mediastinum Shape , Size, Displacement 6.Diaphragms Outline ,Shape , Relative position 7.Pleural spaces Position of horizontal fissure, costophrenic and cardiophrenic angles 8.Lungs Local , generalized abnormalities, comparison of translucency and vascular marking sof the lungs

12. 9.Hidden areas Apices, Posterior sulcus, Mediastinum, Hila, Bones 10. Hila Density, Position, Shape 11. Below the Diaphragm Gas shadows, Calcification

13. PA VIEW Chin up , shoulders rotated forward, taken in full inspiration With plate in front of chest and back to the X-ray machine Scapula away from the upper lung fields Clavicles less apically displaced Vertebral neural arches seen AP VIEW Taken in cases when patient is too ill to stand Film is placed behind the back and x-ray exposure from front . Scapula closer to the lung fields Clavicles less apically displaced Vertebral disc spaces seen better Relative cardiomegaly

14. Technical aspects of viewing a PA film Centering – medial ends of clavicle equidistant from spinous process at t4/5- always look for gastric bubble,aortic arch and heart to confirm normal situs . Penetration – disc spaces+vertebral bodies visible down to t8/9 Degree of Inspiration – full inspiration ant. Ends of 6 th rib or post ends of the 10 th rib on right hemidiaphragm . On expiration larger cardiac shadow and basal opacity due to crowding of normal vascular markings.

15. Trachea Upper part- midline Lower part- deviates slightly around aortic knuckle- marked on expiration Left bronchus not clearly visualized due to aorta 25mm in males , 21 mm in females Right paratracheal stripe- 60% N- 5mm Angle of carina- 60 -75 degrees

16. Mediastinum and Heart Mediastinum, Heart, Spine , Sternum Cardiothoracic ratio – less than 50% in PA and less than 60% in AP. Increased in AP and expiration Right and Left heart borders formed Thymus- triangular Sail shaped structure – Wave sign of Mulvey

17. Diaphragm Right higher than left Normal position of diaphragm, higher in supine Curves which steepen towards chest wall- costophrenic angles are acue Cardiophrenic angles may be blunted due to presence of fat pads

18. The Fissures Horizontal fissure seen often incompletely running from the hilum to the region of the sixth rib Fissures seen clearly seen on lateral view Accessory fissure- Azygos fissure comma shaped right sided triangular based peripherally

19. Lungs Hidden areas- Apices, Mediastinum and hila, Diaphragms, Bones Hila- 97% left higher than right., Clearly defined borders –concave lateral borders- mainly formed by pulmonary areteries and upper lobe veins. Lymph nodes not normal Bronchovascular markings seen upto – 2/3 rd of the lung field Lymphatics – normally not seen

20. Lung zones When describing the lungs divide them into three zones - upper, middle and lower. Each of these zones occupies approximately one third of the height of the lungs. The lung zones do not equate to the lung lobes. Upper zone- from 2 nd  costal cartilage to axilla Middle zone- between 2 nd  and 4 th  costal cartilage. Lower zone- below 4 th  costal cartilage.

21. Lymph Nodes Bronchopulmonary( hilar) nodes – appear as hilar masses Carinal nodes- widening of the carinal angle Tracheobronchial nodes- right paramedian stripe Anterior, Posterior, Paratracheal, parietal

22. Below the diaphragm Gas Chilaiditis syndrome

23. Soft tissue and Bony Cage Breasts may partially obscure the lungs. Skin folds tend to be confused with consolidation as they overlap the lung fields Sternum Clavicle Scapulae Ribs- rib notching Spine- check bone and rib destruction

24. ABCDEFGHI!! Bones and Soft tissue Airway Cardiac Silhouette, Mediastinum. Diaphragms Effusion Fields of lung Gastric Air Bubble Hilum Instruments.

25. Line shadows By: Michelle Rasiah

26. Introduction Normal blood vessels and fissures form linear shadows Certain lung diseases also form linear shadows Linear shadow  < 5 mm wide Band shadow  > 5 mm thick

27. Causes for linear shadows Kerley’s lines Plate-like atelectasis Pulmonary infarcts Thickened fissures Pulmonary / pleural scars Bronchial wall thickening Sentinel lines Curvilinear shadows Anamolous vessels Artefacts Bronchoceles

28. Kerley lines Pulmonary lymphatics are usually not visible Lymphatics drain the interstitial fluid and foreign particles They run in the interlobular septa and drain to the hilum Thickened lymphatics and surrounding connective tissue = Kerley lines Divided into 3 types Kerley A lines – thickened deep septa Kerley B lines – thickened interlobular septa Kerley C lines

29. Acinus  5 - 6 mm in diameter  alveoli, alveolar duct, resp. bronchiole 3 - 5 acini = secondary pulmonary lobule Each lobule is separated by septa (interlobular septa) Thickening of these septa = Kerley B lines Formation of Kerley B lines

30. Types Kerley A line Kerley B line Kerley C line Thin Thin, transverse, faint Fine Non branching Non branching Interlacing lines 2 – 6 cm long 1 -3 cm long Seen throughout lung 1 – 2 mm thick 1- 2 mm thick “Spider web” like appearance Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle) not following course of artery, vein or bronchi Frequently seen than A &C lines Lines arranged in step ladder like pattern (0.5 to 1 cm apart) ALWAYS perpendicular to pleural surface

31. Kerley B lines can be: They are present in the base of the lung due to hydrostatic pressure and gravity Transient Persistent Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis

32. Impaired diaphragmatic motion Underventilation Collapse of small pulmonary sub divisions Disk atelectasis Fleischner line formation

33. Differentiation Fleischner’s lines Kerley B lines Linear scars Fewer in number (1 -2) More in number May show fine strands emanating from borders Irregularly placed Regularly placed (0.5 to 1 cm gaps) Associated pleural effusion Located deep in lung Superficial Permanent Thicker Thin

34. Thickening of fissures

35. Mucous filled bronchi

36. NODULAR LESIONS VINYAS NISARGA(080201014)

37. Nodular lesions could be classified as solitary pulmonary nodules Multiple pulmonary nodules Solitary nodule is defined as an x-ray density completely surrounded by normal aerated lung with circumscribed margins of any shape usually 1-6cm in greatest diameter. If its <3cm → ‘ Coin lessions ’ If > 3cm → masses Cannon ball lesions: Multiple nodules, widely disseminated,usually multiple, clearly demarcated 1- 2cm in diameter circular shadows throughout the lung fields (characteristic of secondary deposits) Milliary shadows : Multiple small shadows 2-4mm in diameter

38. Solitary pulmonary nodule causes Malignant Primary nodule Secondary nodule Lymphoma Plasmacytoma Alveolar cell carcinoma Benign Hamartoma Adenoma Connective tissue tumours Granuloma Tuberculosis Histoplasmosis Paraffinoma Sarcoidosis

39. Infection Round pneumonia Abscess Hydatid Amoebic Fungi Parasites Others Pulmonary haematoma, Pulmonary infarct Collagen diseases-Rheumatoid arthritis, Wegener's granulomatosis Congenital-Bronchogenic cyst, Sequestrated segmen,Congenital bronchial atresia , AVM impacted mucus Amyloidosis, Intrapulmonary lymph node Pleural- fibroma, tumor, loculated fluid

40. Multiple nodules Tumours Benign-hamartoma, laryngeal papillomatosis Malignant-metastases, lymphoma Infection Granuloma-tuberculosis, histoplasmosis, fungi i Round pneumonia Abscesses Hydatid cysts Inflammatory Caplan's syndrome Wegener's granulomatosis Sarcoidosis Drugs

41. Vascular Arteriovenous malformations Haematomas Infarcts Miscellaneous Mucus impaction Amyloidosis

42. Multiple nodules –canonball appaernace (choriocarcnoma) Metastatic lesions

43. Miliary TB

44. Tuberculoma: It appears Round or oval, sharply circumscribed nodule that is seldom more than 4 cm in diameter. Central calcification and satellite lesions are common, as is calcification of hilar lymph nodes. This X-ray shows :Single smooth, well-defined pulmonary nodule in the left upper lobe. In the absence of a central nidus of calcification, this appearance is indistinguishable from that of a malignancy.

45. TUBERCULOMA:(A) Frontal and (B) lateral views of the chest show a large left lung soft-tissue mass (arrows) containing dense central calcification

46. Rheumatoid nodules Large nodules in pulmonary parenchyma bilaterally present, discrete similar to opacities of metastatic lesions – Rhuematoid arthritis

47. Bronchogenic Carcinoma Carcinoma of bronchus. A large, round soft-tissue mass is present at the right apex. Blunting of the right costophrenic angle is due to a small pleural effusion.

48. Hamartoma-popcorn calcification

49. Histoplasmosis -calcified granuloma (coin lesion)

50. Pulmonary infarction Chest radiograph with ‘classical’ appearance of a pulmonary infarction – a wedge-shaped lesion peripherally set against the pleura Chest X ray after 4 days, prior to treatment, showing massive increase in volume of lesion.

51. Lung abscess (air fluid level)

52. Alveolar Shadows Neena S

53. Air-space (Acinar/alveolar) pattern When distal airways and alveoli are filled with fluid, whether it is a transudate, exudate or blood, acinus forms a nodular 4-8mm shadow. These coalesce into fluffy ill-defined round or irregular cotton-wool shadows. Non-segmental, homogenous or patchy, but frequently well defined adjacent to fissures.

54. Cont… Vascular markings usually obscured locally. Air bronchogram and silhouette sign are characteristic Ground-glass appearance of generalised homogenous haze with a “bat’s wing” or “butterfly” perihilar distribution may be seen, sparing the peripheral lungs.

55. Silhouette Sign An intrathoracic lesion touching a border of the heart, aorta, or diaphragm will obliterate that border on the radiograph. An intrathoracic lesion not anatomically continous with a border of one of these structures will not obliterate that border. Eg. Lower lobe pneumonia, disease of lingula

56. Causes of air space filling Pulmonary edema Cardiac Non-cardiac Hypoalbuminemia Uraemia ARDS Mendelson’s syndrome Heroin overdose Infections Localised Generalised eg. Pneumocystis, parasites, fungi Neonatal Aspiration Hyaline membrane disease Alveolar blood Pulmonary haemorrhage Goodpasture’s syndrome Pulmonary infarction Tumours Alveolar cell carcinoma Lymphoma, leukaemia Metastatic adenocarcinoma Miscellaneous Alveolar proteinosis Eosinophilic lung Sarcoidosis Amyloidosis Wegener’s granulomatosis Allergic bronchopulmonary aspergillosis

57. Pulmonary Edema Produces air space opacities with variable distribution. Sparing of the apices and extreme lung bases. “Butterfly” or “Bat wings” distribution – central lungs affected more. With progression – opacities coalesce to form a “white-out” on chest radiograph. Blurring of blood vessels occurs. Air bronchogram – indicating intra alveolar edema.

58. picture

59. Radiologic signs of collapse Preethi .N.B

60. The term collapse is used when a whole lobe or lung is involved. Atelectesis is defined as diminished volume affecting all or part of a lung, whichmay or may not include loss of normal lucency in the affected part of lung . Pulmonary atelectasis can be divided into six types, based on mechanism: resorptive, adhesive, compressive, passive, cicatrization, and gravity-dependent

61. LOBAR ATELECTASIS Radiologic signs of lobar atelectasis :- Direct or Indirect . Direct signs include increased opacification of the airless lobe and displacement of fissures.

62. Indirect signs include displacement of hilar and cardiomediastinal structures toward the side of collapse, narrowing of the ipsilateral intercostal spaces, elevation of the ipsilateral hemidiaphragm , compensatory hyperinflation and hyperlucency of the remaining aerated lung, and obscuration or desilhouetting of the structures adjacent to the collapsed lung (eg, diaphragm and heart borders). Additional radiologic features vary according to the site of atelectasis.

63. RADIOLOGY OF PLEURAL DISEASES Nikitha James 080201018

64. PLEURAL EFFUSION Pleural effusion initially manifests as basal peripheral opacities that first fill the costo-phrenic angle.

65. Curve Of Ellis

66. Massive Pleural Effusion

67. Pneumothorax Chest X-ray PA view shows Sharply defined edge of the deflated lung Complete translucency between the lung and the chestwall .

68. Tension Pneumothorax

69. RADILOGICAL FEATURES OF CONSILIDATION

70. Consolidation Consolidation- replacement of air in one or more acini by fluid or solid material, but does not imply a particular pathology or etiology. Communications between the terminal airways allows fluid to spread between adjacent acini - responsible for larger area of involvement Commonest causes Acute inflammatory exudate from pneumonia. Non cardiogenic pulmonary oedema Cardiogenic pulmonary oedema Hemorrhage Aspiration

71. Radiologic features AIR BRONCHOGRAM- contrast between the column of air which is present in the airway and the surrounding opaque acini Normally the lung fields are radioluscent and the bronchi are not separately visualised But when, there is opacification of the alveoli due to various reasons ( eg : fluid accumulation is pulmonary oedema )the bronchi stand out as radiolucent in contrast to the adjacent alveoli that are radio opaque

72. an x-ray for a patient with right middle zone consolidation and demonstrates air bronchograms

73. Silhouette sign : If the airspace adjacent to one of the normal mediastinal or diaphragmatic contours is filled with dense material i.e. consolidated, then the normal air-soft tissue interface is lost and the normally seen edge of the silhouette disappears

74. .

75. Upper lobe consolidation

76. Middle and Lower lobe consolidation

77. Left lower lobe consolidation

78. Chest X Ray in Mediastinal Lesions Manasa

79. On the lateral radiograph drawing an imaginary line anterior to the trachea and posteriorly to the inferior vena cava. The middle and posterior compartments can be separated by an imaginary line passing 1 cm posteriorly to the anterior border of the vertebral bodies .

80. Approximately 60% of all mediastinal masses arise in the anterior mediastinum , 25% appear in the posterior mediastinum , and 15% occur in the middle mediastinum Most masses (> 60%) are: Thymomas Neurogenic Tumors Benign Cysts Lymphadenopathy In children the most common (> 80%) are: Neurogenic tumors Germ cell tumors Foregut cysts In adults the most common are: Lymphomas Lymphadenopathy Thymomas Thyroid masses

81. S uperior mediastinum origins of the Sternohyoid and Sternothyroid the aortic arch the innominate artery the thoracic portions of the left common carotid and the left subclavian arteries the innominate veins the upper half of the superior vena cava the left highest intercostal vein the vagus , cardiac, phrenic , and left recurrent nerves; the trachea, esophagus , and thoracic duct; the remains of the thymus, and some lymph glands

82. A lung mass abutts the mediastinal surface and creates acute angles with the lung, while a mediastinal mass will sit under the surface creating obtuse angles with the lung  LUNG MASS OR MEDIASTINAL MASS ?

83. Anterior Mediastinum loose areolar tissue, some lymphatic vessels which ascend from the convex surface of the liver, two or three anterior mediastinal lymph glands small mediastinal branches of the internal mammary artery.

84. Anterior Mediastinum Signs Obliterated retrosternal clear space Obliterated cardiophrenic angle Hilum overlay sign

85. Hilum Overlay Sign When there is a mediastinal mass and you still can see the hilar vessels through this mass, then you know the mass does not arise from the hilum .  This is known as the hilum overlay sign. Because of the geometry of the mediastinum most of these masses will be located in the anterior mediastinum .

86. The four T's make up the mnemonic for anterior mediastinal masses: Thymoma (myasthenia, upper anterior mediatinum ) Teratoma (germ cell) Thyroid Terrible Lymphoma

87. thymoma THYMOMA

88. LYMPHOMA

89. .

90. Middle Mediastinum It contains The heart enclosed in the pericardium the ascending aorta the lower half of the superior vena cava with the azygos vein opening into it the pulmonary artery dividing into its two branches the right and left pulmonary veins the bifurcation of the trachea and the two bronchi the phrenic nerves some bronchial lymph glands.

91. Middle Mediastinum Signs Widened paratracheal stripes AP window mass Displaced azygoesophageal recess on the right Lateral ‘doughnut’

92. A denopathy   Infection (fungal and mycobacterial )    Neoplasm ( bronchogenic carcinoma, metastases, lymphoma, leukemia) Sarcoidosis A neurysm/vascular A bnormalities of development    Bronchogenic cyst    Pericardial cyst    Esophageal duplication cyst

93. Saccular aortic aneurysm

94. BRONCHOGENIC CYST

95. Posterior Mediastinum T horacic part of the descending aorta the azygos and the two hemiazygos veins the vagus and splanchnic nerves , the esophagus the thoracic duct some lymph glands.

96. Common  Neural tumors      Neurogenic ( neuroblastoma , ganglioneuroma , ganglioneuroblastoma )      Nerve root tumors ( schwannoma , neurofibroma , malignant schwannoma ) Less common     Paraganglionic cell tumors ( chemodectoma , pheochromocytoma )    Spinal tumor (metastases, primary bone tumor)    Lymphoma   Invasive thymoma    Mesenchymal tumor ( fibroma , lipoma , leiomyoma , hemangioma , lymphangioma )    Abscess    Pancreatic pseudocyst    Esophageal varices    Hematoma    Traumatic pseudomeningocele   Bochdalek hernia    Extramedullary hematopoiesis    Descending thoracic aortic aneurysm

97. On conventional radiographs look for: Cervicothoracic Sign Widening of the paravertebral stripes

98. Cervicothoracic sign The anterior mediastinum stops at the level of the superior clavicle. Therefore, when a mass extends above the superior clavicle, it is located either in the neck or in the posterior mediastinum . When lung tissue comes between the mass and the neck, the mass is probably in the posterior mediastinum .  This is known as the Cervicothoracic Sign.

99. SCHWANNOMA