CXR: 'Silhoutte' and other signs

1. Interesting chest xray for Interesting chest xray for
discussiondiscussion
Prof Magesh kumar unitProf Magesh kumar unit
Dr vijayanandDr vijayanand

2. 60 years old gentleman comes with60 years old gentleman comes with
c/o cough with sputum 3monthsc/o cough with sputum 3months
c/o haemoptysis on &off 3 monthsc/o haemoptysis on &off 3 months
Chronic smokerChronic smoker
No h/o prior anti tb therapyNo h/o prior anti tb therapy

3. Clinical examinationClinical examination
Tracheal shift to RtTracheal shift to Rt
Movements decreased in R infrascapular, Movements decreased in R infrascapular,
interscapular regionsinterscapular regions
Dull note in above areas.Dull note in above areas.
Breath sounds decreased in intensity in Breath sounds decreased in intensity in
above areasabove areas

6. Differential DiagnosisDifferential Diagnosis
1 Bronchogenic carcinoma1 Bronchogenic carcinoma
2 neurogenic tumours2 neurogenic tumours
3 Bronchogenic cyst3 Bronchogenic cyst
4 lung sequestration4 lung sequestration
5 oesophageal lesions5 oesophageal lesions

7. 6 neuro enteric cyst6 neuro enteric cyst
7 Pharyngo-oesophageal pouch7 Pharyngo-oesophageal pouch
8 Aneurysm of descending aorta8 Aneurysm of descending aorta
9 Bochdalek hernia9 Bochdalek hernia
10 Pancreatic pseudo cyst10 Pancreatic pseudo cyst
11 Paravertebral mass11 Paravertebral mass
12 Hiatus hernia12 Hiatus hernia

9. Silhoutte signSilhoutte sign
Dr Ben felson in 1950Dr Ben felson in 1950
Localisation of lesions by studying Localisation of lesions by studying
diaphragm & mediastinal outlinesdiaphragm & mediastinal outlines
The borders are seen because of adjacent The borders are seen because of adjacent
aerated alveoli,diff in radiodensity b/w lung aerated alveoli,diff in radiodensity b/w lung
&adjacent structures.&adjacent structures.
If air is displaced by disease ,borders are If air is displaced by disease ,borders are
obliterated and lesions are localisedobliterated and lesions are localised

10. If the border is retained & abnormality is If the border is retained & abnormality is
superimposedsuperimposed
Lesion may lie anterior or posteriorLesion may lie anterior or posterior
Obliteration may occur with pleural, chest Obliteration may occur with pleural, chest
wall,mediastinal ,pulmonary pathology.wall,mediastinal ,pulmonary pathology.
Silhoutte sign refers to loss of normal Silhoutte sign refers to loss of normal
appearing interfacesappearing interfaces

11. Silhouette/Structure Contact with Lung
Upper right heart border/ascending aortaAnterior segment of RUL
Right heart border RML (medial)
Upper left heart border Anterior segment of LUL
Left heart border Lingula (anterior)
Aortic knob Apical portion of LUL (posterior)
Anterior hemidiaphragms Lower lobes

12. DEFINITION:DEFINITION:
PARTIALPARTIAL

OROR
COMPLETE LOSS OF COMPLETE LOSS OF
VOLUME OF A LUNGVOLUME OF A LUNG
OMPLETEOMPLETE
LOSS OF A LUNG LOSS OF A LUNG
IS REFERRED TO AS COLLAPSE OR IS REFERRED TO AS COLLAPSE OR
ATELECTASISATELECTASIS

15. DISPLACEMENT OF INTERLOBAR DISPLACEMENT OF INTERLOBAR
FISSURESFISSURES- MOST IMP AND RELIABLE - MOST IMP AND RELIABLE
SIGNSIGN
LOSS OF AERATIONLOSS OF AERATION
VASCULAR AND BRONCHIAL SIGNSVASCULAR AND BRONCHIAL SIGNS : :
PARTIALLY COLLAPSED LOBE-PARTIALLY COLLAPSED LOBE-
CROWDING OF ITS VESSELS.CROWDING OF ITS VESSELS.

16. ELEVATION OF HEMIDIAPHRAGMELEVATION OF HEMIDIAPHRAGM - MAY - MAY
BE IN LL-RARE IN OTHERSBE IN LL-RARE IN OTHERS
MEDIASTINAL DISPLACEMENTMEDIASTINAL DISPLACEMENT - ULOBE-- ULOBE-
TRACHEA.LL-HEART.TRACHEA.LL-HEART.
HILAR DISPLACEMENTHILAR DISPLACEMENT - ELEVATED-- ELEVATED-
UL,DEPRESSED-LL.UL,DEPRESSED-LL.
COMPENSATORY HYPERVENTILATIONCOMPENSATORY HYPERVENTILATION

17. MINOR FISSURE MOVES UPWARDS MINOR FISSURE MOVES UPWARDS
WITH CONCAVITY INFERIORLY.WITH CONCAVITY INFERIORLY.
AN AREA OF OPACITY AGAINST APEX AN AREA OF OPACITY AGAINST APEX
OF MEDIASTINUM.OF MEDIASTINUM.
TRACHEAL SHIFT TO RIGHT.TRACHEAL SHIFT TO RIGHT.
RIGHT HILUM IS ELEVATED.RIGHT HILUM IS ELEVATED.
GOLDEN SIGN OF SGOLDEN SIGN OF S

18. Golden “ S’’ signGolden “ S’’ sign
Causes – bronchogenic carcinoma, Causes – bronchogenic carcinoma,
enlarged lymph nodes, metastases.enlarged lymph nodes, metastases.
Distorted minor fissure , laterally concave Distorted minor fissure , laterally concave
inferiorly, medially is convex inferiorlyinferiorly, medially is convex inferiorly
Reverse s apearance Reverse s apearance

20.  Chilaiditi signChilaiditi sign
Rare sign , incidence 0.1%Rare sign , incidence 0.1%
Interposition of colon between liver and Interposition of colon between liver and
diaphragm.diaphragm.
Incidental finding in normal xray Incidental finding in normal xray
No symptoms No symptoms
Chilaiditi syndrome when it causes pain , Chilaiditi syndrome when it causes pain ,
torsion of bowel , shortness of breath.torsion of bowel , shortness of breath.

22. Pneumo peritoneumPneumo peritoneum
Perforated peptic ulcer
Bowel obstruction
Ruptured diverticulum
Penetrating trauma
Ruptured inflammatory bowel disease (e.g. megacolon)
Necrotising enterocolitis/Pneumatosis coli[2]
Bowel Cancer
Ischemic bowel
Steroid

23. After laparotomy
After laparoscopy
Breakdown of a surgical anastomosis
Bowel injury after endoscopy
Peritoneal dialysis
Vaginal insufflation (air enters via the fallopian tubes, e.g. water-skiing, oral sex)
Colonic or peritoneal infection
From chest (e.g. bronchopleural fistula)
Non-invasive PAP [positive airway pressure ]

26. MORE OBVIOUS ON LATERAL VIEWMORE OBVIOUS ON LATERAL VIEW ..
ILL DEFINED SHADOW ADJ TO RIGHT ILL DEFINED SHADOW ADJ TO RIGHT
HEART BORDER,BECOMES HEART BORDER,BECOMES
INDISTINCT.INDISTINCT.
RT HEART BORDER IS SILHOUTTEDRT HEART BORDER IS SILHOUTTED
MINOR FISSURE MOVE DOWNWARDSMINOR FISSURE MOVE DOWNWARDS
LATERAL VIEWLATERAL VIEW: TRIANGULAR SHAPE : TRIANGULAR SHAPE
WITH APEX AT HILUM.WITH APEX AT HILUM.

28. MAJOR FISSURE WHICH IS NOT MAJOR FISSURE WHICH IS NOT
NORMALLY SEEN –SEEN IN RLL NORMALLY SEEN –SEEN IN RLL
COLLAPSE.COLLAPSE.
OBLITERATION OF DIAPHRAGMOBLITERATION OF DIAPHRAGM
HEART BORDER CLEARLY SEENHEART BORDER CLEARLY SEEN
CT SCAN-PARASPINAL MASS LIKE CT SCAN-PARASPINAL MASS LIKE
APPEARANCEAPPEARANCE
NOTENOTE: CONCOMITANT RML AND RLL : CONCOMITANT RML AND RLL
APPEAR AS-SUBPULMONIC APPEAR AS-SUBPULMONIC
EFFUSION.FISSURE IDENTIFICATION-IMPEFFUSION.FISSURE IDENTIFICATION-IMP

31. LUFT SICHEL SIGNLUFT SICHEL SIGN:HYPEREXPANDED :HYPEREXPANDED
SUPERIOR SEGMENT OF LEFT LOWER SUPERIOR SEGMENT OF LEFT LOWER
LOBE INTERPOSITIONED BETWEEN LOBE INTERPOSITIONED BETWEEN
ATELECTATIC UPPER LOBE AND ATELECTATIC UPPER LOBE AND
AORTIC AORTIC ARCH-APPEARANCE OF ARCH-APPEARANCE OF
CRESCENT OF AERATED LUNGCRESCENT OF AERATED LUNG ..
OBLITERATION OF LEFT UPPER OBLITERATION OF LEFT UPPER
CARDIAC BORDERCARDIAC BORDER
SHIFT OF RT UL ACROSS MIDLINESHIFT OF RT UL ACROSS MIDLINE

34. INCREASED RETROCARDIAC INCREASED RETROCARDIAC
OPACITYOPACITY
SILHOUTTING LEFT HEMIDIAPHRAGMSILHOUTTING LEFT HEMIDIAPHRAGM
ROTATION OF HEART-FLATTENING ROTATION OF HEART-FLATTENING
OF CARDIAC WAIST-FLAT WAIST OF CARDIAC WAIST-FLAT WAIST
SIGN.SIGN.
SUPERIOR MEDIASTINUM MAY SUPERIOR MEDIASTINUM MAY
SHIFT-OBLITERATION OF AORTIC SHIFT-OBLITERATION OF AORTIC
KNOBKNOB
HEART-STRAIGHT LATERAL BORDER-HEART-STRAIGHT LATERAL BORDER-
SAILSAIL LIKE SIGNLIKE SIGN