The Radiology Assistant: Chest X-Ray - Basic Interpretation

The Radiology Assistant : Chest X-Ray - Basic Interpretation 4/17/17, 9(03 PM
Chest X-Ray - Basic Interpretation

Robin Smithuis and Otto van Delden
Radiology Department of the Rijnland Hospital, Leiderdorp and the Academical Medical Centre,
Amsterdam, the Netherlands
Publicationdate February 18, 2013
The chest x-ray is the most frequently request-

ed radiologic examination.
In fact every radiologst should be an expert in
chest film reading.
The interpretation of a chest film requires the
understanding of basic principles.
In this article we will focus on:
Normal anatomy and variants.

Systematic approach to the chest film
using an inside-out approach.
Pathology of the heart, mediastinum,
lungs and pleura.
Normal and Variants

PA view
On the PA chest-film it is important to examine

all the areas where the lung borders the di-
aphragm, the heart and other mediastinal
structures.
At these borders lung-soft tissue interfaces are

seen resulting in a:
Line or stripe - for instance the right para

tracheal stripe.
Silhouette - for instance the normal
silhouette of the aortic knob or left
ventricle
These lines and silhouettes are useful localizers

of disease, because they can be displaced or
obscured with loss of the normal silhouette.
This is called the silhouette sign, which we will
discuss later.
The paraspinal line may be displaced by a par-

avertebral abscess, hemorrhage due to a frac-
ture or extravertebral extension of a neoplasm.
Widening of the paratracheal line (> 2-3mm)
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may be due to lymphadenopathy, pleural thick-

ening, hemorrhage or fluid overload and heart
failure.
Displacement of the para-aortic line can be due

to elongation of the aorta, aneurysm, dissection
and rupture.
The anterior and posterior junction lines are

formed where the upper lobes join anteriorly
and posteriorly. These are usely not well seen
and we will not discuss them.
An important mediastinal-lung interface to look

for is the azygoesophageal line or recess
(arrow).
The azygoesophageal recess is the region inferi-

or to the level of the azygos vein arch in which
the right lung forms an interface with the medi-
astinum between the heart anteriorly and verte-
bral column posteriorly.
It is bordered on the left by the esophagus.
Deviation of the azygoesophageal line is caused

by (5):
Hiatal hernia
Azygoesophageal recess. The blue arrow indicates
Esophageal disease
the paraaortic line.
Left atrial enlargement
Subcarinal lymphadenopathy
Bronchogenic cyst
Notice the deviation of the azygoesophageal line

on the PA-film.
It is caused by a hiatal hernia.
Vena azygos lobe
A common normal variant is the azygos lobe.
The azygos lobe is created when a laterally dis-

placed azygos vein makes a deep fissure in the
upper part of the lung.
On a chest film it is seen as a fine line that

crosses the apex of the right lung.
Here another patient with an azygos lobe.

The azygos vein is seen as a thick structure
within the azygos fissure.
In some patients an extra joint is seen in the

anterior part of the first rib at the point where
the bone meets the calcified cartilageneous part
(arrow).
This may simulate a lung mass.
Pectus excavatum
In patients with a pectus excavatum the right

heart border can be ill-defined, but this is nor-
mal.
It produces a silhouette sign and thus simulat-
ing a consolidation or atelectasis of the right
middle lobe.
The lateral view is helpful in such cases.
Pectus excavatum is a congenital deformity of

the ribs and the sternum producing a concave
appearance of the anterior chest wall.
Lateral view
On a normal lateral view the contours of the

heart are visible and the IVC is seen entering
the right atrium.
The retrosternal space should be radiolucent,

since it only contains air. Any radiopacity in this
area is suspective of a proces in the anterior
mediastinum or upper lobes of the lung.
As you go from superior to inferior over the ver-

tebral bodies they should get darker, because
usually there will be less soft tissue and more
radiolucent lung tissue (red arrow).
If this is not the case, look carefully for patholo-
gy in the lower lobes.
The contours of the left and right diaphragm

should be visible.
The right diaphragm should be visible all the

way to the anterior chest wall (red arrow).
Actually we see the interface between the air in
the lungs and the soft tissue structures in the
abdomen.
The left diaphragm can only be seen to a point

where it borders the heart (blue arrow).
Here the interface is lost, since the heart has
the same density as the structures below the
diaphragm.
The left main pulmonary artery (in purple)

passes over the left main bronchus and is high-
er than the right pulmonary artery (in blue)
which passes in front of the right main
bronchus.
Once you know how the normal hilar structures

look like on a lateral view, it is easier to detect
abnormalities.
In this case on the PA-view there is hilar en-

largement.
On the PA-view it is not clear whether this is
due to dilated vessels or enlarged lymph nodes.
On the lateral view there are round structures in
areas where you don't expect any vessels. So
we can conclude that we are dealing with en-
larged lymph nodes.
This patient has sarcoidosis.

Notice also the widening of the paratracheal line
(or stripe) as a result of enlarged lymph nodes.
On the lateral view spondylosis may mimick a

lung mass.
Any density in the area of the vertebral bodies

should lead you to the PA-film to look for
spondylosis, which is usually located on the
right side (arrows).
On the left side the formation of osteophytes is
hampered by the pulsations of the aorta.
On the PA-view the superior mediastinum is

widened.
The lateral view is helpful in this case because it
demonstrates a density in the retrosternal
space.
Now the differential diagnosis is limited to a
mass in the anterior mediastinum (4 T's).
This was a Hodgkins lymphoma.
A common incidental finding in adults is a

Bochdalek hernia, which is due to a congenital
defect in the posterior diaphragm (arrows).
In most cases it only contains retroperitoneal
fat and is asymptomatic, but occasionally it may
contain abdominal organs.
Large hernias are sometimes seen in neonates

and can be complicated by pulmonary
hypoplasia.
A hernia of Morgagni is also a congenital di-

aphragmatic hernia, but is less common.
It is located anteriorly.
Systematic Approach
Whenever you review a chest x-ray, always use

a systematic approach.
We use an inside-out approach from central to
peripheral.
First the heart figure is evaluated, followed by
mediastinum and hili.
Subsequently the lungs, lungborders and finally
the chest wall and abdomen are examined.
You have to know the normal anatomy and vari-

ants.
Find subtle abnormalities by using the sihouette
sign and mediastinal lines.
Once you see an abnormality use a pattern ap-
proach to come up with the most likely diagno-
sis and differential diagnosis.
Old films
It is extremely important to always compare

with old films, as we will demonstrate in this
case.
Actually someone said that the most important
radiograph is the old film, since it gives you so
much information.
For instance a lung mass, which hasn't changed
in many years is not a lung cancer.
First study the chest films.

Then continue.
Based on the CXR that you just saw, you could

have made the diagnosis of congestive heart
failure, but the findings are very subtle.
However once you compare it to the old film,
things become more obvious and you will be
much more confident in your diagnosis:
1. The size of the heart is slightly increased

compared to the old film.
2. The pulmonary vessels are slightly
increased in diameter indicating increased
pulmonary pressure.
3. There are subtle interstitial markings as a
result of interstitial edema.
4. There is pleural fluid bilaterally. Notice
that the inferior border of the lower lobes
has changed in position.
All these findings indicate the presence of heart

failure.
Silhouette sign
This is a very important sign. It enables us to

find subtle pathology and to locate it within the
chest.
The loss of the normal silhouette of a structure
is called the silhouette sign.
Here an example to explain the silhouette sign:

The heart is located anteriorly in the chest and
Silhouette sign in a consolidation located in the
it is bordered by the lingula of the left lung.
lingula (blue arrow). The silhouette of the left heart
border will still be visible in a consolidation in the The difference in density between the heart and
left lower lobe (red arrow). the air in the lung enables us to see the silhou-
ette of the left ventricle.
ette of the left ventricle.

When there is something in the lingula with the
same 'water density' as the heart, the normal
silhouette will be lost (blue arrow).
When there is a pneumonia in the left lower

lobe, which is located more posteriorly in the
chest, the left ventricle will still be bordered by
air in the lingula and we will still see the silhou-
ette of the heart (red arrow).
The PA-film shows a silhouette sign of the left

heart border.
Even without looking at the lateral film, we
know, that the pathology must be located ante-
riorly in the left lung.
This was a consolidation due to a pneumonia
caused by Sterptococcus pneumoniae.
Here we see a consolidation which is located in

the left lower lobe.
There is a normal silhouette of the left heart
border.
On this lateral film there is too much density

over the lower part of the spine.
By only looking at the interfaces of the left and

right diaphragm on the lateral film, it is possible
to tell on which side the pathology is located.
First study the lateral film.

Then continue.
On a normal lateral chest film the silhouette of

the left diaphragm 2- can be seen from posteri-
or up to where it is bordered by the heart,
which has the same density (blue arrow).
One should be able to follow the contour of the

right diaphragm -1- from posterior all the way
to anterior, because it is only bordered by the
lung.
Here we cannot follow the contour of the right

diaphragm all the way to posterior, which indi-
cates that there is something of water-density
in the right lower lobe (red arrow).
On the PA-film there is a normal silhouette of

the heart border, so the pathology is not in the
anterior part of the chest, which we already
suspected by studying the lateral view.
Why do we still see the silhouette of the right

diaphragm on the PA-film?
What we see is actually the highest point of the

right diaphragm, which is anterior to the pneu-
monia in the right lower lobe.
The pneumonia does not border the highest
point of the diaphragm.
Hidden areas
There are some areas that need special atten-

tion, because pathology in these areas can easi-
ly be overlooked:
apical zones
hilar zones
retrocardial zone
zone below the dome of diaphragm
These areas are also known as the hidden

areas.
Notice that there is quite some lung volume be-

low the dome of the diaphragm, which will need
your attention (arrow).
Here an example of a large lesion in the right

lower lobe, which is difficult to detect on the PA-
film, unless when you give special attention to
the hidden areas.
Click on the image for an enlarged view.
Here a pneumonia which was hidden in the right

lower lobe mainly below the level of the dome
of the diaphragm (red arrow).
Notice the increase in density on the lateral film

in the lower vertebral region.
You may have to enlarge the image to get a

better view.
First study the CXR.
Notice the subtle increased density in the area

behind the heart that needs special attention
(blue arrow).
This was a lower lobe pneumonia.
First study the CXR.
We know that in some cases there is an extra

joint in the anterior part of the first rib which
may simulate a mass.
However this is also a hidden area where it can
be difficult to detect a mass.
In this case a small lung cancer is seen behind

the left first rib.
Notice that is is also seen on the lateral view in
the retrosternal area.
Continue with the PET-CT.
The PET-CT demonstrates the tumor (arrow)

which has already spread to the bone and liver.
The diagnosis was made by a biopsy of an os-
teeolytic metastasis in the iliac bone.
First study the CXRs.
There is a subtle consolidation in the left lower

lobe in the hidden area behind the heart.
Again there is increased density over the lower
vertrebral region.
Heart and Pericardium
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On a chest film only the outer contours of the

heart are seen.
In many cases we can only tell whether the
heart figure is normal or enlarged and it will be
difficult to say anything about the different
heart compartments.
However it can be helpful to know where the
different compartments are situated.
Left Atrium
Most posterior structure.

Receives blood from the pulmonary veins
that run almost horizontally towards the
left atrium.
Left atrial appendage (in purple) can
sometimes be seen as a small
outpouching just below the pulmonary
trunk.
Enlargement of the left atrium results on
the PA-view in outpouching of the upper
heart contour on the right and an obtuse
angle between the right and left main
bronchus. On the lateral view bulging of
the upper posterior contour will be seen.
Right Atrium
Receives blood from the inferior and

superior vena cava.
Enlargement will cause an outpouching of
the right heart contour.
Left Ventricle
Situated to the left and posteriorly to the

right ventricle.
Enlargement will result on the PA-view in
an increase of the heart size to the left
and on the lateral view in bulging of the
lower posterior contour.
Right Ventricle
Most anterior structure and is situated

behind the sternum.
Enlargement will result on the PA-view in
an increase of the heart size to the left
and can finally result in the left heart
border being formed by the right ventricle.
Left Atrium
The upper posterior border of the heart is

formed by the left atrium.
Enlargement will result in bulging of the
upper posterior contour
Left Ventricle
Forms the lower posterior border.

Enlargement will displace the contour
more posteriorly.
Right Ventricle
The lower retrosternal space is filled by

the right ventricle.
Enlargement of the right ventricle will
result in more superior filling of this
retrosternal space.
Left Atrium enlargement
This is a patient with longstanding mitral valve

disease and mitral valve replacement.
Extreme dilatation of the left atrium has result-

ed in bulging of the contours (blue and black
arrows).
Right ventricle enlargement
First study the PA and lateral chest film and

then continue reading.
On these chest films the heart is extremely di-

lated.
Notice that it is especially the right ventricle
that is dilated. This is well seen on the lateral
film (yellow arrow).
There is a small aortic knob (blue arrow), while

the pulmonary trunk and the right lower pul-
monary artery are dilated.
All these findings are probably the result of a
left-to-right shunt with subsequent develop-
ment of pulmonary hypertension.
ment of pulmonary hypertension.
The location of the cardiac valves is best deter-

mined on the lateral radiograph.
A line is drawn on the lateral radiograph from
the carina to the cardiac apex.
The pulmonic and aortic valves generally sit
above this line and the tricuspid and mitral
valves sit below this line (4).
On this lateral view you can get a good impres-

sion of the enlargement of the left atrium.
Cardiac incisura
Click image to enlarge.
On the right side of the chest the lung will lie

against the anterior chest wall.
On the left however the inferior part of the lung
may not reach the anterior chest wall, since the
heart or pericardial fat or effusion is situated
there.
This causes a density on the anteroinferior side

on the lateral view which can have many forms.
It is a normal finding, which can be seen on
many chest x-rays and should not be mistaken
for pathology in the lingula or middle lobe.
The explanation for the cardiac incisura is seen

on this CT-image.
At the level of the inferior part of the heart we
can appreciate that the lower lobe of the right
lung is seen more anteriorly compared to the
left lower lobe.
Pacemaker
There are different types of cardiac pacemak-
ers.
Here we see a pacemaker with one lead in the
right atrium and another in the right ventricle.
A third lead is seen, which is guided through the

coronary sinus towards the left ventricle.
This is done in patients with asynchrone ven-
tricular contractions.
Pacing both ventricles at the same time will lead
to synchrone contractions and a better cardiac
output.
More on cardiac pacemakers...
Pericardial effusion
Whenever we encounter a large heart figure, we

should always be aware of the possibility of
pericardial effusion simulating a large heart.
On the chest x-ray it looks as if this patient has

a dilated heart while on the CT it is clear, that it
is the pericardial effusion that is responsible for
the enlarged heart figure.
Especially in patients who had recent cardiac

surgery an enlargement of the heart figure can
indicate pericardial bleeding.
This patient had a change in the heart configu-

ration and pericardial bleeding was suspected.
Ultrasound demonstrated only a minimal peri-
cardial effusion.
Continue with the CT.
There is a large pericardial effusion, which is lo-

cated posteriorly to the left ventricle (blue ar-
row).
The left ventricle id filled with contrast and is
compressed (red arrow).
At surgery a large hematoma in the posterior
part of the pericardium was found.
Notice that on the anterior side there is only a

minimal collection of pericardial fluid, which ex-
plains why the ultrasound examination underes-
timated the amount of pericardial fluid.
Here another patient who had valve-

replacement.
Notice the large heart size.

There is redistribution of the pulmonary vessels
which indicates heart failure.
Continue with the CT.
The CT-image shows a large pericardial

effusion.
Always compare these post-operative chest

films with the pre-operative ones.
Calcifications
Detection of calcifications within the heart is

quite common.
The most common are coronary artery calcifica-
tions and valve calcifications.
Here we see pericardial calcifications which can

be associated with constrictive pericarditis.
In this case there are calcifications that look like

pericardial calcifications, but these are myocar-
dial calcifications in an infarcted area of the left
ventricle.
Notice that they follow the contour of the left

ventricle.
Pericardial fatpad
Pericardial fat depositions are common.

Sometimes a large fat pad can be seen (figure).
Necrosis of the fat pad has pathologic features

similar to fat necrosis in epiploic appendagitis.
It is an uncommon benign condition, that mani-
fests as acute pleuritic chest pain in previously
healthy persons (10).
Pericardial cyst
Pericardial cysts are connected to the pericardi-

um and usually contain clear fluid.
The majority of pericardial cysts arise in the an-
terior cardiophrenic angle, more frequently on
the rightside, but they can be seen as high as
the pericardial recesses at the level of the prox-
imal aorta and pulmonary arteries (11).
Most patients are asymptomatic.
On the chest x-ray it seems as if there is a ele-

vated left hemidiaphragm.
On CT however there is a cyst connected to the

pericardium.
Hili
The normal hilar shadow is for 99% composed

of vessels - pulmonary arteries and to a lesser
extent veins (1).
The vessel margins are smooth and the vessels
have branches.
The left pulmonary artery runs over the left

main bronchus, while the right pulmonary
The left hilum should never be lower than the right artery runs in front of the right main bronchus,
hilum. which is usually lower in position than the left
main bronchus.
Hence the left hilum is higher than the right.

Only in a minority of cases the right hilus is at
the same level as the left, but never higher.
In this illustration the lower lobe arteries are

coloured blue because they contain oxygen-
poor blood.
They have a more vertical orientation, while the

pulmonary veins run more horizontally towards
the left atrium, which is located below the level
of the main pulmonary arteries.
Both pulmonary arteries and veins can be iden-

tified on a lateral view and should not be mis-
taken for lymphadenopathy.
Sometimes the pulmonary veins can be very

prominent.
The left main pulmonary artery passes over the

left main bronchus and is higher than the right
pulmonary artery which passes in front of the
right main bronchus.
These images are thick slab sagittal reconstruc-

tions of a chest-ct to get a better view of the hi-
lar structures.
The lower lobe pulmonary arteries extend inferi-

orly from the hilum.
They are described as little fingers, because
each has the size of a little finger (1).
On the right side the little finger will be visible

in 94% of normal CXRs and on the left side in
62% of normals (1).
Study the CXR of a 70-year old male who fell

from the stairs and has severe pain on the right
flank..
Notice on the PA-film the absence of the little

finger on the right and on the lateral view the
increased density over the lower vertebral
column.
What is your diagnosis?
There is a right lower lobe atelectasis.
Notice the abnormal right border of the heart.

The right interlobar artery is not visible, be-
cause it is not surrounded by aerated lung but
by the collapsed lower lobe, which is adjacent to
the right atrium.
On a follow-up chest film the atelectasis has re-

solved.
We assume that the atelectasis was a result of
post-traumatic poor ventilation with mucus
plugging.
Notice the reappearance of the right little finger

(red arrow) and the normal right heart border
(blue arrow).
Hilar enlargement
The table summarizes the causes of hilar

enlargement.
Normal hili are:
Normal in position - left higher than right

Equal density
Normal branching vessels
Enlargement of the hili is usually due to lym-

phadenopathy or enlarged vessels.
In this case there is an enlarged hilar shadow

on both sides.
This could be the result of enlarged vessels or
enlarged lymph nodes.
A very helpful finding in this case is the mass on
the right of the trachea.
This is known as the 1-2-3 sign in sarcoidosis,

i.e. enlargement of left hilum, right hilum and
paratracheal.
Here some more examples of sarcoidosis.

Click to enlarge.
1. Lymphadenopathy and groundglass

appearance of the lungs
2. Lymphadenopathy, 1-2-3 sign
3. Bulky lymphadenopathy
4. 1-2-3 sign
5. Nodular lung pattern, no
lymphadenopathy
6. Hilar and paratracheal lymphadenopathy
Mediastinum
Mediastinal masses are discussed in more detail

in Mediastinal masses.
Here is just a brief overview.
The mediastinum can be divided into an anteri-

or, middle and posterior compartment, each
with it's own pathology.
Mediastinal lines
Mediastinal lines or stripes are interfaces be-

tween the soft tissue of mediastinal structures
and the lung.
Displacement of these lines is helpful in finding
mediastinal pathology, as we have discussed
above.
Azygoesophageal recess
The most important mediastinal line to look for

is the azygoesophageal line, which borders the
azygoesophageal recess.
This line is visible on most frontal CXRs.
The causes of displacement of this line are sum-

marized in the table.
A hiatal hernia is the most common cause of

displacement of the azygoesophageal line.
Notice the air within the hernia on the lateral

view.
Another common cause of displacement of the

azygoesophageal line is subcarinal
lymphadenopathy.
Notice the displacement of the upper part of the

azygoesophageal line on the chest x-ray in the
area below the carina.
This is the result of massive lymphadenopathy
in the subcarinal region (station 7).
There are also nodes on the right of the trachea

displacing the right paratracheal line.
On the PET we can appreciate the massive lym-

phadenopathy far better than on the CXR.
There are also lymphomas in the neck.

this is an important finding, since these nodes
are accessible for biopsy.
Continue with images of CT and ultrasound.
Here we see a CT-image.

The azygoesophageal recess is displaced by
lymph nodes that compress the left atrium.
The final diagnosis of small cel lungcancer was

made through a biopsy of a lymphnode in the
neck.
First study the chest x-ray.

Then continue reading.
Notice the following:
1. There is displacement of the

azygoesophageal line both superiorly an
inferiorly.
2. There is an air-fluid level (arrow).
Combined with the above this must be a
dilated esophagus with residual fluid. The
final diagnosis was achalasia.
3. The density on the left in the region of the
lingula is the result from prior aspiration
pneumonia.
pneumonia.
Here we have a prior CXR of this patient.
The AP-film shows a right paratracheal mass.

The azygoesophageal recess is not identified,
because it is displaced and parallels the border
of the right atrium.
The large round density in the left lung is the
result of aspiration.
Notice the massive dilatation of the esophagus

on the CT.
Aortopulmonary window
The aortopulmonary window is the interface be-

low the aorta and above the pulmonary trunk
and is concave or straight laterally.
Here the AP-window is convex laterally due to a

mass that fills the retrosternal space on the lat-
eral view.
On the CT-images a mass in the anterior medi-

astinum is seen.
Final diagnosis: Hodgkins lymphoma.
Here another case.

On the PA-film a mass is seen that fills the aor-
topulmonary window.
The PET better demonstrates the extent of the

lymphnode metastases in this patient.
Final diagnosis: small cell lungcarcinoma.
Lungs
Lung abnormalities mostly present as areas of

increased density, which can be divided into the
following patterns:
1. Consolidation
2. Atelectasis
3. Nodule or mass - solitary or multiple
4. Interstitial
Less frequently areas of decreased density are

seen as in emphysema or lungcysts.
These lungpatterns will discussed in more detail

in an article that will be published soon: Chest
X-Ray - Lung disease.
Consolidation
Atelectasis
Nodule - Masses
Solitary pulmonary node - SPN is discussed

here.
Interstitial pattern
Click on the table to enlarge.
Interstitial lung diseases are discussed here.
Pleura
Pleural fluid
It takes about 200-300 ml of fluid before it

comes visible on an CXR (figure).
About 5 liters of pleural fluid are present when
there is total opacification of the hemithorax.
Total opacification of the right hemithorax in a

patient with pleuritis carcinomatosa on both
sides.
On the right there is only some air visible in the

major bronchi creating an air bronchogram
within the compressed lung.
Pleural fluid may become encysted.
Here we see fluid entrapped within the fissure.

This can sometimes give the impression of a
mass and is called 'vanishing tumor'.
Pneumothorax
The table lists the most common causes of a

pneumothorax.
The other cystic lungdisease which causes

pneumothorax is Langerhans cell histiocytosis
(LCH) which is seen in smokers.
Study the CXR.
There are two important findings.
The retracted visceral pleura is seen (blue ar-

row) which indicates that there is a
pneumothorax.
There is a horizontal line visible (yellow arrow).

Normally there are no straight lines in the hu-
man body unless when there is an air-fluid lev-
el.
This means that there is a hydro-
pneumothorax.
When a pneumothorax is small, this air-fluid

level can be the only key to the diagnosis of a
pneumothorax.
Study the CXR.
There are 3 important findings.
Notice that the mediastinum is slightly displaced

to the left.
Does this mean that there is a tension
pneumothorax?
Do you have an idea about the cause of the

pneumothorax?
There is a hydropneumothorax.
Notice the air-fluid level (blue arrow).
The upper lobe is still attached to the chest wall

by adhesions.
Maybe this patient was treated for a prior
pneumothorax.
There is a lung cyst in the upper lobe (red ar-

row).
So we can assume that the pneumothorax has
something to do with a cystic lung disease.
Since this patient is a woman, lymphangi-

Since this patient is a woman, lymphangi-

oleiomyomatosis (LAM) is a possible diagnosis.
LAM is a rare lung disease that results in a pro-
liferation of smooth muscle throughout the
lungs resulting in the obstruction of small air-
ways leading to pulmonary cyst formation and
pneumothorax.
LAM also occurs in patients who have tuberous
sclerosis.
Study the CXR.
What is your diagnosis?
This is not a pneumothorax but a skin fold.
The radiography was performed supine with a

CR cassette inserted underneath the patient,
which resulted in a skinfold.
Notice that there are lung markings beyond the

apparent pneumothorax.
Here two CXRs of another patient with obvious

skinfolds.
Recognition of a pneumothorax depends on the

volume of air in the pleural space and the posi-
tion of the body.
On a supine radiograph a pneumothorax can be
subtle and approximately 30% of pneumotho-
races are undetected.
A sign to look for is the 'deep sulcus sign'.

It represents lucency of the lateral costophrenic
angle extending toward the hypochondrium
(Figure).
The image is of a patient in the ICU who is on

mechanical ventilation. There was an acute ex-
acerbation of the dyspnoe.
There is a deep sulcus sign on the left.
Notice that the left hemidiaphragm is de-

pressed.
This is an important finding since it indicates a
This is an important finding since it indicates a

tension pneumothorax.
The image on the right is after insertion of an

intercostal drain.
Notice that the diaphragm has regained its nor-

mal appearance.
Pleural opacities
The table lists the most common causes of

pleural opacities.
Pleural plaques
The CXR shows multiple opacities.
They have irregular shapes and do not look like
a lung masses or consolidations.
Some of these opacities are clearly bordering

the chest wall (red arrows).
All these findings indicate that we are dealing

asbestos related pleural plaques.
Asbestos related pleural plaques are usually:
1. bilateral and extensive.

2. covering the dome of the diaphragm.
Unilateral pleural calcifications are usually due

to:
infection (TB)
empyema
hemorrhagic
Pleural hematoma
These images are of a patient, who had a pleur-
al opacity after a chest trauma.
It was believed to be a hematoma and resolved

spontaneously.
Chest wall
Ribfractures
The most common identified chest wall abnor-
malities are old ribfractures.
The CXR shows many rib deformities due to old

fracturees.
When a rib fracture heals, the callus formation

may create a mass-like appearance (blue
arrow).
Sometimes a CT is necessary to differentiate a

healing fracture from a lung mass.
Notice the large lung volume and the enlarged

pulmonary vessels.
Probably we are dealing with pulmonary arterial
hypertension in a patient with COPD.
The second most common chest wall abnormali-

ties that we see on a CXR are metastases in
vertebral bodies and ribs.
Notice the expansile mass in the posterior rib

on the right.
Abdomen
The most obvious finding on this CXR is free air

under the diaphragm.
This finding indicates a bowel perforation, un-

less when the patient had recent abdominal
surgery and there is still some air left in the ab-
domen, which can stay there for several days.
There is another subtle finding in the left upper

lobe.
A subtle density projecting over the first rib -
hidden area - proved to be a lungcarcinoma.
Here another patient with free abdominal air.
Notice the very thin regular line which is the di-

aphragm (arrow).
At first impression one might think that this is

just some plate-like atelectasis due to poor
inspiration.
1. The Chest X-Ray: A Survival Guide

by Gerald de Lacey et al.
2. introduction to chest radiology
Introduction to chest radiology
3. Fleischner Society: Glossary of Terms for Thoracic Imaging
by David M. Hansell et al
Radiology 2008;246:697
4. Lines and Stripes: Where Did They Go? From Conventional Radiography to CT
by Jerry M. Gibbs et al
RadioGraphics 2007;27:33-48
RadioGraphics 2007;27:33-48
5. Cardiac Valves: Assessment and Identification
on RadDaily.com
6. A Diagnostic Approach to Mediastinal Abnormalities
by Camilla R. Whitten
May 2007 RadioGraphics, 27,657-671.
7. The Deep Sulcus Sign
Radiology 2003; 228:415-416
8. Chest Radiology Plain Film Patterns and Differential Diagnoses
by James C. Reed
9. Thoracic Imaging: Pulmonary And Cardiovascular Radiology
by Richard Webb and Charles Higgins
10. Lesions of the Cardiophrenic Space: Findings at Cross-sectional Imaging
Vctor Pineda et al.
January 2007 RadioGraphics,27, 19-32.
11. Imaging of Cystic Masses of the Mediastinum
By Mi-Young Jeung, et al.
October 2002 RadioGraphics,22, S79-S93.

The Radiology Assistant: Chest X-Ray - Basic Interpretation

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The Radiology Assistant : Chest X-Ray - Basic Interpretation 4/17/17, 9(03 PM

Chest X-Ray - Basic Interpretation

Publicationdate February 18, 2013

The chest x-ray is the most frequently request-

In this article we will focus on:

Normal anatomy and variants.

Normal and Variants

On the PA chest-film it is important to examine

At these borders lung-soft tissue interfaces are

Line or stripe - for instance the right para

These lines and silhouettes are useful localizers

The paraspinal line may be displaced by a par-

Widening of the paratracheal line (> 2-3mm)

may be due to lymphadenopathy, pleural thick-

Displacement of the para-aortic line can be due

The anterior and posterior junction lines are

An important mediastinal-lung interface to look

The azygoesophageal recess is the region inferi-

Deviation of the azygoesophageal line is caused

Notice the deviation of the azygoesophageal line

It is caused by a hiatal hernia.

Vena azygos lobe

A common normal variant is the azygos lobe.

The azygos lobe is created when a laterally dis-

On a chest film it is seen as a fine line that

Here another patient with an azygos lobe.

In some patients an extra joint is seen in the

This may simulate a lung mass.

In patients with a pectus excavatum the right

The lateral view is helpful in such cases.

Pectus excavatum is a congenital deformity of

On a normal lateral view the contours of the

The retrosternal space should be radiolucent,

As you go from superior to inferior over the ver-

The contours of the left and right diaphragm

The right diaphragm should be visible all the

The left diaphragm can only be seen to a point

The left main pulmonary artery (in purple)

Once you know how the normal hilar structures

In this case on the PA-view there is hilar en-

This patient has sarcoidosis.

On the lateral view spondylosis may mimick a

Any density in the area of the vertebral bodies

On the PA-view the superior mediastinum is

This was a Hodgkins lymphoma.

A common incidental finding in adults is a

Large hernias are sometimes seen in neonates

A hernia of Morgagni is also a congenital di-

Whenever you review a chest x-ray, always use

You have to know the normal anatomy and vari-

It is extremely important to always compare

First study the chest films.

Based on the CXR that you just saw, you could

1. The size of the heart is slightly increased

All these findings indicate the presence of heart

This is a very important sign. It enables us to

Here an example to explain the silhouette sign:

ette of the left ventricle.

When there is a pneumonia in the left lower

The PA-film shows a silhouette sign of the left

Here we see a consolidation which is located in

On this lateral film there is too much density

By only looking at the interfaces of the left and