Radiological Presentation of Chest Diseases

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  • Gamal Rabie Agmy, MD, FCCP Professor of Chest Diseases, Assiut University ERS National Delegate of Egypt
  • L:Lung R:Rib T:Trachea AK:Aortic knob A:Ascending aorta H:Heart V: Vertebra P: Pulmonary artery S:Spleen
  • Missing Right Breast "Hyperlucent" right base secondary to missing breast. Silicone Breast Implantation
  • Cancer Breast Larger right breast Inverted nipple Radiation Fibrosis of Lung Right lung smaller Right hemithorax smaller Paramediastinal fibrosis
  • Cervical Rib
  • Pleural Effusion / Lytic Lesions in Clavicle and Scapula
  • Cervical rib
  • Kyphoscoliosis
  • Rib Fracture / Hematoma
  • Extra Pleural Sign Cancer Lung Density in periphery Sharp inner margin Indistinct outer margin Angle of contact with chest wall Expanding destructive rib lesion Paratracheal widening This is an example of an RUL lesion
  • Neurofibromatosis
  • Sprengel's Deformity High set scapula Vertebral anomaly Rib anomaly
  • Subcutaneous Emphysema Air outlining pectoral muscles Air along chest wall Pneumomediastinum
  • Lateral Chest There is valuable information that can be obtained by a chest lateral view. A few of them are listed below: Sternum Vertebral column Retrosternal space Localization of lung lesions Lobes of lungs Oblique fissures Pulmonary artery Heart Aorta Mediastinal masses Diaphragm Volume measurements SPN Radiologic TLC Tracheoesophageal stripe
  • Tuberculosis of Spine Loss of intervertebral space Vertebral collapse Cold abscess is not present in this case. PA view is not diagnostic.
  • Mediastinal Lymph Nodes Extrapleural Polycyclic margin Anterior mediastinum
  • RML Atelectasis Vague density in right lower lung field, almost normal RML atelectasis in lateral view, not evident in PA view
  • Atelectasis Left Upper Lobe Hazy density over left upper lung field Loss of left heart silhouette Tracheal shift to left A: Forward movement of oblique fissure C: Atelectatic LUL B: Herniated right lung
  • Localization When a lesion is not contiguous to a silhouette, it is not possible to localize it without a lateral view. This is a case of a solitary pulmonary nodule with popcorn calcification: Hamartoma.
  • Air Bronchogram In a normal chest x-ray, the tracheobronchial tree is not visible beyond the 4th order. As the bronchial tree branches, the cartilaginous rings become thinner, and eventually disappear in respiratory bronchioles. The lumen of the bronchus contains air and the surrounding alveoli contain air. Thus, there is no contrast to visualize the bronchi. The air column in the bronchi beyond the 4th order becomes recognizable if the surrounding alveoli is filled, providing a contrast or if the bronchi get thickened The term air bronchogram is used for the former state and signifies alveolar disease.
  • Silhouette Sign Adjacent Lobe/SegmentSilhouette RLL/Basal segmentsRight diaphragm RML/Medial segmentRight heart margin RUL/Anterior segmentAscending aorta LUL/Posterior segmentAortic knob Lingula/Inferior segmentLeft heart margin LLL/Superior and basal segmentsDescending aorta LLL/Basal segmentsLeft diaphragm Cardiac margins are clearly seen because there is contrast between the fluid density of the heart and the adjacent air filled alveoli. Both being of fluid density, you cannot visualize the partition of the right and left ventricle because there is no contrast between them. If the adjacent lung is devoid of air, the clarity of the silhouette will be lost. The silhouette sign is extremely useful in localizing lung lesions.
  • Atelectasis Right Lung Homogenous density right hemithorax Mediastinal shift to right Right hemithorax smaller Right heart and diaphragmatic silhouette are not identifiable
  • Atelectasis Left Lung Homogenous density left hemithorax Mediastinal shift to left Left hemithorax smaller Diaphragm and heart silhouette are not identifiable
  • Lateral Movement of oblique and transverse fissures Atelectasis Right Upper Lobe Homogenous density right upper lung field Mediastinal shift to right Loss of silhouette of ascending aorta
  • Atelectasis Left Upper Lobe Hazy density over left upper lung field Loss of left heart silhouette Tracheal shift to left Lateral A: Forward movement of oblique fissure B: Herniated right lung C: Atelectatic LUL
  • Consolidation Right Upper Lobe / Density in right upper lung field Lobar density Loss of ascending aorta silhouette No shift of mediastinum Transverse fissure not significantly shifted Air bronchogram
  • Consolidation Left Lower Lobe Density in left lower lung field Left heart silhouette intact Loss of diaphragmatic silhouette No shift of mediastinum Pneumatocele One diaphragm only visible Lobar density Oblique fissure not significantly shifted
  • Left Upper Lobe Consolidation Density in the left upper lung field Loss of silhouette of left heart margin Density in the projection of LUL in lateral view Air bronchogram in PA view No significant loss of lung volume
  • Vague density right lower lung field Indistinct right cardiac silhouette Intact diaphragmatic silhouette Density corresponding to RML No loss of lung volume RML pneumonia
  • S Curve of Golden When there is a mass adjacent to a fissure, the fissure takes the shape of an "S". The proximal convexity is due to a mass, and the distal concavity is due to atelectasis. Note the shape of the transverse fissure. This example represents a RUL mass with atelectasis
  • Tracheal Shift Trachea is index of upper mediastinal position. The pleural pressures on either side determine the position of the mediastinum. The mediastinum will shift towards the side with relatively higher negative pressure compared to the opposite side. Tracheal deviation can occur under the following conditions: Deviated towards diseased side Atelectasis Agenesis of lung Pneumonectomy Pleural fibrosis Deviated away from diseased side Pneumothorax Pleural effusion Large mass Mediastinal masses Tracheal masses Kyphoscoliosis
  • Atelectasis Right Lung Homogenous density right hemithorax Mediastinal shift to right Right hemithorax smaller Right heart and diaphragmatic silhouette are not identifiable
  • Pleural Effusion Massive Unilateral homogenous density Mediastinal shift to right Left diaphragmatic and left heart silhouettes lost Left hemithorax larger
  • Pneumonectomy Opacity left hemithorax Tracheal shift to left Cardiac and left diaphragmatic silhouettes missing Crowding of ribs
  • Air Bronchogram In a normal chest x-ray, the tracheobronchial tree is not visible beyond the 4th order. As the bronchial tree branches, the cartilaginous rings become thinner, and eventually disappear in respiratory bronchioles. The lumen of the bronchus contains air and the surrounding alveoli contain air. Thus, there is no contrast to visualize the bronchi. The air column in the bronchi beyond the 4th order becomes recognizable if the surrounding alveoli is filled, providing a contrast or if the bronchi get thickened The term air bronchogram is used for the former state and signifies alveolar disease.
  • Bowing Sign In LUL atelectasis or following resection, as in this case, the oblique fissure bows forwards (lateral view). Bowing sign refers to this feature. The arrow points to the forward movement of the left oblique fissure.
  • Doubling Time Time to double in volume (not diameter) Useful in determining the etiology of solitary pulmonary nodule Utility Less than 30 days: Inflammatory process Greater than 450 days: Benign tumor Malignancy falls in between
  • Eccentric Location of Cavity in a Mass Th