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Radiology Department of the Rijnland Hospital, Leiderdorp and the Academical Medical
Centre, Amsterdam, the Netherlands
PA view
On the PA chest-film it is important to examine all the areas where the lung borders the
diaphragm, the heart and other mediastinal structures.
At these borders lung-soft tissue interfaces are seen resulting in a:
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.
Widening of the paratracheal line (> 2-3mm) may be due to lymphadenopathy, pleural
thickening, 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.
The azygoesophageal recess is the region inferior to the level of the azygos vein arch in which
the right lung forms an interface with the mediastinum between the heart anteriorly and
vertebral column posteriorly.
It is bordered on the left by the esophagus.
Hiatal hernia
Esophageal disease
Left atrial enlargement
Subcarinal lymphadenopathy
Bronchogenic cyst
The azygos lobe is created when a laterally displaced 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.
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).
Pectus excavatum
In patients with a pectus excavatum the right heart border can be ill-defined, but this is normal.
It produces a silhouette sign and thus simulating a consolidation or atelectasis of the right
middle lobe.
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 vertebral 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 pathology in the lower lobes.
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 higher
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.
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.
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.
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.
Silhouette sign in a consolidation located in the lingula (blue arrow). The silhouette of the left
heart border will still be visible in a consolidation in the left lower lobe (red arrow).
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.
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 silhouette of
the heart (red arrow).
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.
On a normal lateral chest film the silhouette of the left diaphragm 2- can be seen from posterior
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
indicates 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
pneumonia 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 attention, because pathology in these areas can easily
be overlooked:
apical zones
hilar zones
retrocardial zone
zone below the dome of diaphragm
Notice that there is quite some lung volume below 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.
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.
Notice the subtle increased density in the area behind the heart that needs special attention
(blue arrow).
This was a lower lobe pneumonia.
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.
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 osteeolytic metastasis in the iliac bone.
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.
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
Right Atrium
Left Ventricle
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
Right Ventricle
This is a patient with longstanding mitral valve disease and mitral valve replacement.
Extreme dilatation of the left atrium has resulted in bulging of the contours (blue and black
arrows).
First study the PA and lateral chest film and then continue reading.
There is a small aortic knob (blue arrow), while the pulmonary trunk and the right lower
pulmonary artery are dilated.
All these findings are probably the result of a left-to-right shunt with subsequent development of
pulmonary hypertension.
The location of the cardiac valves is best determined 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 impression of the enlargement of the left atrium.
Cardiac incisura
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.
Pacemaker
There are different types of cardiac pacemakers.
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 ventricular contractions.
Pacing both ventricles at the same time will lead to synchrone contractions and a better cardiac
output.
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 configuration and pericardial bleeding was suspected.
Ultrasound demonstrated only a minimal pericardial effusion.
Continue with the CT.
There is a large pericardial effusion, which is located posteriorly to the left ventricle (blue
arrow).
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
explains why the ultrasound examination underestimated the amount of pericardial fluid.
Always compare these post-operative chest films with the pre-operative ones.
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
myocardial calcifications in an infarcted area of the left ventricle.
Pericardial fatpad
Necrosis of the fat pad has pathologic features similar to fat necrosis in epiploic appendagitis.
It is an uncommon benign condition, that manifests as acute pleuritic chest pain in previously
healthy persons (10).
Pericardial cyst
Pericardial cysts are connected to the pericardium and usually contain clear fluid.
The majority of pericardial cysts arise in the anterior cardiophrenic angle, more frequently on
the rightside, but they can be seen as high as the pericardial recesses at the level of the
proximal aorta and pulmonary arteries (11).
Most patients are asymptomatic.
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 hilum should never be lower than the right hilum.
The left pulmonary artery runs over the left main bronchus, while the right pulmonary artery
runs in front of the right main bronchus, which is usually lower in position than the left main
bronchus.
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 identified on a lateral view and should not be
mistaken for lymphadenopathy.
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 reconstructions of a chest-ct to get a better view of the
hilar structures.
The lower lobe pulmonary arteries extend inferiorly 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.
Notice the reappearance of the right little finger (red arrow) and the normal right heart border
(blue arrow).
Hilar enlargement
Enlargement of the hili is usually due to lymphadenopathy or enlarged vessels.
This is known as the 1-2-3 sign in sarcoidosis, i.e. enlargement of left hilum, right hilum and
paratracheal.
The mediastinum can be divided into an anterior, middle and posterior compartment, each with
it's own pathology.
Mediastinal lines
Mediastinal lines or stripes are interfaces between 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.
A hiatal hernia is the most common cause of displacement of the azygoesophageal line.
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 lymphadenopathy far better than on the CXR.
The final diagnosis of small cel lungcancer was made through a biopsy of a lymphnode in the
neck.
Here we have a prior CXR of this patient.
Aortopulmonary window
The aortopulmonary window is the interface below 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
lateral view.
The PET better demonstrates the extent of the lymphnode metastases in this patient.
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
Consolidation
Atelectasis
Interstitial pattern
Pleura
Pleural fluid
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.
Pneumothorax
The other cystic lungdisease which causes pneumothorax is Langerhans cell histiocytosis
(LCH) which is seen in smokers.
The retracted visceral pleura is seen (blue arrow) which indicates that there is a pneumothorax.
When a pneumothorax is small, this air-fluid level can be the only key to the diagnosis of a
pneumothorax.
There is a hydropneumothorax.
Notice the air-fluid level (blue arrow).
LAM is a rare lung disease that results in a proliferation of smooth muscle throughout the lungs
resulting in the obstruction of small airways leading to pulmonary cyst formation and
pneumothorax.
LAM also occurs in patients who have tuberous sclerosis.
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.
Recognition of a pneumothorax depends on the volume of air in the pleural space and the
position of the body.
On a supine radiograph a pneumothorax can be subtle and approximately 30% of
pneumothoraces are undetected.
The image is of a patient in the ICU who is on mechanical ventilation. There was an acute
exacerbation of the dyspnoe.
There is a deep sulcus sign on the left.
The image on the right is after insertion of an intercostal drain.
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.
infection (TB)
empyema
hemorrhagic
Pleural hematoma
These images are of a patient, who had a pleural opacity after a chest trauma.
Chest wall
Ribfractures
The most common identified chest wall abnormalities are old ribfractures.
When a rib fracture heals, the callus formation may create a mass-like appearance (blue
arrow).
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 abnormalities that we see on a CXR are metastases in
vertebral bodies and ribs.
The most obvious finding on this CXR is free air under the diaphragm.
This finding indicates a bowel perforation, unless when the patient had recent abdominal
surgery and there is still some air left in the abdomen, which can stay there for several days.
Notice the very thin regular line which is the diaphragm (arrow).
At first impression one might think that this is just some plate-like atelectasis due to poor
inspiration.