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(I)
ATELECTASIS
Lateral
One diaphragm
missing
Herniation of left
lung
retrosternally
Close up
Air bronchogram
Lateral
One diaphragm missing
Increased density over
spine
Herniation of right lung
retrosternally
Lateral Left
diaphragm not
visible
Increased density
over lower spine
Atelectasis Left
Lower Lobe
Loss of left
diaphragmatic
silhouette in PA
view
Triangular density in
lateral
Posterior movement of
left oblique fissure
One diaphragm not
visible
Increased density over
lower vertebra
Atelectasis Left
Lower Lobe
Loss of left
diaphragmatic
silhouette
Blunting of
costophrenic
angle
Left main
bronchus pulled
down
Lateral decubitus
film:
Retrocardiac
triangular
density
No free fluid
Atelectasis
Left Lower
Lobe
Inhomogeneou
s cardiac
density
Triangular
retrocardiac
density
Left hilum
pulled down
Atelectasis Left
Upper Lobe
Mediastinal shift
to left
Density left
upper lung field
Loss of aortic
knob and left
hilar silhouettes
Herniation of right
lung
Atelectatic left upper
lobe
Forward movement
of left oblique fissure
"Bowing sign"
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
C: Atelectatic LUL
B: Herniated right lung
Atelectasis Right
Upper Lobe
Density in the right
upper lung field
Transverse fissure
pulled up
Right hilum pulled
up
Smaller right lung
Smaller right
hemithorax
Lateral
Movement of oblique
and transverse fissures
RUL Atelectasis
Density in the projection of right
upper lung field
Right hilum pulled up
RML Atelectasis
Vague density in right
lower lung field
(almost a normal
film).
Dramatic RML
atelectasis in lateral
view, not evident in
PA view. Movement of
transverse fissure.
Other findings include:
Azygous lobe
RML Atelectasis
Vague density in
right lower lung
field, almost normal
RML atelectasis in
lateral view, not
evident in PA view
Atelectasis Right
Lower Lobe
Density in right
lower lung field
Indistinct right
diaphragm
Right heart
silhouette retained
Transverse fissure
moved down
Right hilum moved
down
Adhesive
Atelectasis
Alveoli are kept
open by the
integrity of
surfactant. When
there is loss of
surfactant, alveoli
collapse. ARDS is an
example of diffuse
alveolar atelectasis.
Plate-like atelectasis
is an example of
focal loss of
surfactant.
Relaxation
Atelectasis
The lung is held in
apposition to the chest
wall because of
negative pressure in
the pleura. When the
negative pressure is
lost, as in
pneumothorax or
pleural effusion, the
lung relaxes to its
atelectatic position.
The atelectasis is a
secondary event. The
pleural problem is
Round Atelectasis
Mass like density
Pleural based
Base of lungs
Blunting of
costophrenic angle
Pleural thickening
Pulmonary
vasculature curving
into the density
Esophageal surgical
clips.
Round Atelectasis
Mass like density
Pleural based
Base of lungs
Blunting of
costophrenic angle,
pleural thickening
Pulmonary
vasculature curving
into the density
This is not a good
example.
Sub-segmental Atelectasis
Also note the posterior mediastinal
mass in the left apex.
Atelectasis
Segmental
Anterior sub-segment of RUL
"Bronchial wedge"
( II )
BREAST
Breast
Breast densities have the following
significance:
Increased basal markings could be due to
breast tissue, especially from lactating
breasts.
Evaluate significance of basal changes
in lateral view.
Asymmetry of breast can be normal, but
can also suggest a disease process.
A missing breast indicates surgical
resection for breast cancer (most likely
reason) and can suggest etiology for the
observed lung lesion.
Cancer Breast
Inflammatory
Carcinoma
Post-Radiation
Larger right breast
Inverted nipple
Radiation Fibrosis of
Lung
Right lung smaller
Right hemithorax
smaller
Paramediastinal
fibrosis
( III )
BRONCHOGRA
M
Bronchogram
Bronchograms are rarely done
nowadays. The need for it
disappeared with the invention
of the fiberoptic bronchoscopy
and high resolution CT scan.
View these images to get a
greater understanding of a
Bronchogram
Bronchograms are rarely
done nowadays. The need
for it disappeared with the
invention of the fiberoptic
bronchoscopy and high
resolution CT scan. Use
these images to understand
the three dimensional view
of a bronchial tree.
( IV )
BRONCHIECTA
SIS
Bronchiectasis
Radiologic findings include:
Normal appearing CXR in most
Tubular shadows
Tram line
Gloved fingers
Mucocele
Ring shadows with thickened bronchial
walls
Air fluid levels
Watch for dextrocardia
Immotile cilia syndrome
Diffuse lung fibrosis
Due to recurrent infections
Bronchiectasis
Left lung atelectasis
due to mucus
plugging
Mucus plugs
suctioned with
bronchoscopy
Bronchogram done
after bronchoscopy
Saccular
bronchiectasis in
bronchogram below
Bronchiectasis
Multiple bilateral
basal air fluid
levels
See close up view
below.
(V)
BRONCHOPLEU
RAL
FISTULA
Bronchopleural Fistula
Tuberculosis
Bilateral upper lobe
disease
Develops pneumothorax
requiring chest tube
Bronchogram reveals
bronchopleural fistula
below
Note in the film below the
dye in the chest tube
and bronchial tree.
( VI )
CADAVER
SECTION
( VII)
CALCIFICATION
Calcification
Focal lung lesion: Ghon's
complex
Miliary lung calcification
Histoplasmosis
Tuberculosis
Alveolar microlithiasis
Chicken pox pneumonia
Solitary pulmonary nodule
Central / Granuloma
Lamellar / Histoplasmosis
Pop corn / Hamartoma
Eccentric / Scar Cancer
Nodes
Homogenous / TB
Clumpy / Histoplasmosis
Egg shell / Silicosis,
Sarcoidosis
Tracheal cartilage / Aging
Tumor
Mediastinal mass / Teratoma
Healed lymphoma / Mets
Vascular
Aortic calcification
Pulmonary artery
calcification / Pulmonary
hypertension
Pleural
Visceral / Hemothorax, TB,
Empyema
Parietal / Asbestosis
Subcutaneous calcification
Cysticercus
Broncholith
Subsegmental
atelectasis
Calcified
histoplasmosis
node
Broncholith
obstructing
bronchus
Sub
segmental
atelectasis
Sub segmental
atelectasis
Broncholith
Lingular
pneumonia below
Broncholith in
lingular orifice
Calcified histo
node
Review films
below.
Lingular pneumonia
Loss of
silhouette of left
heart margin
Post obstructive
pneumonia
Lingular
pneumonia
Post obstructive
pneumonia
Silicosis
Egg shell
calcification of
lymph nodes
Other findings
include:
Diaphragmatic
pleural calcification
Multiple cavities
with fluid levels
Lateral and close up
views below.
Multiple
cavities with
fluid levels
Multiple
cavities
with fluid
levels
Egg shell
calcification of
lymph nodes
Histoplasmosi
s
Calcified
nodes
Clumpy
calcification
Calcified
nodules in
lungs
Histoplasmosis
Calcified hilar and para tracheal
nodes
Clumpy calcification
Histoplasmosi
s
Calcified nodes
Calcified
nodules in
lungs
Hamartoma
Resected
specimen
Popcorn
calcification
Popcorn
Calcification
Solitary
pulmonary nodule
Popcorn
calcification
Hamartoma
Pleural Calcification
Visceral pleural calcification
Parietal pleura appears black
because it is sandwiched between
Pleural
Calcification
Visceral pleura
Probable old
tuberculosis
Note translucent
parietal pleura
Visceral pleural
calcification
Open drainage
with air fluid
levels in pleural
space
Silicosis
Diaphragmatic
pleural calcification
Other findings include:
Multiple cavities with
fluid levels
Egg shell
calcification of
lymph nodes
Pneumothorax
Air in pleural cavity: no
vascular markings
Lung margin: adherent
to chest wall at one
site
Increased density of
atelectatic lung:
abnormal lung
Larger right
hemithorax
Other findings include:
Calcified
diaphragmatic
pleural plaque
Cysticercus
Subcutaneous
calcified lesions
Other findings
include:
Old fractured
ribs
Uncoiling of
aorta
Solitary Pulmonary
Nodule
LUL posterior
segment
Gradual increase in
size over 10 years
Central calcification
Tuberculoma (not
confirmed)
Additional findings
include:
Pleural calcification
( VIII)
CAVITATION
Radiological Criteria
A hole in the lung with a wall, lumen and contents. Focus of
increased density whose central portion has been replaced by air.
The following characteristics help in the differential diagnosis.
Number:
Multiple bilateral cavities would raise suspicion for either
branchiogenous or hematogenous process. You should consider:
Aspiration lung abscess
Septic emboli
Metastatic lesions
Vasculitis (Wegener's)
Coccidioidomycosis, tuberculosis
Single cavity
Primary lung cancer
Post-traumatic lung cyst
Many other diseases
Size:
A large cavity encompassing the entire lobe or lung
should raise suspicion for gangrene of lung.
Location:
Classical locations for aspiration lung abscess
are superior segment of the lower lobes and
axillary subsegments of anterior and posterior
segments of upper lobes.
Tuberculous cavities are common in superior
segments of upper and lower lobes.
When a cavity in anterior segment is
encountered, a strong suspicion for lung
cancer should be raised. TB and aspiration
lung abscess are rare in anterior segments.
Cancer lung can occur in any segment.
Wall Thickness:
Thick walls are seen in:
Lung abscess
Necrotizing squamous cell lung cancer
Wegener's granulomatosis
Blastomycosis
Thin walled cavities are seen in:
Coccidioidomycosis
Metastatic cavitating squamous cell
carcinoma from the cervix
M. Kansasii infection
Congenital or acquired bullae
Post-traumatic cysts
Open negative TB
Lining of Wall:
The wall lining is irregular and nodular in lung cancer
or shaggy in lung abscess . The appearance is akin to
stalactites and stalagmites.
Contents:
The most common cause for air fluid level is lung
abscess. Air fluid levels can rarely be seen in
malignancy and in tuberculous cavities from
rupture of Rasmussen's aneurysm.
A fungous ball should make you consider
aspergillosis. A blood clot and fibrin ball will
have the same appearance.
Floating Water Lily: I have never seen this. The
collapsed membrane of a ruptured echinococcal
cyst, floats giving this appearance.
Associated Features:
Ipsilateral lymph nodes or lytic lesions of the bone
is seen with malignancy.
Evolution of Lesion:
Many times review of old films to assess the
evolution of the radiological appearance of the
lesion extremely helpful. Examples
Infected bullae
Aspergilloma
Sub acute necrotizing aspergillosis
Bleeding from Rasmussen's aneurysm in a
tuberculous cavity
Etiology:
Cavity can be encountered in practically most lung
diseases.
Common diseases and their characteristics include:
Primary Lung Cancer
Thick wall
Shaggy lumen
Eccentric cavitation
Necrotizing Pneumonia
Lung abscess
Gravity dependant segments
Thick wall
Air-fluid levels
Tuberculosis
Superior segments
Infiltrate around
Bilateral
Fungal infections
Aspergillus
Fungous ball
Sub acute invasive aspergillosis
Metastatic disease
Thin walled (Squamous cell)
Thick wall (Adenoma)
Cavity
|Squamous Cell
Carcinoma Lung
LUL mass
Thick walled cavity
Eccentric location of
cavity
Fluid level
Fungous Ball
Long standing cavity
Containing round
density (A)
Mobile density
Adjacent pleural
reaction (B) characteristic of
aspergilloma
Cavitating
Metastasis
Multiple Thin Walled
Cavities
Cancer Cervix
Stalagmites and
Stalactites
Squamous cell cancer
and inflammatory
masses can necroses
and evacuate contents
through the bronchi. The
wall of the resulting
cavity is thick, and the
lumen wall is irregular.
Often times you can see
necrotic or tumor
masses along the wall
similar to stalactites and
stalagmites.
This is an example of
cavitating lymphoma.
Lung Cancer /
Squamous Cell
Mass density
Anterior segment of
LUL
Thick wall
cavitation
Lateral view below.
Mass density
Anterior
segment of LUL
Cavity
Squamous Cell
Carcinoma
Anterior
segment of LUL
Thick wall
Fluid level
Full hilum
Cavity
Squamous Cell
Carcinoma Lung
Thick wall
Irregular lumen
Left hilar fullness:
Nodes
2 Thin
Walled
Cavities
Old
Coccidioid
omycosis
Coccidioidomycosis
Thin walled cavity
Cavitating Metastasis
Multiple Thin Walled
Cavities
Cancer Cervix
( IX)
CHEST WALL
Braid
Broad linear shadow
in right upper lung
field
Not corresponding
to fissure
Projecting beyond
lung fields
Metallic object
See film below with
braid moved out
Cysticercus
Subcutaneous
calcified lesions
Other findings include:
Old fractured ribs
Uncoiling of aorta
Rheumatoid Arthritis
Erosion of Posterior Ribs
Note the
bulbous end of
indwelling
catheter is
projecting at
various sites
of the chest
and can be
mistaken for a
lung lesion.
Kyphoscoliosis
Kyphoscoliosis
Neurofibroma
Round lesions
projected over
lung fields are in
chest wall
Lesions in chest
wall along both
sides and on
abdominal wall
Posterior
mediastinal mass:
Para vertebral line
on right side
Arrrow points to
neurofibromas.
Arrrows point to
neurofibromas over
Rib Fracture
/ Hematoma
Sprengel's
Deformity
High set scapula
Vertebral anomaly
Rib anomaly
Multiple
Congenital
Anomalies
Subcutaneous
Emphysema
Air outlining
pectoral muscles
Air along chest
wall
Pneumomediastinu
m
Patient with
lymphangitic
metastatic spread.
( X)
COLON IN
CHEST
Eventration
Colon in chest
Haustral markings
Other findings include:
Bony mets from prostate cancer
Colon
Transposition
Lye ingestion
Colon in anterior
mediastinum
Colon Pulled up
Following Resection
of Esophagus
Radiolucency of
mediastinum
Note haustral
markings in anterior
mediastinum
Colon in Front of
( XI)
CONSOLIDATION
Consolidation /
Lingula Density in
left lower lung field
Loss of left heart
silhouette
Diaphragmatic
silhouette intact
No shift of
mediastinum
Blunting of
costophrenic angle
Lateral Lobar
density
Oblique 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
Blunting of
costophrenic
angle
Lateral Lobar
density
Oblique fissure not
significantly
shifted
Loss of silhouette:
Posterior portion of
left diaphragm
Lateral Density
corresponding to RML
No loss of lung volume
Air bronchogram (not
demonstrable in this
Consolidation Right
Middle Lobe
Density in right middle
lung field
Loss of right cardiac
silhouette
Pulmonary artery
overlay sign
Air bronchogram not
visible in this
presentation
Minor movement of
fissure
Consolidation Right
Upper Lobe /Air
Bronchogram
Density in right
upper lung field
Lobar density
Loss of ascending
aorta silhouette
No shift of
mediastinum
Transverse fissure
not significantly
shifted
Air bronchogram
( XII)
DIAPHRAGM
Diaphragm
Both hemidiaphragms should be
visible in both PA and lateral
views.
The right hemidiaphragm is at a
higher level due to the congenital
position of the heart, and not due
to the liver.
Dome peaks in the center.
Markings representing
Lateral view
Right diaphragm
Seen in its entirety
Right oblique fissure touching
Projects outside: Phenomenon of
beam divergence
Left diaphragm
Not seen in its entirety because
of the heart resting on
diaphragm: Silhouette sign
Stomach bubble under
Left oblique fissure touching
Pneumoperitoneum
Air under diaphragm
Colon in chest
Haustral markings
Other findings include:
Bony mets from prostate cancer
Eventration
Eventration /
Localized
Herniation of Liver
"Elevated
Diaphragm"
Note
pneumoperitoneu
m
Supradiaphragma
tic mass
Can be mistaken
for elevated
diaphragm
Pellets
Pellets
Alveolar Cell
Carcinoma Progression
Old film on left
Solitary
pulmonary nodule
resected
Onset of
diaphragmatic
paralysis
Progression to
multicentric
acinar nodules
Solitary
pulmonary
nodule in right
mid lung field
Diaphragmatic
paralysis
Multi centric
alveolar
nodules
( XIII)
DIFFUSE
ALVEOLAR
General:
Cannot tell whether there is co-existent
interstitial disease.
Alveolar and interstitial pattern can be evident in
different portions of lung and is of diagnostic
significance.
Evolution of changes in x-ray helpful in the
diagnosis.
None of the x-ray findings are specific.
History and the clinical setting under which the
problem is encountered is of great help in
diagnosis.
Presence of co-existing findings helpful, e.g.,
lympadenopathy, etc.
Options for a diagnostic procedure is based on
the working diagnosis: Sputum evaluation, HRCT,
Distribution
Cortical
Eosinophilic pneumonia
BOOP
Lower lobes / Mineral oil
aspiration
Alveolar Cell
Carcinoma/Miliar
y Form
Bilateral
Miliary acinar
nodules
Nodules of
varying size with
irregular margins
Alveolar
Proteinosis
Bilateral diffuse
alveolar disease
Butterfly pattern
Medullary
distribution
Air
bronchograms
Air
bronchograms
CT scan showing
classical central
"medullary"
distribution of
alveolar density
Adult Respiratory
Distress
Syndrome
Non-cardiogenic
pulmonary edema
Distinguishing
characteristics:
Normal size heart
No pleural effusion
Pulmonary Hemorrhage
Wegener's Granulomatosis
Pulmonary
Hemorrhage
Acute onset
Diffuse
bilateral
alveolar
infiltrates
Bone marrow
transplant patient
Old film below
Lung Metastasis
Alveolar Form
Cancer Pancreas
Soft fluffy lesions
Air bronchogram
Coalesing lesions
Aspiration
Pneumonia Mineral
Oil
Bilateral
Paracardiac
Mass like
Alveolar features
Kerley lines:
Interstitial feature, as
it is being transported
to lymphatics
Myxoedematous
patient, taking mineral
oil for constipation.
Pulmonary
Edema
Acute Diffuse
Alveolar
Bilateral
Diffuse
Butterfly pattern
Soft fluffy lesions
Coalescing
Air bronchogram
Pulmonary Hemorrhage
Wegener's granulomatosis
Review the old film below.
Sarcoidosis /
Alveolar Form
Bilateral
Soft fluffy
lesions
Segmental
Coalesce
Air
bronchogram
Extravasated Myelogram
Dye
( XIV)
HIATAL HERNIA
Hiatal Hernia
Inhomogeneous
cardiac density
Fluid level
Crossing mid-line
Osteoporosis
Retraction of
lateral chest
Hiatal Hernia
Note the two air
fluid levels; one
in the stomach
and the other in
the esophagus
Inhomogeneous
cardiac density
Crossing midline
Retrocardiac
density
( XV)
HILUM
Hilum
The left hilum is
slightly at a higher
level compared to
right hilum. The
hilum can be pulled
up or down by lobar
atelectasis. Alteration
of the normal
relationship between
right and left hilum is
a helpful clue for
determining which
lobe has lost the
Unilateral
Hyperlucent Lung
Left Upper Lobe
Resection
Left lung hyper
lucent
Left hilum pulled up
No abnormal
density
Unilateral
Hyperlucent Lung
Right Upper Lobe
Resection
Right lung
hyperlucent
Right hilum same
level as left hilum
No abnormal density
( XVI)
HYPERLUCENT
LUNG
Hyperlucent Lung
Factors
Vasculature: Decrease
Air: Excess
Tissue : Decrease
Bilateral diffuse
Emphysema
Asthma
Unilateral
Swyer James syndrome
Agenesis of pulmonary artery
Absent breast or pectoral
muscle
Partial airway obstruction
Compensatory hyperinflation
Localized
Bullae
Westermark's sign :
Pulmonary embolus
Agenesis of Left
Pulmonary Artery
Missing vascular
markings in left
lung
Left hilum not seen
Entire cardiac
output to right
lung
Missing Right
Breast
"Hyperlucent"
right base
secondary to
missing breast.
Emphysema
Hyperlucent lung
fields
Multiple blebs
Avascular zones
Prominent pulmonary
arteries
Radiologic TLC
See lateral view
below.
Hyperlucent lung
fields
AP diameter
increased
Flat diaphragms
Multiple blebs
Retrosternal and
infracardiac air
Radiologic TLC
Unilateral
Hyperlucent Lung
Left Upper Lobe
Resection
Left lung hyper lucent
Left hilum pulled up
No abnormal density
Unilateral
Hyperlucent Lung
Right Upper Lobe
Resection
Right lung
hyperlucent
Right hilum same
level as left hilum
No abnormal
density
( XVII)
INNOMINATE
ARTERY
Prominent
Innominate
Artery
( XVIII)
INFILTRATE
Tuberculosis
LUL cavities
RUL infiltrate
Bilateral upper
lobe disease
( XIX)
INTERSTITIAL
DISEASE
Interstitial Disease
Honeycombing
Seen in end stage
lung disease
Indicative of diffuse
interstitial fibrosis
Due to
bronchiolectasia
Most of the time in
bases
Upper lobe
distribution seen in
eosinophilic
granuloma
Lymphangitic
Metastasis
Cancer Breast
Kerley lines
Subpulmonic
effusion on right
Sarcoidosis /
Miliary
Nodules /
Hilar Nodes
Milary
Tuberculosis
Interstitial
nodules
Uniform size
Sharper
edges
Review the close
up below.
Silicosis
Miliary nodules
Left
subpulmonic
effusion
( XX)
LATERAL CHEST
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
Pneumonectomy
Opacity left
hemithorax
Tracheal shift to left
Cardiac and left
diaphragmatic
silhouettes missing
Crowding of ribs
One diaphragm in
lateral
Density over spine
Right pulmonary
artery prominent
Herniation of right
lung in anterior
mediastinum
Tuberculosis 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
Lateral
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.
Review the lateral
view below.
( XXI)
MEDIASTINAL
MASS
Mediastinal Mass
( XXII)
MASS IN LUNG
Mass
Mass density can be encountered in lung cancer,
benign tumors, sarcoma, lymphoma, Wegener's and
blastomycosis and tuberculoma.
Radiological criteria for a mass lesion are chest
lateral and PA views.
Density
Round or oval
Sharp margins
Homogenous density (exception: air
bronchogram in lymphoma and blastomycosis)
No respect for anatomy (in cancer)
Can break down leading to thick walled cavity
May show calcification (histoplasmoma,
tuberculoma, hamartoma)
Mass
Round or oval
Sharp margin
Homogenous
No respect for
anatomy
Lung Cancer: Large
cell
Mass
Round
homogenous
density
Sharp margins
Medial portion
pleural based
(acute angle)
This is a case of
squamous cell
lung
cancer.
Mass
LUL anterior
segment
Aortic knob
silhouette intact
Round
homogenous
density
Sharp margin
This is a case of
lung
cancer.
Fluid in Fissure
Phantom Tumor
Pulmonary edema
Fluid in
fissure
Biconvex
density
In oblique
fissure
Clearance with
treatment
Other findings
include:
Displacement of
right paravertebral
line due to tortuous
descending aorta
( XXIII)
NORMAL PA
VIEW
L:
Lung
R:
Rib
T:
Trachea
Ascending
aorta
H:
Heart
V:
Vertebra
P:
Pulmonary
artery
S:
Spleen