Topic: Chest Abnormalities

Important obscured/invinsible structures-some become visible

whe
n
abn
orm
al

PUSH

PULL

increases pressure/volume in
one hemithorax

Volume loss in one hemithorax

Trachea (*)
shifted to
the left of
the midline
(red line)

-sternum
-esophagus
-spine
Mediastinal thyroid enlargement

-pleura
-fissures

Soft tissue
mass (blue)
to the right
of the
trachea
The CT
findings
correlate
well with
the x-ray

-Aorta

PUSH

PUSH
ASSESSING THE AIRWAYS
If the trachea is deviated,it is important to establish if this is
because the patient
has been incorrectly
positioned(rotated)/
there is pathology.
If deviated try to
decide if it has been
pushed/pulled by a
disease process

JC

Pneumothorax:PUSH

causes:
-masses
-widening of vessels
Aortic knuckle
(red line)
represents the left
lateral edge of the
aorta as it arches
backwards over the
left main bronchus,
and pulmonary
vessels
The contour of the
DESCENDING
THORACIC AORTA
can be seen in
continuation from
the aortic knuckle.
Displacement/loss
of definition of
these lines can
indicate disease:ANEURYSM/ADJACENT LUNG CONSOLIDATION
MEDIASTINAL MASS

MEDIASTINUM

Wide upper mediastinum (arrowheads)

Poorly defined aortic knuckle - indicating adjacent disease
Wide right paratracheal stripe (*)
Normal lungs
Clinical information

Night sweats and weight loss

Palpable neck lymph nodes

Diagnosis

if a PA standing chest x-ray has been taken with good

inspiration and no rotation,any widening of the mediastinum is
likely to be genuine

JC

Hodgkin's lymphoma

If this stripe is thickened(normally <3mm)paratracheal

mass/enlarged lymph node
The left side of the trachea is not so well defined because of the
position of the aortic arch and great vessels
IMAGING STRATEGY
Localize to mediastinum
Localized within the mediastinum
Characterize on CT or MR
AORTA-PULMONARY WINDOW
Lies between
the arch of the
aorta and the
pulmonary
arteries

Mediastinal mass - Lateral view (same

patient) HODGKIN LYMPHOMA
Mass located in the anterior mediastinum anterior to the heart

POTENTIAL
SPACE in the
mediastinum
where
abnormal
enlargement of
lymph nodes
can be seen on
a chest x-ray
The curve arrow
points towards
the aortapulmonary window between the Aortic Knuckle(AK) and the
Left Pulmonary Artery(LPA)
The descending aorta marks its posterior boundary
The right lateral edge of the ascending aorta(AA)is also marked
RIGHT PARA-TRACHEAL STRIPE
From the levels of
the clavicles to the
azygous vein the
right edge of the
trachea is seen as a
THIN WHITE
STRIPEthis
appearance is
created by air of
low density lying
either side of the
comparatively
dense tracheal wall

JC

Thoracic aortic aneurysm

Sternal wires and aortic valve prosthesis (arrowhead)
Massive aortic knuckle (red line)
Displaced trachea (arrow)
Widened, tortuous descending aorta (blue line)

MEDIATINUM
The heart and great
vessels make up a
majority of the
mediastinal
silhouette on the
frontal CXR

LUNG MAS

Mediastinal Mass

-abutts the mediastinal surface

and creats ACUTE angle with the
st
lung(1 image below left)

-sit under the surface creating

nd
OBTUSE angles with the lung(2
image)

Aortic knob->on the

left formed by the
superior and outer
edge of the aortic
arch

Whenever you see a mass on a chest x-ray that is possibly

located within the mediastinum,your goal is to determine the
following:
Is it a mediastinal mass?

2.

Is it in the anterior,middle or posterior mediastinum?

3.

Are you able to characterize the lesion by determining

whether it has any fatty,fluid or vascular components?

Most masses(>60%)

Children(>80%)

Adults

-thymomas

-neurogenic tumors

-lymphomas

-neurogenic tumors

-germ cell tumors

-LAD

-benign cysts

-foregut cysts

-thymomas

lymphadenopathy(LAD)

JC

MEDIASTINAL
MASSAnterior(Thymoma
The following characteristics indicate
) that a lesion originates within
LUNG MASS

1.

-thyroid masses

the mediastinum:
1.

Unlike lung lesions, a mediastinal mass will not contain air

bronchograms.

2.

The margins with the lung will be obtuse.

3.

Mediastinal lines (azygoesophageal recess, anterior and

posterior junction lines) will be disrupted.

4.

There can be associated spinal, costal or sternal

abnormalities

Post mediastinal mass

HILAR STRUCTURES

MEDIASTINAL COMPARTMENTS
-Anterior
-middle
-posterior
It is important to remember
that there is no tissue plane
separating these
compartments.
On the lateral radiograph
the anterior and middle
compartments can be
separated by drawing an imaginary line anterior to the trachea
and posteriorly to the inferior vena cava.

The hila
(lung roots)
are
complicated
structures
mainly
consisting
of the major
bronchi and
the
pulmonary
veins and
arteries.
These structures pass through the narrow hila on each side and
then branch as they widen out into the lungs.
The hila are not symmetrical but contain the same basic
structures on each side.

The middle and posterior compartments can be separated by

an imaginary line passing 1 cm posteriorly to the anterior
border of the vertebral bodies.
This division allows us to make a more narrow differential
diagnosis

Although the hilar lymph nodes are not visible on a normal

chest x-ray, they are of particular clinical importance. Often,
hilar enlargement is due to enlargement of these nodes
There is, however, a wide range of normal appearance.

JC

The hila may be at

the same level, but
commonly the left
hilum is higher
than the right.
Both hila should be
of similar size and
density.

Key points:

If either hilum is
bigger and more
dense, this is a
good indication
that there is an abnormality

Each hilum contains major bronchi and pulmonary

vessels
There are also lymph nodes on each side(not visible
unless abnormal)
The left hilum is often higher than the right
If a hilum is out of position, ask yourself if has been
pushed or pulled
As well as position check the size and density of the
hila

HILAR ENLARGEMENT

Main Pulmonary Artery

May be unilateral or bilateral, symmetrical or asymmetrical

In combination with clinical information, each of these patterns
is often helpful in reaching a diagnosis.
Bilateral, symmetrical hilar enlargement should raise the
suspicion of sarcoidosis, particularly if there is evidence of
paratracheal enlargement, or lung parenchymal shadowing.
1.
HILAR POINTS:
these are the angle formed
by the descending upper
lobe veins, as they cross
behind the lower lobe
arteries

Bilateral hilar enlargement

Both hila are larger and denser than normal
A small degree of patient rotation is irrelevant in this case the observation of bilateral, symmetrical hilar enlargement
can still be made
Patchy bilateral lung parenchyma

Not every normal patient

has a very clear hilar point
on both sides, but if they
are present then they can
be useful in determining
the position of the hila

Clinical details:Joint pain and Erythema nodosum

Diagnosis:Sarcoidosis
Differential:
Lymphoma, metastatic disease or infection may
occasionally look similar
Pulmonary arterial hypertension may also cause
bilateral symmetrical hilar enlargement

JC

hemithorax
2.

Asymmetric hilar enlargement

Clinical details

Both hila are larger and denser than normal

The right hilum is bigger than the left
Multiple small lung nodules
Missing right breast shadow (mastectomy)

History of left hilar malignancy treated with

radiotherapy
Diagnosis: Radiation fibrosis

Clinical details:
Known breast cancer
LUNG ZONES

Increasing shortness of breath

Assess the lungs by comparing the upper, middle and lower

lung zones on the left and right.

Diagnosis:

Asymmetry of lung density is represented as either abnormal

whiteness (increased density), or abnormal blackness
(decreased density). Once you have spotted asymmetry, the
next step is to decide which side is abnormal. If there is an area
that is different from the surrounding ipsilateral lung, then this
is likely to be the
abnormal area.

Metastatic disease
Breast cancer
HILAR POSITION

HILUM

PULL

Reduced
volume

PUSH

Reduced
pressure

Abnormal hilar
position
The left hilum is
large, dense and
pulled laterally
and upwards to
the left
The trachea is
deviated (pulled)
towards the left,
indicating loss of
lung volume in
the left

JC

Increased
volume

Increased
pressure

Dividing the lungs

into zones allows
more careful
attention to be
paid to each
smaller area. If
this is not done it
is easy to ignore
important
abnormalities
Note that the lower zones reach below the diaphragm. This is
because the lungs pass behind the dome of the diaphragm into
the posterior sulcus of each hemithorax.
Normal lung markings can be seen below the well defined
edges of the diapragm.

each zone is
compared with its
opposite side paying
attention to any
asymmetry.
If the lung fields
appear
asymmetrical,it
should be
determined if this
can be explained by
asymmetry of normal styructures,technical factors such as
rotation or lung pathology.
Once you have spotted asymmetry the next step is to decide
which side is abnormal
If there is an area that is different from the surrounding
ipsilateral lung,then this is likely to be abnormal
area

Consolidation with air bronchogram

Clinical information

The patient had a high temperature and a

productive cough

Diagnosis

Asymmetry

Pneumonia - consolidation with pus

Asymmetry of normal structures

Differential diagnosis of consolidation
Lung pathology

Technical factors

Pneumonia - airways full of pus

Cancer - airways full of cells
Pulmonary haemorrhage - airways full of blood
Pulmonary oedema - airways full of fluid

CONSOLIDATION
Consolidation with air bronchogram
The left middle zone is white
Dark lines through the area of white are a good example of air
bronchogram

if the alveoli and small airways fill with dense material,the

lung is said to be CONSOLIDATED

JC

consolidation does not always mean there is

infection, and the small airways may fill with
material other than pus (as in pneumonia), such as
fluid (pulmonary oedema), blood (pulmonary
haemorrhage), or cells (cancer).
They all look similar and clinical information will
often help you decide the diagnosis.

Clinical information

This patient had a history of intravenous drug abuse

and presented with a high fever

Diagnosis

Air bronchogram

If an area of lung is consolidated it becomes dense

and white

Septic embolus

Differential diagnosis of lung cavities

If the larger airways are spared, they are of

relatively low density (blacker). This phenomenon is
known as air bronchogram and it is a characteristic
sign of consolidation

Lung abscess - TB, Klebsiella or Staph aureus

Lung cancer
Septic embolus - infected thrombus
Fungal infection - if immunocompromised
Wegener's granulomatosis

UNILATERAL ZONE ABNORMALITY

CAVITY
The middle
zones are
asymmetrical
There is a
small
irregular
opacity on
the right
This opacity
contains a
dark area cavity
Other areas
of the lungs
are normal

JC

ABSCESS

WEGENERS
GRANULOM

SEPTIC
EMBOLUS

LUNG
CANCER

ATOSIS
TB

STAPH
AUREUS

KLEBSIELL
A

BILATERAL LUNG ABNORMALITY

Comparing sides does not always give the answer.

The lungs may be abnormal on both sides and so
awareness of the normal appearances of lung
parenchyma becomes more important

Multiple bilateral lung nodules

Left darker than right

Symmetrical distribution

Lung hyperexpansion

More nodules at the lung bases

Clinical information

Chronic smoker with increasing shortness

of breath

Clinical information

Diagnosis
Shortness of breath, weight loss and clinically
suspected underlying malignancy

Chronic obstructive pulmonary disease

with a large left lower zone lung bulla

Diagnosis

Pulmonary metastases

UNILATERAL BLACK LOWER ZONE

If there is asymmetry of the lungs, sometimes it is the dark (less

dense) area that is abnormal.
Asymmetrical lower zones

JC

PLEURA AND PLEURAL SPACE

The pleura only become visible when there is an

abnormality present
Pleural abnormalities can be subtle and it is
important to check carefully around the edge of
each lung where pleural abnormalities are usually
more easily seen.

Some diseases of the pleura cause pleural

thickening, and others lead to fluid or air gathering
in the pleural spaces.
Lung
marking
s should
be seen
all the
way to
the edge
of the
chest
wall. If
the lung
edge(vis
ceral
pleura)is
visible(2 cm) and there is black surrounding this
edge then PNEUMOTHORAX should be suspected
This should lead to immediate assessment of the
patients trachea and mediastinum,both on the xray and clinically
Mediastinal shift away from the
pneumothoraxEMERGENCY(TENSION PNEUMOTHORAX)

Clinical information

Fall from height - trauma to chest

PNEUMOTHORAX
Diagnosis
forms when there is air trapped in the pleural space. This may
occur spontaneously, or as a result of underlying lung disease.
The most common cause is trauma, with laceration of the
visceral pleura by a fractured rib.
If the lung edge measures more than 2cm from the inner chest
wall at any point, it is said to be 'large.
If there is tracheal or mediastinal shift away from the
pneumothorax, the pneumothorax is said to be under 'tension.'
1.

Air in pleural space - Pneumothorax

Visible pleural edge (blue line)
Lung markings not visible beyond this edge
Distance from lung edge to chest wall >2cm
Healing rib fracture with callus (arrowhead)

JC

Large left pneumothorax due to a rib fracture

The trachea and mediastinal structures are not
displaced so there is no 'tension'

Clinical information

History of asbestos exposure

Diagnosis

Malignant mesothelioma - a disease caused

by exposure to asbestos

Differential
2.

Unilateral pleural thickening

Peripheral shadowing on the right
Loss of right lung volume
Shadowing over the whole right lung due to circumferential
pleural thickening

JC

Empyema*
Pleural metastases*
Pleural effusions*

* Do not cause volume loss

3.

Asbestos related pleural plaques

Bilateral well defined irregular shadows that are as dense as the
bones
Peripheral pleural thickening

collection of fluid in
the pleural space.
Fluid gathers in the
lowest part of the
chest, according to
the patient's
position.
If the patient is
upright when the xray is taken, a
pleural effusion will
obscure the
costophrenic angle and hemidiaphragm.
If a patient is supine a pleural effusion layers along

Clinical information

Chronic mild shortness of breath

Retired dock worker with clear history of
asbestos exposure

Diagnosis

Bilateral calcified asbestos related pleural

plaques

PLEURAL EFFUSIONS

JC

the posterior aspect of the chest cavity and

becomes difficult to see on a chest x-ray
The left lower zone is uniformly white
At the top of this white area there is a concave surface meniscus sign
The left heart border, costophrenic angle and hemidiaphragm
are obscured
Slight blunting of the right costophrenic angle indicates a small
pleural effusion on that side
Clinical information

Life long smoker

Weight loss and increasing shortness of breath

Diagnosis

JC

Large left pleural effusion

Underlying bronchogenic carcinoma