1

X ray Chest
COMMENT ON:
1. TYPE of X ray :

Usually:
Very rarely:

Plain X ray.
Bronchogram (therefore the diagnosis will be bronchiectasis).

2. VIEW of X ray:

Usually:
Very rarely:

Postero anterior view.

Lateral view
(may be with barium-filled oesophagus to diagnose
left atrial enlargement which pushes the oesophagus posteriorly).

3. GENDER in the X ray:

Male:
Female:

no breast shadow.
breast shadow.

4. CENTRALIZATION in the X ray:

Centralized:
The distance between the edge of the clavicle & the spine must be equal.
Not centralized: The distance between the edge of the clavicle & the spine is not equal.
If the patient is not centralized you cannot comment on the position of the trachea

5. BONY CAGE in the X ray:

Fractures:

trauma (pneumothorax),

tumour (bronchial carcinoma).

6. DIAPHRAGM in the X ray:

Position:
Shape:

cuts the 6th rib anteriorly (the right cupola is slightly higher than the left).
smooth and convex upwards.

7. MEDIASTINUM in the X ray:

Position of the trachea:

-

Central trachea (normal or bilateral chest disease; probably emphysema,

Normal, or bilateral chest disease (probably
emphysema), or mild unilateral chest disease.
-

Shifted trachea to either side:

Pushed to opposite side (pleural effusion or
pnumothorax or hydropneumothorax).

Position of the heart:

- Normally: 1/3 is to the right of the middle line and 2/3s are to the left.

Mediastinal widening:

e.g.

LN, aortic aneurysm, tumours.

8. HEART in the X ray:

See later.

9. LUNG FIELDS in the X ray:

Upper 1/3:

from the apex down to the 2nd rib anteriorly (is divided by the
clavicle into supraclavicular and infraclavicular regions).

Middle 1/3:

from the 2nd rib anteriorly to the 4th rib anteriorly (is divided
into medial half; the parahilar region and lateral half).

Lower 1/3:

from the 4th rib anteriorly to the 6th rib anteriorly (is divided
into medial half; the paracardiac region and lateral half.

Costophrenic angle: it is normally black (free); so if it is normal you

say free costophrenic angle.

ABNORMALITIES IN CHEST X RAY:

1. DIAPHRAGM:

Elevated:
- Supradiaphragmatic:
- Diaphragmatic:
- Infradiaphragmatic:

Collapse and fibrosis.

Diaphragmatic paralysis.
Amoebic liver abscess, subphrenic abscess, ascites.

Depressed:
- Bilateral:
- Unilateral:

Emphysema.
Pneumothorax.

Tenting:
- Fibrosis.

2. MEDIASTIUM:

Position of the trachea:

-

Central trachea (normal or bilateral chest disease; probably emphysema,

Normal, or bilateral chest disease (probably
emphysema), or mild unilateral chest disease.
-

Shifted trachea to either side:

Pushed to opposite side (pleural effusion or
pnumothorax or hydropneumothorax).

Mediastinal widening or enlargement: e.g.

LN, aortic aneurysm, tumours:

- Bilateral hilar LN enlargement: Sarcoidosis, TB, Bronchial

carcinoma, Lymphoma.
- Unilateral hilar LN enlargement: examine lung fields for Bronchial
carcinoma, Ghons focus.

3. LUNG FIELDS:
A. HOMOGENOUS LUNG OPACITY:
1. Total lung opacity:
Shift of trachea and heart to opposite side (if trachea

a) Massive pleural effusion:

is

shifted to same side,

there is underlying collapse; eg in malignancy).
b) Massive lung consolidation: trachea and heart are central.
c) Massive lung collapse:
Shift of trachea and heart to same side + crowded ribs.

2. Localized lung opacity:

a)
b)
c)
d)
e)
f)

Consolidation of a lobe:
Tumour:
Pulmonary infarction:
Partial lung collapse:
Hydatid cyst.
Fungal infection.

e.g. pneumonia.
malignant (irregular outline), benign (regular outline).
wedge-shaped (triangular) with the base outwards.
shrunken lobe, crowded ribs, mediastinal shift.

3. Single rounded opacity (coin shadow):

a)
b)
c)
d)
e)
f)

Tumour:
bronchial carcinoma, or solitary metstasis, or bronchial adenoma.
Tuberculoma.
Pulmonary infections: e.g. TB, pneumonic patch.
Small pulmonary infarction.
Foreign body.
Calcified cyst.

4. Opacity obliterating the costophrenic angle:

a) Pleural effusion:
b) Hydropneumothorax:

rising laterally.
horizontal upper level.

5. Opacity with an upper fluid level:

a) Opacity obliterating the costophrenic angle:

hydropneumothorax.

b) Rounded opacity surrounded by lung tissue:

i. Acute abscess:
irregular outline.
ii. Chronic abscess: regular outline.

lung abscess:

6. Multiple opacities:
a) Multiple metastases.
b) Multiple hydatid cysts.

B. HETEROGENOUS LUNG OPACITY:

1. Ground glass opacities (miliary opacities):

Miliary TB.
IPF.
Sarcoidosis.
Pneumoconiosis.
Lymphangitis carcinomatosis.
Alveolar cell carcinoma.

2. Fluffy cotton opacities:

Bronchopneumonia.
TB pneumonia: apical with cavitation.
Metastatic carcinoma:
look for associated enlarged LN.

3. Soap bubble appearance:

-

Diagnostic of congenital polycystic lung.

If there are multiple fluid levels, this denotes infection.

4. Reticulations:
Bronchiectasis:
Fibrosis:

bilateral basal + honey coomb appearance.

crowded ribs, mediastinal shift, tenting of diaphragm.

5. Increased bronchovascular markings:

- Normally, they are:
i.
Prominent in the inner lung field.
ii.
Present in the middle lung field.
iii.
Absent in the outer lung field.
- They are increased in:
i.
Chronic bronchitis.
ii.
Bronchiectasis.
iii.
Fibrosis.
iv.
Congestion or plethora.
NB Opacities in the lung apex are especially: TB, pancoast tumour, Friedlanders pneumonia

C. HYPERTANSLUCENCY OF THE LUNG:

1. Total lung hypertranslucency:

Bilateral:
Emphysema:
- Increased bronchovascular markings.
- Elongated, thin, ribbon-shaped heart.
- Horizontal ribs, with wide spacing in between.
- Low flat diaphragm.
- Central trachea.

Unilateral:
Pneumothorax:
- Jet black translucency
(no lung tissue).
- Underlying lung collapse.
- Shifted trachea to the opposite side.

2. Localized lung hypertranslucency:

Emphysematous bulla.
TB cavity:
apical and surrounded by infiltrations.

X ray Heart
A)

B)

NORMAL HEART IN X ray:

Cardio-thoracic ratio = 1:2.

Right border:

Left border:
- 1st intercostal space:
- 2nd intercostal space:
- 3rd intercostal space:
- 4th and 5th intercostal spaces:

right atrium.

aortic knuckle.
pulmonary artery.
left atrium.
left ventricle.

ABNORMAL HEART IN X ray:

1.

Ventricular enlargement:
- RV:
- LV:

2.

Atrial enlargement:
- RA:
- LA:

3.

increased right border, enlarged right ventricle..

obliteration of the waist + double contour.

Prominent aortic knuckle:

- Systemic hypertension.
- Aortic regurge.
- Aortic aneurysm.

4.

(increased cardio-thoracic ratio):

acute cardiophrenic angle.

obtuse cardiophrenic angle.

Obliteration of the waist:

- Left atrial enlargement.
- Pulmonary artery dilatation.

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- Pericardial effusion.

5.

Mitralisation:
- There is: BOTH obliteration of the waist + double contour:
a. Associated with RV enlargement = MS.
b. Associated with LV enlargement = MR or double mitral lesion.

6.

Aortic configuration

(Boot-shaped heart):

- There is: enlarged LV + dilated aorta + exaggerated waist:

a. Systemic hypertension.
b. Aortic regurge.
c. Aortic stenosis with post-stenotic dilatation.

7.

Coer en Sabot:
- There is: enlarged RV + dilated aorta + exaggerated waist:
Fallots tetralogy .

8.

CARDIOMEGALY (CORBOVINUM):
- There is: marked and generalized cardiac enlargement:
a.
b.
c.
d.

9.

Multivalvular lesions.
Myocardial infarction.
Cardiomyopathy.
Acromegaly.

DD with
pericardial
effusion

PERICARDIAL EFFUSION:
- It must be differentiated from cardiomegaly by:
a. Double contour.
b. Smooth outline with no angulations (typically: flask-shaped).
c. Maybe obtuse cardiophrenic angle.

10. Congestion or plethora:

Butterfly wing appearance.

Mustache appearance in the upper lung zones (prominent upper lobe vessels).
Hazy lung fields.
Kerley B lines.

11. Oligemia:
- There is diminished bronchovascular markings.