How to Read a Chest X-Ray

Turn off stray lights, optimize room lighting, view images in order

Patient Data (name history #, age, sex, old films)

Routine Technique: AP/PA, exposure, rotation, supine or erect

Trachea: midline or deviated, caliber, mass

Lungs: abnormal shadowing or lucency

Pulmonary vessels: artery or vein enlargement

Hila: masses, lymphadenopathy

Heart: thorax: heart width > 2:1 ? Cardiac configuration?

Mediastinal contour: width? mass?

Pleura: effusion, thickening, calcification

Bones: lesions or fractures

Soft tissues: don’t miss a mastectomy

ICU Films: identify tubes first and look for pneumothorax

Looking for abnormalities

It is best to do a directed search of the chest film rather than simply gazing at the film.
An abnormality will not likely hit you over the head. Remember that detail vision is
only permitted at the fovea centralis of your retina. This area contains only cones and
is the part that you use to read. The remainder of the retina helps you to put this
detailed portion in context and helps to determine whether this is a saber tooth tiger
sneaking up on you. Therefore, it is best to look for abnormalities and to have a
planned search in mind. Your eye gaze should scan all portions of the film, follow
lung/mediastinal interfaces and look again carefully in areas where you know that
mistakes are easily made, such as over the spine on the lateral view and in the apex
on the PA view.
The above diagrams depict the human eye and light waves hitting the fovea, the area of detailed vision.

Stare at the 'X' in the center of the image above. Note how you cannot read the letters in the corner
unless you are looking directly at them (ie unless the letter you are trying to read is hitting your retina at
the fovea).
PA technique for looking at films. Encompassing the entire lung boundaries (left) , scanning with fovea
over each part of lung (right).
 Lateral scanning technique

Signs

Silhouette sign

One of the most useful signs in chest radiology is the silhouette sign. This was
described by Dr. Ben Felson. The silhouette sign is in essence elimination of the
silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the
normally air filled lung. In other words, if an intrathoracic opacity is in anatomic
contact with, for example, the heart border, then the opacity will obscure that border.
The sign is commonly applied to the heart, aorta, chest wall, and diaphragm. The
location of this abnormality can help to determine the location anatomically.

Take a moment to review the makeup of the mediastinal margins and the lobes of the
lungs that interface with the mediastinum. Use the back button on your browser to
return here.

For the heart, the silhouette sign can be caused by an opacity in the RML, lingula,
anterior segment of the upper lobe, lower aspect of the oblique fissure, anterior
mediastinum, and anterior portion of the pleural cavity. This contrasts with an opacity
in the posterior pleural cavity, posterior mediastinum, of lower lobes which cause an
overlap and not an obliteration of the heart border. Therefore both the presence and
absence of this sign is useful in the localization of pathology.
 The right heart border is silhouetted out.
This is caused by a pneumonia, can you determine which lobe the pneumonia affects?
(click image for answer)

Air Bronchogram

An air bronchogram is a tubular outline of an airway made visible by filling of the

surrounding alveoli by fluid or inflammatory exudates. Six causes of air
bronchograms are; lung consolidation, pulmonary edema, nonobstructive pulmonary
atelectasis, severe interstitial disease, neoplasm, and normal expiration.
 This patient has bilateral lower lobe pulmonary edema. The alveoli are filled with fluid making the
bronchi visible as an air bronchogram. The upper right is a closeup of the right side of the film with
arrows outlining a prominent air bronchogram. The lower right is a CT scan demonstrating an air
bronchogram clearly.
 Here is another example of air bronchograms in both a PA and Lateral film. Can you spot them?

Solitary Pulmonary Nodule

A solitary nodule in the lung can be totally innocuous or potentially a fatal lung
cancer. After detection the initial step in analyis is to compare the film with prior films
if available. A nodule that is unchanged for two years is almost certainly benign. If
the nodule is completely calcified or has central or stippled calcium it is benign.
Nodules with irregular calcifications or those that are off center should be considered
suspicious, and need to be worked up further with a PET scan or biopsy.

Be sure to evaluate for the presence of multiple nodules as this finding would change
the differential entirely. If the nodule is indeterminate after considering old films and
calcification, subsequent steps in the work-up include ordering a CT and a tissue
biopsy. The patient may choose to have an indeterminate nodule removed if there is
no evidence of spread on CT as this would diagnose and treat a cancer if present.
This patient clearly has a solitary lung nodule present on chest x-ray. Can you tell which lobe it's in?
Did you spot the other nodule? Some early lung cancers are missed on the initial chest x-ray because
they are small and faint. CT may detect these early cancers.
PA and Lateral of a subtle right lower lobe cancer. Can you find it in the frontal projection?
(Click on the image for the answer)
 Atelectasis

Atelectasis is collapse or incomplete expansion of the lung or part of the lung. This is
one of the most common findings on a chest x-ray. It is most often caused by an
endobronchial lesion, such as mucus plug or tumor. It can also be caused by extrinsic
compression centrally by a mass such as lymph nodes or peripheral compression by
pleural effusion. An unusual type of atelectasis is cicatricial and is secondary to
scarring, TB, or status post radiation.

Atelectasis is almost always associated with a linear increased density on chest x-ray.
The apex tends to be at the hilum. The density is associated with volume loss. Some
indirect signs of volume loss include vascular crowding or fissural, tracheal, or
mediastinal shift, towards the collapse. There may be compensatory hyperinflation of
adjacent lobes, or hilar elevation (upper lobe collapse) or depression (lower lobe
collapse). Segmental and subsegmental collapse may show linear, curvilinear, wedge
shaped opacities. This is most often associated with post-op patients and those with
massive hepatosplenomegaly or ascites .

Note the loss of the right heart border silhouette due to partial atelectasis of the RML. Atelectasis is
usually, but not always, a benign finding as in this example which was caused by an endobronchial
mass in the RML.
This is a PA and lateral film showing round atelectasis, where the lung becomes attached to the chest
wall by an area of previous inflammation. The lung then rolls up, causing this opacity.

Left Lung Atelectasis

 Left Upper Lobe

The left lung lacks a middle lobe and therefore a minor fissure, so left upper lobe
atelectasis presents a different picture from that of the right upper lobe collapse. The
result is predominantly anterior shift of the upper lobe in left upper lobe collapse, with
loss of the left upper cardiac border. The expanded lower lobe will migrate to a
location both superior and posterior to the upper lobe in order to occupy the vacated
space. As the lower lobe expands, the lower lobe artery shifts superiorly. The left
mainstem bronchus also rotates to a nearly horizontal position.

This patient suffered from left upper lobe atelectasis following right upper lobectomy.
 PA and Lateral of a patient with Left Upper Lobe Collapse (arrows). This characteristic finding on CXR
is known as the Luftsichel Sign and may represent collapse due to obstruction from a bronchogenic
carcinoma. The lucency between the mediastinum and the collapsed LUL is caused by hyperexpansion
of the superior segment of the LLL.
 Left Lower Lobe

Atelectasis of either the right or left lower lobe presents a similar appearance.
Silhouetting of the corresponding hemidiaphragm, crowding of vessels, and air
bronchograms are sometimes seen, and silhouetting of descending aorta is seen on
the left. It is important to remember that these findings are all nonspecific, often
occuring in cases of consolidation, as well. A substantially collapsed lower lobe will
usually show as a triangular opacity situated posteromedially against the
mediastinum.

These radiographs demonstrate left lower lobe atelectasis followed by partial resolution, respectively.
 Another PA film of LLL atelectasis (arrows). Note the elevation of the left hemidiaphragm.

Right Lung Atelectasis

Right Upper Lobe

Right upper lobe atelectasis is easily detected as the lobe migrates superomedially
toward the apex and mediastinum. The minor fissure elevates and the inferior border
of the collapsed lobe is a well demarcated curvilinear border arcing from the hilum
towards the apex with inferior concavity. Due to reactive hyperaeration of the lower
lobe, the lower lobe artery will often be displaced superiorly on a frontal view.
 Note the elevation of the horizontal fissure (arrows) caused by RUL atelectasis.

Right Middle Lobe

Right middle lobe atelectasis may cause minimal changes on the frontal chest film. A
loss of definition of the right heart border is the key finding. Right middle lobe
collapse is usually more easily seen in the lateral view. The horizontal and lower
portion of the major fissures start to approximate with increasing opacity leading to a
wedge of opacity pointing to the hilum. Like other cases of atelectasis, this collapse
may by confused with right middle lobe pneumonia.
Right middle lobe atelectasis can be difficult to detect in the AP film. The right heart border is indistinct
on the AP film. The lateral, though, shows a marked decrease in the distance between the horizontal
and oblique fissures.

Right Lower Lobe

Silhouetting of the right hemidiaphragm and a triangular density posteromedially are

common signs of right lower lobe atelectasis. Right lower lobe atelectasis can be
distinguished from right middle lobe atelectasis by the persistance of the right heart
border.
Notice the stretched vessels in the hyperexpanded right upper lobe in right lower lobe atelectasis. The
right hilum is also displaced inferiorly. This is a tough one.

Pulmonary Edema

There are two basic types of pulmonary edema. One is cardogenic edema caused by
increased hydrostatic pulmonary capillary pressure. The other is termed
noncardogenic pulmonary edema, and is caused by either altered capillary membrane
permeability or decreased plasma oncotic pressure.

A helpful mnemonic for noncardiogenic pulmonary edema is NOT CARDIAC (near-

drowning, oxygen therapy, transfusion or trauma, CNS disorder, ARDS, aspiration, or
altitude sickness, renal disorder or resuscitation, drugs, inhaled toxins, allergic
alveolitis, contrast or contusion.

On a CXR, cardiogenic pulmonary edema can show; cephalization of the pulmonary

vessels, Kerley B lines or septal lines, peribronchial cuffing, "bat wing" pattern,
patchy shadowing with air bronchograms, and increased cardiac size. Unilateral,
miliary and lobar or lower zone edema are considered atypical patterns of cardiac
pulmonary edema. A unilateral pattern may be caused by lying preferentially on one
side. Unusual patterns of edema may be found in patients with COPD who have
predominant upper lobe emphysema.
PA film of a patient with pulmonary edema showing cephalization of pulmonary
veins and indistinctness of the vascular margins. The heart is enlarged.
Would you favor pneumonia or CHF in this patient? Why? What pattern is shown?
(Click image for answer)
 Above are two films from the same patient. The left film clearly shows diffuse pulmonary edema with
loss of both hemidiaphragms and silouhetting of the heart. The film on the right was taken two days
later after partial resolution of the edema.

Congestive Heart Failure

Congestive heart failure (CHF) is one of the most common abnormalities evaluated by
CXR. CHF occurs when the heart fails to maintain adequate forward flow. CHF may
progress to pulmonary venous hypertension and pulmonary edema with leakage of
fluid into the interstitium, alveoli and pleural space.

The earliest CXR finding of CHF is cardiomegaly, detected as an increased

cardiothoracic ratio (>50%). In the pulmonary vasculature of the normal chest, the
lower zone pulmonary veins are larger than the upper zone veins due to gravity. In a
patient with CHF, the pulmonary capillary wedge pressure rises to the 12-18 mmHg
range and the upper zone veins dilate and are equal in size or larger, termed
cephalization. With increasing PCWP, (18-24 mm. Hg.), interstitial edema occurs with
the appearance of Kerley lines. Increased PCWP above this level is alveolar edema,
often in a classic perihilar bat wing pattern of density. Pleural effusions also often
occur.

CXR is important in evaluating patients with CHF for development of pulmonary

edema and evaluating response to therapy as well.
 This is a typical chest x-ray of a patient in severe CHF.
Note the cardiomegaly, alveolar edema, and haziness of vascular margins.
 The left image demonstrates a patient with a severe pulmonary edema as a result of CHF. The right
image is the same patient after significant resolution.

Kerley B lines

These are horizontal lines less than 2cm long, commonly found in the lower zone
periphery. These lines are the thickened, edematous interlobular septa. Causes of
Kerley B lines include; pulmonary edema, lymphangitis carcinomatosa and malignant
lymphoma, viral and mycoplasmal pneumonia, interstital pulmonary fibrosis,
pneumoconiosis, sarcoidosis. They can be an evanescent sign on the CXR of a
patient in and out of heart failure.
 The patient above is suffering from congestive heart failure resulting in interstitial edema.
Notice the Kerley's B lines in right periphery (arrows).

Near drowning

The CXR may be normal, especially in children, if laryngospasm (diving reflex) occurs.
Otherwise, a "batwing" pattern of pulmonary edema is seen. The situation may be
complicated by ARDS.
 PA of near drowning patient after resuscitation

Pneumonia

Pneumonia is airspace disease and consolidation. The air spaces are filled with
bacteria or other microorganisms and pus. Other causes of airspace filling not
distinguishable radiographically would be fluid (inflammatory), cells (cancer), protein
(alveolar proteinosis) and blood (pulmonary hemorrhage), Pneumonia is NOT
associated with volume loss. Pneumonia is caused by bacteria, viruses,
mycoplasmae and fungi.

The x-ray findings of pneumonia are airspace opacity, lobar consolidation, or

interstitial opacities. There is usually considerable overlap. Again, pneumonias is a
space occupying lesion without volume loss. What differentiates it from a mass?
Masses are generally more well-defined. Pneumonia may have an associated
parapneumonic effusion.
The type of pneumonia is sometimes characteristic on chest x-ray:

• Lobar - classically Pneumococcal pneumonia, entire lobe consolidated and air

bronchograms common
• Lobular - often Staphlococcus, multifocal, patchy, sometimes without air
bronchograms
• Interstitial - Viral or Mycoplasma; latter starts perihilar and can become
confluent and/or patchy as disease progresses, no air bronchograms
• Aspiration pneumonia - follows gravitational flow of aspirated contents;
impaired consciousness, post anesthesia, common in alcoholics, debilitated,
demented pts; anaerobic (Bacteroides and Fusobacterium)
• Diffuse pulmonary infections - community acquired (Mycoplasma, resolves
spontaneoulsy) nosocomial (Pseudomonas, debilitated, mechanical vent pts,
high mortality rate, patchy opacities, cavitation, ill-defined nodular)
immunocompromised host(bacterial, fungal, PCP)

Major differentiating factors between atelectasis and pneumonia

Atelectasis Pneumonia

Normal or Increased Volume

Volume Loss
No Shift, or if Present Then
Associated Ipsilateral Shift
Contralateral
Linear, Wedge-Shaped
Consolidation, Air Space Process
Apex at Hilum
Not Centered at Hilum

Air bronchograms can occur in both.

 These are PA and lateral films of RML pneumonia (arrows).
Note the indistinct borders, air bronchograms, and silhouetting of the right heart border.
PA and Lateral films of RUL pneumonia
 Tuberculosis

Primary tuberculosis (TB) is the initial infection with Mycobacterium tuberculosis.

Post-primary TB is reactivation of a primary focus, or continuation of the initial
infection. Radiographically, TB is represented by consolidation, adenopathy, and
pleural effusion. A Ghon focus is an area of consolidation that most commonly occurs
in the mid and lower lung zones. A Ghon complex is the addition of hilar adenopathy
to a Ghon focus.

Radiographic features of post-primary TB are; focal patchy airspace disease "cotton

wool" shadows, cavitation, fibrosis, nodal calcification, and flecks of caseous
material. These occur most commonly in the posterior segments of the upper lobes,
and superior segments of the lower lobes.

Endobronchial TB involves the wall of a major bronchus. Complications of

endobronchial TB are cicatrical stenosis and obstruction.

This is a PA film of a patient who has had tuberculosis for years.

This shows fibrosis, cavitation, and calcification, particularly in the left upper lobe.
 Pulmonary Hemorrhage

Pulmonary hemorrhage has an appearance like that of other airspace filling processes
(pneumonia, edema) which have opacity often with air bronchograms. It is caused by
trauma, Goodpastrue's syndrome, bleeding disorders, high altitude, and mitral
stenosis. Blood fills the bronchi and eventually the alveoli. Pulmonary hemorrhage is
notable in that it may clear more quickly than other alveolar densities such as
pneumonia.
PA and Lateral films of a patient with right upper lobe hemorrhage. Notice the large pleural effusion in
the left hemithorax.

Pulmonary Embolism

Pulmonary embolism (PE) is not uncommon in the inpatient setting. The primary
source is thrombus from the deep veins of the legs. Roughly ten percent of
pulmonary embolisms result in pulmonary infarction, but many patients die of PE
without being diagnosed. The primary purpose of a chest film in suspected PE is to
rule out other diagnoses as a cause of dyspnea or hypoxia. Most CXRs in patients
with a PE are normal. Signs that may be present in PE are; Westermark's sign
(oligemia in area of involvement), increased size of a hilum (caused by thrombus
impaction), atelectasis with elevation of hemidiaphragm and linear or disk shaped
densities, pleural effusion, consolidation, and Hampton's hump (rounded opacity). In
the case of pulmonary infarctions, the main radiographic feature is multifocal
consolidation at the pleural base in the lower lungs. Several other important
modalities are used when investigating possible PE. These modalities are venous
ultrasound, V/Q scan, pulmonary arteriogram, and CT angiogram (CTA). Remember, if
the CXR of a patient with hypoxia is normal you should consider PE.

The workup of suspected PE can be divided into two populations. In the inpatient
setting a CTPA will likely be more definitive than a V/Q scan, as it may disclose other
causes of hypoxia not shown on CXR. If the patient has leg swelling, a venous
ultrasound of the leg veins should be done to exclude DVT. In the outpatient setting a
V/Q scan should be the first test and will less likely be indeterminate than in the
inpatient setting. There is also a lower radiation dose for V/Q scans than for CTPA. If
these studies are inconclusive a pulmonary arteriogram is the definitive, but more
invasive test.
These are two PA fiilms demonstrating Hampton's hump (rounded opacities) in patients with pulmonary
embolism.
What is the most common chest x-ray finding in PE? (Click for answer)
 Above are 2 CT scans from the same patient demonstrating a large pulmonary embolus.
Which vessel is it affecting? (Click for answer and arrows)

Pleural Effusion

Common causes for a pleural effusion are CHF, infection (parapneumonic), trauma,
PE, tumor, autoimmune disease, and renal failure.

On an upright film, an effusion will cause blunting on the lateral and if large enough,
the posterior costophrenic sulci. Sometimes a depression of the involved diaphragm
will occur. A large effusion can lead to a mediastinal shift away from the effusion and
opacify the hemothorax. Approximately 200 ml of fluid are needed to detect an
effusion in the frontal film vs. approximately 75ml for the lateral. Larger effusions,
especially if unilateral, are more likely to be caused by malignancy than smaller ones.

In the supine film, an effusion will appear as a graded haze that is denser at the base.
The vascular shadows can usually be seen through the effusion. An effusion in the
supine view can veil the lung tissue, thicken fissure lines, and if large, cause a fluid
cap over the apex. There may be no apparent blunting of the lateral costophrenic
sulci.

A lateral decubitis film is helpful in confirming an effusion in a bedridden patient as

the fluid will layer out on the affected side (unless the fluid is loculated). Today,
ultrasound is also a key component in the diagnosis. Ultrasound is also used to guide
diagnostic aspiration of small effusions.

PA and lateral film of a patient with bilateral pleural effusions.

Note the concave menisci blunting both posterior costophrenic angles.
The CT above on the left demonstrates a large infected pleural fluid collection, an empyema. Compare
and contrast that to the image on the right which is an intrapulmonary abscess.

Mastectomy

One must carefully examine the soft tissues. The patient below has had a
mastectomy. The hemithoraces are asymmetric in density. The finding of a
mastectomy should also make you look even closer at the bones and lungs for
metastases.
 PA and Lateral films of a patient post left mastectomy

This case shows the importance of examining the soft tissues carefully. At first, it
may appear that the asymmetry in density between the two hemithoraces is caused by
a left pleural effusion, giving the appearance of a graded density. A closer look
reveals that the asymmetry is due to the removal of the left breast.

Pneumothorax

A pneumothorax is defined as air inside the thoracic cavity but outside the lung. A
spontaneous pneumothorax (PTX) is one that occurs without an obvious inciting
incident. Some causes of spontaneous PTX are; idiopathic, asthma, COPD, pulmonary
infection, neoplasm, Marfan's syndrome, and smoking cocaine. However, most
pneumothoraces are iatrogenic and caused by a physician during surgery or central
line placement. Trauma, such as a motor vehicle accident is another important cause.
A tension PTX is a type of PTX in which air enters the pleural cavity and is trapped
during expiration usually by some type of ball valve-like mechanism. This leads to a
buildup of air increasing intrathoracic pressure. Eventually the pressure buildup is
large enough to collapse the lung and shift the mediastinum away from the tension
PTX. If it continues, it can compromise venous filling of the heart and even death.

On CXR, a PTX appears as air without lung markings in the least dependant part of the
chest. Generally, the air is found peripheral to the white line of the pleura. In an
upright film this is most likely seen in the apices. A PTX is best demonstrated by an
expiration film. It can be difficult to see when the patient is in a supine position. In
this position, air rises to the medial aspect of the lung and may be seen as a lucency
along the mediastinum. It may also collect in the inferior sulci causing a deep sulcus
sign.

A hydropneumothorax is both air and fluid in the pleural space. It is characterized by

an air-fluid level on an upright or decubitus film in a patient with a pneumothorax.
Some causes of a hydropneumothorax are trauma, thoracentesis, surgery, ruptured
esophagus, and empyema.

This image shows a close-up of a pneumothorax in an upright PA film as a white pleural line (red arrow)
with atmospheric air outside of it. No pulmonary vascular markings are seen outside of the line. Notice
the predilection to the apices and the periphery.
 The above film shows a right sided tension pneumothorax with right sided lucency and leftward
mediastinal shift. This is a medical emergency. Failure to place a right chest tube immediately could
allow venous return to diminish and lead to possible death.
 Left is a supine view of a PTX, note the medial position of the air.
Right is an image demonstrating the deep sulcus sign (letter D in the image) in supine views of a PTX.
 The above three images show a hydropneumothorax in three different views.
The PA, lateral, and right decube reveal a layering out of the air and fluid.
The right decube film demonstrates a right hydropneumothorax.
Note the pleural air/fluid level demonstrated by the horizontal air/fluid interface (arrows).

Interstitial Pulmonary Fibrosis

Interstitial pulmonary fibrosis has many causes. The six most common causes of
diffuse interstitial pulmonary fibrosis are idiopathic (IPF, >50% of cases), collagen
vascular disease, cytotoxic agents and nitrofurantoin, pneumoconioses, radiation, and
sarcoidosis. Clinically the patient with IPF will present with progressive exertional
dyspnea and a nonproductive cough. Radiographically, IPF is associated with hazy
"ground glass" opacification early and volume loss with linear opacities bilaterally,
and honeycomb lung in the late stages. IPF carries a poor prognosis with death due
to pulmonary failure usually occurring within 3-6 years of the diagnosis unless lung
transplant is performed.
 Interstitial Pulmonary Fibrosis

Emphysema

Emphysema is loss of elastic recoil of the lung with destruction of pulmonary capillary
bed and alveolar septa. It is caused most often by cigarette smoking and less
commonly by alpha-1 antitrypsin deficiency. Functional hallmarks are decreased
airflow (decreased FEV1) and diffusing capacity (decreased DLCO2).

Emphysema is commonly seen on CXR as diffuse hyperinflation with flattening of

diaphragms, increased retrosternal space, bullae (lucent, air-containing spaces that
have no vessels that are not perfused) and enlargement of PA/RV (secondary to
chronic hypoxia) an entity also known as cor pulmonale. Hyperinflation and bullae are
the best radiographic predictors of emphysema. However, the radiographic findings
correlate poorly with the patientâs pulmonary function tests. CT and HRCT (high
resolution CT) has emerged as a technique to evaluate different types, panlobular,
intralobular, paraseptal and for guidance prior to volume reduction surgery.

Occasionally the trachea is very narrow in the mediolateral plane in emphysema.

"Saber sheath" tracheal deformity is when the coronal diameter is less than 2/3 that of
the sagittal.

In smokers with known emphysema the upper lung zones are commonly more
involved than the lower lobes. This situation is reversed in patients with alpha-1 anti-
trypsin deficiency, where the lower lobes are affected.

Chronic bronchitis commonly occurs in patients with emphysema and is associated

with bronchial wall thickening.
 Note bilateral flattening of the diaphragms and significant hyperinflation as demonstrated by
visualization of 11 posterior ribs.

Trauma - Rib fracture

Rib fractures have the appearance of an abrupt discontinuity in the smooth outline of
the rib. A lucent fracture line may be seen. A rib fracture may not be visible on a
CXR. CXR is taken to assess for pneumothorax, but it may show them. If it is
necessary to exclude a rib fracture, oblique rib detail films should be obtained.

A common pattern for evaluating the ribs is to examine the posterior portions of the
ribs first, then the anterior portions, and finish be examining the lateral aspects of
each rib. If you see an abnormality, follow that rib in its entirety.

Fracture of the upper three ribs is associated with an increased risk of aortic injury
because of the excessive force needed to fracture these ribs. Fracture of the lower
three ribs can be associated with liver or spleen injury. Multiple bilateral rib fractures
in various stages of healing are associated with child abuse in children or alcohol
abuse.
PA and Lateral films of right ninth rib fracture. No PTX was present.
 CT from the same patient in the PA and lateral films above.
This clearly shows the rib displacement near the liver on the right.

This PA film shows a left flail chest, or multiple rib fractures, that can now move paradoxically with the
rest of the thoracic cage.
 Anterior Mediastinal Mass

Anterior mediastinal masses consist of the 4 "T's" (Terrible lymphadenopathy, Thymic

tumors, Teratoma, Thyroid mass) and aortic aneurysm, pericardial cyst, epicardial fat
pad. Usually CT or fine needle aspiration is needed to make the definitive diagnosis
of an anterior mediastinal mass.
T-cell Lymphoma
Note in these images that the hilum can be seen through the mass. It is not a hilar mass. The lateral
shows nothing abnormal posteriorly.
 The CT sections demonstrate the mass in the anterior mediastinum (arrows) at the aortopulmonary
window which was a thymoma.

Middle Mediastinal Mass

The most common cause of a middle mediastinal mass is lymphadenopathy due to

metastases or primary tumor. Other causes include hiatial hernia, aortic aneurysm,
thyroid mass, duplication cyst, and bronchogenic cyst.
 Can you spot the abnormality? (Click each of the images for arrows)
This mass above the aortic arch can be seen to be posterior to the aorta on the lateral. It does not
silhouette out the superior margin of the aorta. A chest CT was performed to further evaluate the mass.
This CT scan shows that the mass is posterior to the aorta, smoothly marginated, low density, and
associated with the esophagus. It is an esophageal duplication cyst.
 Above is a PA, lateral, and aortogram of a saccular aortic aneurysm, another cause of a middle
mediastinal mass.

Posterior Mediastinal Mass

The differential for a posterior mediastinal mass includes; neoplasm,

lymphadenopathy, aortic aneurysm, adjacent pleural or lung mass, neurenteric cyst or
lateral meningocele, and extramedullary hematopoiesis.
 Note that this mass is detected by a pleural margin search as you move your eye along the
superomedial part of the right lung. The interface is interrupted. Think about the anatomy of the lung in
this area. The anterior mediastinum ends at the level of the clavicles. Any abnormality in the apex of the
thorax must be posterior in the chest.

The mass projects above the clavicles, therefore it is not an anterior structure.
This MRI shows the mass is extrapleural and associated with the spinal nerves. It is a schwannoma, a
benign tumor of the nerve sheath.
 Pleural and Extra-pleural Masses

The differential for pleural mass includes; metastases (especially adenocarcinoma and
malignant thymoma), loculated pleural effusions (pseudotumor), malignant
mesothelioma, pleural plaques from asbestosis (bilateral densities), and lymphoma.
The differential for extrapleural mass includes rib tumor, rib infection (including chest
wall fungal infection), neurofibroma or schwannoma (may erode a rib, but does not
destroy it), and lipoma. One must first determine whether a mass arises from inside
the lung or outside, an oblique margin with lung tissue indicates that the process is
pleural or extrapleural. Distinguishing between a pleural and extrapleural mass can be
challenging. If the center of the lesion is inside the chest wall, a pleural process is
likely. Rib destruction indicates extrapleural involvement and possibly the origin of
the mass.
Lateral film of an intraparenchymal mass. Note acute margins like "A" in the diagram on the right. Both
"B" and "C" have oblique margins. "B" demonstrates a pleural mass while "C" is an extrapleural chest
wall mass.

Pericardial Effusion

Pericardial effusion causes an enlarged heart shadow that is often globular shaped
(transverse diameter is disproportionately increased). A "fat pad" sign, a soft tissue
stripe wider than 2mm between the epicardial fat and the anterior mediastinal fat can
be seen anterior to the heart on a lateral view. Serial films can be helpful in the
diagnosis especially if rapid changes in the size of the heart shadow are observed.
Approximately 400-500 ml of fluid must be in the pericardium to lead to a detectable
change in the size of the heart shadow on PA CXR. Pericardial effusion can be
definitively diagnosed with either echocardiography or CT. It can be critical to
diagnose pericardial effusion because if it is acute it may lead to cardiac tamponade,
and poor cardiac filling. In the postoperative patient it could be a sign of bleeding,
necessitating a return to the OR.
PA of a patient with a pericardial effusion.
 A lateral film and closeup of a pericardial effusion showing the anterior mediastinal fat (blue arrows)
and epicardial fat (red arrows) separated by a soft tissue stripe reflecting the pericardial effusion seen
edge-on.
 Pneumomediastinum

Findings for pneumomediastinum include; streaky lucencies over the mediastinum

that extend into the neck, and elevation of the parietal pleura along the mediastinal
borders.

Causes of pneumomediastinum include; asthma, surgery (post-op complication),

traumatic tracheobronchial rupture, abrupt changes in intrathoracic pressure
(vomiting, coughing, exercise, parturition), ruptured esophagus, barotrauma, and
smoking crack cocaine.

Pneumomediastinum should be distinguished from pneumopericardium and

pneumothorax. In pneumopericardium, air can be present underneath the heart, but
does not enter the neck.

PA film of a pneumomediastinum.
CT scans clearly demonstrating the presence of air in the mediastinum (red arrows) and subcutaneous
emphysema (yellow arrows).

Diaphragmatic hernia

There are 3 types of diaphragmatic hernia that may be seen in CXR. By far the most
common is a hiatal hernia - the stomach slips through the esophageal hiatus into the
chest. A Bochdalek hernia is through a weakness in the diaphragm, and usually
occurs on the left side posteriorly (Bochdalek - back and to the left). Morgagni hernias
typically occur medially. Weakness of the diaphragm can occur without frank
herniation of abdominal contents. This is termed an eventration, and it usually occurs
on the right with a portion of the liver bulging cephalad.
PA and lateral of hiatal hernia. Can you see the air-filled "mass" posterior to the heart?
 Hilar Adenopathy

Enlargement of the lymph nodes within the lung hilum can be an important finding for
underlying pathology.

A differential of possible etiologies can be broken up into three different categories:

• Inflammation (sarcoidosis, silicosis)

• Neoplasm (lymphoma, metastases, bronchogenic carcinoma)
• Infection (tuberculosis, histoplasmosis, infectious mononucleosis)

An important consideration to keep in mind is that since the pulmonary arteries also
course through the same area, enlargement of these vessels may be confused with
hilar adenopathy. Typically, lymphadenopathy has a more lumpy-bumpy appearance,
while an enlarged pulmonary artery appears smooth.

One of the following pictures displays hilar adenopathy and the other shows
pulmonary artery enlargement. Can you determine which one is which?

The above left picture shows bilateral pulmonary artery enlargement. Note the smooth contours of the
arteries. The above right picture shows the lumpy-bumpy opacities characteristic of hilar adenopathy.

Solitary Pulmonary Nodule

A solitary pulmonary nodule is not an uncommon finding on a chest x-ray. A solitary
pulmonary nodule can result from a wide range of causes. Most nodules are benign
but some can be malignant.

Nodules are diagnosed as benign if they:

• Show little or no growth for 2 years

• Calcification
o Central, laminated or diffuse pattern indicates a granuloma
o Eccentric calcification can be seen in a carcinoma or in a cancer that has
engulfed a granuloma

The CT image above shows a right lower lobe centrally calcified nodule, consistent with a benign
granuloma.

A differential of possible etiologies is as follows:

• Granuloma – usually caused by fungal infections like histoplasmosis or

tuberculosis
• Lung Carcinoma
• Solitary metastasis – usually from colon, breast, kidney, ovary, or testis
• Round pneumonia
• Abscess
 • Round atelectasis
• Hamartoma – popcorn calcification is sometimes seen
• Sequestration
• Arteriovenous malformation

Granulomas and lung cancer are by far the two most common causes for a pulmonary
nodule.

Other things can cause an apparent nodule but are actually outside the lung including:

• Fluid in an interlobar fissure

• Pleural plaques – small, often calcified, plate-like surfaces on the pleura often
caused by asbestos fibers that invade the pleura from the lungs
• Skin lesions – nipple shadow, mole, lipoma, etc.

Incidental small pulmonary nodules, especially less than 5 mm, are an extremely
common finding on chest CT in the population over age 50. The current
recommended follow-up of incidental pulmonary nodules per the Fleischner Society
2005 is given below. In a patient with a prior history of malignancy, a difference in
intervals can be based on additional considerations of the likelihood of pulmonary
metastases given the specific primary.

Low Risk Patient

≤ 4mm No follow-up needed

4-6mm 12 mo; if no change - stop
6-8mm 6-12 mo; no change - follow-up at 18-24 mo
> 8mm CT follow-up at 3, 9, 24mo or PET/CT, or biopsy

High Risk Patient (eg. smoking history or history of malignancy)

≤ 4mm 12 mo; if no change - stop

4-6mm 6-12mo; no change - follow-up at 18-24 mo
6-8mm 3-6mo; no change - follow-up at 18-24 mo
> 8mm CT follow-up at 3, 9, 24mo or PET/CT, or biopsy

Lung Cancer
The cell type of primary malignancies of the lung can often be distinguished by their
pattern of growth, appearance and location. Across the world, lung cancer causes to
more cancer deaths than any other tumor.

The most common staging system used for non-small cell lung cancer is the TNM
staging as follows:
The best chance for cure is resection of the tumor. However, it has been found that
not all patients with lung cancer will benefit from surgery. These tumors are thereby
unresectable as below. Other patients may be “unresectable” due to comorbidities
such as emphysema or cardiac disease.

Lung cancers are unresectable once they have progressed to a TNM staging of any of
the below.

• T4 – Invasion of the mediastinum or involvement of the heart, great vessels, trachea,

esophagus, vertebral body, or carina; or neoplasia associated with a malignant pleural
or pericardial effusion, or satellite nodules in the same lobe
• N3 – Metastasis to contralateral mediastinal and hilar nodes, ipsilateral or contralateral
scalene or supraclavicular nodes
• M1 – distant metastasis present

T4 or N3 would stage the tumor IIIB, M1 would stage it Stage IV.

The above CT image shows the spiculated appearance of a lung cancer.

The six cell types of primary lung carcinomas with their typical appearances are as
follows:

• Adenocarcinoma – (35-50%) Peripheral, sometimes associated with scars, high

incidence of early metastasis
• Squamous Cell Carcinoma – (30%) Central, with hilar involvement, cavitation is
common, slow growing
• Small Cell - (15-20%) Central, cavitation is rare, hilar and mediastinal masses often
the dominant feature, rapid growth and early metastases
 • Large cell – (10-15%) Peripheral, large, cavitation present
• Bronchaveolar – (3%) Peripheral, rounded appearance, pneumonia-like infiltrate (air
bronchograms), occasionally multifocal
• Carcinoid – (less than 1%) Typically a well defined endobronchial lesion; nodal, liver
and brain metastases may enhance densely (i.e. They may be hypervascular)

The above image shows a right lower lobe squamous cell cancer. Notice the cavitation, which is found
more characteristically in squamous cell than in other bronchogenic carcinomas.