chest imaging

Dr.wasan Ali
Department of radiology
Collage of medicine
University of Mosul
objectives
▪ To recognize the different imaging modalities that be used in
the diagnosis of chest disease .
▪ Identify the various views in positioning of the chest
radiographs .
▪ Understanding the radiological features of different kinds of
chest pathology .
▪ At the end of the lecture the student should be able to
appreciate , describe the common chest disease and have a
good diagnostic knowledge about them .
 Plain chest radiograph

* Standered views:
1) PA( postero anterior) .
2) Lateral ( right /left) .

* Additional views :
1) Obligue ( rib) .
2) Apical lordotic views .
3) Decubitus .
4) Expiration.
 Hilar structures
▪ Each hilum contains major bronchi and
pulmonary vessels.

▪ There are also contains lymph nodes on

each side(not visible unless abnormal).

▪ The left hilum is often higher than the right.

▪ Both hila should be of similar size and

density. If either hilum is bigger and more
dense, this is a good indication that there is
an abnormality.
Lung markings reflects pulmonary
vasculature
Soft tissues
▪ The soft tissues are often overlooked when viewing a chest
x-ray, however, abnormalities of the soft tissue may give
an important clues for a diagnosis. Whenever you look at
a chest x-ray, have a look at the soft tissues, especially
around the neck, the thoracic wall, and the
breasts.

▪ Fat is less dense than muscle and so appears blacker

The edge of fat is smooth. Irregular areas of black within the
soft tissues may represent air tracking in the subcutaneous
layers. This is known as surgical emphysema .
 Radiological anatomy of the lung

▪ The lungs lie in the thoracic cavity

seperated by the heart and mediastinum.
The two lungs are similar but are not
completely symmetrical , having
adifferent numbers of lobes and a
different bronchial and vascular anatomy.
▪ The right lung is composed of three
lobes while the is composed of two lobes
Lobes and fissures
The lobes of the lung are seperated by the fissures ( double
fold of vesiral pleura).
Each lung has an obligue fissure seperating the upper lobes
from the lower lobes .
The right lung has a horizontal fissure that seperats the right
upper lobe from the middle lobe .
Radiologic anatomy of the right lung lobes
Radiologic anatomy of the left lung lobes
 Consolidation
▪ is defined as replacement of gas with in the alveolar
spaces by fluid (heart failure), pus (pneumonia), blood
(pulmonary haemorrhage) and cells (lung cancer).
Radiographic features
1) Consolidated areas are radio opaque on chest radiograph
and chest CT compared to normally air filled lung tissue.

2)The margin of consolidation are usually poorly defined

except where the consolidation abuts the pleura such as the
fissure.
3) Associted with obscuration of pulmonary vessels.

4) No loss of volume.
5) Air bronchogram (the bronchi becoming visible against
the dense diseased area) .
6) Silhouette sign(loss of normal border between thoracic
structure ) .
Lobar consolidation
Where increased density/opacity is seen in individual lung
lobes. Sharp delineation can be seen when consolidation
reaches a fissure, since it does not cross.
Bulging fissure sign refers to lobar consolidation where the
affectd portion of the lung is expanded , the most common
infective casuative agent is Klebsiella pneumoniae.
Multi-focal consolidation
Multiple areas of opacity seen throughout the lung most
often is due to bronchopneumonia, starting from bronchi
and spreading outwards.
Usually ill defined with peripheral distribution.
Neoplasms such as primary malignancy or metastasis can
also cause this apperance.
 Right upper lobe consolidation
1)Opacification of the right upper zone that may abut and outline
the superior margin of the horizontal fissure .
2)Obscuration of the right superior mediastinal contour (silhouette
sign ).
3)Obscuration of the right hilum , particularly the superior hilum .
4)Air bronchogram .
4)On lateral CXR traingular opacification superior and anterior to
right oblique fissure posteriorly and the horizontal fissure anteriorly
5) +/_ Bulging fissure sign .
RUL consolidation
RUL Consolidation
Bulging fissure sign
Bulging fissure sign
Right middle lobe consolidation
The right middle lobe is bordered superiorly by the horizontal fissure, and
medially by the right heart border. Any abnormality, which increases
density of this lobe, may therefore obscure the right heart border, or be
limited superiorly by the horizontal fissure
Radiographic features
1) opacification of the RML abutting the horizontal fissure.
2) indistinct right heart border.
3) loss of the medial aspect of the right hemidiaphragm.
4) Air bronchogram .
5) On lateral CXR traingular opacification between the horizontal fissure.
superiorly and the right obligue fissure posteriorly .
RML consolidation
RML consolidation
Right lower lobe consolidation
1) Opacification of the right lower zone that may abut the obligue
fissure .
2) Obscuration of the right hemidiaphragm(silhouette sign ).
3) Obscuration of the right hilum particularly the inferior hilum .
4) Visible horizontal fissure.
5)Air bronchogram.
6) On lateral CXR traingular opacification posterior and inferior to
to right obligue fissure with obscuration of the dome and posterior
aspect of the right hemidiaphragm .
RLL consolidation
RLL consolidation
Total lung consolidation
Bronchopneumonia
(also sometimes known as lobular pneumonia ) is a radiological
pattern associated with suppurative peribronchiolar
inflammation and subsequent patchy consolidation of one or
more secondary lobules of the lung ).
Radiographic features
1)multiple small nodular or reticulonodular
opacities which tend to be patchy and /or
confluent( mean patches of inflammation
seperated by normal lung paranchyma) .

2)The distribution is often bilateral and

asymmetric and predominantly involves the lung
bases .
Bronchopneumonia
lung collapse
Atelectasia or lung collapse is the result of loss of air in a
lung or part of the lung with subsequent volume loss due to
airway obstruction or compression of the lung.
Lobar collapse
Individual lobes of the lung may collapse due to obstruction
of the supplying bronchus , causes include:
luminal
_aspirated foreign material in children.
_mucous plugging.
mural
_bronchogenic carcinoma.
extrinsic
_compression by adjacent mass.
Radiological features

1)Right upper lobe collapse .

2)Right middle lobe collapse.
3)Right lower lobe collapse.
4)Left upper lobe collapse.
5)Left lower lobe collapse.
6)Lingular collapse.
7)Total lung collapse.
Radiological features
Some features are generic markers of volume loss and are
helpful in to identify the collapse, as well as enabling
distinction from consolidation(lobar pnumonia) .
Direct sign :
1)Displacement of fissures.
2)Crowding of pulmonary vessels.
In direct sign:
1)elevation of the ipsilateral hemidiaphragm.
2)crowding of the ipsilateral ribs.
3)shift of the mediastinum towards the side of atelectasis.
4)compensatory hyperinflation of normal lobes.
5)hilar displacement toward the collapse.
Right upper lobe collapse
Radiographic features
1) increased density in the upper medial aspect of the right
hemithorax.
2) elevation of the horizontal fissure.
3) loss of the normal right medial cardio mediastinal contour.
4) elevation of the right hilum.
5) hyperinflation of the right middle and lower lobe result in
increased translucency of the mid and lower parts of the
right lung.
*A common cause of lobar collapse is a hilar mass. When a
right hilar mass is combined with collapse of the right
upper lobe, the result is an S shape due to elevated
horizontal fissure. This is known as Golden S sign .

Golden s sign
Right middle lobe collapse
CXR Frontal view :showing right mid to
lower zone opacity cause obscuration of the
right cardiac border.
CXR Lateral film :tongue like opacity in the
anterior aspect of the chest overlying the
cardiac shadow with its apex at the right
hilum .
versus (triangular in shape) in RT middle lobe
consolidation seen in lateral chest X_ray film.
Right lower lobe collapse
1) Triangular opacity at right lower zone usually medially.
2) The medial aspect of the dome of right hemidiaphragm is
obscured .
3)The right hilum is depressed.
4)It is important to note that the right heart border, which is
contacted by the right middle lobe remains well seen.
4) Non-specific signs indicating right sided atelectasis may
also be present (although due to the small size of the right
middle lobe they may well be subtle), include:
* elevation of the hemidiaphragm.
* crowding of the right sided ribs.
* shift of the mediastinum to the right .
 Left upper lobe collapse

Radiographic features
1) The left upper lobe collapses anteriorly becoming a thin
sheet of tissue apposed to the anterior chest wall, and
appears as a hazy or veiling opacity extending out from the
hilum and fading out inferiorly .

2) Parts of the normal cardio mediastinal contour may

also be obliterated where the left upper lobe, particularly
the lingula abut the left heart border. The anterior parts of
the aortic arch are also often obliterated from view.
3) The left hilum is also elevated .
Left upper lobe collapse

5) Non-specific signs indicating left sided atelectasis will also

be present, including:
*elevation of the hemidiaphragm
*peaked' or 'tented' hemidiaphragm: juxtaphrenic peak sign
*crowding of the left sided ribs.
*shift of the mediastinum to the left.
*On lateral projections :the left lower lobe is hyperexpanded
and the oblique fissure displaced anteriorly. There is
associated increase in the retrosternal opacity.
Left upper lobe collapse
Left upper lobe collapse
Left lower lobe collapse
Radiographic features
1) triangular opacity in the posteromedial aspect of the left lung.
2) edge of collapsed lung may create a 'double cardiac contour.’
3) left hilum will be depressed.
4) loss of the normal left hemi diaphragmatic outline.
5) loss of the outline of the descending aorta.
6) Non-specific signs indicating left sided atelectasis are
usually also be present including:
• elevation of the hemidiaphragm
• crowding of the left sided ribs
• shift of the mediastinum to the left
7) On lateral projection the left hemidiaphragmatic outline is
lost posteriorly and the lower thoracic vertebrae appear denser
than normal (they are usually more radiolucent than the upper
vertebrae) .
LLL collapse(left) vs normal(right)
Total lung collapse
Total lung collapse
 Pleural effusion
abnormal accumulation of fluid with in the pleural cavity
 Radiological features
Plain radiograph :
Chest radiographs are the most commonly used examination
to assess for presence of a pleural effusion, that on a
routine erect chest x-ray as much as 250-600 ml of fluid is
required before it becomes evident. A lateral decubitus film
is most sensitive, able to identify even a small amount of
fluid. At the other extreme, supine film can mask large
quantities of fluid.
CXR
lateral decubitus :A lateral decubitus film (obtained with
the patient lying on their side, effusion side down, can
visualize small amounts of fluid layering against the
dependent parietal pleura.
Erect CXR
Both PA and AP erect films are insensitive to small amounts of
fluid but lateral film are able to identify a smaller amount of
fluid as the costophrenic angles are deepest posteriorly .
features include:
*blunting of the costophrenic angle
*blunting of the cardiophrenic angle
*fluid within the horizontal or oblique fissures
*eventually a meniscus signs will be seen, on frontal films seen
laterally and gently sloping medially, in the state of
hydropnumothorax straight (air _fluid level)
*with large volume effusions, mediatinal shift occures away
from the effusion.
Pleural effusion
Pleural effusion
Pleural effusion
 Sub pulmonic effusion(infra pulmonary
effusion )
the pleural fluid lies almost exclusively between the lung
base and the diaphragm, more common in the right side and
usually unilateral .
Radiological features:
plain radiograph
this type of collection can be seen only on an erect projection
,the fluid causes apparent elevation and flattening of the
diaphragm( what appear to be a diaphragm actually represents
the pleura )and the true diaphragm is obscured by the
infrapulmonary fluid , the peak of this pseudo diaphragm will
lie lateral to normal position when this type of effusion
located on the left , an increased distance between the
pseudo diaphragm and the gastric bubble .
* v zdc z
Loculated pleural effusion (pulmonary pseudo
tumor )
the fluid is traped in the pleural fissures
 Pleural empyema(pyothorax)
it means infected purulent and often loculted pleural effusion and
usually the complication of another underlying abnormality such
as pneumonia , subdiaphragmatic abscess , esophageal
perforation .
Features that help distinguish apleural effusion from an
empyema depending on shape and location
Empyemas usually:
▪ Form an obtuse angle with the chest wall.
▪ Unilateral or markedly asymmetric whereas pleural
effusions are (if of any significant size) usually bilateral and
similar in size.
▪ lenticular in shape (bi-convex), whereas pleural effusions are
crescentic in shape (i.e concave towards the lung).
Empyema
 Lung abscess

is a circumscribed collection of pus within the lung, is are

potentially life threatening. They are often complicated to manage
and difficult to treat.

Plain film
The classical appearance of a pulmonary abscess is a cavity
containing an air-fluid level. In general abscesses are round in
shape, and appear similar in both frontal and lateral projections.
Lung abscess
 empyema Abscess

Lentiform Rounded in all projection

Form an obtuse angle with Acute angle

the chest wall

Split pleura sign + No split pleura sign

* Split pleura sign ( seen in contrast enhanced CT
scan that there is enhancement of the thickened
inner and outer pleural layers with separation by a
collection of pleural fluid)
Pulmonary hydatid cyst
is a common manifestation of hydatid disease, the lung is the
second most common site of involvement in adult after the
liver and the most common site in children .
Cyst structure :
_pericyst :composed of inflammatory tissue of host origin .
_exocyst
_ endocyst.

Radiological features
1) Non-complicated hydatid
_multiple or solitary rounded opacity diameter of 1-20 cm
_unilateral or bilateral
_predominantly found in the lower lobes
2)Complicated cysts
a) ruptured hydatid cyst
meniscus sign , air crescent sign or onion peel in which air
lining between the endo cyst and peri cyst
water-lily sign when there is detachment of the endo cyst
membrane which results in floating membranes within the peri
cyst that mimic the appearance of a water lily.
consolidation adjacent to the cyst (ruptured cyst)

b)infected cyst appear as lung abscess

Simple HC Ruptured HC
Meniscus sign
Water lily sign
 Pneumothorax
refers to the presence of gas (air) in the pleural
space.

Radiological features
1)visible visceral pleural edge see as a very thin,
sharp white line.
2) hyper translucency( comparede to adjecent lung)
with no lung markings are seen peripheral to this
line.
3)the lung may completely collapsed.
4) No mediastinal shift.
Pneumothorax
 Tension pneumothorax
It occurs when intrapleural air accumulates progressively in
such a way as to exert positive pressure on mediastinal
and intrathoracic structures. It is a life threatening
occurrence requiring rapid recognition and treatment is
required to avoid cardiorespiratory arrest

Radiographic features
It has the same features as simple pneumothorax with a
number of additional features, helpful in identifying
tension. Which indicate over expansion of the hemithorax
such as :
▪ ipsilateral increased intercostal space .
▪ shift of the mediastinum to the contralateral side.
▪ depression of the hemidiaphragm.
Tension pneumothorax
Tension pneumothorax
 Hydro pnuemothorax
is a term given to the concurrent presence of a
pneumothorax as well as a hydrothorax (i.e. air
and fluid) in the pleural space
Plain radiograph
On an erect chest radiograph, recognition of
hydropneumothorax can be rather easy - and is
clasically shown as an air-fluid level.
Hydropnemothorax
Subcutaneous (surgical) Emphysema
refers to air in the subcutaneous tissues. But the term is
generally used to describe any soft tissue emphysema of
the body wall or limbs, since the air often dissects into the
deeper soft tissue and musculature along fascial planes
Plain film
If affecting the anterior chest wall, subcutaneous
emphysema can outline the pectoralis major muscle ,
giving rise to the ginkgo leaf sign , dissecting air along
tissue fat planes appears as multiple lines of lucency
Subcutaneous Emphysema
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