Chest Radiograph Abnormalities

Ahmed Ghanem M.D

PGMD,PRB,JRB,ARB

Head of Radiology Dep. NNUH

Ahmed.ghanem@najah.edu
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Tracheal displacement

Before deciding if the trachea is central it is important to establish that the patient is
not rotated.

Trachea - Pushed or Pulled ?

If the trachea is genuinely displaced to one side, try to establish if it has been pushed
or pulled by a disease process.

Anything that increases pressure or volume in one hemithorax will push the trachea
and mediastinum away from that side.

Any disease which causes volume loss in one hemithorax will pull the trachea over
towards that side.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
No patient rotation - the spinous processes (red line) are central between the medial clavicles
(blue lines)
Trachea (asterisk) shifted to the left of the midline
Soft tissue mass mainly to the right of the trachea
Diagnosis
Mediastinal thyroid enlargement
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Trachea (asterisk) shifted to the left of the midline (red line)
Soft tissue mass on right of the trachea (highlighted area)
The CT findings correlate well with the X-ray
Diagnosis
Mediastinal thyroid enlargement causing tracheal deviation
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Hilar abnormalities

The hila consist of vessels, bronchi and lymph nodes. On a chest X-ray, abnormalities
of these structures are represented by a change in position, size and/or density.

Hilar enlargement
Hilar enlargement may be unilateral or bilateral, symmetrical or asymmetrical.

Hilar position
If a hilum has moved, you should try to determine if it has been pushed or pulled, just
like you would for the trachea.
Ask yourself if there is a lung abnormality that has reduced volume of one hemithorax
(pulled), or if there has been increase in volume or pressure of the other hemithorax
(pushed).

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Symmetric Bilateral hilar enlargement

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
 mediastinal window
Lung window

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Asymmetric hilar enlargement

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Abnormal hilar position

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
 Lung window

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Lung abnormalities

Assess the lungs by comparing the upper, middle and lower lung zones on the left and
right.
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.

Consolidation

If the alveoli and small airways fill with dense material, the lung is said to be
consolidated. It is important to be aware that 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 hemorrhage), or
cells (cancer).
They all look similar and clinical information will often help you decide the diagnosis.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
CLASSIFYING PARENCHYMAL LUNG DISEASE
■ Diseases that affect the lung parenchyma can be arbitrarily divided into two
main categories based in part on their pathology and in part on the pattern they
typically produce on a chest imaging study.
♦ Airspace (alveolar) disease
♦ Interstitial (infiltrative) disease

■ Why learn the difference?

♦While many diseases produce abnormalities that display both patterns,
recognition of these patterns frequently helps narrow the disease possibilities so
that you can form a reasonable differential diagnosis
Airspace disease characteristically produces opacities in the lung which can be
described as fluffy, cloudlike, or hazy.
■ These fluffy opacities tend to be confluent, meaning they blend into one
another with imperceptible margins.
The margins of airspace disease are indistinct, meaning it is frequently difficult
to identify a clear demarcation point between the disease and the adjacent
normal lung.
■ Airspace disease may be distributed throughout the lungs, as in pulmonary
edema , or it may appear more localized, as in a segmental or lobar pneumonia.

■ Airspace disease may contain air bronchograms.

♦ The visibility of air in the bronchus because of surrounding airspace

disease is called an air bronchogram.
♦ An air bronchogram is a sign of airspace disease.
• Bronchi are normally not visible because their walls are very
thin, they contain air, and they are surrounded by air. When
something like fluid or soft tissue replaces the air normally
surrounding the bronchus, then the air inside of the
bronchus becomes visible as a series of black, branching tubular
structures this is the air bronchogram
Diffuse airspace disease of pulmonary alveolar edema. There are opacities throughout both lungs,
primarily involving the upper lobes that can be described as fluffy, hazy, or cloudlike and are
confluent and poorly marginated, all pointing to airspace disease. This is a typical example of
pulmonary alveolar edema (due to a heroin overdose in this patient).
Right lower lobe pneumonia. There is an area of increased opacification in the right midlung field
(solid black arrow) that has indistinct margins (solid white arrow), characteristic of airspace disease.
The minor fissure (dotted black arrow) appears to bisect the disease, locating this pneumonia in the
superior segment of the right lower lobe. The right heart border and the right hemidiaphragm are still
visible because the disease is not in anatomic contact with either of those structures.
Air bronchograms demonstrated on computed tomography scan. There are numerous black,
branching structures (black arrows) representing air that is now visible inside the bronchi because
the surrounding airspaces are filled with inflammatory exudates in this patient with an obstructive
pneumonia from a bronchogenic carcinoma. Normally on conventional radiographs, air inside
bronchi is not visible because the bronchial walls are very thin, they contain air, and they are
surrounded by air.
Air bronchogram
If an area of lung is consolidated it becomes dense and white. 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.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
 ♦ What can fill the airspaces besides air?
• Fluid, such as occurs in pulmonary edema
• Blood, for example, pulmonary hemorrhage
• Gastric juices, as occurs with aspiration
• Inflammatory exudate, for example, pneumonia
• Water, which can be seen with near-drowning

SOME CAUSES OF AIRSPACE DISEASE

■ There are many causes of airspace disease, three of which will be highlighted
here.

■ Pneumonia:
♦ About 90% of the time, community-acquired lobar or segmental
pneumonia is caused by Streptococcus pneumonia.
Pneumonia usually manifests as patchy, segmental, or lobar airspace
disease. Pneumonias may contain air bronchograms. Clearing usually
occurs in less than 10 days (pneumococcal pneumonia may clear
within 48 hours).
■ Pulmonary alveolar edema:
♦ Acute, pulmonary alveolar edema classically produces
bilateral, perihilar airspace disease, sometimes described as having a bat-
wing or angel-wing configuration.

♦ It may be asymmetric but is usually not unilateral.

Pulmonary edema that is cardiac in origin is frequently associated with pleural
effusions and fluid that thickens the major and minor fissures.

■ Aspiration
♦ Aspiration tends to affect whatever part of the lung is most dependent at the
time the patient aspirates, and its manifestations depend on the substance(s)
aspirated.
For most bedridden patients, aspiration usually occurs in either the lower lobes
or the posterior portions of the upper lobes.
♦ Because of the course and caliber characteristics of the right main bronchus,
aspiration occurs more often in the right lower lobe than the left lower lobe
♦ The radiographic appearance of aspiration and how quickly the airspace
disease resolves is determined by the type of aspirate and whether or not it
becomes infected. Aspiration of bland (neutralized) gastric juice or water
usually clears rapidly within 24 to 48 hours,
Unilateral middle zone abnormality

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Lung Cavitary Lesion

Pulmonary cavities are gas-filled areas of the lung in the center of a nodule,
mass or area of consolidation.
They are usually evident on plain radiography and CT.
They may be thin or thick walled and their walls must be greater than 2-5 mm.
They may be filled with air as well as fluid and may also demonstrate air-fluid
levels.
Terminology:
According to the Fleischner society pulmonary cavities are defined:

"gas-filled space, seen as a lucency or low-attenuation area, within pulmonary

consolidation, a mass, or a nodule”.

Pathology
The cause of pulmonary cavities is broad. They may develop as a chronic
complication of a pulmonary cyst, or secondary to cystic degeneration of a
pulmonary mass.
They may enlarge or involute over time.
A particularly helpful mnemonic for causes of pulmonary cavities is:

CAVITY Mnemonic

C: cancer bronchogenic carcinoma: most frequently squamous cell carcinoma

(SCC),cavitary pulmonary metastasis(es): most frequently SCC.

A: autoimmune; granulomas from Wegener granulomatosis (granulomatosis

with polyangiitis) rheumatoid arthritis (rheumatoid nodules) etc .

V: vascular (both bland and septic pulmonary emboli).

I: infection (bacterial/fungal) pulmonary abscess pulmonary tuberculosis .

T: trauma - pneumatocele.

Y: youth CPAM (congenital pulmonary airway malformation) pulmonary

sequestration bronchogenic cyst
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Bilaterally abnormal lung zones

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Pulmonary emphysema

It is defined as the "abnormal permanent enlargement of the airspaces distal to

the terminal bronchioles accompanied by destruction of the alveolar wall and
without obvious fibrosis".

Emphysema is one of the entities grouped together as chronic obstructive

pulmonary disease (COPD).

Emphysema is best evaluated on CT, although indirect signs can be noticed on

conventional radiography in a proportion of cases.

It should be remembered, however, that the most common plain film

appearance of COPD is "normal" and the role of chest radiography is to
eliminate other causes of lung symptoms such as infection, bronchiectasis or
cancer
Radiographic features on Plain radiograph

Except in the case of very advanced disease with bulla formation, chest
radiography does not image emphysema directly, but rather infers the diagnosis
due to associated features:
■ Aspiration
♦
■ Hyperinflation:
♦ flattened hemidiaphragm(s): most reliable sign.
♦ increased and usually irregular radiolucency of the lungs
♦ increased retrosternal airspace.
♦ increased antero-posterior diameter of chest
♦ widely spaced ribs
♦ sternal bowing tenting of the diaphragm
♦ saber-sheath trachea
■ Vascular changes:
♦ paucity of blood vessels, often distorted
♦ pulmonary arterial hypertension
-pruning of peripheral vessels
-increased caliber of central arteries
-right ventricular enlargement
Unilateral black lower zone

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Both lungs are markedly hyper-inflated with 11 posterior ribs easily visible above the diaphragmatic
domes (yellow dotted lines). The diaphragms are depressed and flattened (best seen on lateral
projection, with loss of the normal acute angle formed by the costophrenic pleural reflection (dotted
blue line).
The lungs appear very radiolucent with some areas devoid of lung markings ( * ) suggesting bullous
formation.
On lateral projection the retrosternal air space (RS) is markedly widened (aorta outlined in red).
Pleural disease
If you miss a tension pneumothorax you risk your patient's life - as well
as your result at finals!

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.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Pneumothorax

A pneumothorax 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 2 cm from the inner chest wall at the level of the
hilum, 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.'

This is a medical emergency! Missing a tension pneumothorax may not only harm your
patient, it is also the quickest way to loose you job and fail exams.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Pleural thickening
Pleural thickening is best seen at the lung edges where the pleura runs tangentially to
the x-ray beam.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Pleural effusions
A pleural effusion is a 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 x-ray is taken, a pleural effusion will
obscure the costophrenic angle and hemidiaphragm.

If a patient is supine a pleural effusion layers along the posterior aspect

of the chest cavity and becomes difficult to see on a chest x-ray.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Costophrenic angle blunting
Blunting of the costophrenic angles is usually caused by a pleural effusion, as already
discussed.
Other causes of costophrenic angle blunting include lung disease in the region of the
costophrenic angle, and lung hyperexpansion.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Lobes, fissures and contours

Two views are usually needed to determine the lobe involved.

Knowledge of the fissures and the diaphragm and heart contours can help determine
where disease is located without the need for a lateral view.
Right middle lobe consolidation

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Right upper lobe collapse

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Diaphragmatic abnormalities
Pneumoperitoneum
Every time you check a chest X-ray you should make sure there is no free intra-
abdominal air under the diaphragm (pneumoperitoneum). This is a sign of bowel
perforation.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Diaphragmatic rupture

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Phrenic nerve palsy

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Heart contour abnormalities
Cardiomegaly and heart failure

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_pathology_page8
Left atrial enlargement

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Left ventricular aneurysm

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Mediastinal abnormalities
Mediastinal widening

Widening of the mediastinum is most often due to technical factors such as patient
positioning or the projection used.

Rotation, incomplete inspiration, or an AP view, may all exaggerate the width of the
mediastinum, as well as heart size.

In the setting of trauma, patients are positioned supine while a chest X-ray is acquired,
very often causing the mediastinum to appear wide spuriously.

Mediastinal masses and vessels

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.

The main pathological causes to consider include masses and widening of vessels.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Mediastinal mass

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Thoracic aortic aneurysm

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Soft tissue abnormalities

It is essential to assess the soft tissues on every chest X-ray you

examine. You will often find important clues to help come to a diagnosis.

The soft tissues are also often misleading and it is important to be

aware of the pitfalls.

Breast tissue

Breast tissue varies greatly between men and women, and between
individuals.

Occasionally you may mistake breast tissue for increased density of the
underlying lung, particularly if there has been a mastectomy on the
other side.
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Gynaecomastia

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Surgical emphesyma

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Bone abnormalities

Chest radiography is not indicated for a suspected simple rib fracture

Malignant bone disease may manifest as either single or multiple lesions

Bones are the densest normal structures seen on a chest X-ray. Despite
this, the power of the X-ray beam used is usually not optimized to view
the bones, but rather to give greater detail to the lungs and soft tissues.

For this reason abnormalities of the bones may not be obvious and so
must be searched for carefully.

Bones visible on a chest X-ray include the ribs, clavicles, scapulae,

humeri, and the spine. The sternum cannot be seen clearly because it
overlies the spine and mediastinum.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Rib fractures
Chest radiography is not indicated for demonstration of a suspected simple rib
fracture.
This is because many fractures are not visible, and because management is not altered
even if it is seen. If there is clinical suspicion of complications such as a pneumothorax,
a chest X-ray is indicated.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH