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William Herring, M.D.

2002

The Fundamentals of
Chest Roentgenology

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The Fundamentals of Chest


Roentgenology
l

Fundamental Observations
n

Silhouette sign

Air bronchograms

Solid spheres vs. hollow tubes

Basic Disease Processes


n

Alveolar vs. interstitial lung disease

Opacified hemithorax

Cavities

The Fundamentals of Chest


Roentgenology

Diseases

Congestive Heart Failure

Pneumothorax

Silhouette Sign
l

When two objects of the same


density touch each other, the
edge between them disappears

Using the Silhouette Sign

Right middle lobe silhouettes right


heart border

Lingula silhouettes left heart border

Right lower lobe silhouettes right


hemidiaphragm

Left lower lobe silhouettes left


hemidiaphragm

Using the Silhouette Sign


The mass (red arrow)
silhouettes the right
heart border which is
to say there is no
longer an edge of the
right heart seen. That
means the mass is (a)
touching the right
heart border (the mass
is anterior) and (b) the
mass is the same
density as the heart
(fluid or soft tissue
density). The mass is a
thymoma.

Where in the chest is this mass?

Air Bronchogram
l

Bronchi are not visible since their walls are


thin, they contain air, are surrounded by air

When something of fluid density fills alveoli,


air in bronchus becomes visible, e.g.
n

Pulmonary edema fluid

Blood

Gastric aspirate

Inflammatory exudate

Air Bronchogram

The visibility of air in the bronchi because of


surrounding airspace disease is called an
air bronchogram

An air bronchogram is almost always a sign


of airspace disease

The black branching


structures are the
result of air in the
bronchi, now visible
because density
other than air
surrounds them (in
this case it is
inflammatory exudate
from a pneumonia).

Solid Spheres vs. Hollow Tubes


A. Solid spheres are homogeneous from one
side to other

Blood vessels and masses

B. Hollow tubes have a lower density in


center

Bronchi and cavities


A

There are multiple


nodules visible on
the CT scan of the
chest in this patient.
In most cases the
nodules are due to
metastases from a
primary malignancy
in an organ other
than the lung.
In this case the
metastases to the l
ung
were from a colon
cancer.
Solid spheres or hollow tubes?

Diseases with Multiple Lung Nodules

Metastases

Multiple AVMs

Rheumatoid nodules

Wegeners Granulomatosis

Disease with Multiple Cystic


Structures

Cystic fibrosis

Bronchiectasis

Tuberculosis

Parenchymal Lung Disease

Two Major Types

Alveolar (air space)

Interstitial

Alveolar Lung Disease

Has air bronchograms

Fluffy and indistinct

Confluent and homogeneous

May have segmental or lobar distribution

This disease is
fluffy and indistinct
in its margins, it is
confluent and
tends to be
homogeneous. In
both upper lobes,
you can see air
bronchograms.
This is an alveolar
(airspace) disease,
in this case
pulmonary edema o
n a noncardiogenic basis.
Pulmonary edema

Common Alveolar Lung Diseases

Pneumonia

Pulmonary edema

Pulmonary hemorrhage

Aspiration

Airspace Disease

Aspiration pneumonia at both bases

Interstitial Lung Disease

Discrete

Inhomogeneous

No air bronchograms

Made up of lines (reticular) or dots


(nodular) or both (reticulonodular)

Interstitial versus Airspace Disease

Interstitial disease discrete,


inhomogeneous, no air
bronchograms

Airspace disease fluffy,


indistinct, homogeneous,
contains air bronchograms

Common Interstitial Lung Diseases

Cancer1 or 2

Sarcoidosis

Cystic fibrosis

Asbestosis

Cystic Fibrosis - interstitial

Opacified Hemithorax
Three Causes

Atelectasis

Pleural effusion

Pneumonia

Recognizing the Causes of an


Opacified Hemithorax

Atelectasis

Opacified hemithorax from volume loss

Shift of heart and mediastinal structures


toward opacified hemithorax

Atelectasis of right lung shift of the mediastinal structures


TOWARD the side of opacification

Pleural Effusion

Opacified hemithorax from large


effusion

Shift of heart and mediastinal


structures away from side of opacified
hemithorax

Large right pleural effusion - shift of the mediastinal structures


AWAY from the side of opacification

Pneumonia

Opacified hemithorax

No shift

Air bronchograms

Pneumonia of LUL no shift of the mediastinal


structures to either side; multiple air bronchograms

Congestive Heart Failure


Four Reliable Signs

Kerley B lines

Pleural effusions

Fluid in the fissures

Peribronchial cuffing
n

Not cardiomegaly

Not cephalization
Recognizing CHF

Four Reliable Signs of CHF

Short (1 -2 cm)
white lines at
the lung
bases,
perpendicular
to the pleural
surface
representing
distended
interlobular
septa

Kerley B Lines

Four Reliable Signs of CHF

Pleural Effusions

Four Reliable Signs of CHF

Fluid in the
minor fissure.
The fissures
may be seen
normally but
they should
be about as
thin as a line
drawn with a
sharpened
pencil.

Fluid in the fissures

Four Reliable Signs of CHF

Fluid in the
walls of the
bronchi make
them visible
and produce
numerous
doughnut
densities
throughout
the periphery
of the lung.

Peribronchial cuffing

Pneumothorax

Must see visceral pleural white line

Absence of lung markings peripherally

Shift of mediastinal structures

None=simple pneumothorax

Away from pneumothorax=tension


pneumothorax

Never a shift toward side of pneumothorax


Recognizing
a Pneumothorax

Visceral pleural white line marks the edge of the lung

Cavitary Lung Lesions


Differentiation

Thickness of the wall

Inner margin of the cavity

Air-fluid level

Cavitary Lung Lesions


Three Causes

Carcinoma of the lung

TB

Abscess

cavities

Thickness of
Wall

Inner Margin

A|F Level

Carcinoma

Thick

Nodular

+/-

TB

Thin

Smooth

No

Abscess

Thick

Smooth

Yes

Thick-walled with nodular inner margin


carcinoma of the left lower lobe

Thick-walled with smooth inner margin


RUL abscess

Thin-walled with smooth inner margins, RUL


Tuberculosis