Chest X-ray

ABNORMALITIES
 Chest X-ray Abnormalities - The lung hilum
A. 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.
 The left hilum must never be lower than the right hilum.
Whenever a left hilum appears lower than the right hilum
– look for other evidence suggestive of:
 Collapse of either the left lower lobe or of the right
upper lobe
 Enlargement of the right hilum
 Chest X-ray Abnormalities - The lung hilum
A. Hilar position:

Superior displacement and Left lower lobe atelectasis. The blue

horizontalization of the right hilum arrows point to the edge of a
(white curved arrow) due to triangular region of atelectatic left
atelectasis of the right upper lobe lower lobe. Left Hilum displaced
(black arrows). the hilum (red arrow) inferiorly. the hilum (red arrow)
 Chest X-ray Abnormalities - The lung hilum
B. Hilar enlargement:
May be unilateral or bilateral, symmetrical or asymmetrical
 Chest X-ray Abnormalities - The lung hilum
Analyze the enlargement of
hilum (if present):
1. Lymph Node
enlargement:
 Lobulated appearance
(lumpy-bumpy opacity )
 Presence of calcification
within the mass
indicates usually
tuberculosis.
 Egg-shell calcification
indicates silicosis or Calcified bilateral hilar
sarcoidosis. lymphadenopathy in
sarcoidosis
 Chest X-ray Abnormalities - The lung hilum
2. Arterial enlargement:
 Smooth margins
 In pulmonary arterial
hypertension the
arteries in the outer
two-thirds of each
lung are smaller than
those at the hila
(peripheral pruning)

Primary pulmonary hypertension

showing right heart enlargement and
enlargement of the main pulmonary
artery and its right and left branches.
 Chest X-ray Abnormalities - The lung hilum
3. Malignancy:
 Spiculated irregular or
indistinct margins
 Hilar enlargement due
to malignant lung lesion
is also associated with
superior mediastinal
lymphadenopathy. Look
at the lung fields (for
presence of tumor) and
bone/ribs for This patient has a bulky right
metastasis. hilum. This was shown to be due
to a bronchogenic tumour.
 Chest X-ray Abnormalities - lung fields
Lung abnormalities:
Abnormal whiteness
(increased density):
 Consolidation
 Atelectasis
 Nodule or mass
Interstitial
Abnormal blackness
(decreased
density):
 Cavity
Assess the lungs by comparing the upper,
 Cyst middle and lower lung zones on the left
 Emphysema and right
 Chest X-ray Abnormalities - lung fields
Four patterns of
increased density:
 Consolidation
 Lobar
 Diffuse
 Multifocal ill-
defined
 Atelectasis
 Nodule or
mass
 Solitary Pulmonary
Nodule
 Multiple Masses
 Interstitial
 Reticular
 Fine Nodular
lung field abnormalities - Consolidation
 lung field abnormalities - Consolidation
The key-findings on the X-ray are:
 Ill-defined
homogeneous opacity
obscuring vessels
 Silhouette sign: loss of
lung/soft tissue
interface
 Air-bronchogram
 Extention to the
pleura
or fissure, but not
crossing it
 No volume loss
 May be Blunting of
 lung field abnormalities - Consolidation
 Air bronchogram refers to the phenomenon of air-filled
bronchi (dark) being made visible by the opacification of
surrounding alveoli (grey/white).
 lung field abnormalities - Consolidation
Tuberculosis (TB): Primary pulmonary tuberculosis:
Imaging Findings:
 Patchy or lobar consolidation
 Cavitation (uncommon)
 Caseating granuloma
(tuberculoma) which usually
calcifies (known as a Ghon
lesion)
 Ipsilateral hilar and
mediastinal (paratracheal)
lymphadenopathy,
usually right sided.
 Calcification of nodes
 Atelectasis Chest X-ray shows right upper lobe
 Pleural effusions and left midzone consolidation
and adenopathy.
 Consolidation - Tuberculosis
Post-primary pulmonary: Imaging Findings:
 Almost always affect:
1. Posterior segments of the
upper lobes
2. Superior segments of the
lower lobes
 Patchy consolidation
 Poorly defined linear and
nodular opacities
 Cavitation, Aspergillomas,
fibrosis and Bronchiectasis
 pleural effusion
 Hilar nodal enlargement
 Lobar consolidation, Patchy bilateral opacification of the
tuberculoma and miliary TB upper lung lobes with cavitation most
marked on the left (arrow)
 Consolidation - Tuberculosis
Tuberculoma and Miliary Tuberculosis: Imaging Findings:
 Tuberculoma and miliary
tuberculosis are rare
 Miliary deposits are seen
both in primary and post-
primary tuberculosis. It
appear as 1-3 mm diameter
nodules, which are uniform in
size and uniformly
distributed
 Tuberculomas are usually
found as single nodules and
they may include a cavity or a
calcification
margins. Theywith
are sharp
usually Miliary Tuberculosis
found in the upper lobes
lung field abnormalities - Consolidation
 Consolidation - Cardiogenic pulmonary edema
Consolidation due to Congestive Heart Failure (CHF) :
 Consolidation - Cardiogenic pulmonary edema
Stage I CHF – Redistribution:
 Redistribution of the pulmonary veins. This is know as
cephalization (blue arrow) because the pulmonary veins
of the superior zone dilate due to increased pressure.

 An increase in width of the vascular pedicle (red arrows)

 Consolidation - Cardiogenic pulmonary edema
Stage II CHF - Interstitial edema Characterized by:
1. Kerley’s A lines: extend radially from the hilum to the
upper lobes; represent thickening of the interlobular
septa that contain lymphatic connections.
 Consolidation - Cardiogenic pulmonary edema
2. Kerley’s B lines: are short horizontal lines situated
perpendicularly to the pleural surface at the lung base;
they represent edema of the interlobular septa.
 Consolidation - Cardiogenic pulmonary edema
3. Thickening of the bronchial walls (peribronchial cuffing)
and as loss of definition of these vessels (perihilar haze).
 Consolidation - Cardiogenic pulmonary edema
4. Fluid in the major or minor fissure (shown here)
produces thickening of the fissure beyond the pencil-
point thickness it can normally attain
 Consolidation - Cardiogenic pulmonary edema
Stage III CHF - Alveolar edema Characterized by:
 Alveolar edema with
perihilar consolidations
and air bronchograms
( Bat's wing or butterfly
pulmonary opacities )
(yellow arrows)
 Pleural fluid (blue
arrow)
 Prominent azygos vein
and increased width of
the vascular pedicle (red
arrow)
 lung field abnormalities - Consolidation
Adult Respiratory Distress Syndrome ( ARDS )
ARDS versus Congestive Heart Failure:
 Diffuse bilateral
patchy infiltrates
 More uniform
opacification
 Homogenously
distributed
 No
cardiomegaly
 No
cephalization
 Usually no
pleural
 lung field abnormalities - Consolidation
Pneumonia can be classified histologically into lobar, lobular,
bronchopneumonia, and interstitial.
Bronchopneumonia characterised by:
 Multiple small nodular
or reticulonodular
opacities which tend to
be patchy and/or
confluent.
 The distribution is often
bilateral and
asymmetric, and
predominantly involves
the lung bases
lung field abnormalities - Alveolar vs. Interstitial
 Alveolar = air sacs  Interstitial = vessels,
lymphatics, bronchi, and
 Radiolucent
connective tissue
Can contain blood,  Radiodense
mucous, tumor, or
 Interstitial disease:
edema (“airless lung”)
prominent lung markings
with aerated lungs
lung field abnormalities - Interstitial disease
 lung field abnormalities - Interstitial disease
Reticular Pattern:
 Fine "ground-glass" (1-2
mm): e.g. interstitial
pulmonary oedema
 Medium
"honeycombing"
(3-10 mm): commonly seen
in pulmonary fibrosis
 Coarse (> 10 mm): cystic
Spaces caused by
parenchymal destruction,
e.g. usual interstitial
pneumonia, pulmonary
sarcoidosis, pulmonary
 lung field abnormalities - Interstitial disease
Nodular pattern:
 A nodular pattern consists
of multiple round
opacities, generally
ranging in diameter from
1 mm to 1 cm
 Nodular opacities may be:
 Miliary nodules: <2 mm
 Pulmonary
micronodule: 2-7 mm
 Pulmonary nodule:
7-30 mm
 Pulmonary mass:
>30mm
 lung field abnormalities - Interstitial disease
Causes of Miliary opacities :
 Infection  Sarcoidosis
 tuberculosis  Pneumoconioses
 fungal (often febrile)  silicosis
 healed varicella pneumonia  coal workers pneumoconiosis
 viral pneumonitis  Pulmonary haemosiderosis
 nocardosis  Hypersensitivity pneumonitis
 salmonella  Langerhans cell histiocytosis
 Miliary metastases  pulmonary alveolar
 thyroid carcinoma proteinosis
 renal cell
carcinoma
 breast carcinoma
 malignant
melanoma
 pancreatic
 lung field abnormalities - Interstitial disease
Ground-glass appearance
A hazy area of increased
attenuation in the lung with
preserved bronchial and
vascular markings.
Aetiology:
 Normal expiration
 Partial filling of air spaces
 Partial collapse of alveoli
 Interstitial thickening
 Inflammation
 Oedema
Perihilar ground-glass
 Fibrosis
appearance in the shape of
 Neoplasm bats-wings
 lung field abnormalities - Interstitial disease
Bronchiectasis:
 CXR may be normal
 Volume loss
 Increased pulmonary markings
 Indistinct vessel margins due
to peribronchial fibrosis.
 Tram lines: dilated and thickened
airways
 Ring shadows: thickened and
abnormally dilated bronchial walls
 Clusters of cysts in Cystic type
 Dextrocardia (Immotile cilia
syndrome)
 Mucus plugging (finger-in-glove)
appearance Tram-Track sign
 Atelectasis or diffuse lung
 lung field abnormalities - Interstitial disease
Bronchiectasis:

Ring shadow ( red arrow) & Tram Cystic bronchiectasis with

lines ( yellow arrow) multiple cystic airspaces
 lung field abnormalities - Atelectasis
CXR show direct and indirect signs of lobar collapse:
 Direct signs include displacement of fissures and opacification of
the collapsed lobe.
 Indirect signs include the following:
 Displacement of the hilum
 Mediastinal shift toward the side of collapse
 Loss of volume in the ipsilateral hemithorax
 Elevation of the ipsilateral diaphragm
 Crowding of the ribs
 Compensatory hyperlucency of the remaining lobes
 Silhouetting of the diaphragm or heart border
 Atelectasis can be sub-categorized by morphology as follows:
 linear (plate, band, discoid, subsegmental) atelectasis
 lobar atelectasis
 segmental and subsegmental atelectasis
 round atelectasis
 lung field abnormalities - Atelectasis
Lobar atelectasis: Right upper lobe collapse:
Increased density in the upper medial
aspect of the right hemithorax
 Elevation of the horizontal fissure
 Loss of the normal right medial
cardiomediastinal contour
 Elevation of the right hilum
 Hyperinflation of the right middle and
lower lobe result in increased
translucency of the mid and lower
parts of the right lung
 Right diaphragmatic tenting
 Non-specific signs :
 Elevation of the hemidiaphragm
 Crowding of the right sided ribs
 Shift of the mediastinum and
 lung field abnormalities - Nodules and Masses
A solitary pulmonary nodule:
Defined as a discrete, well-marginated, rounded opacity less than or
equal to 3 cm in diameter that is completely surrounded by lung
parenchyma, does not touch the hilum or mediastinum, and is not
associated with adenopathy, atelectasis, or pleural effusion.
 lung field abnormalities - Nodules and Masses
A Pulmonary mass:
It is an area of pulmonary opacification that measures more than
3 cm. The commonest cause for a pulmonary mass is lung cancer.
Other causes :
 Hyperdense pulmonary mass:
(a pulmonary mass with internal
calcification)
 Cavitating pulmonary mass:
(gas-filled areas of the lung in
the center of the mass. They are
typically 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).
 lung field abnormalities - Cavities
Pulmonary cavities :
 Are gas-filled areas of
the lung in the
center
of a nodule, mass or
area of consolidation.
 They are typically
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
 lung field abnormalities - Cavities
Pulmonary cavities: A helpful mnemonic is
CAVITY:
 C: cancer  I: infection (bacterial/fungal)
 Bronchogenic carcinoma:  Pulmonary abscess
(especially squamous cell  Cavitating pneumonia
carcinoma)  Pulmonary tuberculosis
 Cavitatory  Septic pulmonary emboli
metastasis(es):  T: trauma - pneumatocoeles
 Squamous cell  Y: youth (not true "cavity")
carcinoma  Congenital cystic
 Adenocarcinoma, e.g. adenomatoid malformation
gastrointestinal tract, breast (CCAM)
 Sarcoma  Pulmonary sequestration
 A: autoimmune; granulomas:  Bronchogenic cyst
 Wegener's granulomatosis
 Rheumatoid nodules.
 V: vascular (both bland and
 lung field abnormalities - Decreased density
Pulmonary emphysema:
1. Hyperinflation
 Flattened hemidiaphragm (s):
most reliable sign
 Increased and usually irregular
radiolucency of the lungs
 Increased retrosternal
airspace
 Increased antero-posterior
diameter
 Sternal bowing
 Obtuse costophrenic angle on
posteroanterior or lateral film.
 Widely spaced ribs
 A narrow mediastinum
 Low flattened diaphragm
 Pleural disease - Pneumothorax
Pneumothorax:
 Rotation of CXR can obscure a
pneumothorax . Rotation can
also mimic a mediastinal shift.
 A linear shadow of visceral
pleura with lack of lung markings
peripheral to it indicates
collapsed lung
 Flattening or inversion of the
diaphragm on the affected side
 Mediastinal shift toward the
contralateral side
 In erect patients: Pleural gas
collects over the apex .
 Pleural disease - Pneumothorax
 large pneumothorax if:
 the vertical distance between
the lung and thoracic cage at
the apex > 3cm
 or the distance between the
lateral lung edge and chest
wall at the level of the hilum
> 2cm
 lateral decubitus studies:
 Should be done with the
suspected side up
 The lung will then 'fall' away
from the chest wall
This chest X-ray shows a large
 Rib films are indicated pneumothorax (P) which is >2 cm
depth at the level of the hilum.
 Pleural disease - Pneumothorax
Hydropneumothorax:
 With the patient
upright, there will be
an air-fluid level in the
thoracic cavity
 On supine radiographs,
a hydropneumothorax
will be more difficult
to see although a
uniform grayness to
the entire hemithorax
with the absence of
vascular markings
suggest the diagnosis
 Pleural disease - Pleural effusion
Pleural effusion is an abnormal
collection of fluid in the pleural space.
Fluid may be (Transudate, Exudate,
Pus, Blood, Chyle, Cholesterol, Urine )
A. Erect frontal Chest X-ray:
1. Blunting of costophrenic angle 
2. Blunting of cardiophrenic angle
3. The diaphragmatic contour is
partially or completely obliterated,
depending on the amount of the
fluid (silhouette sign).
4. Fluid within the horizontal or
oblique fissures
5. Concave meniscus seen laterally and
gently sloping medially (horizontal
in case of hydropneumothorax) 
 Pleural effusion - Erect frontal Chest X-ray
6. Massive pleural effusion:
 Opacification of entire hemithorax
(“white-out” lung) and shifting of
mediastinum to the opposite side
(note: The mediastinal shift can be
less prominent or even absent in
the presence of underlying lung
collapse or contralateral
hemithorax abnormality)
 Around 5-7 liters of pleural fluid
 Generally, the pleural effusion is
said to be massive if it crosses the
anterior border of the 2nd rib. It is Massive right pleural effusion
said to be moderate if it crosses (1), with shift of
the anterior border of the 4nd rib mediastinum towards left (2)
and is said to be mild or small if it
is below that.
 Pleural effusion - Erect frontal Chest X-ray
9. Loculated (encysted, encapsulated) pleural effusion:
 Loculation secondary to
adhesions after an
infected or hemorrhagic
effusion.
 Peripheral soft-tissue
opacity with smooth
obtuse tapering margins

Pleural opacity.
Encapsulated pleural
effusion – Frontal chest
radiograph; shows a
lenticular opacity with
smooth borders and obtuse
angles (black arrows)
 Pleural disease - Pleural effusion
How do you determine the etiology of effusion from chest x-ray?
 Bilateral: consider transudative effusions first. You will need
clinical information.
 Bilateral effusions with cardiomegaly: Congestive heart
failure
 Bilateral pleural effusions associated with ascites in a alcoholic:
Cirrhosis
 Unilateral: most of them are exudative
 Massive unilateral effusion: Malignancy
 Pleural effusion with apical infiltrates: Tuberculosis
 Pleural effusion with nodes or mass or lytic bone lesions:
Malignancy
 Loculated effusions are empyemas
 Pleural effusion with a missing breast suggesting resection for
cancer: Malignancy
 Pleural effusion following chest trauma: Hemothorax
 Chest X-ray Abnormalities - Diaphragm
Elevated hemidiaphragm: If the left hemidiaphragm is higher
than the right or the right is higher than the left by more than 3 cm
Can result from:
 Above the diaphragm
 Decreased lung volume
 Atelectasis/collapse
 Lobectomy/
pneumonectomy
 Pulmonary
hypoplasia
 Diaphragm
 Phrenic nerve palsy
 Diaphragmatic
eventration
 Contralateral stroke:
usually middle cerebral
 Chest X-ray Abnormalities - Diaphragm
Diaphragmatic hernia: defect in the diaphragm can result
from:
 Congenital:
 Bochdalek hernia: most common, More frequent on left
side, located posteriorly and usually present in infancy
 Morgagni hernia: smaller, anterior and presents later,
through the sternocostal angles
 Acquired:
 Traumatic diaphragmatic rupture
 Hiatus hernia
 Iatrogenic
 Chest X-ray Abnormalities - Diaphragm
Hiatus hernias occur when there is herniation abdominal contents
through the oesophageal hiatus of the diaphragm into the thoracic
cavity. Appears as retrocardiac opacity with air-fluid level

Posteroanterior (PA) and lateral view of hiatal hernia.

Can you see the air-filled "mass" posterior to the heart
 Chest X-ray Abnormalities - Diaphragm
Free gas under diaphragm (Pneumoperitoneum): It is a
finding in the chest X-ray seen in case of perforation of
hollow viscus.

CXR shows Minor

opacity in the left
lower zone. Large
volume of free
subdiaphragmatic
gas ( yellow arrow).
 Chest X-ray Abnormalities - Heart
Cardiomegaly and heart failure:
The heart is enlarged if the cardiothoracic ratio (CTR) is greater than
50% on a PA view. If the heart is enlarged, check for other signs of
heart failure such as pulmonary oedema, septal lines (or Kerley B
lines), and pleural effusions.
CXR shows:
• Cardiomegaly CTR = 18/30 (>50%)
• Upper zone vessel enlargement (1)
- a sign of pulmonary venous
hypertension
• Pulmonary oedema (2) - bilateral
increased lung markings (classically
peri-hilar and shaped like bats wings
- more widespread in this case)
• Septal (Kerley B) lines (3)
• Pleural effusions (4)
 Chest X-ray Abnormalities - Heart
Pulmonary embolism (PE): Features include:
 Normal CXR
 Plate atelectasis
 Hampton hump: pleural-based
opacity (pulmonary
infarction)
 Small pleural effusion
 Elevated hemidiaphragm
 Fleischner’s sign (prominent
amputated pulmonary artery)
 Westermark’s sign (peripheral
oligaemia)
 Palla's sign: Enlarged right
descending pulmonary artery
 The more abnormal the CXR, the less likely is Pulmonary embolism
Normal CXR in a breathless hypoxic person in the absence of
 Heart- Pulmonary embolism

Fleischner sign: Refers to the A chest radiograph shows a

prominence of central pulmonary
artery caused either by pulmonary
hypertension that develops secondary
to PE or by distension of the vessel by
a large clot
Westermark sign (arrow), with a
focal area of oligemia in the right
middle zone and cutoff of the
pulmonary artery in the upper
lobe of the right lung.
 Chest X-ray Abnormalities - Heart
Pulmonary Arterial Hypertension: Features include:
 Elevated cardiac apex due to right ventricular hypertrophy
 Enlarged right atrium
 Prominent pulmonary outflow tract
 Enlarged pulmonary arteries
 Pruning of peripheral pulmonary vessels
 Chest X-ray Abnormalities - Heart
Pericardial effusion:
 It occurs when excess fluid collects in
the pericardial space (a normal
pericardial sac contains approximately
30-50 mL of fluid).
 CXR Suggestive but not usually
diagnostic.
 Globular enlargement of the cardiac
shadow giving a water bottle
configuration
 Widening of the subcarinal angle
without other evidence of left atrial
enlargement may be an indirect clue
 Mediastinal abnormalities - Masses
Clues to locate mass to mediastinum
Mediastinal masses Masses in the lung
 Not contain air bronchograms  May contain air
 The margins with the lung will be obtuse. bronchograms
 Mediastinal lines (azygoesophageal recess,  A lung mass abutts
anterior and posterior junction lines) will be the mediastinal
disrupted. surface and creates
 There can be associated spinal, costal or with lung an acute
sternal abnormalities. angles.

LEFT: A lung mass abutts the

mediastinal surface and creates
acute angles with the lung.
RIGHT: A mediastinal mass will
sit in the mediastinum, creating
obtuse angles with the lung.
 Mediastinal abnormalities - Masses
Clues to locate mass to mediastinum:

LEFT: there is a lesion that has an acute border

with the mediastinum. This must be a lung mass.
RIGHT: shows a lesion with an obtuse angle to the
mediastinum. This must be a mediastinal mass.
Localize mass within the mediastinum
In lateral CXR, mediastinum is divided into superior and Inferior.
Inferior mediastinum is divided into anterior, middle, and posterior
 Mediastinal abnormalities - Masses
Anterior Mediastinal Masses (5Ts)

 Thymus Abnormalities (thymoma, invasive thymoma, thymic carcinoma,

thymolipoma/thymoliposarcoma, thymic cyst, thymic hyperplasia, thymic
carcinoid)
 Thyroid (thyroid neoplasms, thyroid goiter)
 Terrible Mediastinal Lymphoma (Hodgkin and non-Hodgkin lymphoma)
 Germ Cell Tumors (Teratoma, teratocarcinoma, seminoma,
choriocarcinoma,
embryonal cell carcinoma, endodermal sinus tumors (yolk sac tumors))
 Thoracic Aortic Aneurysm
 Pericardial Cyst
 Morgagni Hernia
 Sternal Tumors
 Pericardial Fat Pad

B-cell lymphoma. (A) a very large

mass (arrows). (B) The mass in the
anterior mediastinum (outlined
in yellow) is displacing the
trachea (blue lines) posteriorly.