cxr: 'silhoutte' and other signs

Interesting chest xray for Interesting chest xray for discussiondiscussion

Prof Magesh kumar unitProf Magesh kumar unit

Dr vijayanandDr vijayanand

60 years old gentleman comes with60 years old gentleman comes with c/o cough with sputum 3monthsc/o cough with sputum 3months c/o haemoptysis on &off 3 monthsc/o haemoptysis on &off 3 months Chronic smokerChronic smoker No h/o prior anti tb therapyNo h/o prior anti tb therapy

Clinical examinationClinical examination

Tracheal shift to RtTracheal shift to Rt Movements decreased in R infrascapular, Movements decreased in R infrascapular,

interscapular regionsinterscapular regions Dull note in above areas.Dull note in above areas. Breath sounds decreased in intensity in Breath sounds decreased in intensity in

above areasabove areas

Differential DiagnosisDifferential Diagnosis

1 Bronchogenic carcinoma1 Bronchogenic carcinoma

2 neurogenic tumours2 neurogenic tumours

3 Bronchogenic cyst3 Bronchogenic cyst

4 lung sequestration4 lung sequestration

5 oesophageal lesions5 oesophageal lesions

6 neuro enteric cyst6 neuro enteric cyst

7 Pharyngo-oesophageal pouch7 Pharyngo-oesophageal pouch

8 Aneurysm of descending aorta8 Aneurysm of descending aorta

9 Bochdalek hernia9 Bochdalek hernia

10 Pancreatic pseudo cyst10 Pancreatic pseudo cyst

11 Paravertebral mass11 Paravertebral mass

12 Hiatus hernia12 Hiatus hernia

Silhoutte signSilhoutte sign Dr Ben felson in 1950Dr Ben felson in 1950 Localisation of lesions by studying Localisation of lesions by studying

diaphragm & mediastinal outlinesdiaphragm & mediastinal outlines The borders are seen because of adjacent The borders are seen because of adjacent

aerated alveoli,diff in radiodensity b/w lung aerated alveoli,diff in radiodensity b/w lung &adjacent structures.&adjacent structures.

If air is displaced by disease ,borders are If air is displaced by disease ,borders are obliterated and lesions are localisedobliterated and lesions are localised

If the border is retained & abnormality is If the border is retained & abnormality is superimposedsuperimposed

Lesion may lie anterior or posteriorLesion may lie anterior or posterior Obliteration may occur with pleural, chest Obliteration may occur with pleural, chest

wall,mediastinal ,pulmonary pathology.wall,mediastinal ,pulmonary pathology. Silhoutte sign refers to loss of normal Silhoutte sign refers to loss of normal

appearing interfacesappearing interfaces

Silhouette/Structure Contact with Lung

Upper right heart border/ascending aorta Anterior segment of RUL

Right heart border RML (medial)

Upper left heart border Anterior segment of LUL

Left heart border Lingula (anterior)

Aortic knob Apical portion of LUL (posterior)

Anterior hemidiaphragms Lower lobes

DISPLACEMENT OF INTERLOBAR DISPLACEMENT OF INTERLOBAR FISSURESFISSURES- MOST IMP AND RELIABLE - MOST IMP AND RELIABLE SIGNSIGN

LOSS OF AERATIONLOSS OF AERATION

VASCULAR AND BRONCHIAL SIGNSVASCULAR AND BRONCHIAL SIGNS: : PARTIALLY COLLAPSED LOBE-PARTIALLY COLLAPSED LOBE-CROWDING OF ITS VESSELS.CROWDING OF ITS VESSELS.

ELEVATION OF HEMIDIAPHRAGMELEVATION OF HEMIDIAPHRAGM- MAY - MAY BE IN LL-RARE IN OTHERSBE IN LL-RARE IN OTHERS

MEDIASTINAL DISPLACEMENTMEDIASTINAL DISPLACEMENT- ULOBE-- ULOBE-TRACHEA.LL-HEART.TRACHEA.LL-HEART.

HILAR DISPLACEMENTHILAR DISPLACEMENT- ELEVATED-- ELEVATED-UL,DEPRESSED-LL.UL,DEPRESSED-LL.

COMPENSATORY HYPERVENTILATIONCOMPENSATORY HYPERVENTILATION

MINOR FISSURE MOVES UPWARDS MINOR FISSURE MOVES UPWARDS WITH CONCAVITY INFERIORLY.WITH CONCAVITY INFERIORLY.

AN AREA OF OPACITY AGAINST APEX AN AREA OF OPACITY AGAINST APEX OF MEDIASTINUM.OF MEDIASTINUM.

TRACHEAL SHIFT TO RIGHT.TRACHEAL SHIFT TO RIGHT.

RIGHT HILUM IS ELEVATED.RIGHT HILUM IS ELEVATED.

GOLDEN SIGN OF SGOLDEN SIGN OF S

Golden “ S’’ signGolden “ S’’ sign

Causes – bronchogenic carcinoma, Causes – bronchogenic carcinoma, enlarged lymph nodes, metastases.enlarged lymph nodes, metastases.

Distorted minor fissure , laterally concave Distorted minor fissure , laterally concave inferiorly, medially is convex inferiorlyinferiorly, medially is convex inferiorly

Reverse s apearance Reverse s apearance

Chilaiditi signChilaiditi sign Rare sign , incidence 0.1%Rare sign , incidence 0.1% Interposition of colon between liver and Interposition of colon between liver and

diaphragm.diaphragm. Incidental finding in normal xray Incidental finding in normal xray No symptoms No symptoms Chilaiditi syndrome when it causes pain , Chilaiditi syndrome when it causes pain ,

torsion of bowel , shortness of breath.torsion of bowel , shortness of breath.

Pneumo peritoneumPneumo peritoneumPerforated peptic ulcer

Bowel obstruction Ruptured diverticulum

Penetrating trauma Ruptured inflammatory bowel disease (e.g. megacolon)

Necrotising enterocolitis/Pneumatosis coli[2] Bowel Cancer

Ischemic bowel Steroid

After laparotomy After laparoscopy

Breakdown of a surgical anastomosis Bowel injury after endoscopy

Peritoneal dialysis Vaginal insufflation (air enters via the fallopian tubes, e.g. water-skiing, oral sex)

Colonic or peritoneal infection From chest (e.g. bronchopleural fistula)

Non-invasive PAP [positive airway pressure ]

LUFT SICHEL SIGNLUFT SICHEL SIGN:HYPEREXPANDED :HYPEREXPANDED SUPERIOR SEGMENT OF LEFT LOWER SUPERIOR SEGMENT OF LEFT LOWER LOBE INTERPOSITIONED BETWEEN LOBE INTERPOSITIONED BETWEEN ATELECTATIC UPPER LOBE AND ATELECTATIC UPPER LOBE AND AORTIC AORTIC ARCH-APPEARANCE OF ARCH-APPEARANCE OF CRESCENT OF AERATED LUNGCRESCENT OF AERATED LUNG..

OBLITERATION OF LEFT UPPER OBLITERATION OF LEFT UPPER CARDIAC BORDERCARDIAC BORDER

SHIFT OF RT UL ACROSS MIDLINESHIFT OF RT UL ACROSS MIDLINE

INCREASED RETROCARDIAC OPACITYINCREASED RETROCARDIAC OPACITY

SILHOUTTING LEFT HEMIDIAPHRAGMSILHOUTTING LEFT HEMIDIAPHRAGM

ROTATION OF HEART-FLATTENING OF ROTATION OF HEART-FLATTENING OF CARDIAC WAIST-FLAT WAIST SIGN.CARDIAC WAIST-FLAT WAIST SIGN.

SUPERIOR MEDIASTINUM MAY SHIFT-SUPERIOR MEDIASTINUM MAY SHIFT-OBLITERATION OF AORTIC KNOBOBLITERATION OF AORTIC KNOB

HEART-STRAIGHT LATERAL BORDER-HEART-STRAIGHT LATERAL BORDER-SAILSAIL LIKE SIGNLIKE SIGN