X-Ray INTERPRETATION AND TEACHING

SAMIR EL ANSARY

Radiological signs of Disease

Cavitary lung lesions Loculated empyemaHydropneumothorax

Esophageal obstruction Mediastinal abscess

HydropneumopericardiumHiatal hernia

Chest wall abscess

Air Fluid Levelsin the following conditions:

• A mediastinal lesion should have a sharp margin convex towards the lungs and its base abutting the mediastinum .

Most disease processes will either increase or decrease the density of the lung parenchyma

• A pleural lesion should be seen as a homogenously dense opacity abutting the pleural surface, without air bronchogram.

• If the pleural lesion is free fluid, it will gravitate to the dependant lung parts first to form a miniscus(concavity) along its upper surface.

• An extra pleural lesion demonstrates a homogenous density which makes obtuse angles with the chest wall, or may appear similar to pleural disease.

• A lung opacity may be due to a mass or lung-parenchymal opacification.

• Identification of clear margins vs indistinct or diffuse opacification is important in making the differentiation.

• If the diffuse opacification demonstrates lucencies or air bronchogram within it, it is most likely air space disease (consolidation).

Signs of lobar collapse

• Local increase in density due to non-aerated lung.

• Decreased lung volume.

• Displacement of pulmonary fissures.

• Elevation of hemidiaphragm.

• Displacement of hila.

COMMENT ON NEXT SLIDE

left upper lobe atelectasis following right upper lobectomy.

The left lung lacks a middle lobe and therefore a minor fissure, so left upper lobe atelectasis presents a different picture from that of the right upper lobe collapse.

The result is predominantly anterior shift of the upper lobe in left upper lobe collapse, with loss of the left upper cardiac border. The expanded lower lobe will migrate to a location both superior and posterior to the upper lobe in order to occupy the vacated space.

As the lower lobe expands, the lower lobe artery shifts superiorly. The left mainstem bronchus also rotates to a nearly horizontal position.

Pleural effusion + lobar densities

• Pneumonia with empyema

• Pulmonary infarction

• Bronchogenic carcinoma

• Tuberculosis

Pleural effusion + subsegmental atelectasis

• Postoperative (thoracotomy, splenectomy, renal surgery) secondary to thoracic splinting + small airway mucous plugging

• Pulmonary infarction

• Abdominal mass

• Ascites

• Rib fractures

Upper lung zone distribution

• Cystic fibrosis

• Ankylosing spondylitis

• Sarcoidosis

• Silicosis

• Histiocytosis (Langerhan's cell)

• TB, fungal

• Radiation pneumonitis ( cancers of head/neck and breast)

Peripheral lung zone distribution

• BOOP (bronchiolitis obliterans organizing

pneumonia)

• UIP (usual interstitial pneumonitis, and DIP

desquamative interstitial pneumonitis)

• Infarcts

• Eosinophilic pneumonia

• Alveolar sarcoidosis

• Contusions

LUNG VOLUME

*Reduced• Idiopathic pulmonary fibrosis.• Chronic interstitial pneumonia• Asbestosis• Collagen vascular disease• Chronic pulmonary tuberculosis *Normal

SarcoidosisHistiocytosis

*IncreasedBronchial AsthmaEmphysemaLymphangioleiomyo-

matosis

Reticulations & Hilar Adenopathy

Sarcoidosis

Silicosis

Lymphoma/leukemia

Lung primary: particulary oat cell carcinoma

Metastases: lymphatic obstuction/spread

Fungal disease

Tuberculosis

Viral pneumonia (rare combination)

Lung mass

• of more than Clinical history and patient’s age .• Mass borders .• Comparison with previous examinations.• Presence of calcifications.• Associated adjacent rib erosions, pleural effusion,

hilar or mediastinal nodal enlargement.• Presence of more than one mass.

Distribution of opacities

• Unifocal or multifocal.

• Lobar.

• Segmental.

• Perihilar.

• Peripheral.

• Upper, middle or lower zones.

Lung fields appear dark because of air. Ninety-nine percent of the lung is air.

The pulmonary vasculature, interstitium constitute 1% and give the

lacy lung pattern.

Normal Female . older, youngNote breast shadows Look for asymmetry or missing breast (surgery) Be aware of basal lung changes due to breast tissue. Review lateral to evaluate basal changes.

Which lung is larger? Which diaphragm is higher and why? What is the normal size of the heart? What is the normal size and shape of

the aorta?

Dextrocardia

GASTRIC GAS BUBBLE

Silhouette sign is extremely useful in

localizing lung lesions

Silouhette Adjacent lobe/segment

Right Diaphragm RLL/Basal segments

Right Heart margin RML/Medial segment

Ascending Aorta RUL/Anterior segment

Aortic knob LUL/Posterior segemnt

Left Heart margin Lingula/Inferior segment

Descending Aorta LLL/Superior and medial segments

Left Diaphragm LLL/Basal segments

Consolidation / LingulaDensity in left lower lung field Loss of left heart silhouette Diaphragmatic silhouette intact No shift of mediastinumBlunting of costophrenic angle

Lobar Pneumonia Right Middle Lob

Note the upward movement of the left hilum following LUL resection for cancer

Pleural Effusion /Upright and Supine

Upright Supine

Hyperlucent Lung

• Factors– Vasculature: Decrease – Air: Excess – Tissue : Decrease

• Bilateral diffuse– Emphysema – Asthma

Unilateral– Swyer James syndrome – Agenesis of pulmonary artery – Absent breast or pectoral muscle – Partial airway obstruction – Compensatory hyperinflation

Localized– Bullae– Westermark's sign : Pulmonary embolus

.

Emphysema

R mastectomy

Unilateral Hyperlucent LungLeft Upper Lobe Resection

Unilateral Hyperlucent LungRight Upper Lobe Resection

Unilateral Hyperlucent LungPeanut in Left BronchusPartial Airway Obstruction Left lung hyperlucentLeft lung stays hyperlucent on expiration Mediastinal shift with respiration

Honeycombing

Honeycombing

• Seen in end stage lung disease

• Indicative of diffuse interstitial fibrosis

• Due to bronchiolectasia

• Most of the time in bases

• Upper lobe distribution seen in eosinophilicgranuloma

LymphangiticMetastasisCancer BreastKerley lines Subpulmoniceffusion on right

Sarcoidosis / MiliaryNodules / Hilar Nodes

Milary TuberculosisInterstitial nodules

Uniform size Sharper edges

Aspergilloma

Aspergilloma. Bilateral upper lobe disease Long standing cavity due to sarcoidosisCavity containing round density Crescent sign - semilunar air space above mass density

AspergillosisSolitary Pulmonary NodulePatient on steroids. Develops solitary pulmonary nodule with air bronchogram. Short doubling time indicating inflammatory process. Air bronchogram indicating that it is an alveolar process.- On steroids (film below) - Develops solitary pulmonary nodule within one month - Air bronchogram in the density FNAB: AspergillusResolved with discontinuation of steroids

PneumonectomyOpacity left hemithorax Tracheal shift to left Cardiac and left diaphragmatic silhouettes missing Crowding of ribs

Pleural Effusion Massive

Atelectasis Right Lung

Pneumothorax

Tension Pneumothorax No vascular markings on right Shift of mediastinum to left Deep sulcus Atelectatic right lung Increased haziness on left: Diversion of entire cardiac output

Tracheal Shift /Thyroid Mass

AP Window Nodes - Small Cell Cancer

Hilar NodesNote bilateral symmetrical hilar nodes and para tracheal nodes.A clear space between the nodes and heart, identifies the nodes as hilar.

Pulmonary SchistosomiasisAneurysmal dilatation of pulmonary arteries

Pulmonary EdemaCardiomegalyBilateral alveolar densities Bilateral pleural effusions Hilar haze Rapid clearance

Adult Respiratory Distress SyndromeNon-cardiogenic pulmonary edemaDistinguishing characteristics: Normal size heart No pleural effusion

Pulmonary OsteoarthropathyAnterior Mediastinal Mass

Lung CancerRUL primary lesion Para tracheal nodes

Achalasia CardiaInhomogeneous cardiac density Right sided inlet to outlet shadow Crossing mid line Barium swallow below: Dilated esophagus

Aneurysm Arch of AortaMediastinal mass Extrapleural

Aneurysm Arch of AortaLeaking Blood into Pleural SpaceMediastinal mass Calcification of periphery evident along upper margin Loss of silhouettes of

aortic knob left heart margin left diaphragm

Left pleural effusion Tracheal indentation Old and New x rays

Aneurysm Arch of Aorta"Mass" density Extrapleural Middle mediastinal mass

Aneurysm of Descending Aorta- Inhomogeneous cardiac densityRetrocardiac density Extrapleural

Dissecting AneurysmMediastinal widening Inlet to outlet shadow on left side Retrocardiac: Intact silhouette of left heart margin Pulmonary artery overlay sign: Density behind left lower lobe Wavy margin Lat view demonstrates increased density over spine

Aneurysm of Descending Aorta"Mass" density Extrapleural Posterior mediastinal mass

Bronchiectasis

• Normal appearing CXR in most

• Tubular shadows

• Tram line

• Gloved fingers

• Mucocele

• Ring shadows with thickened bronchial walls

• Air fluid levels

• Watch for dextrocardia – Immotile cilia syndrome

• Diffuse lung fibrosis – Due to recurrent infections

Cystic Fibrosis - BronchiectasisBilateral diffuse Multiple cavities / Bronchiectasis Peribronchial fibrosis Prominent hilum Hyperinflated

Carcinoid

Branchial cyst .Asymptomatic young lady presents with abnormal chest x-ray. Mass density Round with sharp margins .L. old film..R.new film

Branchial cyst .Cystic nature is evident in CT

Coarctation AortaPost stenotic dilatation: Mogul signRib notching: Difficult to see in this presentation

Coarctation Aorta

Right Sided Aortic ArchAortic knob missing on left and seen on right Descending aorta missing on left and seen on right Paravertebral line on right

Right Sided Aortic ArchAortic knob on right Descending aorta on right Paravertebral line Right Sided Aortic ArchAortic knob on right Descending aorta on right Paravertebral line

Hamman-Rich SyndromeRapid progression of interstitial disease

Anterior Mediastinal MassWidened mediastinumLoss of cardiac silhouette Intact silouhette of descending aorta Lateral view below.This is a case of anaplastic carcinomaRetrosternal area is filled with mass density.

TuberculosisLUL cavities RUL infiltrateBilateral upper lobe disease

Pulmonary Embolism

. The primary purpose of a chest film in suspected PE is to rule out other diagnoses as a cause of dyspnea or

hypoxia. Most CXRs in patients with PE are normal.

These are two PA fiilms demonstrating Hampton's hump (rounded opacities) in patients with pulmonary embolism

Aneurysm of Descending Aorta"Mass" density ExtrapleuralPosterior mediastinal mass

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamir@yahoo.com