Chest X-Ray:1

Basic Interpretation

Lecturer: M.K. Sastry

• Deviation of the azygoesophageal line is caused by (5):
– Hiatal hernia
– Esophageal disease
– Left atrial enlargement
– Subcarinal lymphadenopathy
– Bronchogenic cyst
• Notice the deviation of the azygoesophageal
line on the PA-film.
• It is caused by a hiatal hernia.
• Vena azygos lobe
• A common normal variant is the azygos lobe.
• The azygos lobe is created when a laterally displaced azygos vein makes a
deep fissure in the upper part of the lung.
• On a chest film it is seen as a fine line that crosses the apex of the right lung.
• Azygos lobe.
The azygos vein is seen as a thick structure within
the azygos fissure.
• In some patients an extra joint is seen in the anterior
part of the first rib  at the point where the bone
meets the calcified cartilageneous part (arrow).
• This may simulate a lung mass.
• Pectus excavatum : is a congenital deformity of the ribs and the sternum  a
concave appearance of the anterior chest wall.
• In which right heart border can be ill-defined, but this is normal.
It produces a silhouette sign simulating a consolidation or atelectasis of the right
middle lobe.
• The lateral view is helpful in such cases.
• The left main pulmonary artery (in purple) passes
over the left main bronchus and is higher than
the right pulmonary artery (in blue) which passes
in front of the right main bronchus.
Once you know how the normal hilar
structures look like on a lateral view,
 it is easier to detect abnormalities.
• In this case
PA-view :
hilar
enlargement.
* On the PA-
view it is not
clear
whether this
is due : to
dilated
vessels / or
enlarged
lymph nodes.
• On lateral view:
• there are round
structures in areas where
you don't expect any
vessels.
• So we can conclude that
we are dealing with
enlarged lymph nodes.
• This patient has
sarcoidosis.

• Notice also the widening

of the paratracheal line
(or stripe) as a result of
enlarged lymph nodes.
• On the lateral view spondylosis may mimick a lung mass.
• Any density in the area of the vertebral bodies should lead you to the PA-
film to look for spondylosis, which is usually located on the right side
(arrows).
On the left side the formation of osteophytes is hampered by the pulsations
of the aorta.
• On the PA-view the superior mediastinum is widened.
The lateral view is helpful in this case because it demonstrates a density in the retrosternal
space.
Now the differential diagnosis is limited to a mass in the anterior mediastinum (4 T's).
• This was a Hodgkins lymphoma.
• A common incidental finding in adults is a Bochdalek hernia, which is due to a congenital
defect in the posterior diaphragm (arrows).
In most cases it only contains retroperitoneal fat and is asymptomatic, but occasionally it
may contain abdominal organs.
• Large hernias are sometimes seen in neonates and can be complicated by pulmonary
hypoplasia.
• A hernia of Morgagni is also a congenital diaphragmatic hernia, but is less common.
It is located anteriorly.
 Systematic Approach

• Whenever you review a chest x-ray,

…………………….. always use a systematic approach.
• We use an inside-out approach from central to peripheral.
= First the Heart figure is evaluated, followed by
mediastinum and Hili  Subsequently the Lungs, lung borders
and  finally the chest wall and Abdomen are examined.

• You have to know the normal anatomy and Variants.

• Find subtle abnormalities by using the sihouette sign and
mediastinal lines.
Once you see an abnormality use a pattern approach to come
up with the most likely diagnosis and differential diagnosis.
Old films
• Always compare with old films,
• Actually someone said that the most
important radiograph is the old film,
since it gives you so much
information.
• A lung mass, which hasn't changed in
many years
•  is not a lung cancer.
• First study the chest films. Then
continue.
• Based on the CXR that you just saw, you could have made
the diagnosis of  congestive heart failure,
but the findings are very subtle.

However once you compare it to the old film, things become

more obvious and you will be much more confident in
your diagnosis:
– The size of the heart is slightly increased compared to the old
film.
– The pulmonary vessels are slightly increased in diameter
indicating increased pulmonary pressure.
– There are subtle interstitial markings as a result of interstitial
edema.
– There is pleural fluid bilaterally.
• Notice that the inferior border of the lower lobes has
changed in position.
• All these findings indicate the presence of heart failure.
 Silhouette sign
• A very important sign.
• It enables us to : find subtle pathology and to
locate it within the chest.

• The loss of the normal silhouette of a structure is

called the silhouette sign.
• The heart is :
– located anteriorly in the chest and it is bordered by the lingula of the left lung.
• The difference in density between the heart and the air in the lung enables us
to see the silhouette of the left ventricle.
When there is something in the lingula with the same 'water density' as the
heart,  the normal silhouette will be lost (blue arrow).
• When there is a pneumonia in the left lower lobe, which is located more
posteriorly in the chest, the left ventricle will still be bordered by air in the
lingula and we will still see the silhouette of the heart (red arrow).
• The PA-film shows a silhouette sign of the left heart border.
Even without looking at the lateral film,  the pathology must
be located anteriorly in the left lung.

• This was a consolidation due to a pneumonia caused by

Sterptococcus pneumoniae.
• a consolidation which is located in the left lower
lobe.
There is a normal silhouette of the left heart
border.
• The retrosternal space should be radiolucent,  since it only contains
air.
• Any radiopacity in this area is suspective of a proces in the anterior
mediastinum or upper lobes of the lung.
• The contours of the left and right diaphragm should be visible.
• The right diaphragm should be visible all the way to the anterior chest wall (red
arrow).
Actually we see the interface between the air in the lungs and the soft tissue
structures in the abdomen.
• The left diaphragm can only be seen to a point where it borders the heart (blue
arrow).
• On this lateral film there is too much density
over the lower part of the spine.
• By only looking at the interfaces of the left and
right diaphragm on the lateral film, it is possible
to tell on which side the pathology is located.
• First study the lateral film.
Then continue.
• On a normal lateral chest film the silhouette of the left diaphragm 2- can be
seen from posterior up to where it is bordered by the heart, which has the
same density (blue arrow).
• One should be able to follow the contour of the right diaphragm -1- from
posterior all the way to anterior, because it is only bordered by the lung.
• Here we cannot follow the contour of the right diaphragm all the way to
posterior, which indicates that there is something of water-density in the right
lower lobe (red arrow).
• On the PA-film: normal silhouette of the heart border,  so the pathology
is not in the anterior part of the chest, which we already suspected by
studying the lateral view.
• Why do we still see the silhouette of the right diaphragm on the PA-film?
• What we see is actually the highest point of the right diaphragm, which is
anterior to the pneumonia in the right lower lobe.
The pneumonia does not border the highest point of the diaphragm.
 Hidden
areas

•Apical zones
•Hilar zones
•Retrocardial zone
•zone below the dome of
diaphragm

Some areas that need special attention,

pathology in these areas can easily be overlooked:
These areas are also known as the hidden areas.
• Notice : quite some lung volume below the dome
of the diaphragm, which will need your attention
(arrow).
• An example of a large lesion in the right lower lobe, which is difficult to detect
on the PA-film, unless when you give special attention to the hidden areas.
• Click on the image for an enlarged view.
• Pneumonia in the right lower lobe mainly below the level of
the dome of the diaphragm (red arrow).
• Notice the increase in density on the lateral film in the lower
vertebral region.
• Notice the subtle increased density in the area behind the
heart that needs special attention (blue arrow).
 a lower lobe pneumonia.
• We know that in some cases there is an extra
joint in the anterior part of the first rib which
may simulate a mass.
However this is also a hidden area where it
can be difficult to detect a mass.
• In this case a small lung cancer is seen behind the left first rib.
Notice that is is also seen on the lateral view in the retro-sternal
area.
• ………….Continue with the PET-CT.
• The PET-CT demonstrates the tumor (arrow) which has
already spread to the bone and liver.
The diagnosis was made by a biopsy of an osteeolytic
metastasis in the iliac bone.
• There is a subtle consolidation in the left lower lobe
in the hidden area behind the heart.
Again there is increased density over the lower
vertrebral region.
 Heart and
Pericardium
• On a chest film only the outer contours of the
heart are seen.
In many cases we can only tell whether the
heart figure is normal or enlarged and it will be
difficult to say anything about the different
heart compartments.

• However it can be helpful to know where the

different compartments are situated.
Left Atrium
•Most posterior structure.
•Receives blood from the pulmonary veins that run almost horizontally towards the left atrium.
•Left atrial appendage (in purple) can sometimes be seen as a small outpouching just below the
pulmonary trunk.
•Enlargement of the left atrium results on the PA-view in outpouching of the upper heart
contour on the right and an obtuse angle between the right and left main bronchus. On the
lateral view bulging of the upper posterior contour will be seen.

Right Atrium

•Receives blood from the inferior and superior vena cava.

•Enlargement will cause an outpouching of the right heart contour.
Left Ventricle

•Situated to the left and posteriorly to the right ventricle.

•Enlargement will result on the PA-view in an increase of the heart size to the left and on the
lateral view in bulging of the lower posterior contour.

Right Ventricle
•Most anterior structure and is situated behind the sternum.
•Enlargement will result on the PA-view in an increase of the heart size to the left and can finally
result in the left heart border being formed by the right ventricle.
Left Atrium
•The upper posterior border of the heart is
formed by the left atrium.
•Enlargement will result in bulging of the upper
posterior contour

Left Ventricle

•Forms the lower posterior border.

•Enlargement will displace the contour more
posteriorly.

Right Ventricle

•The lower retrosternal space is filled by the right

ventricle.
•Enlargement of the right ventricle will result in
more superior filling of this retrosternal space.
Left Atrium enlargement
This is a patient with longstanding mitral valve disease and mitral valve
replacement.
• Extreme dilatation of the left atrium has resulted in bulging of the contours
(blue and black arrows).
On these chest films :
•the heart is extremely dilated.
Notice that it is especially the right ventricle that is dilated. This is well
seen on the lateral film (yellow arrow).
•There is a small aortic knob (blue arrow),
•while the pulmonary trunk and the right lower pulmonary artery are
dilated.
All these findings are probably the result of a left-to-right shunt with
subsequent development of pulmonary hypertension.
The location of the cardiac
valves is best determined on
the lateral radiograph.

A line is drawn on the lateral

radiograph from the carina to
the cardiac apex.

The pulmonic and aortic

valves generally sit above this
line and the tricuspid and
mitral valves sit below this
line (4).

On this lateral view you can

get a good impression of the
enlargement of the left
atrium.
 Cardiac incisura

• On the right side of the chest the lung will lie against the anterior chest wall.
On the left however the inferior part of the lung may not reach the anterior
chest wall, since the heart or pericardial fat or effusion is situated there.
• This causes a density on the anteroinferior side on the lateral view which can
have many forms.
It is a normal finding, which can be seen on many chest x-rays and should not
be mistaken for pathology in the lingula or middle lobe.
explanation for the cardiac incisura is seen on
this CT-image.
At the level of the inferior part of the heart we
can appreciate that the lower lobe of the right
lung is seen more anteriorly compared to the
left lower lobe.
 Pericardial effusion
•Whenever we encounter a large heart figure, we should always be
aware of the possibility of pericardial effusion simulating a large heart.
•On the chest x-ray it looks as if this patient has a dilated heart while on
the CT it is clear, that it is the pericardial effusion that is responsible for
the enlarged heart figure.
• Especially in
patients who had
recent cardiac
surgery an
enlargement of the
heart figure can
indicate pericardial
bleeding.
• This patient had a
change in the heart
configuration and
pericardial bleeding
was suspected.
Ultrasound
demonstrated only
a minimal
pericardial effusion.
Continue with the
CT.
• There is a large pericardial effusion, which is located posteriorly to the left ventricle (blue arrow).
The left ventricle id filled with contrast and is compressed (red arrow).
At surgery a large hematoma in the posterior part of the pericardium was found.
• Notice that on the anterior side there is only a minimal collection of pericardial fluid, which explains why the
ultrasound examination underestimated the amount of pericardial fluid.
 Calcifications

• Detection of calcifications within the heart is quite common.

• The most common are coronary artery calcifications and valve

calcifications.
• Here we see pericardial calcifications which can be associated with
constrictive pericarditis.
• In this case there are calcifications that look like pericardial
calcifications, but these are myocardial calcifications in an
infarcted area of the left ventricle.
• Notice that they follow the contour of the left ventricle.
• Pericardial fatpad
• Pericardial fat depositions are common.
Sometimes a large fat pad can be seen (figure).
• Necrosis of the fat pad has pathologic features similar to fat necrosis in epiploic
appendagitis.
It is an uncommon benign condition, that manifests as acute pleuritic chest pain in
previously healthy persons
 Pericardial cyst
•Pericardial cysts are connected to the pericardium and usually contain
clear fluid.

•The majority arise in the anterior cardiophrenic angle,

•more frequently on the rightside,
•but they can be seen as high as the pericardial recesses at the level of the
proximal aorta and pulmonary arteries .

•Most patients are asymptomatic.

•On the chest x-ray it seems as if there is a elevated left hemidiaphragm.

•On CT however there is a cyst connected to the pericardium.

Hili
• The normal hilar shadow is for 99% composed of
vessels - pulmonary arteries and to a lesser
extent veins.

• The vessel margins are smooth and the vessels

have branches.
• The left pulmonary artery runs over the left main
bronchus,
• while the right pulmonary artery runs in front of
the right main bronchus, which is usually lower
in position than the left main bronchus.
• Hence the left hilum is higher than the right.

• Only in a minority of cases the right hilus is at the

same level as the left, but never higher.
• In this illustration :
• lower lobe arteries are coloured ďlue ď
͞ eĐause theLJ Đontain odžLJgen-poor
ďlood͟.
• They have a more vertical orientation,
• while the pulmonary veins run more horizontally towards the left atrium,
which is located below the level of the main pulmonary arteries.
• Both pulmonary arteries and veins can be identified on a lateral
view and should not be mistaken for lymphadenopathy.
• Sometimes the pulmonary veins can be very prominent.
• The lower lobe pulmonary arteries extend inferiorly from the hilum.
They are described as little fingers, because each has the size of a little finger .
• On the right side the little finger will be visible in 94% of normal CXRs and on
the left side in 62% of normals.
 Right Descending Pulmonary Artery

Right
Descending
Pulmonary
Artery
< 17 mm

Serves right
middle and
lower lobes
• Study the CXR of a 70-year old male who fell from the stairs and has severe pain on the
right flank..
• Notice on the PA-film the absence of the little finger on the right and on the lateral view
the increased density over the lower vertebral column.
• What is your diagnosis?
 Hilar enlargement

• The table summarizes the causes of hilar enlargement.

• = Normal hili are:
• •Normal in position - left higher than right
• •Equal density
• •Normal branching vessels
• Enlargement of the hili is usually due to:
lymphadenopathy or enlarged vessels.
• In this case there is an enlarged hilar shadow on
both sides.
This could be the result of enlarged vessels or
enlarged lymph nodes.
A very helpful finding in this case is the mass on
the right of the trachea.
• This is known as the 1-2-3 sign in sarcoidosis, i.e.
enlargement of left hilum, right hilum and
paratracheal.
• Here some more examples of sarcoidosis.

1. Lymphadenopathy and groundglass appearance

of the lungs
2. Lymphadenopathy, 1-2-3 sign
3. Bulky lymphadenopathy
4. 1-2-3 sign
5. Nodular lung pattern, no lymphadenopathy
6. Hilar and paratracheal lymphadenopathy
 Mediastinum

divided into an anterior, middle and posterior compartment, each with it's own
pathology.
 Mediastinum

• Mediastinal masses are discussed in more detail in Mediastinal masses.

• Here is just a brief overview.
 Mediastinal lines
Mediastinal lines or stripes
are
interfaces between the soft
tissue of mediastinal
structures and the lung.
Displacement of these lines
is helpful in finding
mediastinal pathology,
• Azygoesophageal recess
• The most important mediastinal line to look for is
the azygoesophageal line, which borders the
azygoesophageal recess.

• This line is visible on most frontal CXRs.

• The causes of displacement of this line are

summarized in the table.
• A hiatal hernia is the most common cause of
displacement of the azygoesophageal line.
• Notice the air within the hernia on the lateral view.
• Another common cause of displacement of the azygoesophageal line is subcarinal
lymphadenopathy.
• Notice the displacement of the upper part of the azygoesophageal line on the chest x-
ray in the area below the carina.
This is the result of massive lymphadenopathy in the subcarinal region (station 7).
• There are also nodes on the right of the trachea displacing the right paratracheal line.
• On the PET we can appreciate the massive
lymphadenopathy far better than on the CXR.

• There are also lymphomas in the neck.

this is an important finding, since these nodes
are accessible for biopsy.

• Continue with images of CT and ultrasound.

• Here we see a CT-image.
The azygo esophageal recess is displaced by lymph
nodes that compress the left atrium.
• The final diagnosis of small cel lung cancer was
made through a biopsy of a lymph node in the neck.
• Notice the following:
• There is displacement of the azygoesophageal
line both superiorly an inferiorly.
• There is an air-fluid level (arrow).
Combined with the above this must be a dilated
esophagus with residual fluid. The final diagnosis
was achalasia.
• The density on the left in the region of the
lingula is the result from prior aspiration
pneumonia.
• Here we have a prior CXR of this patient.
• The AP-film shows a right paratracheal mass.
The azygoesophageal recess is not identified, because it is
displaced and parallels the border of the right atrium.
The large round density in the left lung is the result of
aspiration.

• Notice the massive dilatation of the esophagus on the CT.

 Aortopulmonary window

• The aortopulmonary window is the

interface below the aorta and above the
pulmonary trunk and is concave or straight
laterally.
• Here the AP-window is convex laterally due
to a mass that fills the retrosternal space on
the lateral view.
• On the CT-images a mass in the anterior mediastinum
is seen.
• Final diagnosis: Hodgkin's lymphoma in the lungs.
• Here another case.
On the PA-film a mass is seen that fills the
aortopulmonary window.
• The PET better demonstrates the extent of the
lymphnode metastases in this patient.
• Final diagnosis: small cell lungcarcinoma.
 Lungs
• Lung abnormalities mostly present as areas of increased density,
which can be divided into the following patterns:

1. Consolidation

2. Atelectasis

3. Nodule or mass - solitary or multiple

4. Interstitial

• Less frequently areas of decreased density are seen as in

emphysema or lungcysts.
• These lungpatterns will discussed in more detail in an article that
will be published soon: Chest X-Ray - Lung disease.