THORAX

A normal chest x ray

 Method for examining a CXR
start centrally and work out.
the middle is the heart, which usually lies to the left and measures up to half of the
total thoracic measurement in adults (more in children). Look carefully at the heart, and
if the patient has had previous heart surgery you may see prosthetic valves or coronary
stents.
Next, look at the hilar region which is the region where the main vessels from the upper
lobe and those from the lower lobe meet. The left should be higher than the right by
about 2 cm, and they should be of equal size and density.
The lungs should be fairly evenly dark, and areas of increased opacity may well reflect
consolidation, but do not be fooled by breast shadows. The breasts are quite dense,
especially in younger women
Next, look at the ribs and soft tissues, making sure that both breasts are present. ( for
women)
Finally, look carefully at the areas above the clavicles and below the diaphragm, as free
gas below the diaphragm--either postoperative or indicating bowel perforation--is best
seen on an erect chest film.
Do not forget to make sure that the film side marker is correct, as the commonest
cause of diagnoses of dextrocardia is incorrect labelling.
42 y.o. male
presents with acute
SOB and has a CXR.
What is the
diagnosis?
What would you do
next?
40 year old female has onset of fever and shortness of breath. What are the
findings and the most likely diagnosis?
What other etiologies could give similar imaging appearances?
 35 y.o female after a recent transatlantic flight presents with right sided
pleuritic chest pain and severe shortness of breath. Does the CXR explain
the shortness of breath?
What are the various imaging investigations that can be performed for the
clinical suspicion?
Which concerns are there if the patient is pregnant
Signs in Thoracic Imaging

Different signs are used as clues to

the characteristics and anatomy of
the radiological findings
 Silhouette sign
sign describes the observation that an
intrathoracic lesion will obliterate borders
of shadows of similar radiodense
structures that it contacts
example: right middle lobe pneumonia will
obliterate apex of the right heart border
 Silhouette sign

Normal

Pneumonia
(+) silhouette sign
(no heart silhouette)
Pulmonary edema
+ silhouette sign
Pneumonia
- silhouette sign
 Cervicothoracic sign
describes the finding that
only structures seen in the
posteriorly located apex of
the lung are seen above the
clavicles
Also differentiates an
intrathoracic soft tissue
mass vs. soft tissue mass of
the neck
example: structures of the
neck will appear cutoff in
the lung anatomy above the
clavicles
 Air-bronchogram sign

Air-filled bronchi are

normally not seen because
they are surrounded by air-
filled lung. If the lung is
filled with a water-based
pathology (ie, pneumonia)
the air filled bronchi will
appear as radiolucent
tubular densities
transversing the lung.
Airbronchogram =
Pneumonia
Air-space pattern of lung disease (notice the air-
bronchogram of the right upper lobe)
 Diseases of the airways
Atelectasis
Bronchial Asthma
Bronchiectasis
Bronchopulmonary sequestration
Congenital bronchogenic cysts
Emphysema
 Atelectasis

incomplete inflation of the lung

involves lung, lobe, segment, or subsegment
suggests presence of another disease
radiographic findings:
loss of pulmonary volume
increased radiodensity
distorted anatomical structures
Atelectasis of the right upper lobe caused by hilar
mass
high right hemidiaphragm
elevated horizontal fissure
reversed S configuration (s sign of Golden)
 Emphysema (imaging
findings)
bilaterally flat, depressed hemidiaphragm
lung overinflation
increased pulmonary radiolucency
increased retrosternal space (>4.5cm)
accentuated kyphosis
increased intercostal spaces
prominent hilar vasculature, decreased
peripheral
bullae
 normal
emphysema
Bullous emphysema
 Pneumonia (radiographic type)

*broncho (lobular) pneumonia (mc)

alveolar and bronchial, central

lobar pneumonia-
alveolar, peripheral

interstitial pneumonia-
thickened interstitium

aspiration pneumonia-
bilateral gravity dependent consolidation
pneumonia
where is the pneumonia
located?
 Tuberculosis (imaging findings)

primary infection
often no radiographic findings
lymphadenopathy with or without
parenchymal consolidation; central lung
typically resolve completely
Ranke complex

-hilar lymph node calcification with a

parenchymal (Ghon) granuloma

Hilar LN Calcif
and peripheral
granuloma (ranke
complex)
Pulmonary granulomas
 Tuberculosis (imaging
findings)
secondary infection = reactivation of previous
primary infxn
upper lobe distribution
parenchymal involvement causes incomplete
consolidation with strand-like radiodensities
and cavitations
Complication: superinfections by fungus

 Tuberculosis (imaging
findings)
secondary infection = reactivation of previous
primary infxn
upper lobe distribution
parenchymal involvement causes incomplete
consolidation with strand-like radiodensities
and cavitations
Complication: superinfections by fungus

Bronchitis
5 years before

today
Patient Not Responding to Treatment
AIDS and Lung Disease

l Tumors
n Kaposis
n Non-Hodgkins lymphoma
l
 AIDS:
Opportunistic Infections

Pneumocystis carinii (85%)

CMV-most frequent infection at
autopsy
Mycobacterium (20%)
Avium-intracellulare (83%)
Tuberculosis (9%)
CXR:Bilateral diffuse air-space opacities with
cystic/cavitary lesions of varying size in a predominant
perihilar distribution. The walls of these lesions appear
thick.
 ARDSyndrome

This CXR shows diffuse bilateral

alveolar infiltrates similar to acute
pulmonary edema of cardiac origin,
except that the cardiac
silhouette is usually normal.
CXR changes often lag many hours
behind functional changes and the
hypoxemia may seem
disproportionately severe compared to
the edema observed by CXR.