Prof Dr samir alansary

1. X-Ray
INTERPRETATION
AND TEACHING
SAMIR EL ANSARY

2. Radiological signs of Disease

3. Cavitary lung lesions
Loculated empyema
Hydropneumothorax
Esophageal obstruction
Mediastinal abscess
Hydropneumopericardium
Hiatal hernia
Chest wall abscess
Air Fluid Levels
in the following conditions:

4. • 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

5. • 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.

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

7. • 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).

8. 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.

9. COMMENT ON NEXT
SLIDE

10. 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.

11. Pleural effusion + lobar densities
• Pneumonia with empyema
• Pulmonary infarction
• Bronchogenic carcinoma
• Tuberculosis

12. Pleural effusion + subsegmental
atelectasis
• Postoperative (thoracotomy, splenectomy, renal surgery)
secondary to thoracic splinting + small airway mucous plugging
• Pulmonary infarction
• Abdominal mass
• Ascites
• Rib fractures

13. Upper lung zone distribution
• Cystic fibrosis
• Ankylosing spondylitis
• Sarcoidosis
• Silicosis
• Histiocytosis (Langerhan's cell)
• TB, fungal
• Radiation pneumonitis ( cancers of
head/neck and breast)

14. Peripheral lung zone distribution
• BOOP (bronchiolitis obliterans organizing
pneumonia)
• UIP (usual interstitial pneumonitis, and DIP
desquamative interstitial pneumonitis)
• Infarcts
• Eosinophilic pneumonia
• Alveolar sarcoidosis
• Contusions

15. LUNG VOLUME
*Reduced
• Idiopathic pulmonary fibrosis.
• Chronic interstitial pneumonia
• Asbestosis
• Collagen vascular disease
• Chronic pulmonary tuberculosis *Normal
Sarcoidosis
Histiocytosis
*Increased
Bronchial Asthma
Emphysema
Lymphangioleiomyo-
matosis

16. Reticulations & Hilar Adenopathy
 Sarcoidosis
 Silicosis
 Lymphoma/leukemia
 Lung primary: particulary oat cell carcinoma
 Metastases: lymphatic obstuction/spread
 Fungal disease
 Tuberculosis
 Viral pneumonia (rare combination)

17. 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.

18. Distribution of opacities
• Unifocal or multifocal.
• Lobar.
• Segmental.
• Perihilar.
• Peripheral.
• Upper, middle or lower zones.

19. 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.

20. Normal Female . older, young
Note 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.

21. 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?

22. Dextrocardia
GASTRIC GAS BUBBLE

23. Silhouette sign is
extremely useful in
localizing lung lesions

24. 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

25. Consolidation / Lingula
Density in left lower lung field
Loss of left heart silhouette
Diaphragmatic silhouette intact
No shift of mediastinum
Blunting of costophrenic angle

27. Lobar Pneumonia Right Middle Lob

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

29. Pleural Effusion /
Upright and Supine
Upright Supine

30. 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
.

31. Emphysema

32. R mastectomy

33. Unilateral Hyperlucent Lung
Left Upper Lobe Resection

34. Unilateral Hyperlucent Lung
Right Upper Lobe Resection

35. Unilateral Hyperlucent Lung
Peanut in Left Bronchus
Partial Airway Obstruction Left lung hyperlucent
Left lung stays hyperlucent on expiration
Mediastinal shift with respiration

37. Honeycombing

38. 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 eosinophilic
granuloma

39. Lymphangitic
Metastasis
Cancer Breast
Kerley lines
Subpulmonic
effusion on right

40. Sarcoidosis /
Miliary
Nodules /
Hilar Nodes

41. Milary Tuberculosis
Interstitial nodules
Uniform size
Sharper edges

42. Aspergilloma

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

44. Aspergillosis
Solitary Pulmonary Nodule
Patient 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: Aspergillus
Resolved with discontinuation of steroids

45. Pneumonectomy
Opacity left hemithorax
Tracheal shift to left
Cardiac and left diaphragmatic silhouettes
missing
Crowding of ribs

46. Pleural Effusion Massive

47. Atelectasis Right Lung

48. Pneumothorax

49. 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

50. Tracheal Shift /
Thyroid Mass

51. AP Window Nodes - Small
Cell Cancer

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

53. Pulmonary Schistosomiasis
Aneurysmal dilatation of pulmonary
arteries

54. Pulmonary Edema
Cardiomegaly
Bilateral alveolar densities
Bilateral pleural effusions
Hilar haze
Rapid clearance

55. Adult Respiratory Distress Syndrome
Non-cardiogenic pulmonary edema
Distinguishing characteristics:
Normal size heart
No pleural effusion

56. Pulmonary Osteoarthropathy
Anterior Mediastinal Mass

57. Lung Cancer
RUL primary lesion
Para tracheal nodes

58. Achalasia Cardia
Inhomogeneous cardiac density
Right sided inlet to outlet shadow
Crossing mid line
Barium swallow below: Dilated esophagus

59. Aneurysm Arch of Aorta
Mediastinal mass
Extrapleural

60. Aneurysm Arch of Aorta
Leaking Blood into Pleural Space
Mediastinal 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

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

62. Aneurysm of Descending Aorta- Inhomogeneous cardiac density
Retrocardiac density
Extrapleural

63. Dissecting Aneurysm
Mediastinal 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

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

65. 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

66. Cystic Fibrosis - Bronchiectasis
Bilateral diffuse
Multiple cavities / Bronchiectasis
Peribronchial fibrosis
Prominent hilum

67. Carcinoid

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

69. Branchial cyst .Cystic nature is evident in CT

70. Coarctation Aorta
Post stenotic dilatation: Mogul sign
Rib notching: Difficult to see in this presentation

71. Coarctation Aorta

72. Right Sided Aortic Arch
Aortic knob missing on left and seen on right
Descending aorta missing on left and seen on right
Paravertebral line on right

73. Right Sided Aortic Arch
Aortic knob on right
Descending aorta on right
Paravertebral line
Right Sided Aortic Arch
Aortic knob on right
Descending aorta on right
Paravertebral line

74. Hamman-Rich Syndrome
Rapid progression of interstitial disease

75. Anterior Mediastinal Mass
Widened mediastinum
Loss of cardiac silhouette
Intact silouhette of descending aorta
Lateral view below.
This is a case of anaplastic carcinomaRetrosternal area is filled with mass density.

76. Tuberculosis
LUL cavities
RUL infiltrate
Bilateral upper lobe disease

77. 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.

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

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

80. GOOD LUCK
SAMIR EL ANSARY
ICU PROFESSOR
AIN SHAMS
CAIRO
elansarysamir@yahoo.com