This document provides an overview of how to interpret chest x-rays, describing key anatomical structures and common findings. It discusses the appearance of the lungs, heart, diaphragm, blood vessels, and other mediastinal structures. Common pathologies like pneumonia, enlarged lymph nodes, and cardiac abnormalities are also reviewed. The goal is to teach the basic systematic approach for interpreting chest x-rays and recognizing both normal and abnormal findings.

1. CHEST X – RAY
BASIC INTERPRETATION
ROBIN SMITHIUS AND OTTO VAN DELDEN

2. PA VIEW
lung – soft tissue interface
Line or stripe
Silhouette
Paraspinal line – paravertebral
abscess, hemorrhage from
fracture, space occupying
neoplasm
Paratracheal line – (>2-3mm)
lymphadenopathy, pleural
thickening, hemorrhage or fluid
overload and heart failure
Para-aortic line - elongation of
the aorta, aneurysm, dissection
and rupture.

3. AZYGOESOPHAGEAL RECESS
• A mediastinal-lung interface
• inferior to the level of the
azygos vein arch and
bordered on the left by the
esophagus.
• Deviation is caused by (5):
• Hiatal hernia
• Esophageal disease
• Left atrial enlargement
• Subcarinal lymphadenopathy
• Bronchogenic cyst

4. VENA AZYGOUS LOBE

5. PECTUS EXCAVATUM
• a congenital
deformity of the ribs
and the sternum
producing a concave
appearance of the
anterior chest wall
• right heart border
can be ill-defined,
but this is normal
• silhouette
sign consolidation
or atelectasis of the
right middle lobe

6. LATERAL VIEW
• Contours of the heart
• Retrosternal space
• N - Radiolucent
• abN - radiopacity -
anterior mediastinum
or upper lobes of the
lung.
• More darker
vertebral bodies
• More radiolucent
lung tissue

7. DIAPHRAGM
• Right diaphragm should
be visible all the way to
the anterior chest wall
(red arrow)
• (+)interface between the
air in the lungs and the
soft tissue structures in
the abdomen.
• Left diaphragm can only
be seen to a point where
it borders the heart
(blue arrow)
• (-) interface is lost, since
the heart has the same
density as the structures
below the diaphragm.

8. PULMONARY ARTERY
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.

9. SARCOIDOSIS
• HILAR
ENLARGEMENT
• dilated vessel
• enlarged lymph
node
• widening of the
paratracheal line
(or stripe) as a
result of enlarged
lymph nodes.

10. SPONDYLOSIS VS LUNG MASS
Formation of osteophytes is hampered by the pulsations of the aorta.

11. SUPERIOR MEDIASTINUM
• Mass in the
anterior
mediastinum (4
T’s)
• Terrible
lymphadenopath
y, Thymic tumors,
Teratoma,
Thyroid mass
• Hodgkins
lymphoma

12. BOCHDALEK HERNIA
• A congenital defect
in the posterior
diaphragm (arrows).
• May contain
retroperitoneal fat
or 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.

13. SYSTEMIC APPROACH

15. SILHOUETTE SIGN • “difference in density”

16. Consolidation due to a pneumonia caused by
Streptococcus pneumoniae.

17. Consolidation in the left lower lobe with normal
silhouette of the left heart border.

18. DIAPHRAGM

19. Water-density in the right lower lobe (red arrow).

20. Pneumonia in the right lower lobe

21. HIDDEN AREAS
• apical zones
• hilar zones
• retrocardial zone
• zone below the
dome of
diaphragm

22. large lesion in the right lower lobe

23. Pneumonia which was hidden in the right lower lobe
mainly below the level of the dome of the diaphragm

24. lower lobe pneumonia

25. Consolidation in the left lower lobe with
increased density over the lower vertebral region.

26. HEART AND PERICARDIUM

27. • Left Atrial Enlargement
• Outpouching of the upper heart
contour on the right and an obtuse
angle between the right and left main
bronchus on PA
• Bulging of the upper posterior
contour on Lateral
• Right Atrial Enlargement
• Outpouching of the right heart
contour

28. • .
• Left Ventricular
Enlargement
• On PA-view, an increase of
the heart size to the left
• On the lateral view in bulging
of the lower posterior
contour.
• Right Ventricular
Enlargement
• On PA-view, increase of the
heart size to the left and can
finally result in the left heart
border being formed by the
right ventricle.

29. • Left Atrial
Enlargement
• bulging of the upper
posterior contour
• Left Ventricular
Enlargement
• displace the contour
more posteriorly.
• Right Ventricular
Enlargement
• more superior filling
of this retrosternal
space.

30. Left Atrium enlargement
Extreme dilatation of the left atrium has resulted in bulging of the contours
(blue and black arrows)

31. Right ventricle enlargement
• The right ventricle
that is dilated
(yellow arrow)
• There is a small
aortic knob (blue
arrow), while the
pulmonary trunk and
the right lower
pulmonary artery
are dilated
• Result of a left-to-
right shunt with
subsequent
development of
pulmonary
hypertension.

32. Cardiac Valves
• Carina to
cardiac apex
• SL valves
ABOVE
• AV valves
BELOW

33. Cardiac Incisura
A density on the anteroinferior side on the lateral view. 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.

34. PACEMAKER

35. PERICARDIAL EFFUSION

36. PERICARDIAL EFFUSION
Whenever we encounter a large heart figure, we should always be
aware of the possibility of pericardial effusion simulating a large heart.

37. CALCIFICATIONS
The most common are coronary artery calcifications and valve
calcifications. Here we see pericardial calcifications which can be
associated with constrictive pericarditis.

38. Myocardial calcifications in an infarcted area
of the left ventricle.

39. PERICARDIAL FATPAD
It is an uncommon benign condition, that manifests as acute pleuritic
chest pain in previously healthy persons (10).

40. PERICARDIAL CYST
• connected to the
pericardium and
contains clear
fluid.
• arise in the
anterior
cardiophrenic
angle, rightside
• 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.

41. HILI
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.

42. The arteries have a more vertical orientation, while the pulmonary veins run more horizontally.

43. PULMONARY ARTERIES AND VEINS
• The pulmonary veins
can be very
prominent.
• The left main
pulmonary artery
passes over the left
main bronchus and
is higher than the
right pulmonary
artery which passes
in front of the right
main bronchus.

44. LOWER LOBE ARTERIES - Extend inferiorly from the hilum.
They are described as little fingers, because each has the size of a little finger (1).
On the right side the little finger will be visible in 94% of normal CXRs and on the left side in 62%
of normals (1).

45. DIAGNOSIS???

46. RIGHT LOWER LOBE ATELECTASIS

48. Enlargement of the hili is usually due to lymphadenopathy or enlarged
vessels. In this case there is an enlarged hilar shadow on both sides.