A comprehensive presentation on abnormal chest radiographs and various named signs

1. ABNORMAL CHEST X-RAYS
Dr. Tom Mishael J
PG Resident
St. John’s Medical College Bangalore

2. RADIOGRAPH OF CHEST
• Lung parenchyma
• Pleura
• Hilum
• Mediastinum
• Diaphragm
• Chest wall

3. LUNG PARENCHYMA

4. ALVEOLAR VS INTERSTITIAL
Alveolar disease :
Filling of alveolar air
spaces with
abnormal material
(blood, pus, water,
protein, cell debris)
Interstitial disease :
Affects the
supporting tissues of
the lung parenchyma
(connective tissue,
vessels, lymphatics,
bronchi, alveolar
wall)

5. ALVEOLAR VS INTERSTITIAL

6. ALVEOLAR VS INTERSTITIAL

7. CONSOLIDATION
CONSOLIDATION = PNEUMONIA ?
NO
CONSOLIDATION refers not only to
infection, but to any pathological process
that fills the alveoli with either pus, blood,
fluid, cells etc
Pneumonia - commonest cause of
consolidation

8. CONSOLIDATION
Pathological features :
1. Alveolar space filling with inflammatory exudate
2. Interstitium & architecture of lung remain intact
3. Airway is patent
Radiological correlation :
1. Density corresponding to a segment/ lobe
2. No significant volume loss
3. Air bronchogram

9. PNEUMONIA
• Bronchitis : Acute
or chronic inflammation
of the lining of a
bronchus
• Pneumonia :
Inflammation, usually
due to infection involving
the alveoli
• Lobar pneumonia :
Involving a large part of
the lobe, sometimes the
entire lobe
• Bronchopneumonia :
Pneumonia plus
bronchitis

10. LOBAR VS BRONCHOPNEUMONIA

11. BULGING FISSURE SIGN
• Refers to lobar consolidation where the affected portion of lung
expands and displaces an interlobar fissure
• Seen in infection with Klebsiella pneumoniae, Streptococcus
pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus

12. SILHOUETTE SIGN
Concept :
• When two structures with identical densities are in
contact with each other, the interface/ border between
them will be obscured (loss of silhouette)
Application :
• An intrathoracic lesion touching a border of the heart,
aorta or diaphragm will obliterate that border on CXR
• An intrathoracic lesion not anatomically contiguous with
a border will not obliterate that border

13. SILHOUETTE SIGN

14. SILHOUETTE SIGN

15. SILHOUETTE SIGN

16. SILHOUETTE SIGN
ABSENCE CAN TELL YOU WHERE A SHADOW IS NOT SITUATED

17. SILHOUETTE SIGN

18. SILHOUETTE SIGN
PITFALLS :
• In few normal individuals, right heart border will not be clearly seen
• A depressed sternum can produce loss of the right heart border, an appearance
which mimics the right middle lobe pneumonia
• Fat or pulmonary vessels close to the heart border may result in a false positive
silhouette sign

19. AIR BRONCHOGRAM SIGN
• Definition : Phenomenon of air filled bronchi (dark) being made
visible by the opacification of surrounding alveoli (grey/white) –
reverse concept of silhouette sign?
• Significance : Says that the opacity is intrapulmonary (excludes a
pleural or mediastinal lesion

20. AIR BRONCHOGRAM
Branching lucencies surrounded by consolidative opacity

21. LUNG COLLAPSE
• Concept : Diminished volume of air in lung associated with reduction in
lung volume
Direct Signs :
• Displacement of interlobar fissures
• Loss of aeration: Opacity of the affected lobe(s)
• Crowding of the vessels and bronchi within the collapsed area
Indirect Signs : Compensatory changes to volume loss
• Elevation of the ipsilateral hemi-diaphragm in case of lower lobe collapse
• Compensatory hyperinflation of the normal lung
• Displacement of the mediastinal structures towards the affected side
• Displacement of the ipsilateral hilum (elevated/depressed) which changes
shape
• Crowding of ribs on the affected side

22. RIGHT UPPER LOBE COLLAPSE
PA View :
• Area of whiteness in the upper
zone of right lung
• Horizontal fissure elevated
• Apparent right hilar mass
• Trachea deviated to the right
• Ribs over the area of whiteness
are closer than normal
Lateral view :
• Increased whiteness in the
upper part of the right lobe

23. GOLDEN S SIGN
• Due to a central mass
obstructing the upper
lobe bronchus
• Collapse of upper lobe
pulls up the lateral part of
minor fissure while the
large central mass
produces downward
convexity of the minor
fissure

24. RIGHT MIDDLE LOBE COLLAPSE
Lateral view:
• Triangular opacity in anterior aspect of
the chest overlying the cardiac shadow
• Apex at the hilum
• Base is running between the sternum
and the diaphragm
• Horizontal fissure is inferiorly displaced
and oblique fissure superiorly displaced
PA view:
• Right hemi diaphragm is slightly raised
with blurring of the right heart border
• Upper part of lower zone may have a
hazy appearance

25. RIGHT LOWER LOBE COLLAPSE
PA view:
• Complete collapse looks like a wedge
shaped shadow merging with
mediastinum
• Medial aspect of the dome of the
diaphragm is lost
• Descending right pulmonary artery is
not visualized
• Right hilum is depressed
Lateral view:
• Major (oblique) fissure moves
posteriorly but maintains its normal
slope
• Right hemi diaphragmatic outline is lost
posteriorly
• Lower thoracic vertebrae appear denser
than normally

26. LEFT UPPER LOBE COLLAPSE
PA view:
• Most of the left upper lobe lies in
front hence collapse causes a haze
to appear over the entire lung field
• Left hilum is drawn upwards
• Aortic knuckle appears obscured
• Trachea deviated to left
Lateral view:
• Increase in the retrosternal opacity
• Oblique fissure displaced anteriorly
• Left lower lobe is hyper expanded

27. LUFTSICHEL SIGN
• In left UL collapse, aortic knuckle maybe abutted by collapsed lung
• In some cases, a sickle shaped air shadow of hyperinflated left lower
lobe or herniated right upper lobe interpose between collapsed UL
and mediastinum (aortic knuckle)
• “Luft” = air, “sichel” = sickle

28. LEFT LOWER LOBE COLLAPSE
PA view:
• Left lung fields appear darker
• Cardiac shadow appears whiter
• White triangle behind the heart
Lateral view:
• White triangle at the bottom
posterior corner of the lung fields
• Vertebral bodies appear whiter
• Oblique fissure pulled posteriorly

29. COLLAPSE VS CONSOLIDATION

30. DIFFUSE LUNG DISEASES
Non- homogenous opacities
Various patterns :
Linear, septal lines, miliary shadows,
reticulonodular, honeycomb shadowing,
cystic, ground-glass pattern etc
Zonal distribution :
• Asbestosis – lung bases
• Sarcoidosis – spares lung bases
• Histiocytosis – reticular upper zone
opacity
• Lymphangitis carcinomatosis –
unilateral distribution

31. DIFFUSE INTERSTITIAL DISEASES
Reticular/ Linear shadowing :
• Fine irregular network of lines surrounding air-filled alveoli
Reticulonodular shadowing :
• Nodules are less than 1 cm in diameter
• Ill defined and irregular in outline

32. DIFFUSE RETICULONODULAR SHADOWING

33. HONEYCOMB SHADOWING
• Air containing spaces with
thick walls that are lined with
bronchiolar epithelium and
fibrous tissue
• Seen in end-stage pulmonary
fibrosis due to extensive
parenchymal destruction
• Cysts are usually 5-10 mm in
size
• Increases risk of
pneumothorax

34. MILIARY SHADOWING
Widespread
small discrete
opacities of
similar size (2-4
mm in diameter)

35. MILIARY SHADOWING
Infections :
• Tuberculosis
• Coccidioidomycosis
• Blastomycosis
• Histoplasmosis
• Chicken pox
Dust Inhalation :
• Tin, Barium
• Beryllium, Silicosis
• Coal miner’s
pneumoconiosis
Bronchiolitis obliterans
Alveolar microlithiasis
Hyaline membrane
disease
Metastases
Histiocytosis X
Hemosiderosis
Sarcoidosis
Secondary
hyperparathyroidism
Amyloidosis

36. LINEAR AND BAND SHADOWS
• Normal structures such as blood vessels and fissures
form linear shadows within the lung fields
• It can be pathological too
• Linear shadows – less than 5 mm wide
• Band shadows – greater than 5 mm wide

37. LINEAR AND BAND SHADOWS
CAUSES :
• Pulmonary infarcts
• Sentinel lines
• Thickened fissures
• Pulmonary/ pleural scars
• Bronchial wall thickening
• Curvilinear shadows (bullae, pneumatoceles)
• Anomalous vessels
• Artefacts
• Fleischner lines (plate atelectasis)
• Kerley lines
• Resolving infection
• Bronchoceles

38. PULMONARY INFARCTION
• Irregular thick wedge-
shaped lines with the
base adjacent to pleura
(Hampton’s Hump)
• Resolution tends to be
slow (Melting sign)
• Accompanying features :
Splinting of the diaphragm
and a pleural reaction

39. MELTING ICE SIGN

40. PLATE ATELECTASIS
• Seen post-operatively and is thought to be due to under ventilation
with obstruction of medium-sized bronchi
• Several centimetres long, 1-3 mm thick and run parallel to the
diaphragms extending to the pleural surface (Fleischner line)
• Resolution is rapid (compared to pulmonary infarct)

41. BRONCHOCELE
• These are bronchi distended with mucus or pus beyond an obstructing
lesion, but with aeration of the distal lung from collateral air flow
• Typical bronchocele has Gloved finger branching pattern with fingers
several millimetres wide
• Causes to consider to include malignancy, benign tumours, FB
aspiration, bronchial atresia etc

42. SENTINEL LINES
• Thought to be mucus-
filled bronchi and
appear as coarse lines
lying peripherally in
contact with the pleura
and curving upward
• Often left sided and
associated with left LL
collapse

43. KERLEY LINES
Kerley’s A lines:
• Linear opacities extending from the periphery to the hila
• Due to distention of anastomotic channels between peripheral
and central lymphatics
Kerley’s B lines:
• Short horizontal lines situated perpendicularly to the pleural
surface at the lung base
• Due to thickening of interlobular septa
Kerley’s C lines:
• Reticular opacities at the lung base representing
superimposed Kerley’s B lines

44. KERLEY LINES
Causes :
• Pulmonary edema
• Infections (viral, mycoplasma)
• Mitral valve disease
• Idiopathic pulmonary fibrosis
• Congenital heart disease
• Alveolar cell carcinoma
• Pneumoconiosis
• Lymphoma
• Lymphangitis carcinomatosis
• Pulmonary venous occlusive
disease

45. PLEURAL AND PULMONARY SCARS
• Scars are unchanged in
appearance on serial films
• Appear as a thin linear
shadows often with
associated pleural thickening
and tenting of the diaphragm
• Apical scarring is a common
finding in healed tuberculosis,
sarcoidosis and fungal
disease

46. BRONCHIAL WALL THICKENING
• They cast parallel tramline
shadows
• Ring shadows when seen
end-on
• Common in bronchiectasis,
recurrent asthma, pulmonary
oedema and lymphangitis
carcinomatosis

47. SOLITARY PULMONARY NODULE
• Discrete, well – marginated,
rounded opacity
• Less than or equal to 3 cm in
diameter
• Completely surrounded by lung
parenchyma
• Doesn’t touch the hilum or
mediastinum
• Not associated with
adenopathy, atelectasis or
pleural effusion
• Lesions larger than 4 cm are
treated as malignancies until
proven otherwise

48. SOLITARY PULMONARY NODULE

49. SOLITARY PULMONARY NODULE
• Intrapulmonary mass forms an acute angle with the lung edge
• Extra-pleural and mediastinal masses form obtuse angles

50. SOLITARY PULMONARY NODULE
• Carcinomas often have irregular, spiculated or notched margins
• Calcification favors a benign lesion although a carcinoma may arise
coincidentally at the site of an old calcified focus
• Calcified metastasis is rare, the primary tumor being usually an
osteogenic or chondrosarcoma
• Granulomas frequently calcify and are usually well defined and
lobulated

51. SOLITARY PULMONARY NODULE
Hamartoma Chondrosarcoma

52. MULTIPLE PULMONARY NODULES
• Multiple small nodules 2-4
mm are called miliary
shadows
• Mostly metastasis or
tubercular granulomas
• Calcified nodules are
generally benign except
for metastasis from bone
or cartilaginous tumors

53. MULTIPLE PULMONARY NODULES
Canon ball metastasis

54. CAVITATING LESIONS AND CYSTS
• It’s a gas filled space
surrounded by a complete
wall which is 3mm or
greater in thickness
• Thin walled – cysts/ bullae
• Requires a patent airway to
communicate with necrotic
area
• Common cavitating
diseases are TB, staph
infections and carcinoma

55. CAVITATING LESIONS
Common sites :
• TB – upper zones and
apical zones of lower lobes
• Traumatic lung cysts – Sub
pleural
• Amoebic abscess – right
base
• Pulmonary infarcts –
Usually in left lower lobe
• Lung abscess – right side
and lower zone

56. CAVITATING LESIONS

57. FLUID LEVELS
• Abscesses
• Hydropneumothorax : trauma,
surgery, bronchopleural fistula
• Esophageal : pharyngeal pouch,
diverticula
• Obstruction : tumour,
achalasia
• Mediastinal : infections,
esophageal perforation
• Pneumopericardium
• Fluid levels are common in primary tumors -> irregular masses of blood clot
or necrotic tumor may be present
• Fluid levels are uncommon in cavitating metastases and tubercular cavities

58. HYDATID DISEASE
Signs of non-ruptured cysts :
• Honeycomb (wheel spoke, spoke wheel, rosette,
racemose) pattern: multivesicular mother cyst with
daughter cysts separated by radiating septa representing
cyst walls and hydatid sand/matrix
• Double line sign: unilocular cyst with double layered wall
representing pericyst and laminated cyst membrane

59. HYDATID DISEASE
Signs of partially ruptured cyst in pulmonary hydatid
disease :
• Crescent sign: when the hydatid cyst erodes the
adjacent bronchus or bronchiole, the trapped air
between the pericyst and the laminated membrane of the
endocyst give a crescent-shaped rim of air around the
cyst
• Inverted crescent sign: crescent-shaped rim of air at the
lower edge of the cyst

60. HYDATID DISEASE
Signs of complete rupture / cyst degeneration in pulmonary
hydatid disease :
• Cumbo (onion peel, double arch) sign: curvilinear membrane
outlined by air both inside the endocyst and a crescent of air
between the endocyst and pericyst
• Water lily (camalote) sign: folded membranes floating at the
air-fluid interface
• Empty (dry) cyst sign: air filled cyst after expectoration of
membranes and fluid

61. HYDATID DISEASE
Signs of ruptured endocyst in hydatid cysts :
• Serpent (snake) sign: wavy membranes within the cyst
• Spin (whirl) sign: twisting membranes within the cyst
• Ball of wool (yarn, congealed water lily, mass within a
cavity) sign: solid conglomeration of membranes settled
in the dependent portion of the cyst

62. HYDATID DISEASE
Cumbo sign
Water lily sign

63. AIR CRESCENT SIGN
• Crescent shaped
radiolucency within
parenchymal consolidation
or opacity
• Air fills the space between
the devitalized tissue and
surrounding parenchyma
• Opaque rim of haemorrhagic
tissue peripheral to the
radiolucency
• Common in aspergilloma

64. CALCIFICATIONS

65. CALCIFICATIONS
• Calcification is most easily recognized with low kVP films
• In elderly, calcification of the tracheal and bronchial cartilage
is common
• TB is the commonest calcifying pulmonary process usually
upper zone.
• Chickenpox – smaller(1-3 mm) regular in size and widely
distributed
TB CHICKEN POX

66. CALCIFICATIONS
Egg shell calcification :
Silicosis, Sarcoidosis
Alveolar microlithiasis:
Sand grain like calcification

67. APICAL SHADOWING
Common causes are :
• Pleural caps
• Pleural fluid
• Bullae
• Pancoast tumour
• Pneumothorax
• Infections –TB,
fungal infections
(histoplasmosis,
coccidioidomycosis,
aspergillosis)

68. UNILATERAL HYPERTRANSLUCENCY
Looks for signs of obstructive or compensatory
emphysema such as :
• Splaying of the ribs
• Separation of vascular markings
• Mediastinal displacement
• Depression of the hemidiaphragm
 Most common causes - Patient rotation and scoliosis
 With rotation to a side, that side becomes more
prominent

69. UNILATERAL HYPERTRANSLUCENCY
Mastectomy Pneumonectomy

70. OPAQUE HEMITHORAX

71. PLEURA

72. PLEURAL ABNORMALITIES
• Pleural effusion
• Pneumothorax
• Pleural plaques
• Pleural thickening
• Pleural calcification
• Pleural neoplasm
• Fibrothorax

73. PLEURAL EFFUSION
An area of whiteness at the
base of the lung :
• Pleural effusion
• Raised hemi diaphragm
• An area of consolidation/
collapse.

74. PLEURAL EFFUSION
Pleural Effusion vs Consolidation:
• Texture of whiteness ->
Consolidation usually causes
more heterogeneous shadowing
typically with the presence of an
air bronchogram
• Shape of the upper border of the
shadowing -> Fluid will have a
meniscus so the upper border of
an effusion will be concave

75. PLEURAL EFFUSION
Pleural effusion vs Raised hemidiaphragm :
Effusion will peak much more laterally than you would
expect the diaphragm to do
Pleural effusion vs Collapse :
Collapse usually causes shift of trachea towards the white
lung field. Hence of absence of shift excludes collapse.
Collapse can also accompany an effusion. So presence of
shift doesn’t exclude effusion.

76. PLEURAL EFFUSION
Look for …
• Presence of the meniscus,
which often on the lateral
view, is seen to tent up into
one of the fissures.
• Size of the heart (large =>
heart failure), enlargement of
hilum, visible parts of lung
fields for obvious masses,
bones for signs of mets, apex
pf lung for TB and tumors

77. PLEURAL EFFUSION
Lateral decubitus view

78. SMALL EFFUSION WITH BLUNTING OF
CP ANGLE
• Most dependent recess of the pleura is the CP angle.
• Small amount of effusion will tend to collect posteriorly (100-300 ml)
• 200 ml of fluid is required in Frontal film, 75 ml in lateral film.

79. MODERATE PLEURAL EFFUSION
• Fairly well defined upper edge, concave upwards, is higher
laterally than medially and obscures the diaphragmatic
shadow

80. MASSIVE EFFUSION WITH MEDIASTINAL
SHIFT

81. PLEURAL EFFUSION WITH COLLAPSE
No mediastinal shift in spite of the presence of
massive effusion

82. LAMELLAR PLEURAL EFFUSION
• Shallow collections
between the lung and
visceral pleura,
sometimes sparing the
CP angle
• Represents interstitial
pulmonary fluid
• Eg: Post cardiac
surgery

83. SUBPULMONIC PLEURAL EFFUSION
• Fluid is between
pleura and
diaphragm
• Lung floats above
the fluid
• Large subpulmonic
effusions mimics
elevation of hemi
diaphragm

84. LOCULATED PLEURAL EFFUSION
Pseudo tumor or
Phantom tumor –
effusion within the
fissures

85. PNEUMOTHORAX
Refers to presence of air in the pleural cavity
• Open pneumothorax : Air move freely in and out during
respiration
• Closed pneumothorax : No movement of air occurs (eg.
due to pleural adhesions)
• Valvular pneumothorax : Air enters the pleural space on
inspiration and doesn’t leave during expiration
• Tension pneumothorax : As intrapleural pressure
increases in a valvular pneumothorax

86. PNEUMOTHORAX
• Visible pleural edge seen as a
thin, sharp white line
• No lung markings peripheral to
this line
• Peripheral space is
radiolucent compared to
adjacent lung
• Lung may completely collapse
• No mediastinal shift unless
tension pneumothorax is
present

87. DEEP SULCUS SIGN
CP angle appear
abnormally deep and
lucent because of air in
the anterolateral pleural
space

88. DOUBLE DIAPHRAGM SIGN
Visualization of the anterior
CP angle as an edge
separate from the dome of
diaphragm but parallel to it
(especially in a supine film as
air collects and outlines the
anterior portion of
hemidiaphragm in a supine
patient with pneumothorax)

89. TENSION PNEUMOTHORAX
• Shift of mediastinum
away from the side of
pneumothorax
• Downward
displacement or
inversion of hemi
diaphragm
• Medical emergency

90. HYDROPNEUMOTHORAX
• Pneumothorax
containing a horizontal
fluid level which
separates opaque fluid
below from lucent air
above
• Classically seen as an
air-fluid level

91. PLEURAL PLAQUES
• Plaques are focal areas of
thickening of parietal pleura
(classically due to previous
exposure to asbestosis)
• Characteristically appear as
scattered islands of well
circumscribed pleural densities
(Holly leaf sign)
• Usually in the lower 2/3rd of the
thorax and are bilateral
• Most often affects the parietal
and diaphragmatic pleura
(virtually pathognomic)
• Do not involve the CP angles

92. PLEURAL CALCIFICATION
Unilateral :
• Previous empyema,
hemothorax or
pleurisy (in the
visceral pleura)
Bilateral :
• Asbestosis,
pneumoconiosis (in
the parietal pleura)

93. PLEURAL CALCIFICATIONS
• From previous pleurisy, calcification occurs in the
visceral pleura
• Associated pleural thickening is almost always present
and separates the calcification from the ribs
• Pleural calcification may be in a continuous sheet or in
discrete plaques usually producing dense, coarse,
irregular shadows, often sharply demarcated laterally
• In asbestosis, calcification occurs in the parietal pleura,
is more delicate and bilateral sparing the CP angles
seen
• Frequently visible over the diaphragm and adjacent to
the axillae

94. PLEURAL TUMOURS
• Commonest malignant disease of the
pleura is mets (most frequently from
bronchus and breast)
• Primary malignancy of pleura is
associated with asbestosis exposure
(malignant mesothelioma)
• Unilateral pleural effusion(30-95%) and
concentric or lobulated pleural
thickening
• Benign calcified or non-calcified
plaques may be present
• Frozen mediastinum sign : Because
of the pleural thickening and
mediastinal infiltration, the involved
hemithorax may be normal in volume,
despite presence of large effusion

95. FIBROTHORAX
• Fibrosis within the pleural
space
• Occurs secondary to the
inflammatory response
• Seen in tuberculosis,
asbestosis, hemothorax etc

96. HILUM

97. HILAR ABNORMALITIES
Superior margin of left hilum is
usually higher than the right
Whenever the left hilum appears
lower than right, check for any
evidence s/o :
• Collapse of left lower lobe or
right upper lobe
• Enlargement of right hilum
(tumour or nodes)

98. SMALL HILUM : CAUSES
* Mac Leod’s syndrome : U/L hemithoracic lucency as a result of post infectious obliterative
bronchiolitis

99. ENLARGED HILUM : CAUSES

100. BATWING APPEARANCE
• A pattern of b/l perihilar shadowing seen in pulmonary edema,
pneumonia (aspiration, PCP, viral, lipoid)

101. REVERSE BATWING APEARANCE
• Peripheral opacities in b/l lung fields with perihilar
sparing - chronic eosinophilic pneumonia,
bronchoalveolar CA, pulmonary contusion… and also
documented in COVID-19 pneumonia

102. GARLAND TRIAD
• Also called as 1-2-3 triad:
1. Right paratracheal nodes
2. Right hilar nodes
3. Left hilar nodes
• Typically seen in
Sarcoidosis

103. PULMONARY HYPERTENSION
• Prominent pulmonary outflow
tract
• Enlarged pulmonary arteries
• Pruning of peripheral
pulmonary vessels
• Elevated cardiac apex due to
right ventricular hypertrophy
• Enlarged right atrium

104. MEDIASTINUM

105. MEDIASTINAL COMPARTMENTS

106. MEDIASTINAL MASSES

107. CERVICOTHORACIC SIGN
• Any lesion with a visualized upper border above the level of
clavicle must be located posteriorly in the chest (apical
segment of upper lobes, pleura or posterior mediastinum

108. HILUM OVERLAY SIGN
• To distinguish between cardiac enlargement and an anterior mediastinal mass
• Hilum lateral to the lateral border of the mass – cardiac enlargement
• Hilum medial to the lateral border of the mass – mediastinal mass present

109. HILUM CONVERGENCE SIGN
• Allows an enlarged hilum due to pulmonary arteries to be
distinguished from enlargement due to tumor
• If the vessels arise from or converge directly onto the hilar
shadow – enlargement is vascular
• If the vessels appear to arise or converge medial to the lateral
aspect of the hilar shadow – enlargement is a mass

110. THORACOABDOMINAL SIGN
A sharply marginated mediastinal mass projected over the diaphragm on a CXR will be
wholly or party in the thorax because it is outlined by air in the lung

111. ANTERIOR MEDIASTINAL MASS
Lymphoma

112. MIDDLE MEDIASTINAL MASS
Thoracic aortic aneurysm

113. POSTERIOR MEDIASTINAL MASS
Neuroblastoma

114. PNEUMOMEDIASTINUM
• Presence of extra luminal gas within the mediastinum
Etiology :
Secondary to chest, neck or retroperitoneal surgery
Esophageal perforation :
• Endoscopic intervention
• Boerhaave syndrome (spontaneous perforation – increased
esophageal pressure as in vomiting, severe straining)
• CA esophagus

115. CONTINUOUS DIAPHRAGM SIGN
• Air in mediastinum tracks
extrapleurally between heart
and diaphragm forming a
continuous lucency outlining
base of heart representing
pneumomediastinum
• Pneumopericardium shows air
circumferentially outlining heart,
hence differentiated

116. SPINNAKER SAIL SIGN(ANGEL WING SIGN)
Seen in neonates
when thymic lobes are
displaced laterally by
mediastinal air

117. RING AROUND ARTERY SIGN
Air around pulmonary
artery and main
branches produces a
black ring
appearance

118. TUBULAR ARTERY SIGN
Air outlining the
major aortic
branches

119. PNEUMOPERICARDIUM
Air circumferentially outlining the heart

120. ABNORMAL HEART SHADOWS
Total anomalous pulmonary
venous connection :
Snowman / Figure of 8 sign
TOF – Boot shaped heart

121. ABNORMAL HEART SHADOWS
Ebstein’s anomaly (abnormal
tricuspid) :
Box shaped heart
Transposition of great
arteries :
Egg on string appearance

122. MITRAL STENOSIS
Double density sign – left atrial enlargement

123. LV ANEURYSM

124. PERICARDIAL EFFUSION
Retrosternal (paracardial) fat < Pericardial effusion > Epicardial fat

125. DIAPHRAGM

126. ELEVATED DIAPHRAGM

127. DIAPHRAGMATIC HERNIA
• Congenital or acquired
defect in the diaphragm
• More common on the
left side
Causes :
1. Hiatus hernia
2. Bochdalek hernia
3. Morgagni hernia
4. Traumatic
5. Iatrogenic

128. DIAPHRAGMATIC HERNIA
Bochdalek hernia Morgagni hernia
(most common, posterolateral, neonatal) (smaller, anterior, sternocostal angle,
presents later on)
*Hiatus hernia – through esophageal hiatus

129. EVENTRATION OF DIAPHRAGM
• A congenital condition
• Incomplete
muscularization of
diaphragm with a thin
membranous sheet
replacing the normal
muscle
• May affect only a part of
the diaphragm resulting in
a smooth hump

130. CHEST WALL

131. CLAVICULAR ABNORMALITIES
Fractures and old healed fractures

132. CLAVICULAR ABNORMALITIES
• Erosion of the outer ends of the clavicle is associated with RA
and hyperparathyroidism
• Hypoplastic clavicles in Holt-Oram Syndrome and Cleido
Cranial Dysostosis
Holt-Oram Syndrome Rheumatoid arthritis

133. STERNAL ABNORMALITIES
Pectus excavatum (funnel chest) :
• Depressed sternum
• Prominent shadowing adjacent to the right heart border
• Widening of cardiac silhouette
• Heart is displaced to the left and has a straight left heart border

134. STERNAL ABNORMALITIES
Pectus carinatum (pigeon
chest) : Sternum protrudes
anteriorly

135. ABNORMALITIES OF RIB
• Superior rib notching : RA, SLE, hyperparathyroidism, Marfan’s
syndrome, NF and in paraplegics and polio victims
• Inferior rib notching : Develops as a result of hypertrophy of the
intercostal vessels or with neurogenic tumors.

136. ABNORMALITIES OF RIB

137. CERVICAL RIB
• Cervical Rib :
Supernumerary rib
which arises from
the seventh
cervical vertebra
• Congenital rib
anomalies like bifid
ribs, hypoplasia
and bridging are
common

138. RIB FRACTURES
• Stress fractures – Common
in 7th rib
• 6th – 9th lines are the
common sites for cough
fractures
• Pathological fractures:
Senile osteoporosis,
myeloma, metastasis,
steroid therapy, Cushing’s
disease and other
endocrine disorders
• Cushing’s disease is
associated with abundant
callus formation

139. THORACIC SPINE
• Check for abnormal curvature or
alignment, bone and disc
destruction, sclerosis,
paravertebral soft-tissue masses
and congenital lesions such as
butterfly vertebrae
• Anterior erosion of vertebral
bodies sparing the disc spaces is
noted with aneurysm of
descending aorta, vascular
tumors and NF
Scoliosis

140. THORACIC SPINE
• A single dense vertebra, the ivory vertebra – classical
appearance of lymphoma, but also a feature of Paget’s
disease and metastasis
• Destruction of pedicle is typical of Metastasis
• Destruction of the disc with adjacent bony involvement is
characteristic of an Infective process
• Disc calcification occurs in oochronosis and ankylosing
spondylitis

141. SOFT TISSUE
• Skin lesions including naevi and lipomas may simulate lung tumors
• Multiple nodules occur with neurofibromatosis
• Mastectomy is one of the commonest causes of translucent
hemithorax

142. GINKGO LEAF SIGN
• Seen in extensive subcutaneous edema of chest wall
• Gas outlines the fibers of pectoralis major and creates a
branching pattern that resembles veins of a ginkgo leaf

143. If you have any questions…
THANK YOU