Radiological signs of Disease

Air Fluid Levels You can encounter air fluid levels in chest x-rays in the following conditions: Cavitary lung lesions Loculated empyema Hydropneumothorax Esophageal obstruction Mediastinal abscess Hydropneumopericardium Hiatal hernia Chest wall abscess

Most disease processes will either increase or decrease the density of the lung parenchyma

A mediastinal lesion should have a sharp margin convex towards the lungs and its base abutting the mediastinum .

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

A lung opacity may be due to a mass or lung- parenchymal opacification 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).

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.

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.

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

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

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

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

'Bat's wing distribution Acute Chronic * Pulmonary oedema: * Atypical pneumonia - cardiac * Lymphoma/Leukemia - non cardiac * Sarcoidosis: interstitial * Pneumonia: form much more common - often 'unusual' etiology; * Pulmonary alveolar - pneumocystis carinii (AIDS); proteinosis - TB, viral pneumonias; * Alveolar cell carcinoma: - mycoplasma. localised form more common * Pulmonary haemorrhage: - Goodpasture's syndrome; Wegner's and other vasculitides - anticoagulants; - bleeding diathesis: haemophilia, DIC;  extensive contusion.

LUNG VOLUME Idiopathic pulmonary fibrosis. *Reduced Idiopathic pulmonary fibrosis. Chronic interstitial pneumonia Asbestosis Collagen vascular disease Chronic pulmonary tuberculosis *Normal Sarcoidosis Histiocytosis *Increased Bronchial Asthma Emphysema Lymphangioleiomyomatosis

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

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.

SIGNS OF INTERSTITIAL DISEASE

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

Lung fields appear dark because of air 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.

You have to know what is normal before you can recognize abnormalities You have to know what is normal before you can recognize abnormalities. Knowledge of anatomy is essential for this purpose.

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.

Which lung is larger. Which diaphragm is higher and why 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?

Dextrocardia

Silhouette sign is extremely useful in localizing lung lesions

LUL/Posterior segemnt 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

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

Lobar Pneumonia Right Middle Lobe

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

Pleural Effusion / Upright and Supine

Hyperlucent Lung Factors Bilateral diffuse Unilateral Localized 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 .

Emphysema

R mastectomy

Unilateral Hyperlucent Lung Left Upper Lobe Resection

Unilateral Hyperlucent Lung Right Upper Lobe Resection

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

Honeycombing

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

Lymphangitic Metastasis Cancer Breast Kerley lines Subpulmonic effusion on right

Sarcoidosis / Miliary Nodules / Hilar Nodes

Milary Tuberculosis Interstitial nodules Uniform size Sharper edges

Aspergilloma

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

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 7/77 (film below) - Develops solitary pulmonary nodule within one month 8/77 - Air bronchogram in the density FNAB: Aspergillus Resolved with discontinuation of steroids.

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

Pleural Effusion Massive

Atelectasis Right Lung

Pneumothorax

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  

Tracheal Shift / Thyroid Mass  

AP Window Nodes - Small Cell Cancer

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

Pulmonary Schistosomiasis Aneurysmal dilatation of pulmonary arteries

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

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

Pulmonary Osteoarthropathy Anterior Mediastinal Mass

Lung Cancer RUL primary lesion Para tracheal nodes  

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

Aneurysm Arch of Aorta Mediastinal mass Extrapleural

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

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

Aneurysm of Descending Aorta- Inhomogeneous cardiac density Retrocardiac density Extrapleural Peripheral in location One margin indistinct in PA and lateral view

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

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

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

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

Carcinoid

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

Branchial cyst .Cystic nature is evident in CT

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

Coarctation Aorta

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

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

Hamman-Rich Syndrome Rapid progression of interstitial disease  

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.

Tuberculosis LUL cavities RUL infiltrate  Bilateral upper lobe disease  

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. 

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

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