CLINICAL RADIOLOGY:

THE THORAX

COMPILED AND EDITED BY:

NAVEEN NAIR GANGADARAN

(0402005198)
 Imaging Strategies: The Thorax

Plain film and CT are the two primary

modalities for imaging the thorax
Selected clinical diagnoses utilize MR and/or
nuclear imaging
CT and US are used to guided percutaneous
procedures, such as biopsies and thoracentesis
 Thoracic Imaging Strategies
The imaging findings, Think of possible:
together with the Infection/inflammatory
clinical presentation, diseases
history, and findings on Neoplasm
physical examination Metabolic
will lead you to the Vascular
correct diagnosis or Exposures
Congenital
possible diagnoses
 Clinical pearls in radiography
Remember: in a radiograph
Black = air-filled
White = bone, calcium, fluid, pus,
blood, collapse
Gray = soft tissues and solid organs
 The frontal chest film
may be acquired PA
or AP
Aortic knob
Ascending View the film as
aorta
Descending
though the patient is
aorta facing you with his
LA left on your right
RA
If the film is
RV
LV unmarked, remember
your anatomy (heart
and aortic arch are
left of midline)
 The frontal film
Pleura not normally
visible
Trachea
Pulmonary artery
Blood-filled
pulmonary vessels
L main cast soft gray
R main bronchus
bronchus shadow and
typically taper out to
periphery, while
bronchi and
bronchioles are air
filled and do not cast
a shadow on the
image
Gastric air bubble
 typically left chest is placed
Normal lateral film against detector to minimize
cardiac magnification

T
DA
Two films at right angles to one another are Major fissure
needed to determine the true location of any
foreign body or mass within the thorax

The nodule is
in the RML
and calcified
RML

Granuloma within the RML

Thoracic Imaging Strategies
1. Approach to image interpretation
-What is the expected normal and variant
anatomy?
a. Is something absent?
b. Is there some additional structure
present?
Look at the bones and soft tissues
Look at the heart and mediastinum
Look at the lungs and pleura
Look at the airways
Look at the diaphragms and upper abdomen
 Thoracic Imaging Strategies
1. Identifying the normal/variant anatomy.
2. Look at the bones
3. Survey the soft tissues
4. Look at the mediastinum
5. Look at the heart
6. Look at the Lungs and Pleura
7. Look at the airway
8. Look at the diaphragm and upper abdomen
1. WHATS WRONG WITH THIS RADIOGRAPH?

Notice the
absence of
both clavicles.
The heart and
aortic arch are
also on the
right side
(situs
inversus), a
congenital
variant.
2. LOOK AT THE BONES
Examine scapulae, humeri,
1 shoulder joints, clavicles,
2
3 ribs and spine for symmetry
4
5
6
Identify the 1st rib by its
7
anterior junction with the
8 manubrium then count
9
down the posterior ribs

10
The location of an
11 abnormal shadow can be
described by its proximity
12
to a particular rib or
interspace
 Healing fracture

Note the multiple right and left sided rib fractures.

Chronic Rotator Cuff Tear on Plain Film

Notice the narrowed acromiohumeral distance

 3. SURVEY THE
SOFT TISSUES

Breast tissues (if applicable)

Skin
Supraclavicular areas
Axillae
Subcutaneous fat
Muscles
Which film is that of a woman?
What happened to
this patient?
Notice the asymmetry
of the left breast
shadow relative to the
right and the surgical
clips in the left axilla

Diagnosis: Left
breast cancer
treated with
lumpectomy and
axillary node
dissection
Subcutaneous emphysema and pneumomediastinum

Notice the air within

the right lateral soft
tissues and in the
supraclavicular
region. There are
also linear streaks of
air outlining the
mediastinal
structures.
4. LOOK AT THE MEDIASTINUM
look at right paratracheal stripe and hilar contours to evaluate for
lymphadenopathy
look at paraspinal lines, anterior clear space, and the spine to evaluate
for a mediastinal mass

A P
 5. LOOK AT THE HEART
The plain film diagnosis of heart disease is limited to determining:

Cardiac enlargement

Pulmonary vascular abnormalities

Congestive failure

The width of the adult heart NORMAL

should be < half the greatest
thoracic diameter, measured
from inside the rib cage at its
widest point near the level of the
diaphragm
Cardiac enlargement on plain film

Small bronhus with rim of soft tissue

opacity = peribronchiolar cuffing =
fluid in the central pulmonary lobule

Signs of congestive heart failure include indistinct pulmonary vessels,

peribronchiolar cuffing, and interstitial Kerley lines; often accompanied by
cardiac enlargement and pleural effusions
 CHF

Pacemaker

Notice the Kerley lines (fluid within the peripheral lymphatics

of the secondary pulmonary lobules). Also note the indistinct
pulmonary vasculature with a perihilar distribution
 Mitral valve
replacement from
rheumatic heart
disease

a complication of a
streptococcal infection
resulting in mitral
valve dysfunction
over time
Treated with valve
replacement

Mitral valve replacement LA enlargement secondary to

long-standing MV stenosis
and regurgitation
Cardiac enlargement can be due to
chamber enlargement (hypertrophy
and/or dilatation) or pericardial fluid Pericardial effusion
on CT

Normal

Focal aortic
calcification Note fluid in the pericardial cavity
surrounding the heart
6. LOOK AT THE LUNGS AND
PLEURA

Bilateral diaphragmatic and left pleural calcification

Pleural
Effusion
fluid fills the
left pleural
space; note
that there is no
shift of other
structures from
their normal
position
Status post pneumonectomy with shift of
heart/mediastinum to the left

Clips at bronchial stump

Pneumothorax
Tension
pneumothorax: the
left lung has
collapsed completely

Take note of the

resultant low X-ray
attenuation (black)
where the airways
have collapsed
The non-aerated lung
is significantly
diminished in size
Pneumothorax where the air Air is seen in the pleural
goes depends on positioning space. Notice the air in the
costophrenic sulcus when
the patient is supine for CT.
62 year old with LUL mass

mass

Note prior median sternotomy Axial PET confirms malignancy

 Centrilobular emphysema

Hyperinflated lungs, paucity of upper lung vessels, crowding of

lower vasculature, and flattened diaphragms are seen in emphysema
Centrilobular emphysema vs. Normal
Lung on CT

Azygous lobe, a
normal variant

With emphysema, there is destruction of the secondary pulmonary

lobules resulting in large air-filled sacs as compared to the
normal lung architecture with branching vessels and bronchi.
 Consolidation
Consolidation means that either part of or an
entire lobe is almost airless (that is, filled with
pus, blood, or fluid)
The nearly airless (essentially solid) part will
cast a uniform shadow of approximately the
same density as the heart
The projected shadow relates to the shape of
the part involved
 LLL pneumonia

Notice the retrocardiac opacity

with air bronchograms on CT
 RML pneumonia
Note the more rounded opacity in
the RML c/w pneumonia
 7.LOOK AT THE AIRWAYS
Coronal

Note the
evidence of
paraseptal
emphysema
(dark air-
filled sacs
along the
lung
periphery)

Image provided by Boiselle et al., AJR 2002

 Airway
traffic
follow the trachea
down to the carina and
into the mainstem
bronchi
look for shadows
within the lumen,
transition in caliber, or
cut-off
Dx: Multiple
tracheal papillomas
obstructing air
CT Correlate
flow
Invasion of the airway
by lung cancer

Images provided by Boiselle et al., AJR 2002

 8. LOOK AT THE DIAPHRAGM
AND UPPER ABDOMEN

~ interspace
R

L
R

L
The diaphragm is a
musculotendinous
sheet separating the
thoracic and
abdominal cavities
The left and right The plane of the right
hemidiaphragms diaphragmatic dome is
are usually well usually about half an
seen on PA and interspace higher than
lateral films the left
 Left phrenic nerve paralysis

The left hemidiaphragm is elevated and demonstrates paradoxical

motion with inspiration consistent with paralysis of the phrenic nerve.
 The stomach
Air may be present in the
stomach and can be seen bubble
on PA and lateral chest
films

Air, being less dense than

fluid, will rise and can be
seen in the fundus of the
stomach on plain film
provided the patient is
upright
In the lateral chest film,
the presence of the air
bubble close under one R
diaphragmatic shadow L

determines which is the

left hemidiaphragm
Misplaced air
on plain film
Peritoneal air trapped under
the right hemidiaphragm
(not to be confused with the
stomach bubble which
would appear on the left)

Can you determine the

cause for the free air ?
Dialysis catheter
responsible for air into
the peritoneal space
 Imaging Strategies: The Chest
Indications
Shortness of breath or dyspnea or chest pain
CHF
Pneumonia
Pneumothorax
Pulmonary embolism
Trauma
Fractures, contusions, pneumothoraces
Check position of lines and tubes
Start with plain film; Order CT if needed
 Common Tubes and Lines in the
Thorax
Endotracheal tube within trachea with tip 2-8 cm
above the carina
Nasogastric tube within esophagus with tip and
sideport in the stomach
Central line course of internal jugular vein or
subclavian vein with tip in the mid to distal superior
vena cava
Swan-Ganz IJ, subclavian, or femoral through RA,
RV, and into pulmonary artery with tip in the outflow
tract to 1/3rd the way out into branch pulmonary
artery
Chest tube placed in the pleural space to evacuate
either air, fluid or pus
 Carina

The endotracheal tube has its tip at the thoracic inlet

and the right internal jugular central line has its tip
in the superior vena cava.
The Swan
Ganz has its
tip in the right
pulmonary
artery, the left
chest tube is
in place with
its sideport
within the
pleural space,
and the
feeding tube is
coiled in the
stomach
Whats wrong?
After placing a NG
tube, always listen for
the gastric air bubble
What is the
expected course of
the esophagus and
where is the stomach
located ?
The feeding tube is
coursing to the right
of midline this is
the normal course of
the trachea and right
mainstem bronchus
Chest trauma: Classical physical
examination findings
Happy interpreting