This document provides an overview of respiratory imaging modalities and how to interpret chest radiographs. It lists the learning outcomes as understanding various imaging modalities for respiratory pathologies and how to systematically evaluate a normal and abnormal chest x-ray. Key points include identifying the structures on a normal CXR, differentiating abnormal opacity patterns, and recognizing common conditions like pneumonia that appear as airspace filling or consolidation on CXR.

1. RESPIRATORY IMAGING
MBBS Year 3
Dr Norhasiza Mat Jusoh
Medical Lecturer (Radiologist)

2. Learning outcomes
i. List various modalities and their appropriate usage in
investigation of respiratory and mediastinal
pathologies.
ii. Interpret a chest radiograph in a systemic approach.
iii. Recognise and describe features of pneumothorax,
pulmonary collapse, pneumonia, pulmonary oedema,
pleural effusion, lung nodule/mass, bronchiectasis and
emphysema on chest radiograph.
iv. Identify abnormal shadows on chest radiograph and
provide possible differential diagnosis.

3. Imaging modalities
Non ionizing
radiationIonizing radiation
1. Ultrasound
2. Magnetic
Resonance
Imaging (MRI)
1. Plain Radiograph (CXR)
2. Computed Tomography
(CT)
3. Angiography
4. Radionuclide imaging (V/Q
scans)
5. PET/ PET CT scan

5. ConditionsthatmaybeassessedwithachestX-ray
include,butarenotlimitedto thefollowing:
Structures Clinical condition
To visualise the lung fields
and rule out pathology:
infection, tumour, etc
Mediastinal stuctures and
pathology:
mediastinal mass, large vessels
abnormality (e.g aortic aneurysm)
Pleural and pleural space: air, fluid or mass
(pneumothorax, pleural effusion)
Traumatic injury: rib fracture, pulmonary
haemorrhage etc

6. Computed Tomography of the
respiratory system
Specific method Indications
Contrast enhanced CT
Thorax
Assessment of pulmonary masses
Assessment of large airway
narrowing/stenosis
High –resolution CT
without contrast
(HRCT Thorax)
Assessment of diffuse infiltrative
lung disease
Assessment of bronchiectasis
CT Angiography Arterial assessment ( pulmonary
artery, thoracic aorta)

7. Magnetic resonance imaging
• MRI only has limited role in assessing the respiratory
system due to artifact from the large volume of air makes
imaging of the lung is difficult.
Mediastinal and
chest wall are
well assessed
by MRI.
However CT is quicker and
more widely available.
Multidetector CT
technology can now give
excellent multiplanar and
three-dimensional
reconstruction.

8. Positron emission tomography (PET)
and PET-CT of respiratory system
• PET – functional information
• CT- anatomical information
• PET-CT – lung cancer imaging tool.
• Play important role in regional and distant
staging of lung cancer.

9. BASIC INTERPRETATION OF
NORMAL CHEST RADIOGRAPH

10. Essential labels on CXR
• Patient’s name
• Age
• Gender
• Male
• Female
• Type of CXR views
• Frontal
• Lateral
• Decubitus
• Oblique
• Path of x-ray beam
• PA
• AP
• Patient Position
• Upright
• Supine
• Lateral
• Lateral Decubitus
(view is one taken
with the patient lying
down on the side)
Body marker (left/right)
Right lateral decubitus
chest x-ray showing
pleural effusion

11. PA or AP view?
APprojectionimagesareoflowerqualitythanPAimages.
• The heart&medicatinum is
larger/wider
• Patient Position marker
• Scapulae are over lung fields
• Fewer ribs visible above the
diaphragm.
• Anterior ribs are wider.
 Air fluid level (PA view taken in
upright position)
 Patient Position marker
 Scapula in periphery of thorax
 Posterior ribs are more distinct.

12. EVALUATION OF THE CHEST X-RAY
Technical quality:
1. COLLIMATION
2. DENSITY or X-Ray Penetration
3. ROTATION of patient on the CXR
4. POSITION of the scapulae
5. DEGREE of inspiration

13. COLLIMATION
• Cover all lung fields
including the lung apices
and costophrenic angles.

14. Is thex-rayunderexposedoroverexposed?
• Vertebral bodies must be just VISIBLE through the
cardiac shadow
• An over-penetrated CXR shows the vertebral bodies very
distinctly.
• CXR will be darker and the subtleties will be harder to
see.
• An under-penetrated unable to identified the vertenral
bodies behind the heart shadow at all.
• CXR whiter than normal. Make the normal CXR appear
as if there are infiltrates (areas of opacification).

15. Exposure
Over penetrated
Acceptable

16. Is there significant rotation?
• Medial ends of the claviculae should be
EQUIDISTANT from the spinous process.

17. Significantrotation introducesdistortion
• The lungs look
asymmetrical
• The side which has
been lifted may appear
narrower and more
opaque (whiter)
• The cardiac silhouette
appears more in the
opposite lung field.

18. POSITIONof the scapulae:They should
projectoutsidethe lung fields
The edges of the scapulae
are retracted laterally with
only a small portion
projected over each lung.
The lungs are therefore
more easily seen.
The scapulae are not
retracted laterally
and they remain
projected over each
lung.

19. DEGREE of inspiration:
• Good Inspiration - THE DOME OF THE RIGHT
HEMIDIAPHRAGM AT THE LEVEL OF:
Anterior segment of the 6th rib or
Posterior segment of the 9th rib
• Poor Inspiration result in:
* False enlarged heart
* Difficult evaluation of the lungs

20. DEGREE of inspiration:
EXPIRATION
•The lung bases are white -
Is there consolidation?
•How big is the heart?
INSPIRATION
• The lungs are not consolidated
• The heart size is clearly normal

21. How to assesslung hyperexpansion?
Assess for hyperexpansion
1. by counting ribs, or
2. by checking for flattening
of the hemidiaphragms.
Normal expansion
The diaphragm is intersected by:
• Anterior segment of the 6th
rib or
• Posterior segment of the 9th
rib

22. How to assesslung hyperexpansion?
Normal expansion
• An imaginary line (green)
between the costophrenic and
cardiophrenic angles. The
distance between this line and
the diaphragm (red line) should
be greater than 1.5cm(asterisk)
in normal individuals.
In practice this is rarely
measured and a quick
assessment of diaphragm
shape is all that is necessary

23. Hyperexpension
• While checking for
technical quality of CXR,
adequate inspiration ,
you may notice that a
patient's lungs are
hyperexpanded
• i.e. >6th anterior rib
intersecting the
diaphragm at the mid-
clavicular line.
• This is a sign of
obstructive airways
disease.
Quicker to assess for
hyperexpansion by looking at the
shape of hemidiaphragms.
These are clearly flattened in this
patient.

24. Anatomy-ChestX-ray correlation

25. The Normal PA Chest X-ray

26. Systematic Approach: OUT IN
1. Examine the periphery of the film, including the bones,
soft tissue, and pleura. Look for rib fractures, rib
notching, bony metastases, shoulder dislocation, soft
tissue masses, and pleural thickening.
2. Then evaluate the lung, looking for infiltrates,
pulmonary nodules, and pleural effusions.
3. Finally, concentrate on the heart size and contour,
mediastinal structures, hilum, and great vessels. Also
note the presence of instrumentation.

27. Alternative Approach: 'A,B,C,D,E,F,G,H,I'.
Normal chest x-ray. A=Airway; B=Bone, C=Cardiac silhouette,
D=Diaphragm, E=Edge of the heart, F=Field of lung, G=Gastric
bubble, H=Hilum of lung. I= instrumentations.

28. Airway:Check to see if the airway is patent
and at midline.
• For example, in a
tension pneumothorax,
the airway is deviated
away from the affected
side.
• Look for the carina,
where the trachea
bifurcates (divides) into
the right and left main
stem bronchi.
• Normal carina angle is
60-65 degree.

29. Bones: Checkthe bones for any fractures,
lesions,or defects.
• Ribs
• Sternum
• Spine
• Shoulder
girdle
• Clavicles

30. Cardiacsilhouette: Anormalcardiacsilhouetteoccupiesless
thanhalfthechestwidth.
The cardiothoracic ratio
(CTR)— the ratio of the
transverse cardiac diameter
to the maximal internal
diameter of the thorax at
the level of the diaphragm
on an upright PA chest
radiograph.
In adults, a CTR greater than
0.5 is considered to
represent cardiomegaly.

31. Diaphragms:Lookforaflatorraiseddiaphragm.
• As a result of the heart and sub-
diaphragmatic organs, the
hemidiaphragms are not at the
same level but are usually
within 1 rib intercostal space
height (~ 2.5cm) of each other.
• The left hemidiaphragm is
usually lower than the right.
• If the left hemidiaphragm is
higher than the right or the
right is higher than the left by
more than 2.5 cm one of the
many causes of diaphragmatic
elevation should be sought.

32. Diaphragms:Lookforaflatorraiseddiaphragm.
• A flattened diaphragm may
indicate emphysema.
• A raised diaphragm may
indicate area of airspace
consolidation (as in
pneumonia) making the
lower lung field
indistinguishable in tissue
density compared to the
abdomen.

33. Diaphragms:Lookforcostophrenicangle andair
underdiaphragm.
• Also look at the
costophrenic angle
(which should be sharp)
for any blunting, which
may indicate effusion (as
fluid settles down). It
takes about 300-500 ml
of fluid to blunt the
costophrenic angle on PA
CXR.
• Air under diaphragm
indicate
pneumoperitoneum.

34. Edgesofthe heart andExternalsoft tissues
• Check the edges of the
heart for any
radioopacity obscuring
the heart's border.
• Also, look at the
external soft tissues for
any abnormalities.
• Note the
axillary/cervical lymph
nodes, look for
subcutaneous
emphysema (air density
below the skin), and
other lesions.
Normal contours of the
cardiomediastinum on chest
radiography .

35. Identifytheabnormalityofthe externalsoft
tissues?

36. Externalsoft tissues;subcutaneous
emphysema

37. Fields of the lungs
• Look for symmetry,
vascularity, presence of
any mass, nodules,
infiltration, fluid,
bronchial cuffing, etc.
• If fluid, blood, mucous,
or tumor, etc. fills the
air sacs, the lungs will
appear opaque (white),
with less visible
interstitial markings.

38. Gastricbubble:Lookforthepresenceofagastric
bubble,justbelowtheheart(erectCXR).
• note whether it is
obscured or absent.
• Assess location of the
gastric bubble.
• Normal gas bubbles
may also be seen in
the hepatic and splenic
flexures of the colon.
• Not seen in SUPINE
position.

39. Hila:Lookfornodes andmassesinthehilaofboth
lungs.
• On the Normal frontal
CXR, most of the hilar
shadows represent
the left and right
pulmonary arteries.
• The left pulmonary
artery is always more
superior than the
right, making the left
hilum higher.
• Look for lymph nodes
in the hilar.

40. Instrumentations:Lookforanytubes,IVlines,ECG
leads,surgicaldrains,prosthesis,etc.

41. CXR3 zones techniquesareusefulwhendescribingthe
locationofpathologyonafrontalchestradiograph.
CXR is a 2-dimensional representation of
an object.
Since the interfaces between the lobes
are orientated obliquely, it is often not
possible to determine which lobe
pathology is located in or whether it is
located anteriorly or posteriorly.
Hence, describing the location of
pathology using the 3-zone technique is
helpful.
It is recommended to use the zones
loosely while reporting as the
distinctions are arbitrary and do not
correspond to anatomic structures.
Upper zone= right anterior border
2nd rib
Mid zone= right anterior border 2nd
rib and 4th ribs
Lower zone= right anterior border
2nd rib and the diaphragm

42. Abnormalities on CXR

43. Stages of Evaluating an
Abnormality
1. Identification of abnormal shadows
2. Localization of lesion
3. Identification of pathological process
4. Identification of etiology
5. Confirmation of clinical suspension
 Complex problems
• Introduction of contrast medium
• CT Thorax
• HRCT

44. Understanding Pathological
Changes
• Most disease states replace air with a
pathological process
• Each tissue reacts to injury in a predictable
fashion
• Lung injury or pathological states can be
either a generalized or localized process

45. Liquid/Mass Density = Opacity
Air density = Lucency
Opacity Increased lucency
Generalized Localized
Diffuse alveolar
Diffuse interstitial
Mixed
Infiltrate
Consolidation
Cavitation
Mass
Atelectasis
Vascular
Localized airway obstruction
Diffuse airway obstruction
Emphysema
Bulla

46. “WHITELUNG”
• VOLUME INCREASE
• Massive effusion
• Large tumors
• Mesothelioma
• Diaphragmatic hernia
• cardiomegaly
• DECREASE VOLUME
• Atelectasis
• Tuberculosis
• Pneumonectomy
• Agenesis of lung
• Pleural plaques
• fibrosis

47. Alveolar Vs Interstitial pattern
• Alveolar opacity
• As a result of
pathological process
in the alveolar space
• Often describe as
fluffy, cotton wool-
like or cloud like
appearance/ air
space opacity
• Interstitium =
supporting structure
of the lung
• Can be linear,
reticular, nodular or
reticulonodular
opacity

48. Abnormalopacity:
Try toplaceanyabnormalCXRfindingsintooneor
moreofthesefollowingbroadcategories:
1. Air-space filling (alveolar opacity pattern)
2. Pulmonary collapse (atelectasis)
3. Spherical shadows
4. Lines shadows
5. Widespread small shadows

49. A. Air-spacefilling=replacementofairinthealveoli
byfluidand/orcells.
1. A shadow with ill-defined
border
2. An air bronchogram =an air-
filled bronchus against
surrounding opacified less air
alveoli, when alveoli are filled
with fluid/blood/mass
3. Silhouette sign = refers to the
loss of normal borders between
thoracic structures. Radioopacity
obscuring the thoracic structures
( e.g heart's border, aorta,
diaphragm)

50. Air space diseases
Acute air space disease
1.Pulmonary edema
2.Pneumonia
3.Aspiration
4.Hemorrhage
Rapidly Clearing Airspace Disease
1.Hemorrhage
2.Pulmonary edema
3. Aspiration
4.Pneumococcal pneumonia
Chronic air space disease
1. Alveolar cell ca
2. Alveolar sarcoid
3. Lymphoma
4. Alveolar proteinosis

51. Respiratory distress syndrome

52. ACUTE ALVEOLAR INFILTRATE
PULMONARY OEDEMA
PNEUMONIA
ASPIRATION
HEMORRHAGE

53. Pneumonia
isairspacediseaseandconsolidation (The
processofbecomingafirmsolidmass,asinan
infectedlungwhenthealveoliarefilledwithexudate)
• The air spaces are filled with bacteria or other
microorganisms and pus.
• Other causes of airspace filling not distinguishable
radiographically would be
-fluid (inflammatory),
-cells (cancer),
-protein (alveolar proteinosis) and
-blood (pulmonary hemorrhage).

54. Cont…
• Pneumonia is lack of volume loss.
• The x-ray findings of pneumonia are;
- airspace opacity,
- lobar consolidation, or
- interstitial opacities.
Usually considerable overlap between these findings.
• Pneumonia may have an associated parapneumonic
effusion.
• What differentiates it from a mass? Masses are generally
more well-defined.

55. Right upperlobe pneumonia-
PACXR-airspaceopacityatmidzone,however theheart
borderisnotobscured.
Lateral CXR confirm right
upper lobe pneumonia.

56. Middle lobe pneumonia–
ConsolidationwithAirbronchogramand silhouettesign

57. Lobar pneumonia:
classicallyPneumococcalpneumonia
entire/segmentallobeconsolidation,airbronchogram,
expansionoflobewithbulgingoffissure, lungnecrosiswith
cavitation,lackofvolumeloss.

58. A48-yearoldforeign-bornwomandevelopedcough,sputumproduction,and
blood-tingedsputum.Onemonthlater,sheshowedsignificantimprovement
afterantiTBtherapy.

59. Alveolarcellcarcinoma:pneumonicform,theimportanceof
repeatCXR4-6weekspostantibioticcourseandcomparison
withpreviousCXR.

60. Cardiogenicpulmonaryedema:
Rapidclearing,24hoursafterdiuretictherapy.

61. B.Atelectasis=thelossoflungvolumeduetothecollapseof
lungtissuebyablockageoftheairpassages(bronchusor
bronchioles)orbypressureontheoutsideofthelung.
Common causes:
1. Bronchial wall lesions,
usually primary carcinoma,
2. Intraluminal occlusion,
usually foreign body or
mucus plug.
3. Invasion or compression by
adjacent an adjacent
tumour or enlarged lymph
nodes.
4. Pneumothorax or pleural
effusion
Signs of lung collapse:
1. Displacement of
structures ( trachea,
mediastinal etc).
2. Shadow of the
collapsed lung
(opaque).
3. The Silhouette sign.

62. Rightupperlobecollapses:increasedopacityintheright
upperzone,whichisdelineatedinferiorlybythehorizontal
fissure. Thefissuremovesandbowsupwards.

63. Themarginbetweenopaque,collapsedlungandnormal
aeratedlungshowslateralconvexityinferiorly,consistentwith
ahilarmassasacauseofthecollapse.
“Golden S sign”
Most commonly
due to a primary
bronchogenic
carcinoma.

64. Middlelobecollapse:
Illdefinedshadowingisevidentadjacenttotherightheartborder.
LateralCXR;Thecollapsedlobeisclearlyseenasathinwedgebetweenthe
horizontalandobliquefissures,whicharedisplaced.

65. Left lowerlobe collapses mediallyand
posteriorlytoliebehindtheheart..
• Displays a triangular
opacity visible through
the cardiac shadow, or
may overlie it, giving
the heart an unusually
straight lateral border.
• The hemidiaphragm
may be obscured
where the opacity lies
against it. “silhouette
sign”

66. Right lower lobe collapse
Silhouettesign:obscurationoftherighthemidiaphragm

67. C.Sphericalshadows:lungmass(morethan3cm)orlung
nodule(smalllessthan3cm).
Solitary Pulmonary Nodule/Mass
1. Bronchogenic carcinoma
2. Hamartoma
3. Histoplasmoma
4. TB granuloma
5. Carcinoid tumor
6. Solitary metastasis
7. Round pneumonia
8. Rounded atelectasis
Multiple lung nodules:
1. Metastases
2. Metastases
3. Metastases
4. Wegener’s granulomatosis
5. Rheumatoid nodules
6. AVMs
7. Septic emboli
Micronodular Lung Disease
1.Metastases
2.Sarcoid
3.Pneumoconiosis
4.Miliary TB

68. Assessments of spherical shadow
• Comparison with previous films is important to asses rate
of growth of a spherical lesion. Enlarging mass likely
bronchial CA.
• Calcification – indicates benign lesion.
• Outline of lesion – ill-defined with lobulated/ notched/
spiculated /infiltrated indicates aggressive/ malignant
lesions
• Cavitation
• Size ( solitary mass over 4 cm, not contain calcification
almost always either primary CA/lung abscess/rarely
round pneumonia).
• Involvement of adjacent chest wall & bone destruction –
invasion by CA.

69. Lung Mass

70. Metastatic Lung Cancer: multiple lung nodules of varies sizes –
‘cannon ball lesions”

71. Pneumoconiosis duetotissuereactiontothepresenceofan
accumulationofdustinlung(pathology:fibrosis,aggregatesof
particle-ladenmacropahges)
• Fine nodular/
reticulonodular pattern
• Fibrosis
Nodular pattern

72. D. Lines or band-like shadows
• Septal lines – thickened interlobular septa (connective tissue
containing lymph vessels). Two important causes are
pulmonary edema and lymphangitis carcinomatosis.
• Pleuropulmonary scars (fibrosis) form previous infection or
infarction and linear atelectasis.
• Emphysematous bullae – thin line shadow almost
imperceptible with lack of normal vessels.
• The pleural edge in a pneumothorax.

73. Linearatelectasis: band-likeshadow

74. Lung fibrosis: Linesshadows

75. Pneumoconiosis/occupationallung diseaseresultin
scarring

76. Combinedpulmonaryfibrosisandemphysemainatyre
industryworker -Corpulmonale,pulmonaryhypertension,
enlargedpulmonaryarteries

77. E. Widespreadsmall pulmonaryshadows
• Not more than 2-3mm.
• Descriptive terms including fine nodules, reticular,
reticulonodular, milliary nodules, honeycomb.
• Abnormal shadow obscured the bronchovascular
marking of the lung and the border of the heart or
diaphragm become less sharp.
• Multiple ring shadows of 1 cm or larger –
e.g.bronchiectasis
• Widespread small pulmonary calcifications.

78. Miliary Pulmonary Tuberculosis
• Generalised
milliary nodules
in both lungs.
• obscured the
bronchovascular
marking of the
lung.
• the heart border
and diaphragm
become less
sharp.

79. Bronchiectasis:Irreversibledilatationofthe
bronchi.
• Multiple ring-like
lesions with air
fluid level.
• Fibrosis
• Pleural thickening

80. Cavitating = the mass undergoesnecrosis
Cavitary Lung Lesions
1.Abscess
2.Carcinoma
3.Tuberculosis
4. Necrotising
pneumonia
5. Pulmonary
embolism
Cavities Containing Masses
1.Aspergillosis
2.Cavitating bronchogenic CA
3.Tuberculosis

81. Primary tuberculosis
• Consolidation (Ghon focus) in any
area of the lung – usually in the
periphery of the lung in the mid
or upper zones.
• Isolated hilar or mediastinal
adenopathy may be only finding.
• Combination of pulmonary
consolidation and
lymphadenopathy = primary
complex.
• May present with pleural
effusion.
• Spread via bronchial tree -patchy
small infiltrates or involve the
whole lobe.
• Spread via blood stream – miliary
TB.
Primary tuberculosis
• Sequence of events:
• Pulmonary consolidation
• Caseous necrosis 2-10 wk
after infection
• Lymphadenopathy (hilar &
pretracheal) 95%
• Pleural effusion (uncommon
10%)
• Usually heals without
complications

82. Post primary tuberculosis/ Reactivation.
• Infiltrates/consolidation usually
upper posteror part of the lung -
upper lobe and superior segment
of lower lobe (high O2)
• Multiple small and often bilateral
consolidation.
• New cavity
• +/- pleural effusion
• +/- hilar or mediastinal lymph
nodes
• Immunocompromised/HIV
patients less likely to have classic
lesions and may have normal CXR

83. Healing PTB • Partial or complete
healing
• Pulmonary nodules in
the hilar area or upper
lobes
• +/- fibrotic scars and
volume loss.
• Bronchiectasis and
pleural thickening may
be present.
• +/- Calcified lymph
nodes or lung nodules
• NB: fibrosis and
calcification also
presence of continuing
activity.

84. Is the tuberculosis active?
• Development of new
lesion/consolidation.
• Demonstration of cavities +/-
fluid within cavities.
• Comparison with previous
films is essentials.
• Lack of changes over period
of years suggestive of
inactive.
• However, the decision is
mainly based on the clinical
findings and the results of
sputum AFB.

85. Lung Abscess: Cavity with air fluid level

86. A single, thin-walled cavity is noted in the left midlung.
One-third of squamous cell carcinoma masses show cavitation

87. Myecetoma/Aspergilloma:
CavitiesContainingMasses,commoncomplicationof
PTB
“Air crescent
sign”

88. “BLACK lung”/Hyperlucent
BILATERAL
• Normal Volume
• Pulmonary Emboli
• PAH
• Pulmonary Stenosis
• Congenital Heart Disease
• Increased Volume
• Emphysema
• Acute Asthma
• Upper airway stenosis
• Acute Bronchiolitis
UNILATERAL
• Pneumothorax
• Emphysema/bullae
• Pulmonary embolism
• Compensatory
Hyperinflation
• Post mastectomy
• Air-trapping due to central
obstruction. E.g. an inhaled
foregin body,
• Artifacts
• Overexposure

89. COADfoundinthefollowingdiseases:chronic asthma,chronic
bronchitis,andemphysema.
• diminished
vascularity (become
hyperlucent)
• Hyperinflated lung –
flattened
diaphragms
• increase in the AP
dimension of the
chest (Lateral CXR)

90. Classicemphysemareflecttheoverinflation,lossof
compliance,andparenchymaldestruction.Themostreliable
radiographicsignisdecreasedvascularity.
Other signs are:
i. Hyperlucency
ii. increased retrosternal clear
space on lateral CXR
iii. increased lung volume;
flattening of the diaphragm
iv. presence of prominent central
pulmonary arteries with rapid
tapering ("marker") vessels.
i. vertical cardiac configuration.
ii. Bullae may be present to a
greater or lesser extent.

91. Pneumothorax i. Absent of
bronchovascular lung
marking.
ii. Sharp delineation of
visceral pleural by
lucent pleural space.
iii. Collapse left lung
iv. Shift mediastinal.
v. Flattened left
hemidiaphragm.
vi. “ deep sulcus” sign

92. DifferentialDiagnosisof EnlargedHila
i. Lympadenopathy
(Sarcoidosis, Lymphoma,
Infection, Neoplasm)
ii. Malignancy (Primary or
Secondary)
iii. Pulmonary Arterial
Hypertension
i. Pulmonary Artery
Aneurysm

93. Enlarged Lymph nodes
Hilar Lymphadenopathy: Bilateral
or unilateral
1. Sarcoid (B/L)
2. TB (U/L)
3. Lymphoma (B/L)
4. Bronchogenic ca (U/L)
5. Mets (B/L)
Mediastinal adenopathy:
1.Bronchogenic ca
2.Lymphoma
3.TB
4.Mets
5.Sarcoid

94. Lung Disease & Rib Destruction
1.Bronchogenic ca,
i.e Pancoast tumor
2.Actinomycosis
3.Multiple myeloma

95. Pleural effusion:
Transudate
• CCF
• Hepatic failure
• Nephrotic syndrome
Exudate
• Infection
• Malignancy
• Pulmonary infarction
• Collagen vascular disease
• Subphrenic abscess
• Pancreatitis
Haemorrhagic
• Carcinoma of bronchus
• Trauma
• Pulmonary infarction
• Bleeding disorder
Chylous
• Obstructed thoracic duct
– due to trauma,
malignant invasion,
filariasis.

96. Fluidinpleuralspacecanadoptseveraldifferent
appearancesonCXR.
Erect CXR:
Commonest appearance is a
meniscus at a costophrenic angle.
Semi erect CXR:
Large effusion, the entire
hemithorax is opaque and the
heart is pushed towards the
normal side.

97. Supine CXR:
More opaque hemithorax due
to effusion spread posteriorly
within pleural space.
Pleural fluid that
had collected in a
loculated region
e.g fluid within a
fissure = Vanishing
or ‘Phantom
Tumour’ of the
Lung

98. Suggested readings:
• Armstrong, P., & Wastie, M. (2013). Diagnostic Imaging (7th
edition). Wiley- Blackwell.
• Chest x rays made easy by Elizabeth Dick (PDF)
• Learning radiology.com.
• Chapman, S., & Nakielny, R. (2009). A Guide to Radiological
Procedures (5th edition). Philadelphia: WB Saunders.
• Sutton, D. (2003) Text Book of Radiology and Imaging (7th
edition). Edinburgh: Churchill Livingstone.
• Malaysian Radiological Society Guidelines for clinical
practice in Radiology retrieved from
http://www.mrs.org.my

99. Questions?