Chest X-rays

Part 2: Common Abnormalities, Lines and Tubes

 Silhouette Sign
When a normally visible border/silhouette cannot be
seen, this is referred to as the silhouette sign. This
sign is very useful for identifying and localizing areas
of lung consolidation.
 Silhouette Sign
For example, we normally see the left and right
borders of the heart as distinct contours because
(normally) both borders of the heart (soft tissue
density) are in contact with the air density of the
lungs. The silhouettes/contours of the
hemidiaphragms are visible for the same reason.
 Silhouette Sign
The lingula of the left upper lobe is adjacent to the
left heart border. When the normally air-filled
spaces of the lingula are filled with pus or edema
fluid, the left heart border is obscured because it is
now adjacent to a soft tissue density (the fluid-filled
air spaces of the lingula.
Silhouette Sign
 Silhouette Sign

Left hemidiaphragm silhouette sign

– left lower lobe consolidation /
atalectasis
 Silhouette Sign

Right hemidiaphragm silhouette sign

– right lower lobe consolidation /
atalectasis
In this example, there is consolidation of much of the left lower lobe. This lobe is not adjacent to the left heart border and
the consolidation does not include the basilar segments adjacent to the left hemidiaphragm. Therefore, while the
consolidation is evident on the frontal chest film, the left heart and left hemidiaphragm silhouettes can still be clearly seen
(no silhouette sign).
Silhouette Sign
Silhouette Sign
Tracheal Displacement

Right paratracheal mass

pushing trachea to the left
Tracheal Displacement

Right tension pneumothorax

pushing airways and
mediastinal structures to the
left
Tracheal Displacement

Left tension pneumothorax –

pushing airways and mediastinal
contents to the right
Tracheal Displacement

Left lower lobe atalectasis –

volume loss on left pulling
trachea towards left

LLL atalectasis
Sail sign
left hemithorax volume loss
left hilum inferiorly displaced
Tracheal Displacement

Right lower lobe atalectasis –

volume loss on right pulling
trachea towards right

RLL atalectasis
Triangular opacity pointing to
right mediastinum
Right hemidiaphragm silhouette
sign
Right hilum pulled inferiorly
(can’t see right interlobar
pulmonary artery)
Right heart border still seen
(adjacent to right middle lobe)
Volume loss on right
Hilar Enlargement
Hilar Enlargement
Hilar Enlargement
 Anterior mediastinal
clear space?
Aorticopulmonary
window?
Hodgkin’s
lymphoma
Hodgkin’s
lymphoma
Peritoneal
free air (and
left upper
lobe mass
Small right pleural effusion
Pleural plaques
(calcified)

Look at both
hemidiaphragms

Pleural plaques have

a characteristic
“geographic”
appearance (they
look like little
countries on a map)
Pleural plaques
(calcified)
With moderate right
pleural effusion and
fluid in the horizontal
fissure
Pneumomediastinum and extensive subcutaneous
emphysema
Congestive heart failure

Cardiomegaly
Left atrial enlargement
Cephalization of
pulmonary vessels
Kerley B-lines (interstitial
edema)
Nasogastric (NG) tube
Correct position
Tip > 10 cm distal to gastroesophageal junction (left hemidiaphragm)

Malposition includes tip position

In the esophagus
Coiled in the pharynx
Traversing trachea and either bronchus
Crossing the midline to the right (duodenum)
Endotracheal tube (ETT)

Correct position
The ETT tip should be 5 cm +/- 2cm above the carina. The carina is not
always visible, so other landmarks include the aortic arch and medial
ends of the clavicles.

ETT position changes with head position. With neck flexion the tip of
the tube descends in the trachea.
45o
Central venous line/catheter (CVL/CVC)

Correct position
Tip in the distal superior vena cava at the cavo-atrial junction

Malposition
Proximal superior vena cava
Right atrium or ventricle
Acknowledgments

Ceessentials.com
CTisUS.com
Geekymedics.com
Global Library of Women’s Medicine
Mevis-research.de
ResearchGate.net
Radiopaedia.org
Wikipedia