DECEMBER, i68

APICAL ROENTGENOGRAPHIC VIEWS

OF THE CHEST*
By GEORGE JACOBSON, M.D., and E. NICHOLAS SARGENT, M.D.
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LOS ANGELES, CALIFORNIA

O N CONVENTIONAL roentgenograms tine posteroanterior chest roentgenogram).

of the chest, the apical portions of the The manubrial notch of the sternum is
lungs are frequently obscured by the over- centered to a loX 12 inch film placed trans-
lying soft tissues, clavicles and upper ribs. versely. (For practical purposes, the soft
Additional important diagnostic informa- tissues of the shoulders are placed so that
tion which can be obtained from apical their upper margin is approximately i inch

roentgenograms of the chest warrants their above the transverse center line of the
more frequent and general use. film.) The tube, fixed 6 feet from the film,
Various examinations for detection of is angled cephalad
i 5#{176} with the central ray
pathology in the apices have been described entering through the body of T 3 poste-
which include the usual anteroposterior riorly, and emerging at the level of the
lordotic view, the reverse posteroanterior sternal notch anteriorly. This roentgeno-
lordotic view, and the posteroanterior gram is taken with the patient in deep
kyphotic view-all of which require either expiration (Fig. IA; and 21).
marked angulation of the patient or of the The patient is then rotated and an
roentgen-ray tube.’’2 Objections to the anteroposterior roentgenogram is taken
use of these techniques include uncomfort- with the patient in exactly the same posi-
able and awkward positions for the patient, tion but with the back against the film.
especially those who cannot cooperate due Here, the body of T 2 is centered to the
to illness; an uncontrollable tendency for film. (Again, for practical purposes, the
the scapulae to move medially prior to the upper borders of the soft tissues of the
roentgen-ray exposure, thus obscuring the shoulders are placed so that they are ap-
underlying lung fields; technical difficulties proximately i inch above the transverse
associated with faulty ceiling and floor center line of the film.) The tube, fixed 6
heights resulting in improper tube_film feet from the film, is again angled 150

distances and angulations; and a general cephalad. The central ray enters anteriorly
lack of reproducibility when repeat com- at the manubrial angle of Louis and
parative examinations are required. emerges at the level ofthe body of T 2.
This roentgenogram is taken in deep
TECHNIQUE
inspiration (Fig. iB; and 2B).
A satisfactory reproducible standardizod Both roentgenograms are taken in the
technique for detection of apical pulmonary erect position. However, when a patient is
pathology has been used at the Los Angeles ill, similar studies can be obtained with the
County-University of Southern California patient in the recumbent position.
Medical Center which has been slightly
DISCUSSION
modified from that described by Merrill.8
A posteroanterior roentgenogram is first During expiration, the clavicles and the
taken with the patient’s hands upon the manubrium of the sternum descend infe-
hips, palms outward, and the shoulders riorly along with the articulating anterior
and elbows arched anteriorly toward the ends of the first two ribs. As a result, in
film (i.e., the usual position for any rou- the posteroanterior view with expiration,

* From the Department of Radiology, Los Angeles county-University of Southern california Medical Center, Los Angeles, cali-
fornia.

822
 \oL. 104, No. Apical Roentgenographic Views of the Chest 823
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-f
Ti
FIG. I. (A) Posteroanterior apical roentgenogram. With
B

patient in expiration, the central ray- is angled 15#{176}

cephalad, entering through the body of T 3 posteriorly and emerging at the level of the sternal notch an-
teriorly. (B) Patient in inspiration. The central ray’ is angled 15#{176} cephalad, entering at the manubrial-
sternal body’junction anteriorly and emerging posteriorly’ at the level of the body of T 2.

0 0

FIG. 2. (il) Line drawing of central ray in Figure IA. (B) Line drawing of central ray- in Figure iB.
 824 George Jacobson and E. Nicholas Sargent DECEMBER, 1968

greater extent than the posterior ribs which

are closer to the film. Thus, a posterior view
of the apices is obtained with the apices
lying below the shadows of the clavicles
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(Fig. 3B; and 4B). In addition, the anterior

and posterior ends of the ribs are super-
imposed and an unobstructed view of the
intervening lung is obtained.
Utilizing these two views, one is able to
study the apices without the marked
anatomic distortion that is obtained with
the conventional lordotic views (Fig. 5, zI
and B).
Pathology in the apices such as neo-
plasms which are not readily identified on

FIG. 3. (A) Posteroanterior apical roentgenogram

with the apices projected above the shadow of the
clavicles. (B) Anteroposterior apical roentgeno-
gram with the apices projected below the shadows
of the clavicle.

the apical portions of the lung are thus un-

covered and are less obscured. In addition,
angulation of the tube 15#{176}towards the
head results in projecting the posterior ribs
cephalad to a greater extent than the ante-
rior ribs, since the anterior ribs are closer to
the film. Thus, an anterior view of the
apices is obtained projected above the
11G. 4. (A) Line drawing of osseous structures in
shadow of the clavicles (Fig. 3z1; and 4M. relation to apices showing projection of the pos-
The complementary anteroposterior api- terior aspects of the ribs superiorly while the
cal roentgenogram is taken in inspiration anterior portions of the ribs, clavicles and sternum
causing the anterior ends of the first two remain inferiorly, as demonstrated in Figure 3A.
ribs, the clavicles and the manubrium of (B) Line drawing of the osseous structures of the
thorax showing projection of the clavicles and
the sternum to move superiorly. With a
anterior ribs superiorly while the posterior as-
J50 cephalad angulation, the anterior ribs pects of the ribs remain inferiorly, as demon-
and clavicles are projected superiorly to a strated in Figure 3B.
 VOL. 504, No. Apical Roentgenographic Views of the Chest 825
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11G. (B) Line drawing

#{231}. of the osseous structures
of the upper thorax showing more marked dis-
lqG. g. (A) Conventional anteroposterior lordotic tortion of the anatomic outlines, as demonstrated
view. in Figure 54.

a routine posteroanterior chest roentgeno- Obscured and hidden lesions of tubercu-

gram are better visualized in the apical losis are brought out to a greater advan-
views (Fig. 6, zI, B and C). tage (Fig. 7, 1, B and C).

/ Riztui ptcrtitc1 1

chst r )t11 ti.Lfl( erani In 0 1

p(nrlv visiiaIiii plasiii iii tIn

r1LI1t apical ui n (/ \ritcr
tcrl)r a;dcd rcnticn i.raiii Ii V -

th k- r h-t ak ailtain:.

(:) llar: ii sIna in lack f d

citicatn n
Downloaded from www.ajronline.org by 43.247.157.154 on 12/30/22 from IP address 43.247.157.154. Copyright ARRS. For personal use only; all rights reserved

B’

I in. -. .1 Postcroantcrior chicst runruen-

raiii shin in lusion f tiihurctilosis oh)-
scitrul h vurl vin ssc ins stiticturus.
)( )stcV ariturior apical )ctitu1i)
raiii - (. :\ntcr ))( stcli( it apical rount
Li ii iii

l1(,. . .l avitatin ICSIUI1 inc tn tuhcr

Ci )S1S Vt thu lctt ppcr lh is not

\ si1al1/cI on th ; stcrnanturor r cOt-

.LctlOi..irafll. Pisturoanturior apical
1oci1tctiOTaI11. (i :\11turopnSrcrnr 11)1-
cal n un tCcii( cra in -
 VoL. 504, No. Apical Roentgenographic Views of the Chest 827
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0
FIG. (A)
#{231}. Posteroanterior chest roentgenogram showing a linear shadow overlying the clavicle but no evi-
dence of an apical emphysematous bleb. (B) Posteroanterior apical roentgenogram. (C) Anteroposterior
apical roentgenogram showing the bleb to best advantage.

Cavitating lesions which are not readily In the study of emphysema, emphysema-
visible on routine chest roentgenograms are tous blebs which may be hidden behind
better shown in the apical views (Fig. 8, A, the overlying obscuring ribs and clavicles,
B and C). It should be emphasized that can be seen to a much greater advantage
both the posteroanterior and anteroposte- in the apical views (Fig. 9, A, B and C).
nor apical roentgenograms are complemen- In addition, since the anteroposterior
tarv and one view does not substitute for roentgenogram is taken in inspiration, and
the other. the posteroanterior roentgenogram in ex-

FIG. 10. (A) Routine chest roentgenogram with a questionable lesion in right upper lobe. (B) Anteroposterior
apical roentgenogram showing lesion due to congenital anomaly of second rib. (C) Complementary postero-
anterior apical roentgenogram.
 828 George Jacobson and E. Nicholas Sargent DECEMBER, 5968

of these views as an adjunct to the routine

posteroanterior chest examination.
The advantages over previously de-
scribed methods include technical simplic-
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ity and easy ieproducibility when repeated

comparative examinations are necessary.
The examination can be performed in the
erect or recumbent position with no patient
discomfort. The resultant roentgenograms
are obtained with a minimum of anatomic
distortion.
E. Nicholas Sargent, M.D.
Department of Radiology
Los Angeles County General Hospital
I 200North State Street
Los Angeles, California 90033

REFERENCES

I. BAUM, I”., and BLACK, L. T. Importance ol

apical roentgenogram in pulmonary tuber-
culosis. Am. Rev. Tuberc., 1925, 12, 228-232.
FIG. II. (A) Routine chest roentgenogram with Ii. CLARK, K. Positioning in Radiography. Inter-
suspected lesion in anterior end of right first rib. continental Medical Book Corporation, New
(B) Anteroposterior apical roentgenogram show- York, 1964, 458-459.
ing coccidioidomycosis of anterior end of right
3. FELSON, B. Fundamentals of Chest Roent-
first rib,
genology. W. B. Saunders Company, Phil-
adelphia, 1960, pp. 17-18.
4. FELSON, B., WEINSTEIN, A., and SPITZ, H.
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Principles of Chest Roentgenology. W. B.
with aeration and de-aeration may be Saunders Company, Philadelphia, 1965, p. 15.
demonstrated when comparing both sides. . FLEIsCHN ER, F. Mediastino-interlobar pleurisy:
The use of apical views for the detection frequent occurrence in mediastinal gland
of fractures of the first two ribs, which may tuberculosis. K/in. Wchnschr., 1925, 4, 875-
877.
not be visualized with routine examina-
6. HINSHAW, H. C., and GARLAND, L. H. Diseases
tions, is also advantageous. When congeni- of the Chest. Third edition. W. B. Saunders
tal anomalies of the ribs tend to simulate Company, Philadelphia, 1965, p. 49.
pulmonary disease, apical views can also 7. LEVITiN, J. Interlobar empyema. AM. J.
be used for definitive diagnosis (Fig. 10, ROENTGENOL. & RAD. THERAPY, 1946, 56,
156-162.
A, B and C).
8. MERRILL, V. Atlas of Roentgenographic Posi-
Other osseous lesions of the first two tions. Volume I. Second edition. C. V. Mosby
ribs such as infectious processes are better Company, St. Louis, 1959, pp. 512-513.
delineated in the apical views. Figure ii, 9. PERRY, K., and SELLERS, T. Chest Diseases.
A and B demonstrates coccidioidomycosis Volume I. Butterworth & Co., Ltd., London,
1963, p. 77.
of the right first rib.
10. SANTE, L. Principles of Roentgenological In-
terpretation. Tenth edition. Edwards
SUMMARY
Brothers, Ann Arbor, 1955, p. 276.
A simple standardized technique for the II. SIMON, G. Principles of Chest X-Ray Diagno-
detection and visualization of otherwise sis. Second edition. Butterworth & Co., Ltd.,
London, 1962, 190-191.
hidden apical and subapical pulmonary
12. ZINN, B., and MONROE, J. Lordotic position in
disease is described. fluoroscopy and roentgenography of chest. AM.
The additional information obtained J. ROENTGENOL., RAD. THERAPY & NUCLEAR
warrants the more general and frequent use MED., 1956, 75, 682-700.