A wayang kulit

CHEST RADIOGRAPHS, A WAYANG KULITPart OneSecond Edition February 2012

A REVISION OF THE FUNDAMENTALSDr Ng Kian Seng

MBBS (Singapore) MCGP (Malaysia)Master Of Medicine (Internal Medicine,

Singapore)FAFP (Malaysia) Cert In Occupational

MedicinePh D (Theology, USA)

Hippocrates of Cos, Father of M

edicine

ANATOMY IN THE CHEST RADIOGRAPH

A Normal Chest Radiograph

Some examiners like you to call x ray films ‘Radiographs’; strictlyspeaking you can’t actually see the x rays themselves.

Anatomy in the Chest Radiograph

The right main bronchus is slightly larger than the left & comesoff at a less acute angle than the left (hence septic material &foreign substances are more likely to be inhaled into the right lung than into the left).

Trachea Apex Of Lung

Carina

Aortic arch

Left ventricle

Gastric Air Bubble

Right para-tracheal stripe

MainPulmonaryArtery

Left AtrialappendageDescending thoracic aorta

Chest Radiograph, PA View, No 1

Right lower lobe pulmonary

artery

Right hilum

Right upper lobe pulmonary

vein

Right Cardiophrenic Angle

Right Costophrenic Angle

Right atrium

Horizontal fissure

Chest Radiograph, PA View, No 2

Chest Radiograph, PA View, No 3

Scapula

Breast Soft Tissue

Diaphragm

Anterior Rib

Posterior Rib

Spinous Process

Clavicle

Left Main Bronchus

Right Main Bronchus

Lung TissueSuperimposedOn diaphragm

Retrocardiac Vertebra

Anatomy Of the Heart In The Chest Radiograph

MEDIASTINAL SILHOUETTE IN MIDDLE AGE & THE ELDERLY

Aorto-pulmonary window. The aorto-pulmonary window lies between the arch of the aorta and the pulmonary arteries. It contains the ligamentum

arteriosum, the recurrent laryngeal nerve, lymph nodes, and fatty tissue.

Aorto-pulmonary Window

From the level of the clavicles to the azygous vein the right edge of the trachea is seen as a thin white stripe. This appearance is created by air of low density (blacker) lying either side of the comparatively dense (whiter) tracheal wall. If this stripe is thickened

(normally less than 5 mm) this may represent pathology such as a paratracheal mass or enlarged lymph node. The left side of the trachea is not so well defined because

of the position of the aortic arch and great vessels.

RIGHT PARA-TRACHEAL STRIPE

Anatomy in the

LateralChestX-ray

1. Ascending thoracic Aorta2. Sternum3. Right ventricle4. Left ventricle5. Left atrium 6. Gastric air bubble7. Right Hemidiaphragm8. Left Hemidiaphragm9. Right upper lobe bronchus10. Left upper lobe bronchus11. Trachea.

Anatomy in the

LateralChestX-ray

In the lateral CXR, you will see the Right Hemidiaphragm in its entiretyBut where the Left Hemidiaphragm is concerned, you can only see a

part of it because anteriorly it “merges” with the inferior border of the heart.

NAME THE STRUCTURES IN THE LATERAL CHEST X-RAY

9

10

1.Trachea2. Aortopulmonary window 3. Sternum4. Right ventricle 5. Right Hemidiaphragm 6. Left Hemidiaphragm 7. Left atrium 8. Scapula 9. Right Upper Lobe Bronchus10. Left upper Lobe Bronchus

 The mediastinum is divided by a plane passing from the sternal angle to T4-T5 into: Superior mediastinum and The inferior mediastinum

The inferior mediastinum is further subdivided into three regions namely:Anterior mediastinum Middle mediastinumPosterior mediastinum

These divisions are for descriptive purposes, theymerge into each other imperceptibly. There are no distinct boundaries between them.

THE MEDIASTINUM

ZONES OF THE CHEST RADIOGRAPH

UPPERZONE

MIDDLEZONE

LOWERZONE

Apex to a line drawn throughthe lower borders of theanterior ends of the 2nd costalcartilage.

From the 1st line to one drawnthrough the lower borders of the4th costal cartilage & includesthe Hila of the lungs

From the 2nd line to thebases of the lungs.

THE FISSURES OF THE LUNGS

Oblique Fissure From 4 th Dorsal spine sweeping downobliquely to the 6th rib in mid mammary line or the 6th costochondral junction, anteriorly.Horizontal Fissure. From the 4th costo chondral junctionto meet Oblique Fissure at the mid axillary line.

THE LOBES & FISSURES OF THE LUNGS

Base of the Lung: 6th costochondral junction, obliquely to the 10th rib in Anterior Axillary Line,

then horizontally to 12th thoracic vertebra

Oblique Fissure : From 4th Dorsal spine sweeping downobliquely to the 6th rib in mid mammary

line or the 6th Costochondral junction, anteriorly.Horizontal Fissure. Runs from the 4th costochondral

junction to meet Oblique Fissure at the mid axillary line.

OBLIQUE FISSURE , HORIZONTAL FISSURE

From 4th dorsal spine sweeping down obliquely to the 6th rib

in midmammary line or the 6th

costochondral junction, anteriorly.

THE RIGHT & LEFT OBLIQUE FISSURES

Horizontal Fissure. Runs from the 4th costochondral junction to meet Oblique Fissure at the Mid Axillary Line.

THE HORIZONTAL FISSURE

WHAT IS THE ABNORMALITY HERE?

ACESSORY FISSURE, THE AZYGOS FISSURE

.The azygos lobe appears starting in a teardrop shape at around the level of T5 to the right of the midline as a pale line curving outward and upward and then back in to meet the root of the neck, the line is the infolding of the pleura. Also described as a “curvilinear opacity,Inverted comma, tadpole.”

Hippocrates of Cos, Father of M

edicine

THE BLACK & WHITE RADIOLOGICAL TERMS

RADIODENSITY SCALE

radioLucent = bLack radiopaquE = whitE

Radiodensity : Physical quality of an object that determines how muchradiation it absorbs from the X-Ray beam. Radiodensity is determined

by composition ( atomic weight) and thickness

“WHITE IMAGES” “BLACK IMAGES”

The greater the density, the lesserthe penetration of the X-Raysthrough the object.

The lesser the density, the greaterthe penetration of the X-Raysthrough the object

The film remains less exposed The film is more exposed

White Image Black Image

Term used : RadiodenseOr Radiopaque

Term Used : Radiolucent

RADIODENSITY SCALE

Term Density Appearance Example

Radiolucent Low Black Air, Fat

Radiodense(Opaque)

High White Bone, Barium

RADIODENSERADIOPAQUE

RADIO

LUCEN

T

RADIODENSE VERSUS RADIOLUCENT

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