CHEST RADIOGRAPHS, A WAYANG KULITPart Two

Second Edition February 2012

NORMAL VARIANTS IN THE CHEST RADIOGRAPH

Dr Ng Kian SengMBBS (Singapore) MCGP (Malaysia)

Master Of Medicine (Internal Medicine, Singapore)

FAFP (Malaysia) Cert In Occupational Medicine

Ph D (Theology, USA)

An Album On The Normal Variants In TheChest Radiograph

You need to know the normal well enoughso that you will not mistake a normalvariant for some pathological condition.Practise looking at the normal Chest Radiograph…do not disdain it because it has no bizarre or frightful shadows you canbe excited about! The “practice of looking” at the normal Chest radiograph is what I call a “trifle of medicine” & in Medicine “Trifles Makes Perfection & Perfection Is No Trifle”.

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.”

NIPPLE SHADOWS

RIGHT NIPPLE LEFT NIPPLE

Confirm these are indeed nippleshadows by using metal markers!

NIPPLE SHADOWS

ASYMMETRY OF THE BREASTS

Breast asymmetry is very common, even to the extent that no breast tissue is visible on one side.

It should not be assumed that the patient has had a mastectomy, unless this is known from

the history.

BONE ISLAND IN THE RIB

DROMEDARY HUMP IN THE DIAPHRAGM

These two Chest Radiographs belong to the same Nepalese Worker who presented for a Fomema ME on 27 Dec 2011. The first “shocked” me. It showed a high right dome shaped diaphragm with a medial dromedary hump. It is 8 cm higher than the left. He was asymptomatic and a clinical examination was unremarkable, specifically there was no Hepatomegaly . I asked for a repeat CXR. The second was taken minutes later. Imagine my second “shock”. The second CXR is reproduced here on the right. Now the Left Hemidiaphragm appears to be slightly higher than the right, and it appeared to have been pushed up by the Splenic flexure of the colon. A very mobile see saw diaphragm.

“Ripley’s Believe It Or Not” The See Saw Diaphragm

Note the triangular opacity at mid part of right hemi-diaphragm (arrow).

Diaphragmatic tenting is due to fibrosis and may not have any clinical significance.

Diaphragmatic tenting is a localized accentuation of the normal convexity of the hemidiaphragm as if "pulled upwards by a string." This finding is minor, may be due to any inflammatory condition and not suggestive of TB.

Tenting In The Diaphragm

Source : Nexradiology

Note multiple arcuate elevations of the right hemi-diaphragm. Scalloping is seen in about

10% of normal CXR.

This is due to incomplete muscularization of the diaphragm. Instead of the normal diaphragmatic muscle, the diaphragm is now consists of a thin membranous sheet. This is a very common abnormality. Most of the time, the abnormality is partial, involving one half to one third of the hemidiaphragm. Usually the anteromedial portion is affected.

Diaphragmatic Hump

Source : Nexradiology

Scalloping In The Diaphragm

1.Discontinuity of the first rib

2. Bridge formation posteriorly, forked rib anteriorly

3. Costal bridge

4. Bridge-shaped fusion

5. Fusion dorsally

6. Suggestion of costal bridging 7. Bifurcation suggested

8. Luschka's bifurcated rib

Normal Variants in the Rib Cage

EXAMINE THE FIRST & SECOND RIBS ON BOTH SIDES

See Next Two Slides For The Answers

FUSION OF FIRST & SECOND RIB ON THE RIGHT

A bicipital rib is seen in relation to the first thoracic rib. It appears to be the result of the fusion of two ribs, either of a cervical and first thoracic or of the first two thoracic ribs. Fusion of the first two ribs is common.

PSEUDO-ARTHROSIS OF THE FIRST TWO RIBS ON THE LEFT

BIFURCATED RIB

Ribs bifurcated at their sternal ends are occasionally observed, with the two extremities joined to a bifid costal cartilage.

What is the bony abnormality in this patient?

Chest radiograph is showing well developed bilateral cervical ribs.

Look at the transverse processes that articulate with these ribs. Cervical

transverse processes points down while thoracic transverse processes points up.

CervicalTransverseProcessesPoints Downwards=CD

ThoracicTransverseProcessesPoints Upwards =TU

The Cervical Rib is an extra rib that arises from the7th Cervical Vertebrae. How do you know these areCervical Ribs and not the 1st Thoracic Ribs?

At first sight there appears to be an oval opacity the Left apical region which could be a coin lesion or something ominous…click to see!What do you think this is?

Ossification at the anterior end of the first rib, which is a common finding!

Female, Aged 78 Male, Aged 79

Look at the ossified costal cartilages of these two individuals,a female, aged 78 on the left & a male, aged 79 on the right.

What is the difference? There is a Sexual Dimorphism Of Ossified Costal Cartilage…

Male, Aged 79

The first is the “Peripheral Ossification Pattern”, the male pattern, in which there is subperichondral deposits which contour the upper and lower margin of cartilage. Some radiologists described this appearance as that of 2 fingers making a “peace sign”.

Male, the peace sign

Another Image ofThe peace sign

Female, Aged 78

The second is the “Central Lingual Ossification Pattern”, the female patternwhich is characterized by the pyramidal (lingual) shape of ossifications with a peak towards the sternum. The ossification involves the central portion of the cartilage and is described by Radiologists as a solitary finger.

Female, A solitary Finger

What is the abnormalityIn this Indonesian man ?

A “Charm Needle” insertedinto the chest wall, a commonpractice among Indonesianmen

Soft tissue fat This close-up demonstrates a normal fat plane between layers of muscle. Fat is less dense than muscle and so appears blacker. Note that the edge

of fat is smooth. Irregular areas of black within the soft tissues may represent air tracking in the subcutaneous layers. This is known as

surgical emphesyma

Fat Tissue

Pectus excavatum is usually an isolated anomaly but can be associated with Marfan’s Syndrome, Noonan’s Syndrome, Fetal Alcohol syndrome and Homocystinuria

Pectus Excavatum, Funnel Chest

(1)Indistinct R heart border, sometimesmimic R Middle Lobe Pathology(2)Decreased Heart density(3)Displacement of heart to Left(4)Anterior ribs have an accentuated downward slope so that the ribs appear heart shaped

Pectus Excavatum, Funnel Chest

If you did not look at the side marker you would have missed the diagnosis of

Dextrocardia

Dextrocardia with Situs Inversus

Collage, Shanghai Girl Series, By Ng Kian Seng

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