Lecture Two

THE CHEST RADIOGRAPH

THE RESPIRATORY SYSTEM AND MEDIASTINUM

The routine chest radiographs to examine the respiratory system and mediastinum
comprise a posteroanterior (PA) and a lateral view. Ideally, both should be exposed on full
inspiration with the patient in the upright position. Films taken on expiration are difficult
to interpret because in expiration the lung bases appear hazy and the heart shadow
increases in size. Even though chest films are the commonest x-ray examinations
performed they are also one of the most difficult plain films to interpret.

NORMAL RADIOLOGICAL ANATOMY OF THE CHEST

The chest radiograph is an image of the anatomy of the thorax. Diseases produce additional
features or alter the anatomy in ways which are characteristic of the disease process
involved.

Posteroanterior (PA) Chest Radiograph

An ideal PA radiograph of the chest is the one shown in figure 1. The radiograph has been
annotated to make understanding of the radiological anatomy which follows thereafter
easy.

The Lungs: The lung fields are divided for descriptive purposes into three zones: the upper
zone, above the anterior part of the second rib; the lower zone, below the upper part of the
fourth anterior rib; and the middle zone lying in between the upper and lower zones. The
lungs are the main translucent areas in chest radiograph. Within them are seen some
structures which are relatively less well penetrated by the x-ray beam. These are the hilar
pulmonary artery branches, pulmonary veins and the septae. The bronchi because they
contain air are not normally visible.
The Hilar Shadows: These are largely due to the pulmonary arteries and their main
branches, and also the upper lobe pulmonary veins. Normal lymph nodes are too small to
contribute significantly to these shadows. They are normally V-shaped lying on its sides,
that is “>”. The upper limb of the V-shaped shadow is formed by the upper lobe veins
reaching the left atrium while the lower limb represents the branch of the pulmonary
artery to the lower lobe. The midpoint of the right hilum lies at the level of the sixth rib in
the axillary line (that is the horizontal fissure). The left hilum lies about 1-2cm higher than
the right. This is because the right pulmonary artery lies below the right main bronchus
while the left pulmonary artery lies above the left main bronchus as illustrated in figure 2.
Trachea: It appears as a vertical translucent band centrally situated in the neck at the level
of the thoracic inlet and slightly deviating to the right in its lower third. The walls of the
trachea are usually not visible.

1
Figure 1: An ideal chest radiograph exposed in PA position

Fissures: The lungs are anatomically divided into lobes which are separated by tissues
formed by the reflections of visceral pleura. The right lung is divided into three lobes which
are referred to as upper, middle and lower lobes. The left lung is divided into two lobes
namely; upper and lower lobes. The left lung has an equivalent of the right middle lobe in
the lingula which is a part of the left upper lobe. The normal interlober fissures vary
considerably in depth, but the lobes are never completely separated to the lung root. The
horizontal fissure on the right separates the upper and middle lobes and is seen as a fine
line running horizontal or slightly downwards from the hilum to end anywhere between
the mid-portion of the third and sixth ribs. The horizontal fissure is only seen in about 65-
80% of subjects. In rare instances, there may be an azygous lobe and an associated fissure;
and also an inferior accessory fissure in the basal portion of the right lung.
Diaphragm: The hemi diaphragms appear as convex bands lying at the level of the anterior
end of fifth rib on the right and sixth rib on the left in full inspiration. The right hemi
diaphragm is usually higher them its left counterpart by between 1-3 cm but in 10% of the
2
cases the right and left hemi diaphragms may lie at the same level. On very rare occasion
the left hemi diaphragm may be higher than its right counterpart. Occasionally, a hemi
diaphragm may appear to be high due to a diaphragmatic hump. This is a congenital
elevation of the anteromedial segment of the diaphragm. The diaphragm forms the
costophrenic angles with the lateral chest walls and cardiophrenic angles with the heart.
The acuity of costophrenic angles is an important consideration in diagnosing pleural
effusion. The costophrenic angles should not be missed in any chest radiograph.
The Thoracic Cage and Overlying Soft Tissues: The thoracic cage consists of the ribs,
sternum and the lateral chest walls. At least 6-7 anterior ribs should be visible on a normal
and appropriately taken PA chest radiograph. Companion shadows are water density
reflections of the skin over the clavicles. The skin reflections lie directly in the longitudinal
axis of the x-ray beam. They are almost always visible over both clavicles and may also
occur below the first and second ribs. The overlying soft tissues visible are breast shadows,
nipples and anterior skin fold associated with the pectoralis major muscle. The nipples are
seen as rounded opacities between 5mm and 10 mm in diameter with varying position. The
variation in positions is a direct result of turgidity of the mammary tissues. The very turgid
breast tissues are firm while the non-turgid tissues cause the breasts to become pendulous
with attendant instability in nipple position.
The Intrapulmonary Vessels: The intrapulmonary arteries are seen passing out into the
lungs from the main pulmonary arteries. They are well seen in the medial portion of the
right lung base. They become smaller as they pass towards the periphery of the lung, and
are normally smaller in the upper zones than in the lower in radiographs done in erect
position as shown in figures 1 and 2. The segmental pulmonary arteries have the same
arrangement as the bronchi. The segmental pulmonary veins do not lie with the arteries or
bronchi, but at the periphery of the lung segments. They form two main pulmonary veins
on each side which empty into the left atrium. The veins are slightly larger than the
arteries; those from the upper zones being smaller than those from the lower zones.
The Mediastinum: This is one continuous space between the sternum at the front, the
spine and ribs at the back and the lungs on the two sides. The mediastinum is divided into
superior and inferior compartments. The superior mediastinum lies above the imaginary
line joining the manubrosternal joint (sternal angle) and the upper border of the fifth
thoracic (T5) (dorsal D5) vertebral body. The inferior mediastinum lies below the sternal
angle and is divided into anterior mediastinum which is anterior to the heart; middle
mediastinum which includes the heart and the great vessels; and posterior mediastinum
which is behind the heart.

In the centre of the chest overlying the spine is the heart. The heart is a dome-shaped
structure in the midline with a maximum transverse diameter of 15.5cm or less.
Approximately, two third to three quarter of the cardiac mass lie to the left of midline. The
heart and the great vessels form most of the mediastinal borders. The right mediastinal
border is formed superiorly by the superior vena cava (SVC). With increasing age and
tortousity of vessels the innominate artery often comes to form this border. Below the SVC
the lower one third of the right mediastinal border is formed by the right atrium and
occasionally by a small portion of inferior vena cava (IVC) inferiority. The left mediastinal
border is formed superiorly by the aortic knuckle (aortic arch) and below this by the

3
pulmonary artery and left atrial appendage. Approximately, the lower half of the
mediastinum is formed by the left ventricle.

Figure 2: A posteroanterior chest x-ray illustrating the relative positions of the lung hila

Lateral Radiograph
A lateral radiograph, which is shown in figure 3 may give additional information and
normally the one obtained is the left. However, if a pathological process is known to be
present the lateral view which brings it closest to the radiographic film should be the one
obtained. A lateral radiograph is particularly important in confirming the position of an
abnormality and identifying lesions in the mediastinum.

Figure 3: An ideal chest radiograph exposed with the patient in lateral position
4
The oblique and horizontal fissures may be seen in the lateral view. The horizontal fissure
is seen running anteriorly from the hilum towards the sternum. It is normally convex
upwards. The oblique fissures usually have their upper extent at the level of fifth thoracic
(T5) vertebral body or disc space; the right being lower than the left. They lie parallel with
the sixth rib and reach the diaphragm several centimeters behind the anterior costopheric
angle. The left oblique fissure is usually more vertical than the right.

The heart is seen as an elliptical structure in the anterior half of the chest stretching from
the anterior costophrenic angle to the tracheal bifurcation. The aortic arch is seen passing
upwards and then inferiorly behind the heart. Behind the manubrium sternum and in front
and above the heart is a transradiant area called retrosternal transradiancy or
retrosternal space. In this region the two lungs are nearly in apposition and because of
this high aeration the space is the darkest on lateral radiograph of the chest. There is also a
dark patch behind the heart known as retrocardiac transradiancy or retrocardiac space.

Anteroposterior (AP) Radiograph

An anteroposterior (AP) film may at times be obtained from a very ill patient with the
patient lying on the film or sitting with his back to it. This film will demonstrate the lung
fields clearly but is not appropriate for heart or mediastinal size evaluation because of
geometric distortion. It should be noted that whenever possible AP projection should be
avoided.

Criteria for ideal chest radiograph (PA):

1. The radiograph must be taken with the patient in deep inspiration. To meet this
criterion about 9-10 posterior rib segments must be seen or the fifth anterior rib
segment must bisect the dome of the diaphragm.
2. The costopheric and cardiophrenic angles must be seen on the radiograph.
3. Both lung apices must be seen on the radiograph.
4. The scapula should not obscure any part of the lung field. The scapula overlying any
part of the lung field is indicative of poor positioning.
5. The sternoclavicular joints must be equidistant from the midline. Unequal
sternoclavicular joint spaces indicate rotation. If the patient’s thorax is rotated and
is not parallel with film the distances between the medial ends of the clavicles and
the spinous processes of the vertebral bodies will not be equal. The side of the chest
rotated away from the film is the one in which this joint space is larger. The lung
field on that side will also appear more lucent.
6. Some cervical vertebrae should be seen; at least 4-6 lower cervical vertebrae should
be visible on the radiograph.
7. The trachea should be clearly delineated.
8. The spine behind the heart shadow should be seen but the disc spaces should not be
delineated. Delineation of the disc spaces is an indication for over- penetration.
Over-penetration of chest radiographs can cause missed lesions because the lesions
will be “burnt-off”.

5
 9. The cardiac outline should be seen on the radiograph.

ORDER OF INSPECTION OF CHEST RADIOGRAPH AND SIGNIFICANCE OF

APPEARANCES

1. Projection: Is the film a PA or AP view? This is especially important for radiographs

meant for cardiac size assessment.
2. Patient’s Data: Details regarding the patient such as name, age, sex, date of
examination and clinical history should be retrieved and documented in the
radiological report. Apart from assisting in patient identification, parameters such
as sex can influence the appearances seen in a chest radiograph. For instance, an
adult female patient is expected to have breast shadows and men tend to have
broader chest than women.
3. Symmetry of Chest Wall: Any slight rotation produces unequal transradiancy of
the lungs and undue prominence of one hilum which can be mistaken for a lung
disease. Rotation is assessed by looking at the space between the medial ends of the
clavicles and the lateral margins of the dorsal vertebrae.
4. Adequacy of Penetration: This is assessed by the visibility of disc spaces between
the dorsal vertebral bodies behind the heart. They should just be barely visible.
Subtle lesions behind the hilar and heart shadows may be missed in an
underpenetrated film. On the other hand pulmonary lesions could be burnt off in
over penetrated chest radiographs.
5. Diaphragm: Trace the diaphragmatic contour and assess the level of the hemi
diaphragm on both sides. Evidence of depression or elevation of one or both hemi
diaphragms should be documented and evaluated to determine the clinical cause of
such appearance. The diaphragm can be elevated in segmental collapse of the lung,
hepatomegaly, subphrenic abscess, and phrenic nerve palsy. It can become flattened
in chronic obstructive airway disease (COAD) such as chronic bronchitis and
emphysema, massive pleural effusion, tension pneumothorax and even in excessive
inspiration effort in normal subjects. Assess the costophrenic angles which should
be acute if normal. In erect position, costophrenic angles represent the lowest
dependent areas and early pleural effusion is seen as blunting of these recesses
where the fluid collects.
6. Heart: The size of the cardiac silhouette should be assessed for size and contour.
The maximum transverse cardiac diameter should be 15.5cm or less in normal
subjects. Cardiac size and contour assessments are important for diagnosis of
cardiomegally. It is also important to check for abnormal displacement of cardiac
silhouette to the right or left of midline.
7. Mediastinal Shift: Evidence of mediastinal shift should be checked using the
positions of the trachea and heart. Mediastinal shift can occur in chronic pulmonary
tuberculosis (PTB), lobar collapse of the lungs, mediastinal mass, and
pneumothorax.
8. Hilar Shadow: Both shadows should be assessed for prominence or otherwise.
Hyperaemia of hilar vessels may occur in disorders such as pneumonia, sickle cell

6
 disease (SCD) and hypertension. Enlarged hilar lymphnodes can be seen in
situations of inflammatory response such as pneumonia and PTB. Displacement of
hilar shadows occurs is usually a feature seen in atelectasis.
9. Fissures: Examine the fissures very well to find out any changes in the position.
Displacement of lung fissures from their normal positions is also indicative of
atelectasis.
10. Lung Fields: The following inspections should be carried for lung fields:
a. Look for evidence of homogenous opacity such as in pleural effusion.
b. Look for evidence of segmental or lobar consolidation such as in lobar pneumonia.
c. Look for evidence unequal transradiancy such as in atelectasis. Note that rotation of
the chest or x-ray tube in relation to the chest (technical factor) can lead to unequal
transradiancy of both lungs. Always be sure that unequal transradiancy of both lung
fields when seen is not due to technical factors.
d. Look for evidence of mottled appearances or opacities that may indicate miliary
PTB, metastases from a distant primary malignancy, and pneumoconiosis.
e. Look for evidence of nodular masses which may be indicative of cancer of the
bronchus and bronchial adenoma.
f. Look for evidence of changes in pulmonary vasculature. Loss of pulmonary vascular
markings may be due to emphysema while undue prominence of vascular markings
may be as a result of hyperaemia. Reversal of the normal pattern of pulmonary
vasculature is usually linked to cardiac disease.
g. Look for evidence of hyperinflation such as loss of pulmonary vascular markings,
flattened hemi diaphragms, and over-expansions of the lungs. All these appearances
are indicative of COAD.
11. Bony Thorax: The thoracic cage should be assessed to rule out fractures in cases
trauma. Arthropathies of the shoulder joint such as rheumautoid arthritis should be
ruled out. Bony outline should be evaluated to discover areas of bone destructive
lesions such as metastases from a distant malignant tumor.
12. Soft Tissue Shadows:
Breast shadows may be absent in post mastectomy women. Axillary soft tissue
fullness can give indication of the nutritional status of a patient. In emaciated
patient thickness of the axillary line is usually decreased.

Note that a lateral chest radiograph is less easy to analyze due to superimposition of the
lung fields. A complete symmetry is usually a strict requirement.

ABNORMAL CHEST RADIOGRAPHS

The first step in localizing a shadow in an abnormal chest radiograph is to ask: “where is
the abnormality?” “How extensive is it?” After locating the abnormality then the question
that naturally follows is: “what is it?” Note well the differential diagnose for pulmonary
lesions are quite different from mediastinal and, chest wall abnormalities. It is also
important to examine all available films before making a conclusive diagnosis.

The silhouette sign is an invaluable sign for localizing lesions on the plain chest
radiograph. But a good knowledge of radiological anatomy of the chest is required to apply
7
this. The information on a chest radiograph is largely dependent on the contrast between
the radiolucent air in the lungs compared and the opacity of the heart, blood vessels,
mediastinum and diaphragm. An intrathorax lesion touching a border of the heart, aorta or
diaphragm will obliterate that border on the chest radiograph as shown in figure 5. This
sign named “the silhouette sign” by Felson has two important applications. The
applications are:
i. It most times makes it possible to localize a shadow by observing which borders are
lost. An example is loss of the heart border which means that the shadow lies in the
anterior half of the chest. Alternatively, loss of part of the diaphragmatic outline
indicates disease of the pleura or lower lobes of the lung.
ii. It makes it possible on occasion to diagnose disorders such as pulmonary
consolidation even when one is uncertain as to the presence of opacity. It is a
surprising fact that a wedge or lens-shaped opacity may be very difficult to see
because of the way the shadow fades out at its margins, but if such a lesion is in
contact with the mediastinum or diaphragm it causes loss of this normally distinct
borders.

If a shadow is surrounded on all sides by aerated lung it must be wholly within the lung.
When a lesion is in contact with the pleura or mediastinum it may be difficult to decide
where it originates. If a shadow has o broad base with smooth convex borders projecting
into the lung and a well-defined outline it is likely to be pleural, extra pleural or mediastinal
in origin. It is imperative to see the lateral projection when evaluating hilar shadows as
such shadows may just have been projected over it.
Air Bronchogram: This is an important sign that shows that an opacity or shadow is
intrapulmonary. The bronchus contains air and when normal is not seen on a radiograph
because the walls are too thin. But when there is consolidation, that is a situation where the
air in alveoli is replaced by fluid, mainly exudates, the bronchus surrounded by the fluid-
filled parenchyma becomes visible. Air bronchogram is often seen as scattered linear
translucencies rather than continuous branching pattern of translucencies. It is commonly
seen in pneumonia and pulmonary oedema. Air bronchogram is not seen within pleural
effusions and rarely occurs in tumors except for alveolar cell carcinoma and rarely
lymphoma. It is also a feature seen in consolidation distal to malignancy if the bronchus
remains patient. An important fact to always remember is that air bronchogram is a feature
seen in all disease processes that are characterized by air-space filling.

Types of Abnormal Pulmonary Shadows

Abnormal pulmonary shadows can be classified into three broad types as follows:

1. Nodular Shadows: These are round discrete opacities of various sizes. They have
smooth borders except in those occurring with granulomatous diseases which
irregular borders.
2. Interstitial Shadows: They are linear and if extensive form circular shadows
enclosing air. They can lead to lack of definition of diaphragm and heart (silhouette
sign).

8
 3. Alveolar Shadows: They are described as ill-defined blotches which may coalesce
to form bigger shadows. Air bronchograms may be seen within the blotches.
MAKING SENSE OF ABNORMAL CHEST RADIOGRAPHS IN SOME SELECTED
PATHOLOGIES

Localized Intrapulmonary Shadows:

Pathological processes in the lungs that absorb more x-ray than the normal tissues will
cause additional shadows on the radiograph. Some common causes of localized
intrapulmonary shadows on radiographs are:
a. Lobar pneumonia: The radiological features seen in lobar pneumonia are:
i. Consolidation of a whole lobe of lung.
ii. The consolidated lung remains the same size or becomes slightly larger.
iii. There is no displacement of hilar shadows, fissures, mediastinum or
diaphragm.
iv. The consolidated lobe can be made out using the silhouette sign discussed
earlier.
b. Lung Collapse (Atelectasis): The radiological features of lung collapse are:
i. Shadow of the collapsed lung or lobe of the lung.
ii. The silhouette sign; that is obliteration of the borders to the collapsed lung or
lobe of the lung.
iii. Displacement of structures to take up the space normally occupied by the
collapsed lung or lobe of the lung. If the collapsed lung is the left, structures
such as the trachea will be displaced towards the left as the right lung and
mediastinum move to take up the space normally occupied by it.
iv. Compensatory over-inflation of the unobstructed lobes (compensatory
emphysema) which is reflected by displacement of fissures and the
movement of the hilum towards the collapsed lobe.
v. Elevation of the hemi diaphragm in case of lower lobe collapse.
vi. No air bronchogram is seen if the cause of the collapse is bronchal
obstruction.

The features of atelectasis listed above are shown in the PA chest radiograph of this patient
with the condition (Figure 4)
c. Bronchopneumonia: This presents as multiple subsegmental or lobular shadows
seen usually at the basal portion of the lungs. This pattern can also occur in
pulmonary embolism, aspiration of gastric or oesophageal contents (mid and lower
zone consolidation) and alveolar cell carcinoma. In pulmonary embolism the chest
radiograph is often normal but shadowing occurs if there is accompanying
infarction.

9
Figure 4: Mediastinal shift and over inflation of the right lung following the collapse of the left
lower lobe. Note the shadow of the collapsed lobe, deviation of the trachea to the left and loss of
the outline of the left hemi-diaphragm

Solitary Rounded Shadows:

These are commonly due to primary carcinomas although secondary deposits may at times
be solitary. Most primary carcinomas are central and cause hilar enlargement. Peripheral
primary carcinomas are usually rounded but have ill-defined or spiculated outline. They
may involve the ribs, the apex of the lung (known as Pancoast tumor) and the brachial
plexus. Primary carcinomas do not contain calcium and when calcification is seen
carcinoma can be ruled out confidently. There may be cavitations and progressive

10
enlargement over several weeks is highly characteristic. Peripheral carcinomas are always
silent and can reach large sizes before being discovered incidentally.

Other causes of solitary rounded intrapulmonary shadows are harmatomas which are
benign tumors consisting largely of cartilage and fat with sharp outline and characteristic
“popcorn” calcification which may be present, tuberculomas which have irregular outline
and may both cavitate and calcify, hydatid cyst, pulmonary arteriovenous fistulae and
bronchial adenomas.

Solitary Shadows with Cavities:

a. Lung Abscess: It is usually rounded and with air-fluid level if the abscess had
ruptured into a bronchus allowing air to enter it.
b. Cavitating Carcinoma: It usually has thicker and more irregular wall than pyogenic
lung abscess.
c. Tuberculosis: The lesion usually has multiple cavities which are thin walled. Air-
fluid levels are usually not common.
d. Mycetoma: It appears as cavities in the apex of the lung which may contain a mass
with a halo of air in the cavity.

Diffuse Nodular Shadows:

These conditions are usually considered as differentials when this type of pulmonary
shadows is seen:
a. Miliary PTB
b. Sarcoidosis
c. Pneumoconiosis
d. Allergic aleovitis
e. Secondary malignant deposits

Chronic Obstructive Airways Disease (COAD):

Chronic obstructive airway disease (COAD) is a collective term for asthma, chronic
obstructive bronchitis and emphysema. In these three conditions, radiological appearances
are often normal; the value of chest x-ray examination being to exclude other diseases and
complications. Asthma is characterized by variable airflow obstruction while there is
chronic productive cough in chronic bronchitis and; tissue destruction at alveolar level in
emphysema. The common feature in the three conditions is airflow limitation mainly in
expiration which leads to over inflation of the lungs and occasionally appearance of bullae
in emphysema.

The radiological features of over inflation of the lungs are:

a. Flattened diaphragms: The dome of hemi diaphragms less than 1.5cm high.
b. Increased size of retrosternal transradiancy on the lateral radiograph. Normal size
of retrosternal transradiancy is 2-3cm at the level of sternal angle and 7cm at the
lower limit which is just above the diaphragm.
11
 c. The heart shadow tends to be long and narrow with a transverse diameter of
11.5cm or less.
d. Lower levels of hemi diaphragms.
e. Limited diaphragmatic excursion on fluoroscopic screening of the chest.

Changes on pulmonary vascular pattern are observed in emphysema. There is usually a

decrease in number of intrapulmonary vessels or their complete absence, especially where
bullae are present. A bulla is a hair-line shadow containing a translucent area. If infection is
present it may fill with fluid and contain air-fluid level. Chronic obstructive airways disease
may also cause pulmonary hypertension and heart enlargement.

Pulmonary Tuberculosis (PTB):

The remarkable feature of PTB that must be borne in mind at all times is that any shadow
on the lung fields can be due to PTB as it has widely varying patterns. However the
common radiological appearances (features) are as follows:
a. Homogenous areas of consolidation.
b. Mottled opacities of varying sizes.
c. Associated hilar adenopathy.
d. Pulmonary cavities appearing as ring shadows with transradiant centres.
e. Calcification may occur in healed fibrotic scars.
f. Tracheal displacement due to collapse or fibrosis may occur later.
g. Pleural effusion which is usually unilateral.
h. Pleural and diaphragm calcifications.

Pleural Effusion:
In pleural effusion, there is a homogenous opacity usually starting at the base of the lung
and extending upwards as shown in figure 5. The opacity usually has a medially directed
concave menicus (upper border) with the fluid tracking higher at the lateral margins than
the medial margins. The amount of fluid present may produce changes varying between
obliteration of the costophrenic angle and the entire lung field. It should be noted that a
minimum of 200ml of fluid must be present in the pleural space before the costophrenic
angle becomes obliterated. At this early stage ultrasonography is more sensitive in
detecting pleural effusion.

Bilateral pleural effusions occur in heart failure, pulmonary infarction, hypoproteinaemia,

renal failure, collagen vascular disease and subdiaphragmatic inflammation. Unilateral
pleural effusion occurs as a result of infections including PTB and, malignancy.
It is often very difficult to distinguish pleural effusion from shadow due to basal
consolidation or lung collapse. To do this a lateral decubitus projection is essential to see if
the suspected fluid will move to the dependent part.

12
Figure 5: Right-sided pleural effusion. The fluid tracks up laterally producing a medially
directed concave meniscus. The left lung field is normal and the left costophrenic angle is not
obliterated. Note the obliteration of the right heart border by the opacity cast by the effusion.

13
Cardiomegaly:
Cardiac size assessment is performed by:
a. Measuring the maximum transverse diameter of the heart represented by the
horizontal distance between the extreme edges of the heart borders. This must not
exceed 15.50cm on PA film of normal subjects. Any value greater than 15.50cm is
suggestive of cardiomegaly.
b. Use of cardiothoracic ratio (CTR): This gives a ratio of about 0.5 in normal subjects.
Any CTR value significantly greater than 0.5 is suggestive of cardiomegaly.
c. Comparison with pre-existing radiographs done in standard projection. This enables
the clinician to note any change in heart size over a time interval.
d. Two thirds of the heart lies closer to the left of the midline than the right on a PA
film. A distortion of this pattern of cardiac mass distribution in correctly projected
chest radiograph is suggestive of cardiomegaly.

The causes of cardiomegaly include the following:

a. Congestive cardiac failure.
b. Pericardial effusion.
c. Multiple valvular lesions.
d. Dilated cardiomyopathy.
e. Myocarditis.
f. Ebstain’s disease.
g. Hyperdynamic circulation.
h. Complete heart block.
i. Ischaemic heart disease.
Chest Trauma:
Features that may be seen in chest trauma are:
a. Fracture of a rib segment. Fractured ribs may at times be multiple.
b. Localized or extensive opacification of the lungs due to contusion, pneumothrax or
haemothorax.
c. Widening of the mediastinum.
d. Elevation of the diaphragm which may be due to rupture of the diaphragm or
segmental collapse of the lungs.

14