Humongous Insurance

Normal Anatomy of Chest X- Ray

Presented by:
Dr. Anila Faisal

Jan 16, 2009

 Agenda
i. How to Study Chest X-Ray?
ii. Mediastinum
a. Trachea
b. Hilar Region
c. Heart
iii. Diaphram
iv. Lungs & Pleura
v. Bones
vi. Soft Tissues
vii. Questions and answers

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 Mediastinum
• Overall size and shape
• Trachea: position
• Margins
• Lines and stripes
• Paratracheal
• Paraspinal
• Paraesophageal (azygoesophageal)
• Paraaortic
• Retrosternal clear space

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Mediastinum

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 Mediastinum
•Define
•Area between the lung
•Water density
•Surrounded two air filled lungs and
•Intersected by the air filled trachea and major
bronchi.
•Key is knowledge of anatomical
relationships and
• how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins
may be distorted by pathological lesion
• Masses
• otherwise

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MEDIASTINUM
 MEDIASTINUM

• Anatomy dividing region

– SUPERIOR MEDIASTINUM
• Begins - root of the neck and
• Ends - line drawn T-4 vertebrae ---
sternomandible junction.
– line skims the top of the aortic arch. T
– Mediastinum
• Begins - this line
• End- diaphragm
• Further divided into three regions
– Anterior
– Middle
– Posterior.
 Trachea

Look trachea/major
bronchus
•Size
•Position
•Intraluminal masses

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 Lateral view of tracheal wall

• Posterior tracheal
< 4mm
 Right Pratracheal stripe

• Normal- < 5 mm,

usually 2-3 mm.
•Important marker for subtle adenopathy.
• Distal end - formed by azygous vein
•Distended vein, stripe > 1 cm.
• Medial margin -soft tissue interface /right
mucosal surface of trachea.
• Outer margin -begins medial end of
clavicle/formed by plural surface of right
upper lobe (RUL).
• Normal structures in soft tissue density
between air trachea and the RUL
•Right wall of the trachea
•Nerves
•Fat
•Lymph nodes
•Pleura of the RUL.
• Azygous vein - anteriorly to empty into
the posterior surface of the SVC. 
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Paraspinal stripe

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 Paraspinal Stripe

• Sometimes (+) on the frontal view

• Plural edge parallel to the lateral
margins of the vertebral bodies.
• Edge > millimeters beyond the
vertebral bodies
• Should not be lumpy or bulging.

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Azygoesophageal line or
Paraesophageal line

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 Azygoesophageal line or
Paraesophageal line
• On the forntal view only
• Formed by the right lower lobe &
Mediastinum, containing
– Esophagus
– Azygous vein.
• Overlies the thoracic spine
– Near the midline
– Fairly straight, vertical.
• Bulges convex to lung
– S/p mediastinal mass, eg.
• subcarinal lymph nodes
• Enlarged left atrium.

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Left Bronchus

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Anatomy & project
1. Carina
2. Left Main Stem
Bronchus
3. Descending Aorta
4. Main Pulmonary
Artery
5. Aorticopulmonary
Window
6. Arch of Aorta
 Hilum
• Made of:

• 1. Pulmonary Art.+Veins
• 2. The Bronchi

• Left Hilus higher (max 1-2,5 cm)

• Identical: size, shape, density

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 Frontal view of the hila
• Frontal view, hilar shadows most
– left pulmonary arteries.
– right pulmonary arteries.
• Bronchi(with the arteries)
– Radiolucent.
• Pulmonary veins
– Not clearly seen
• they are behind the widest parts of the heart, inferior to
the hila, where they converge into the left atrium.
• Left pulmonary artery always more superior
> right,  left hilum higher.
• Calcified lymph nodes may be visible within
the hilar shadows. 
 Lateral view of the hila

1. Trachea
2. Lower lobe bronchi
(left and right
superimposed)
3. Right Pulmonary
Artery
 Heart
• Right border: Superior Venacava above
Edge of (r) Atrium and Inferior Venacava
below
• Apex & Left border: Left Ventricle
• Anterior border: Right Ventricle
• Inferior Surface is formed by Both
Ventricles

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Heart

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 Heart
• Superimposed on the frontal view.
• The major structure is the heart.
• Pericardium and heart is inseparable on plain film views.
• Review the heart for overall size and shape.
• Rough yardstick - cardiac-thoracic ratio
– Widest diameter of the heart /widest width of the thoracic
cage( inner aspect of rib to rib).
– > 50%
• Check
– Calcifications
– Pneumopericardium
– Pneumomediastinum
– Sutures
– Prosthetic valves etc.,
• You may have overlooked on the general survey of the
entire mediastinum.
 Lateral view of heart

1. Trachea
2. Right Ventricle
3. Left Ventricle
4. Left Atrium
5. Right Pulmonary
Artery
 Cardiothoracic Ratio

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 Heart Valves

• How to Locate Heart Valves?

– At Lateral View of CXR

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Position of Heart Valves on
PA View

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Questions and answers

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