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Thread: Don't miss lesions in Chest X-ray

  1. #1
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    Dec 2006
    Mauritius (SSRMC)
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    Thumbs up Don't miss lesions in Chest X-ray

    Before I finish looking at any film, I always give a second look for some of the lesions that I commonly see people miss. While these should be found on the initial systematic evaluation of the film, it is so common for other people to miss them that I always think it is worth looking for them twice. I call these “don’t miss” lesions. The lesions I commonly see missed are:
    1. Deviation of the trachea
    2. Retrocardiac masses/densities
    3. Lesions “below” the diaphragm
    4. Lesions near the hilum
    5. Adenopathy

    Deviation of the trachea
    Because the trachea is so well seen, it can give good clues about what is going on in the neck or mediastinum. Enlargement of one side of the thyroid gland (whether from multinodular goiter, tumor, etc.) is common cause of deviation of the trachea. Unless you specifically look for this finding, though, it is easy to miss.

    Retrocardiac Masses/Densities

    It must always be remembered when looking at a frontal film that is quite a lot of lung sitting behind the heart. On a good film this lung can still be well seen and evaluated. Nodules, masses and pneumonias (along with any other lung pathology) may be found hiding there. Since most films obtained on hospitalized patients are done portably without a lateral view, your only chance to see these findings is if you remember to look “through” the heart.

    Lesions “Below” the Diaphragm
    The diaphragm has a three-dimensional shape that should be remembered whenever you are looking at a frontal film. The
    “diaphragm” that you see on the frontal film actually represents the highest point of the diaphragm and it is usually far anterior. Posteriorly the diaphragm drops far inferior. All of that lung below (really posterior to) the highest part of the diaphragm can be seen “through” the diaphragm, similar to the lung behind the heart. Again, lesions here are easy to miss unless you make a specific effort to look for them.

    Lesions Near the Hilum

    The hilum is a busy place on the chest film, and it is easy to miss subtle lesions that occur here. Because I often see people miss these types of lesions, I always give the perihilar regions a second look. This figure shows an example of a very large mass that was partially obscured by the hilum and easy to miss if you are not paying attention and specifically
    looking for it.


    Hilar and mediastinal adenopathy is commonly seen with many diseases, both malignant and benign. Often, the presence of adenopathy will be the only abnormality in an otherwise normal chest film. Identifying adenopathy can have a significant effect on a patient’s workup and management. Because the adenopathy is usually seen in either the hilum or mediastinum (where many other soft tissue densities live) it can easy to overlook. It always worth asking yourself about adenopathy just before you finish looking at the film.

  2. #2
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    Dec 2008
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    thank you so much

  3. #3
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    Nov 2007
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    thank you very much really nice.....

  4. #4
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    Feb 2010
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    Good one!

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