1. CHEST RADIOGRAPHS, NORMAL VARIANTS IN THE CHEST
A WAYANG KULIT RADIOGRAPH
Part Two Dr Ng Kian Seng
MBBS (Singapore) MCGP (Malaysia)
Second Edition Master Of Medicine (Internal Medicine, Singapore)
February 2012 FAFP (Malaysia) Cert In Occupational Medicine
Ph D (Theology, USA)

2. An Album On The Normal Variants In The
Chest Radiograph
You need to know the normal well enough
so that you will not mistake a normal
variant for some pathological condition.
Practise looking at the normal Chest
Radiograph…do not disdain it because it
has no bizarre or frightful shadows you can
be 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”.

3. 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.”

4. NIPPLE SHADOWS

5. NIPPLE SHADOWS
RIGHT NIPPLE LEFT NIPPLE
Confirm these are indeed nipple
shadows by using metal markers!

6. 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.

7. BONE ISLAND IN THE RIB

8. DROMEDARY HUMP IN THE DIAPHRAGM

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

10. Tenting In The Diaphragm
Note the triangular opacity at mid part
of right hemi-diaphragm (arrow). Diaphragmatic tenting is a localized
Diaphragmatic tenting is due to fibrosis accentuation of the normal convexity
and may not have any clinical significance. 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.
Source : Nexradiology

11. Diaphragmatic Hump
Scalloping In The Diaphragm
Note multiple arcuate elevations of the right This is due to incomplete muscularization of the
hemi-diaphragm. Scalloping is seen in about diaphragm. Instead of the normal diaphragmatic
10% of normal CXR. 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.
Source : Nexradiology

12. Normal Variants in the Rib Cage
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

13. EXAMINE THE FIRST & SECOND
RIBS ON BOTH SIDES
See Next Two Slides For The Answers

14. 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.

15. PSEUDO-ARTHROSIS OF THE FIRST TWO RIBS ON THE LEFT

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

17. What is the bony abnormality in this patient?
Chest radiograph is showing well developed bilateral
cervical ribs.

18. The Cervical Rib is an extra rib that arises from the
7th Cervical Vertebrae. How do you know these are
Cervical Ribs and not the 1st Thoracic Ribs?
Cervical
Transverse
Processes
Points
Downwards=
CD
Thoracic
Transverse
Processes
Points
Upwards =
TU
Look at the transverse processes that
articulate with these ribs. Cervical
transverse processes points down while
thoracic transverse processes points up.

19. 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!

20. 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…
Female, Aged 78 Male, Aged 79

21. Male, the peace sign
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, Aged 79
Another Image of
The peace sign

22. Female, A solitary Finger
The second is the “Central
Lingual Ossification
Pattern”, the female pattern
which 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, Aged 78

23. What is the abnormality
In this Indonesian man ?
A “Charm Needle” inserted
into the chest wall, a common
practice among Indonesian
men

24. Fat Tissue
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

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

26. Pectus Excavatum, Funnel Chest
(1)Indistinct R heart
border, sometimes
mimic 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

27. Dextrocardia with Situs Inversus
If you did not look at the side marker
you would have missed the diagnosis of
Dextrocardia

28. Collage, Shanghai Girl Series, By Ng Kian Seng
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