Reading Normal Pediatric Chest X Ray - DR Sandra

“Reading Normal Pediatric Chest X-ray” Made Easy
The interpretation of Pediatric chest x ray is a taught skill that consists of

multistep approach, as shown on scheme 1.
Preliminary steps before looking for the abnormalities:
1. The clinical history indicated on the request should be checked as it will
be interrelated with the CXR findings in the future.
2. The patient's name and the study date should be confirmed with the
information labeled on the CXR. Of particular importance is the patient's
age, which is correlated with the presence or absence of the thymus and
the expected signs of bony maturity.
3. Technical factors are scrutinized, as poor inspiratory and rotated films
may lead to misinterpretations.
Technical factors:
Good inspiration: (Figure 1-4) and Central positioning (figure 5-8) are the most
crucial factors to be assessed.
Criteria for optimal inspiratory film on an erect CXR:
1. The medial endpoint of the first rib medially.
2. Six right anterior ribs intersect with the copula of the diaphragm.
3. The entire cardiac contour is positioned above the diaphragm.
4. The base of the heart forms an acute angle with the diaphragm.
On the supine film, the same criteria are followed except for five right anterior
ribs intersect with the copula of the diaphragm.
Pitfalls of poor inspiration: false cardiomegaly and diffuse opacification of the
lungs.
Central positioning:
Criteria for central position:
1. Symmetrically shaped clavicles,
2. The trachea is centrally positioned between the right and left pedicles.
Please note that the pedicles are considered as the reference because
spinous processes may not be ossified and the clavicular medial ends
maybe indistinguishable from the surrounding shadows.
Perfectly centralized CXR films are hard to acquire, most of the time, so
minimal rotation is accepted.
Pitfalls of rotation:
1. False hyperlucency of the lung ipsilateral to the side of rotation, and
pseudo contralateral hilar plethora.
2. Pseudo right paratracheal mass from the sternum manubrium.
3. False positive impression of cardiomegaly.
Patient’s posture: Whether the x ray is taken in supine or erect position, is

considered mainly to assess the criteria of proper inspiration.
Exposure: In the era of digital radiology, exposure evaluation plays no role.
4. Developing a systematic approach:

There are several approaches that can be utilized when reading a Pediatric
CXR. Potential methods for the initiation of checklist assessment are the
following:
A. From caudal to cranial direction, or vice versa,
B. From the peripheral to central structures or vice versa,
C. From the least important (chest wall) to the most important (blind
spots) or vice versa,
D. The 3 shades (air, soft tissue, and bone)
Applying either of the aforementioned strategies would result in a proper
evaluation of the 11 structures illustrated on CXR. It is essential to be
aware of the normal appearance of these structures as well as their
variants.
5. Comparison with previous CXR, chest CT and other relevant radiological
studies from archives.
Normal Anatomy: (Scheme 2-3)

1. Abdomen:
a) Free air:
Subdiaphragmatic pneumoperitoneum is noted if the CXR is acquired in
the erect position.
b) Stomach air bubble position:

Situs assessment is discussed at (9. Heart)
c) Calcifications:
Paravertebral calcifications may refer to neuroblastoma or neurogenic
tumors.
Calcifications in the projection of the liver maybe due to hepatoblastoma.
Gallbladder or kidney stones maybe picked up on CXR.
d) Foreign body
e) Bowel distension
f) Bowel loops above the diaphragm
2. Diaphragm:
Both domes are sharp with smooth contour. Usually both domes are at the
same level, but the left dome maybe 1.5 cm lower than the right side.
Appears flattened when lungs are hyperinflated.
3. Costophrenic angle:
The lateral angles normally form sharp acute angles.
Blunted or obliterated angle is due to pleural effusion or extension of
lower lobe consolidation.
Deep sulcus sign: Deep, lucent, costophrenic angle on supine chest
radiograph, as a sign of pneumothorax.
4. Chest wall soft tissue:

a) Swelling:
Can be due to masses (focal swelling) or due to cellulitis (diffuse
swelling)
b) Calcifications: the most common cause is BCG-oma.
c) Foreign body
d) Subcutaneous emphysema:
Due to rib fractures with air leak or pneumomediastinum.
e) Artifacts: from external shadows like a skin fold, hair braid, bandage,
buttons, or clothes.
5. Bones:
All bones must be searched for presence/ absence of fractures,
osteolytic/ expansile/ destructive lesions.
a) Vertebra:
Vertebral bodies are normally rectangular with rounded pedicles.
Loss of vertebral body heightà fracture DDX
Segmentation anomaliesà VACTREL
Intervertebral disc space widening/ narrowing.
b) Ribs:
12 pairs of ribs, hypoplastic and bifid ribs are common.
Rib notching,
Intercostal space widening,
c) Clavicles:
Absent or short clavicles refer to cleidocranial dysostosis.
Elongated clavicles (handlebar deformity) refer to skeletal dysplasia like
osteogenesis imperfecta and campomelic dysplasia.
d) Scapula:
Elevated scapulaà Sprengel’s deformity +/- Klippel Feil syndrome
Small scapula and hypoplastic glenoid fossa à skeletal dysplasia.
e) Humeri:
Normally the humeral head epiphysis is ossified at the age of 4 months. It
is an important landmark to assess the bony maturity of the patient. Its
delayed ossification maybe due to prematurity, failure to thrive or
hypothyroidism.
6. Airways: (figure 9-10)

Trachea should be visible on all normal CXR, in the midline or
occasionally with a slight buckle to right at the thoracic inlet.
Bronchial branching pattern is pursued to help determine the situs besides
the use of cardiac apical and gastric air-bubble positions.
7. Hila: (figure 11)

The diameter of the pulmonary arteries in the hilum is compared to the
accompanying bronchus and it is normally identical in size.
Hilar plethora is the term used to describe vascular dilatation (i.e. the
artery’s diameter is double that of the bronchus,) on the contrary, hilar
oligemia is the reverse.
Vessels extend to the mid lung third, tapering gradually and no vessels
are seen in the outer one third.
Bilateral hilar vascular diameter should be compared (to rule out
pulmonary artery hypoplasia)
8. Aorta and pulmonary trunk: (figure 11)

The aortic knob should always be looked for on the left side. If not seen,
an indentation on the right wall of the trachea should be excluded to rule
out a right sided aortic arch. Otherwise, mediastinal lesions must be ruled
out.
The pulmonary trunk contour is seen below the aortic knob, must form a
straight contour (not a bulge)
The descending aorta is usually seen as a straight line in the left
paravertebral region.
9. Heart: (figure 11 & 12)

Correlation with the gastric air bubble position with the site of cardiac
apex is used to determine the situs.
A. If both are on the left side à situs solitus.
B. If both are on the right side à situs inversus.
C. If each is on the opposite side of the other à situs ambiguous.
Criteria for cardiac size assessment:
The left cardiac contour should not exceed the left copula, and the
right cardiac contour should not exceed the medial third of the
right hemithorax. These criteria can be followed only on a good
inspiratory and central CXR.
10. Lungs: (figure 13)

Divided into three zones, which are used to describe the location of an
abnormality when the lobe affected can’t be decided confidently.
§ Upper zone: from lung apex to an imaginary line at the 2nd
anterior rib.
§ Middle zone: from an imaginary line at the 2nd to the 4th anterior
rib.
§ Lower zone: below an imaginary line at the 4th anterior rib.
Symmetrical zonal aeration and intercostal spacing is looked for.
Blind spot areas are those areas where pathologies are most missed.
§ The retrocardiac region is clear à when its density is equal to
other parts of the mediastinum and when the left hemidiaphragm
overlapping with the cardiac contour is sharp (not obscured).
§ The paraspinal region is clear à no convex lesions.
§ The apex à no pleural effusion or convex lesions
11. Thymus: (figure 14-15)

A soft organ with similar density as the other mediastinal structures,
located in the superior anterior mediastinum. Its rectangular form winds
seamlessly into the cardiac silhouette. Usually seen until 3 years of age.
The most common appearance of thymus, having quadrangular
“widened-mediastinum like appearance” with straight contour and soft
tissue density that is indiscernible from aortic knob, pulmonary trunk or
heart silhouette.
§ Thymic notch sign: notch at the inferior border of the normal
thymus at the point where it interrupts with the border of the
cardiac silhouette.
§ Thymic Wave Sign: the left wavy contour of the thymus refers to
the impression of the anterior portion of the ribs on the soft thymus
gland.
§ Thymic Sail Sign: triangular lateral extension of thymus into the
right hemithorax, against the transverse fissure.
Normal variants (figure 16-20)

Reading Normal Pediatric Chest X Ray - DR Sandra

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“Reading Normal Pediatric Chest X-ray” Made Easy

The interpretation of Pediatric chest x ray is a taught skill that consists of

Patient’s posture: Whether the x ray is taken in supine or erect position, is

4. Developing a systematic approach:

Normal Anatomy: (Scheme 2-3)

b) Stomach air bubble position:

4. Chest wall soft tissue:

6. Airways: (figure 9-10)

7. Hila: (figure 11)

8. Aorta and pulmonary trunk: (figure 11)

9. Heart: (figure 11 & 12)

10. Lungs: (figure 13)

11. Thymus: (figure 14-15)

Normal variants (figure 16-20)

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