The British Journal of Radiology, 74 (2001), 89±97 E 2001 The British Institute of Radiology

Pictorial review
Lobar atelectasis: diagnostic pitfalls on chest
radiography
1
K ASHIZAWA, MD, 1K HAYASHI, MD, 1N ASO, MD and 2K MINAMI, MD
1
Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501
and 2Department of Radiology, Nagasaki Municipal Hospital, 6-39 Shinchi-machi, Nagasaki 850-8555, Japan

Abstract. This pictorial review looks at the pitfalls in the diagnosis of lobar atelectasis on chest
radiographs. Lobar atelectasis with marked volume loss is hard to recognize and may be easily
missed. Lobar atelectasis presenting as a mass-like opacity may be misdiagnosed as mediastinal or
lung tumour. Lobar atelectasis in an unusual location may also be misdiagnosed as other entities.
Familiarity with such manifestations and consideration of anatomical alterations as the signs of
lobar atelectasis are important in making the correct diagnosis.

Diagnosis of lobar atelectasis showing typical
radiographic appearances is clear [1±4]. However,
when the features of lobar atelectasis are unusual,
it may easily be missed or misdiagnosed as other
diseases, resulting in a delay in diagnosis and
management [1±4]. In this pictorial review, we
looked at unusual manifestations of lobar atelec-
tasis on chest radiographs.
Classi®cation of unusual manifestations
of lobar atelectasis
We classi®ed unusual manifestations of lobar
atelectasis into three groups: Group 1: atelectasis
with marked volume loss; Group 2: atelectasis
presenting as a mass-like opacity; and Group 3:
atelectasis in an unusual location.
Group 1: atelectasis with marked volume loss
Most cases of atelectasis in this group are
caused by peripheral airway obstruction. This
chronic atelectasis without central airway obstruc-
tion is referred to as non-obstructive atelectasis.
An atelectatic lobe with marked volume loss is
small and may be overlooked on plain chest
radiographs. When volume loss is marked,
however, many anatomical alterations as indirect
signs of lobar atelectasis can be identi®ed. It is
important to seek these changes to diagnose lobar
atelectasis.
Cases of marked lobar atelectasis for each lobe
are shown in Figures 1±6. In marked upper lobe
atelectasis, the small and elevated hilum and the
disappearance of the upper lobe pulmonary artery
are clues for the correct diagnosis (Figures 1 and
2). The crescentric lucency between the mediasti-
num and the atelectatic upper lobe on frontal
chest radiographs is called the Luftsichel sign [5].
This sign is more commonly seen in left upper
lobe atelectasis than in right upper lobe atelectasis
(Figure 2). A peak-like shadow located along the
medial half of the hemidiaphragm, called the
juxtaphrenic peak, is also seen in some cases of
upper lobe atelectasis.
In lower lobe atelectasis, inferior displacement
of the small hilum and the disappearance of the
descending branch of the pulmonary artery are
characteristic features (Figures 3±5). Shift of the
anterior mediastinal structures to the right,
referred to as ``the upper triangle sign'' [6], is
occasionally seen in right lower lobe atelectasis
(Figure 3). In marked atelectasis of the lower
lobe, the hemidiaphragm is seen throughout
its length (no silhouette sign) on the lateral
chest radiograph because of compensatory over-
in¯ation of the upper and middle lobe (Figures 3
and 4).
Anatomical alterations are infrequently present
in right middle lobe atelectasis because of the
smaller volume of the right middle lobe compared
with the other lobes (Figures 5 and 6). In severe
atelectasis, the frontal chest radiograph may be
normal and the apical lordotic view character-
istically demonstrates a wedge with its apex
directed away from the hilum (Figure 6).

Received 4 January 2000 and accepted 4 May 2000.

The British Journal of Radiology, January 2001 89


Group 2: atelectasis presenting as a mass-like
opacity
Lobar atelectasis sometimes presents as a mass-
like opacity with a sharp lateral margin on the
chest radiograph (Figures 7±10), and may be
misdiagnosed as a mediastinal or lung tumour.
To avoid this, it is important to appreciate
anatomical alterations as the key radiographic
®ndings. CT is useful in differentiating atelectasis
from mediastinal or lung tumours. In some cases,
bronchiectasis containing mucus within the atelec-
tatic lobe is clearly demonstrated on contrast
enhanced CT (Figures 8 and 9). Combined right
middle lobe and right lower lobe atelectasis can be
confused with cardiac enlargement and with
simple elevation of the right hemidiaphragm.
Group 3: atelectasis in an unusual location
The lower lobe is generally tethered to the
mediastinum and the hemidiaphragm by the
inferior pulmonary ligament. In contrast, the
upper lobe and right middle lobe are incompletely
®xed. The atelectatic upper lobe and right middle
lobe are therefore often mobile, resulting in an
unusual location. This appearance may be mis-
diagnosed as other diseases. Representative cases
of this group include atelectasis with lung torsion
(Figure 10), right middle lobe atelectasis in the
tipped up (Figure 11) or tipped down position,
and atypical peripheral upper lobe atelectasis
(Figure 12).
Heavy atelectatic lobes, whether ®lled with
¯uid, chronic pneumonia or tumour, may migrate
(a)
Figure 1. 68-year-old woman with marked right upper lobe atelectasis due to bronchial tuberculosis.
(a) Posteroanterior radiograph showing markedly atelectatic right upper lobe as a band opacity at the right super-
ior mediastinum (arrows). Note the small and elevated right hilum and the decreased vascular markings in the
right lung. (b) CT clearly demonstrates the atelectatic right upper lobe as a band opacity (arrows).
90
K Ashizawa, K Hayashi, N Aso and K Minami
with a change in the patient's position [2]. Unless
radiographic signs of atelectasis are recognized,
the atelectatic lobe may be mistaken for a
mediastinal tumour (Figure 10). This condition
has been termed ``lobar torsion'' [7], and should
be considered when an atelectatic lobe has shifted
from its usual to an atypical location (Figure 10).
The atelectatic middle lobe is very mobile and
easily displaced because the right middle lobe
bronchus is the narrowest and longest of the lobar
bronchi. This atelectatic lobe may swing forward
to a tipped up position or may be displaced
posteriorly into a tipped down position. In the
tipped up position, the atelectatic lobe lies
horizontally and the frontal chest radiograph
shows it to have a con®guration usually seen on
apical lordotic views (Figure 11).
Atypical (peripheral) upper lobe atelectasis
occurs most frequently in children and most
commonly involves the right lung. The radio-
graphic ®ndings of this type of atelectasis may
easily be mistaken for a pleural mass or effusion
(Figure 12). Recognition of this unusual pattern
of upper lobe atelectasis is important to avoid
unnecessary diagnostic biopsy or thoracentesis.
Lobar atelectasis may cause pneumothorax.
Localized pneumothorax adjacent to an atelec-
tatic lobe is described as a sign of bronchial
obstruction (Figure 13) [8] and has been termed
``pneumothorax ex vacuo''. Treatment should be
directed to the underlying bronchus and not the
pleural space. For appropriate treatment, it is
important to differentiate this condition from
pneumothorax-induced atelectasis.
(b)
The British Journal of Radiology, January 2001
Pictorial review: Lobar atelectasis on chest radiography

(a) (b)

(c)

Figure 2. 61-year-old man with marked left upper lobe atelectasis due to a carcinoid tumour in left upper lobe
bronchus. (a) Posteroanterior radiograph shows a small left perihilar opacity. The left hilum is elevated and the
left upper lobe pulmonary artery is invisible. (b) Anteroposterior scout radiograph on CT shows a radiolucent
stripe (arrowheads) between the atelectatic left upper lobe and the aortic arch (Luftsichel sign). (c) CT shows the
atelectatic left upper lobe as a triangular opacity with its apex directed posteriorly. The hyperin¯ated superior seg-
ment of the left lower lobe extends medially to the atelectatic lobe (arrow), producing the Luftsichel sign.

The British Journal of Radiology, January 2001 91

 K Ashizawa, K Hayashi, N Aso and K Minami

(a) (b)
Figure 3. 20-year-old man with marked right lower
lobe atelectasis due to bronchiectasis as a result of
childhood pulmonary infection. (a) Posteroanterior
radiograph. The atelectatic right lower lobe is so
small that it can hardly be seen. The right hilum is
small, and compensatory overin¯ation and decreased
vascular markings in the right lung are present. Note
that the anterior mediastinal triangle has shifted to
the right (black and white arrowheads), forming the
upper triangle sign. (b) Lateral radiograph. The
atelectatic lobe cannot be identi®ed. Note that the
right hemidiaphragm is seen throughout. (c) CT
shows a small opacity with air bronchogram at the
(c)
right paravertebral region (arrow).

(a) (b)

Figure 4. 74-year-old man with marked left lower lobe atelectasis due to bronchiectasis. (a) Posteroanterior radio-
graph shows a small hilum on the left and decreased vascular markings in the left lung. Lateral margin of the
atelectatic left lower lobe can easily be mistaken for the descending aortic interface (arrowheads). (b) CT demon-
strates a markedly atelectatic left lower lobe as a small opacity with air bronchogram in the left paravertebral
region.

92 The British Journal of Radiology, January 2001

Pictorial review: Lobar atelectasis on chest radiography

(a) (b)

(c)

Figure 5. 52-year-old woman with marked left lower lobe and right middle lobe atelectasis with bronchiectasis.
(a) Posteroanterior radiograph shows obliteration of the right cardiac border (the silhouette sign). Although the
left hilum is small and the vascular markings in the left lung are decreased, it is dif®cult to detect the atelectatic
left lower lobe. (b) Lateral radiograph shows the atelectatic right middle lobe as an oblique linear opacity. The
atelectatic left lower lobe is not identi®ed. The left hemidiaphragm is seen throughout. (c) CT demonstrates the
right middle lobe atelectasis as a triangular opacity with air bronchogram. Marked left lower lobe atelectasis is
seen at the left paravertebral region.

The British Journal of Radiology, January 2001 93

 K Ashizawa, K Hayashi, N Aso and K Minami

Figure 6. 22-year-old man with marked right middle

lobe atelectasis due to bronchiectasis. (a) Postero-
anterior (PA) radiograph shows obliteration of the
right cardiac border, but the ®nding is rather subtle.
(b) Lateral radiograph shows a thin linear opacity
(arrowheads). The diagnosis of right middle lobe
atelectasis cannot be clearly made from PA and lat-
eral views. (c) Apical lordotic radiograph demon-
strates the atelectatic right middle lobe as a
triangular opacity. Note the air bronchogram within
the atelectatic lobe, indicating non-obstructive atelec-
tasis.

(a)

(b) (c)

94 The British Journal of Radiology, January 2001

Pictorial review: Lobar atelectasis on chest radiography

(a) (b)

Figure 7. 46-year-old man with right upper lobe atelectasis due to adenocarcinoma arising from the right upper
lobe bronchus. (a) Posteroanterior radiograph shows a large opacity with a sharp lateral margin. Since the tra-
chea is slightly displaced to the left, a mediastinal mass may be considered. Note elevation of the right hemi-
diaphragm. (b) CT demonstrates the atelectatic right upper lobe adjacent to the mediastinum. The right main
bronchus is stenotic due to tumour invasion.

(a) (b)
Figure 8. 40-year-old woman with combined right middle and lower lobe atelectasis due to bronchial tuberculosis.
(a) Posteroanterior radiograph shows a mass-like opacity with a convex lateral margin. A thymoma was suspected
as the patient had been suffering from myasthenia gravis. (b) CT clearly demonstrates atelectatic right middle
lobe (arrow) and right lower lobe (arrowhead) with dilated bronchi containing mucus. Bronchial tuberculosis was
con®rmed at right middle and lower lobe.

(a) (b)
Figure 9. 61-year-old woman with combined right middle and lower lobe atelectasis due to bronchial tuberculosis.
(a) Posteroanterior radiograph shows a mass-like opacity with a sharp margin lateral to the right cardiac border
(arrow). The right hilum is small and inferiorly displaced. (b) CT clearly demonstrates marked atelectasis of the
right middle lobe (arrow) and right lower lobe (arrowhead) with dilated bronchi containing mucus.

The British Journal of Radiology, January 2001 95

 K Ashizawa, K Hayashi, N Aso and K Minami

(a) (b)

(c) (d)
Figure 10. 70-year-old man with right upper lobe atelectasis associated with lung torsion due to squamous cell
carcinoma. (a) Posteroanterior radiograph shows a mass-like opacity with sharp lateral margin overlying the right
hilum. (b) Anterior location and sharp outer margin of the atelectatic lobe are demonstrated on the lateral radio-
graph. (c) Note that the atelectatic lobe migrates with change in the patient's position, as seen on CT scout view.
(d) The atelectatic right upper lobe is located posteriorly on axial CT in the supine position. (Courtesy of
Yasuyuki Kurihara, MD, St Marianna University, School of Medicine, Kawasaki-shi, Japan.)

Figure 11. 78-year-old man with right middle lobe

atelectasis. Anteroposterior radiograph shows right
middle lobe atelectasis in the tipped up position. The
atelectatic lobe swings forward and lies horizontally.
This appearance is similar to the con®guration of
right middle lobe atelectasis on the apical lordotic
view (Figure 6c).

96 The British Journal of Radiology, January 2001

Pictorial review: Lobar atelectasis on chest radiography

Figure 12. 73-year-old man with peripheral left upper

lobe atelectasis due to squamous cell carcinoma.
Posteroanterior radiograph shows the pleural-based
opacity over the left apex mimicking a pleural/extra-
pleural mass or pleural effusion (arrowheads).

Figure 13. 7-year-old girl with right upper lobe atelec-

tasis associated with localized pneumothorax. The
patient had congenital hypertrophic cardiomyopathy.
Anteroposterior radiograph shows a localized pneu-
mothorax adjacent to the atelectatic right upper lobe,
``pneumothorax ex vacuo''. Note that the pneu-
mothorax is bounded by the outline of the atelectatic
upper lobe (arrowheads).

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