PA view

• Line or stripe - for instance the right para tracheal stripe.

• Silhouette - for instance the normal silhouette of the aortic knob or left
ventricle
• These lines and silhouettes are useful localizers of disease, because
they can be displaced or obscured with loss of the normal silhouette.
This is called the silhouette sign, which we will discuss later.
• The paraspinal line may be displaced by a paravertebral abscess,
hemorrhage due to a fracture or extravertebral extension of a
neoplasm.
• Widening of the paratracheal line (> 2-3mm) may
be due to lymphadenopathy, pleural thickening,
hemorrhage or fluid overload and heart failure.
• Displacement of the para-aortic line can be due to
elongation of the aorta, aneurysm, dissection and
rupture.
• The anterior and posterior junction lines are
formed where the upper lobes join anteriorly and
posteriorly. These are usely not well seen and we
will not discuss them.
• An important mediastinal-lung interface to look for
is the azygoesophageal line or recess (arrow).
 Azygoesophageal
recess. The blue arrow
indicates the
paraaortic line

• The azygoesophageal recess is the region inferior to the level of the azygos vein
arch in which the right lung forms an interface with the mediastinum between the
heart anteriorly and vertebral column posteriorly.
It is bordered on the left by the esophagus.
Deviation of the azygoesophageal line is caused by (5):
• Hiatal hernia
• Esophageal disease
• Left atrial enlargement
• Subcarinal lymphadenopathy
• Bronchogenic cyst
Notice the deviation of the azygoesophageal line on the PA-film.
It is caused by a hiatal hernia
Vena azygos lobe
• A common normal variant is the azygos lobe.
• The azygos lobe is created when a laterally displaced azygos
vein makes a deep fissure in the upper part of the lung.
• On a chest film it is seen as a fine line that crosses the apex of
the right lung.
• On the lateral view spondylosis may mimick a lung mass.
• Any density in the area of the vertebral bodies should lead
you to the PA-film to look for spondylosis, which is usually
located on the right side (arrows).
• On the left side the formation of osteophytes is hampered by
the pulsations of the aorta.
• On the PA-view the superior mediastinum is widened.
The lateral view is helpful in this case because it demonstrates a
density in the retrosternal space.
Now the differential diagnosis is limited to a mass in the anterior
mediastinum (4 T's).
• This was a Hodgkins lymphoma
Silhouette sign in a consolidation located in the lingula (blue arrow). The silhouette of
the left heart border will still be visible in a consolidation in the left lower lobe (red
arrow)
Silhouette sign
• The difference in density between the heart and the air in the lung
enables us to see the silhouette of the left ventricle.
• When there is something in the lingula with the same 'water density' as
the heart, the normal silhouette will be lost (blue arrow).
• When there is a pneumonia in the left lower lobe, which is located
more posteriorly in the chest, the left ventricle will still be bordered by
air in the lingula and we will still see the silhouette of the heart (red
arrow).