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Lobar atelectasis: diagnostic pitfalls on chest radiography

¹ Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501
² Department of Radiology, Nagasaki Municipal Hospital, 6-39 Shinchi-machi, Nagasaki, 850-8555, Japan

View larger version (62K): [in a new window]   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 superior 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).

View larger version (100K): [in a new window]   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 hyperinflated superior segment of the left lower lobe extends medially to the atelectatic lobe (arrow), producing the Luftsichel sign.

View larger version (107K): [in a new window]   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 overinflation 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 identified. Note that the right hemidiaphragm is seen throughout. (c) CT shows a small opacity with air bronchogram at the right paravertebral region (arrow).

View larger version (69K): [in a new window]   Figure 4. 74-year-old man with marked left lower lobe atelectasis due to bronchiectasis. (a) Posteroanterior radiograph 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 demonstrates a markedly atelectatic left lower lobe as a small opacity with air bronchogram in the left paravertebral region.

View larger version (103K): [in a new window]   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 difficult 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 identified. 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.

View larger version (116K): [in a new window]   Figure 6. 22-year-old man with marked right middle lobe atelectasis due to bronchiectasis. (a) Posteroanterior (PA) radiograph shows obliteration of the right cardiac border, but the finding 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 lateral views. (c) Apical lordotic radiograph demonstrates the atelectatic right middle lobe as a triangular opacity. Note the air bronchogram within the atelectatic lobe, indicating non-obstructive atelectasis.

View larger version (62K): [in a new window]   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 trachea is slightly displaced to the left, a mediastinal mass may be considered. Note elevation of the right hemidiaphragm. (b) CT demonstrates the atelectatic right upper lobe adjacent to the mediastinum. The right main bronchus is stenotic due to tumour invasion.

View larger version (65K): [in a new window]   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 confirmed at right middle and lower lobe.

View larger version (70K): [in a new window]   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.

View larger version (141K): [in a new window]   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 radiograph. (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.)

View larger version (161K): [in a new window]   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 configuration of right middle lobe atelectasis on the apical lordotic view (Figure 6c).

View larger version (176K): [in a new window]   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/extrapleural mass or pleural effusion (arrowheads).

View larger version (161K): [in a new window]   Figure 13. 7-year-old girl with right upper lobe atelectasis associated with localized pneumothorax. The patient had congenital hypertrophic cardiomyopathy. Anteroposterior radiograph shows a localized pneumothorax adjacent to the atelectatic right upper lobe, "pneumothorax ex vacuo". Note that the pneumothorax is bounded by the outline of the atelectatic upper lobe (arrowheads).