Is the image diagnostic? (10 point plan)

10. Anatomical variations & pathological appearances

Anatomical variations

There are a number of anatomical variants on mobile chest radiographs. The radiographer/ technologist must be aware of common variants and their imaging appearances. This is available at:

https://portal.e-lfh.org.uk/Catalogue/Index?HierarchyId=0_33_30128_374&programmeId=33 

These include:

  • Dextrocardia with or without situs inversus.
    • This can be accidentally displayed by the radiographer/technologist when processing the image. The computer protocol will automatically display the image depending on the examination selected, AP or PA. Images are displayed in the anatomical position and can be flipped
  • Azygous fissure. This can be seen on the right side in a small number of chest X-ray images (1-2%). The azygos vein lined with visceral and parietal pleura makes a small connection with the rest of the upper lobe.
    • Accessory fissures can also be seen occasionally on chest images
  • Cervical rib and rib variants.
    • Cervical ribs are usually bilateral (80%) but are rarely symmetrical. They arise from the seventh cervical vertebrae and are usually asymptomatic.
  • Calcification of the cartilages.  Costochondral calcification of the anterior and/ or medial ends of the ribs is more prominent with ageing and can be particularly marked in some individuals
  • Scoliosis makes image interpretation more difficult and is accompanied with rotation of the thorax. Assessment of heart size may not be accurate
Pathological appearances

Chest radiographs are one of the front line investigations for Covid-19. Characteristic findings are bilateral, peripheral ground glass opacities and consolidation. Pleural effusions and lymphadenopathy are uncommon. Chest radiograph sensitivity has been reported to be around 70% when compared to reverse transcription polymerase chain reaction (RT-PCR). However, in a single series, chest radiographs were abnormal in 9% of cases with a negative initial swab. It is important that decision on healthcare PPE and cohorting of patients integrate clinical risk as well as imaging findings.

It is important for radiographers to recognise other non-Covid-19 pathology that could explain the patient’s symptoms including pneumothorax, pleural effusion and pulmonary oedema.

The following links have recent peer reviewed articles on  COVID 19 and the appearance / value of chest radiographs:

Case report: A case series to support radiographer preliminary clinical evaluation by Woznitza N., Nair A. and Hare S.S.

https://www.radiographyonline.com/article/S1078-8174(20)30054-7/pdf

Frequency and Distribution of Chest Radiographic Findings in COVID-19 Positive Patients by Wong et al

https://pubs.rsna.org/doi/10.1148/radiol.2020201160

*UPDATED**Version 2 BSTI COVID-19 Guidance for the Reporting Radiologist and data base

https://www.bsti.org.uk/standards-clinical-guidelines/clinical-guidelines/bsti-covid-19-guidance-for-the-reporting-radiologist/

BSTI reporting templates/standards can be found at:

https://www.bsti.org.uk/covid-19-resources/covid-19-bsti-reporting-templates/

Appendix 4 has 4 diagnostic quality images which can be classed as: Bilateral asymmetrical mid-lower zone ground opacification. Classical/Probable COVID.