Chest X-ray Abnormalities
Soft tissue abnormalities

Key points

  • Soft tissue abnormalities are often overlooked
  • Soft tissues may be mistaken for lung pathology
  • Smooth black lines in the soft tissue may represent normal fat – but irregular black areas may represent surgical emphysema

It is essential to assess the soft tissues on every chest X-ray you examine. You will often find important clues to help come to a diagnosis. Appearances of the soft tissues can be misleading and it is important to be aware of the pitfalls.

Breast tissue

Breast tissue varies greatly between men and women, and between individuals. Occasionally you may mistake breast tissue for increased density of the underlying lung, particularly if there has been a mastectomy on the other side.

Mastectomy

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Mastectomy

  • Increased density over the right lung?
  • Decreased density of the left lung?
  • Breast asymmetry

Clinical information/diagnosis

  • Previous breast cancer of the left breast treated by mastectomy

Note

  • Do not mistake soft tissue asymmetry for lung disease

Gynaecomastia

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Gynaecomastia

  • Mobile AP sitting chest X-ray
  • Cardiac monitoring leads
  • Dense breast tissue
  • Male patient

Clinical information

  • Patient on spironolactone

Diagnosis

  • Gynaecomastia – male breast enlargement

Soft tissue low density

Normal fat planes are often clearly defined in the soft tissues. These appear as smooth layers of low density (black), between layers of relatively dense (whiter) muscles. Irregular low density within the soft tissues may be due to tracking air as a result of injury to the airways or pleura. This is know as surgical emphysema and produces the distinctive clinical sign of palpable subcutaneous 'bubble-wrap.'

Occasionally subcutaneous gas may relate to infection, but this is usually more localised. As always, correlation with the clinical features is necessary.

Surgical emphesyma

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Surgical emphesyma

  • AP erect chest X-ray
  • Left chest drain (orange)
  • Raised left hemidiaphragm (arrow)
  • Stomach/bowel bubble (asterisk)
  • Multiple irregular areas of low density within the chest wall soft tissues (arrowheads) due to surgical emphysema
  • Multiple rib fractures (#)

Clinical information

  • Road traffic crash
  • Chest pain, shortness of breath and marked clinical surgical emphysema

Diagnosis

  • Multiple rib fractures complicated by left hemidiaphragm injury, left pneumothorax (treated by drain) and widespread surgical emphysema (tracking subcutaneous air)