Chest X-ray Abnormalities
Lobes, fissures and contours

Key points

  • Knowing the anatomical structures adjacent to the fissures, diaphragm and heart contours can help determine where disease is located without the need for a lateral view
  • Disease within the right middle lobe may obscure the right heart border, or may be limited by the horizontal fissure, or both

Zones or lobes?

Although it is generally best to refer to the location of lung abnormalities in terms of zones, occasionally you will see signs, that will tell you which specific lobe is involved.

Right middle lobe disease

The right middle lobe is bordered superiorly by the horizontal fissure, and medially by the right heart border. Any abnormality, which increases density of this lobe, may therefore obscure the right heart border, or be limited superiorly by the horizontal fissure.

Right middle lobe consolidation

Hover on/off image to show/hide findings

Tap on/off image to show/hide findings

Click image to align with top of page

Right middle lobe consolidation

  • The right heart border (right atrial edge) is obscured
  • Consolidation (asterisk) is limited above by a crisp line, formed by the horizontal fissure
  • The pathology must therefore involve the right middle lobe
  • More extensive shadowing also involves the right and left peri-hilar regions

Clinical information

  • Child with a cough and fever

Diagnosis

  • Pneumonia involving the right middle lobe

Horizontal fissure displacement

Displacement of the horizontal fissure may be another indicator of the location of pathology. If the fissure is displaced upwards, this may be because of volume loss of the right upper lobe, for example due to collapse, or fibrosis. If the horizontal fissure is displaced downwards, there may be a process which has caused volume loss of the right lower lobe.

Right upper lobe collapse

Hover on/off image to show/hide findings

Tap on/off image to show/hide findings

Click image to align with top of page

Right upper lobe collapse

  • The horizontal fissure (white line) has been displaced upwards from its original position (red line)
  • Dense opacification (asterisk) of the medial part of the right upper zone
  • Enlarged right hilum

Clinical information

  • Smoker
  • Progressive shortness of breath and cough

Diagnosis

  • Right upper lobe collapse

Other investigations

  • Bronchoscopy revealed a lung cancer causing obstruction to the right upper lobe bronchus

Major fissures

The major (or oblique) fissures cannot be identified on a frontal chest X-ray. This is because they are oriented obliquely en-face.

A lateral view can demonstrate if a lung abnormality is anterior or posterior to the major fissures.

Left lower lobe cavity - frontal view

Hover on/off image to show/hide findings

Tap on/off image to show/hide findings

Click image to align with top of page

Left lower lobe cavity - frontal view

  • Large, round, thick-walled lung cavity
  • The cavity is in the left middle zone, close to the hilum
  • Which lobe do you think it is in? See the lateral view below

Left lower lobe cavity - lateral view

Hover on/off image to show/hide findings

Tap on/off image to show/hide findings

Left lower lobe cavity - lateral view

  • The cavity is behind the oblique fissure (blue line) and so must be in the lower lobe

Clinical information

  • Long term smoker with a cough

Diagnosis

  • Left lower lobe lung cavity – in this case due to a squamous cell lung carcinoma

Page author: Salisbury NHS Foundation Trust UK (Read bio)

Last reviewed: September 2016