Chest Radiograph (CXR) Critique

Chest Radiograph (CXR) Critique

• Standard CXR critiques ensure diagnostic quality and freedom from pathology/artifacts
• Key elements are evaluated in a standard CXR critique

Image Quality Assessment

• The patient should be aligned properly with the X-ray beam
• Clavicles should be equidistant from the spinous processes to confirm no rotation
• Scapulae should be projected outside of the lung fields
• The diaphragm should appear level, or only slightly elevated on the right due to the liver
• The radiograph should have adequate penetration
• The thoracic spine should be faintly visible through the heart shadow
• Lung apices, costophrenic angles, and lateral rib edges should be clearly visible
• The image should ideally show 9-10 posterior ribs above the diaphragm
• The presence of 9-10 posterior ribs above the diaphragm indicates adequate inspiration
• The image should be free from external objects (e.g., jewelry, ECG leads)
• Check for motion blur or overlying clothing obscuring detail

Radiological Assessment of the CXR

• Heart size should occupy less than 50% of the thoracic width in a PA film
• The mediastinal contour should be smooth without widening
• Lungs should appear symmetrical with uniform radiolucency
• Absence of consolidation, nodules, or interstitial patterns should be confirmed
• Diaphragmatic domes should be well-defined and smooth
• Costophrenic and cardiophrenic angles should be sharp
• There should be no evidence of pleural effusion or thickening
• Ribs, clavicles, vertebrae and scapulae should appear intact without fractures, lesions, or deformities
• Soft tissues should be symmetric without masses or swelling
• The trachea should be midline without deviation
• Airway caliber should be normal without signs of obstruction

Common Challenges in Chest Radiography Critique

• Rotation can obscure mediastinal structures and distort anatomy
• Poor penetration may lead to missed subtle pathologies like small nodules
• Inadequate inspiration can mimic conditions like cardiomegaly or pulmonary edema

Skull Radiograph Technical Quality

• Patient's skull positioning should be verified; straight and symmetrical alignment is crucial
• Any rotation or tilt can distort anatomical relationships
• Projection should be identified (lateral, posteroanterior, or Waters view) and matched to clinical indication
• Brightness and contrast should be assessed to ensure all structures are visible without being over/under exposed
• Presence of motion blur or unsharp edges should be evaluated because it might result from patient movement or improper focus
• Look for any unwanted objects (jewelry, hair clips, external shadows) obscuring anatomical features

Anatomical Clarity in Skull Radiographs

• Cranial bones, including frontal, parietal, temporal, occipital, and sphenoid bones should be visible and symmetrical
• Frontal and maxillary sinuses should be checked for visibility and symmetry
• Presence of visible cranial sutures (coronal, sagittal, and lambdoid) with normal morphology, should be confirmed
• Clarity and symmetry of the orbits and nasal cavity should be evaluated
• Foramen magnum and other structures of the skull base should be examined for proper visualization

Diagnostic Utility of Skull Radiographs

• Confirm if the image provides enough detail to identify potential abnormalities, such as fractures, lytic lesions, or calcifications
• Radiographs should be assessed to align with the intended diagnostic purpose (trauma evaluation, infection, or tumor assessment)
• Recognize some conditions, such as soft tissue injuries or subtle fractures, may need additional imaging (CT or MRI)

Sinuses Radiographs: Quality

• Ensure the patient's head is positioned correctly based on the projection (Caldwell view, Waters view, lateral view)
• Symmetry checks should be done, mainly in the nasal septum and maxillary sinuses
• The central beam should align with the sinuses of interest
• Radiographs should include all relevant sinuses (frontal, ethmoidal, sphenoidal, maxillary) with minimal overlap of surrounding anatomy
• Brightness and contrast should be assessed to ensure clear differentiation between air-filled sinuses, bony structures, and soft tissues.
• Check for external objects (earrings, glasses, dental fillings), that may obscure the view

Sinus Radiographs: Anatomical Coverage

• Frontal sinuses should be visible without overlap or distortion
• Clear visualization of the maxillary antra is essential
• Adequate visualization should be done to the ethmoid air cells
• Ensure the sphenoid sinus is visible and not obscured by overlapping structures
• Evaluation should be done for any obscured or missing anatomical landmarks involving Orbits and Nasal Structures

Diagnostic consideration for evaluating sinus radiographs

• Sinuses should appear symmetrical unless pathology is present
• Fluid levels indicative of sinusitis or other pathologies should be checked
• fractures, deformities, or sclerosis of the sinus walls should be looked for

Common errors to avoid when evaluating sinus radiographs

• Misalignment causing asymmetry or incomplete visualization is an incorrect positioning
• Overexposion causing washed-out details or underexposion obscuring structures is a poor exposure
• Motion blur causes movement artifacts can reduce image sharpness
• Poor technique or patient positioning may lead to obscured sinuses

Mandibular Radiograph Technical Quality

• Check for proper contrast and brightness while evaluating exposure parameters because over/underexposure can obscure details
• Proper patient position and equipment stability can be indicated with Sharpness and clarity, with a check to ensure clear anatomical structures without motion blur
• Look for any unwanted artifacts, like metal crowns or earrings, which could obscure diagnostic areas
• Assuring proper coverage of the mandible and restricting radiation exposure is achieved with appropriate Collimation and beam alignment

Mandibular Radiographs: Patient Positioning

• Symmetry should be shown bilaterally of the mandible, with even spacing bothsides of the condyles
• The midsagittal plane must be perpendicular to the floor/centered in the XRay Field
• Occlusal Plane should appear as a smooth upward curve ("smile line"), without distortion
• Poor Chin position (too high/low) causes image distortion ("reverse smile," excessive elongation)

Mandibular Radiographs: Anatomical Visibility

• Mandible must have visibility of entire anatomy like the condyles, ramus, body, and symphysis
• Teeth must have visibility of all anatomy including tooth apices, to evaluate dental caries, root morphology, and periodontal condition
• Check soft tissue for shadows from the tongue as it could obscure structures
• Evaluate incidental airway structures around the sinuses and airway for abnormalities

Mandibular Radiographs: Pathology Assessments

• Look for irregularity/discontinuity of mandibular cortical bone because fracture can be spotted here
• Identify Lesions (radiolucent/radiopaque) suggesting abnormal conditions
• Check impacted teeth (especially 3rd molars)
• Bone Density helps evaluate osteopenia signs, sclerosis, or bone changes

Mandibular Radiographs: Common errors

• alignment /movement while exposure lead to Double Images
• non-ideal patient positioning and improper X-Ray beam angulation leads to Magnification/distortion
• ensure critical area cropping is avoided, particularly ensure critical areas like the condyles / lower incisor tooth

MASE Skull Radiographs: Positioning

• If assessing skull base symmetry, ensure there is symmetry in structures and anatomical alignment
• Head's alignment must be appropriate relative to X-Ray beam (orbitomeatal or other references)
• Must ensure Central Ray is directed towards the target structure

Skull Base Anatomical Visibility

• Key landmarks for a skull base should be visible like including:
• Foramina including magnum, jugular and ovale
• Bony structures including clivus, petrous ridges and sphenoid
• Adequate display of the sphenoid sinus (if included)
• Overlap of all should be avoided and no structures should obscure each other thanks to the patient positioning and the angled ray

Skull radiographic image quality to consider

• Ensure proper exposure settings and prevent both "over/under" to have proper distinguishment for cortical bones details (softs tissues to)
• when differentiating bone tissues ensure enough contrast is to show especially on cortical zones
• Clarity without any blurring of all bone details ,like sutures and bone structures (trabeculae)
• rule out objects that will cause artifacts or motion effects and gridlines issues should also be ruled out

MASE Skull Radiographs: key factor while considering pathology

• Pathological findings can be identified through assessing abnormal calcifications, finding fractures
• Soft tissues that looks swollen, could be another important factors to look out for
• in Spaces and Sinuses; if liquid is present ,look to confirm that air fluid levels , as some trauma could be caused

Mase skull radiographs: technical parameters

• Highlight the skull base by ensuring angular beam for these images
• Good way in evaluating orbital floor/ paranasal sinuses ,would be occipitomental (waters view)
• Submentovertical (SMV) provides good direct base imaging
• Collimated to the exact area, this helps avoiding unnecessary radiations
• markers/identification must have proper placements with their designated orientations

Sella Turcica Radiography: Technical Factors

• Appropriate projection (skull view/other views of Turcica-Sella) is confirmed
• Lateral view is usually preferred
• If the skull is aligned right, then there can be no overlap or turcica-sella may appear
• Soft tissues and bony details must be shown through correct penetration and exposure

Anatomical Assessment for Sella Turcica Radiography

• Assess whether the limits like Clinoid anterior (sella turcica) and dorsum sellae are well specified
• check for blurring and look at sharp well-designated borders
• Soft tissues (if look)and bones adjacent should be assessed as abnormalities could affect their integrity

Considerations while taking Sella Turcical images

• dimensions must be compared with the limits
• enlargement may signal tumors or conditions such as Empty Sella and adenomas
• abnormal bone presence
• calcifications have to be verified around

Sella Turcica imaging: errors to avoid

• teeth structures cannot be superimposed to the needed area
• any patients motion artifacts causing blurriness
• view fields showing surrounding anatomy must be confirmed

Adenoid Radiography Image Quality Considerations

• Radiographs must be clear, contrasted, and properly exposed
• Evaluation requires correct positioning (lateral neck)
• Key landmarks must be visualized (nasopharynx, airway, soft palate)

Assessment Factors in Adenoid Radiography

• Evaluating adenodial pad size can show hypertropy if space is reduced
• Irregularities and Shape shows pathologies
• inflammation and Edema (soft tissue signs) are shown by increase in Density

Airway Assesment in Radiography

• Narrowing signals a problem
• Airways , and the hypopharynx should be carefully assess due to their effect in narrowing compensation

Findings Associated to Radiography

• Spinal alignment and congenital anomalies could be detected with a scan of the skeleton
• Sinus evaluation, is essential to note sinus issues
• Masses or swelling must be looked for

Clinical Correlations in Radiography

• clinical symptoms must match
• age considerations must be analyzed

TMJ Radiography Requires Sharpness and Contrast

• Sufficient contrast to distinguish medullary bone, cortical bone, and soft tissues

TMJ Radiography: Evaluate Anatomical Coverage, and Confirm Symmetry

• Symmetry of mandibular Condyles
• Sagittal plane orientation

Pathological Findings

• Joint space narrowing or widenings indicates dysfunction
• Bone changes such as osteophyte erosion suggests arthritis
• Soft tissue calcifications or masses needs evaluation

TMJ: Technical Details and Recommendation

• Note any metallic artifact
• Alternate modalities maybe needed (MRI/CBCT)

Improvement for Radiographs

• Bite blocks are positioning aids for better alignment

Zygomatic Arch Radiographs

• Symmetry between sides is mandatory as well as head position
• Image should show adjacent structures, good contrast, and sharpness with correct exposure
• Field of view must include visibility of both the arches

Radiographic Techniques

• Review for correct projection and view is mandatory
• Evaluate and look for superposition
• Discontinuity of the arch, displacement, hardware, and symmetry are critical

Optical Foramina Radiograph

• Evaluate symmetry for the patient positioning: Alignment (Caldwell or Waters View), also check other structures for any overlapping
• Quality: Contrast must have distinguish between optical walls, and soft tissues, proper density
• Resolution- Sharpness must be sufficient to reveal any details of foramina anatomy

Anatomy

• Optica Foramina: Should be symmetrical and clearly visible, it is located symetrically within Sphenoid Bone
• Irregularities/Fractures must have confirmation by evaluating the orbital walls structures
• Evaluate the tissues, to asses swellings

Pathology

• Evaluation for possible metallic objects like Foreign Bodies may distract the process
• Proper patient positioning and asymmetries of the structure indicates a disorder
• Techniques: Beam angulation, should be confirmed to avoid foreshadowing

Cervical Vertebra Radiography

• Proper Patient Identification and visible labeling is necessary
• Confirm views requested
• Evaluate the projection addressed

Critiques

• Incomplete visualization leads to positioning issues
• improper exposure might lead to critical details and critical positioning

Cervical radiograph for images

• alignment should properly be checked
• alignment must be evaluated, such that midline spinous process
• proper evaluation may lead to miss some errors so evaluation is critical here
• minimize any artifacts due to any object

Patient Labelling in Chest Radiographs

• Patient details properly labeled
• proper labeling markers

Positioning - Technical Factors

• PA, AP and lateral sides must be positioned correctly
• symmetry must be visible in the bone processes
• alignement alignment must be well visible

Chest Radiographs: Exposure factors

• Penetration through heart shadow for lung markings
• count visible processes near lungs to measure proper Inspiration
• check artifacts for external objects or any obscurity to the images

Clinical Assments

• Inspect body airways, or deviated airways ,look foreign objects
• Lungs must have equal opacity in each sides
• Mediastinum (cardio ratio must be less than 50% in PA to confirm)
• Diaphragm's domed shape must be examined with its sharp angles
• any abnormalities of bones including spinal, examine their integrity
• Examine if there is swelling or masses present

Key pathology with chest radiographs

• trauma must be assessed, also effusion should be noted
• infections must be considered ,and their consolidation must be looked

Abdominal Radiography: Technical Factors

• Check radiograph orientation (upright, supine, or lateral decubitus helps to determine possible free fluids)
• check outline details such as outline/psoas muscle, and renal shadows should be evaluated
• View is ensured to include all abdominal structures
• Ensure there is no presence of external objects

Abdominal Radiographs: Systematic Approach

• Evaluating air (bowel patterns) , bones (spine integrity) ,and calcifications (Kidney stone etc)
• masses are evaluated based on their change to organ symmetry (organomegaly)

Abdominal Radiographs: Key Points to Note

• Obstruction means dilated loops
• perforation means potential air pockets
• infections must have tissue integrity

Costal Bone Radiography: Technical Aspects

• Appropriate exposure to allow visualize nearby structures like tissues
• Edge definition without blur
• Include view that will minimize pathology and increase radiation exposure during collimation

Positioning in Costal bone radiography

• Projection views should match what the patient is in when imaging and positioning
• Aligment and symmetry of the side ribs should be present

Diagnostic Findings In Costal Bone Radiography

• Fractures must be looked for. and other structures
• Tissue ,lung presence and irregularities must be looked for
• Sharp Costophrenic angles or Smooth diaphragm's are factors needed to check

Costal bones: Common Errors

• structures interposing with another
• subtle fractures must be evaluated carefully
• avoid overlooking artifacts because it will obscure details

Thoraciac spine radiography

• Ensure appropriate positioning , as well as patient alignment in general
• Ensure images shows vertebrae and upper structure like diaphragm
• avoid over and underexposure that can hide some critical areas

Key Anatomical Landmarks in Radiography and its evalution

• Spinal process/bone quality must be visible to ensure there is non issues
• alignment must be checked for ,scoliosis should not be present and must be maintained properly
• presence of masses and tissue changes must be confirmed

Screening for the spinal cord

• abnormal curvature must be looked out for
• other bone conditions should not be present

Spine Radiographs

• Spinal view should be visible as well to ensure all is ready
• artifacts and positioning

Lumbar Spine Radiography: Technical Aspects

• Projection must be correct and appropriate
• positioning is critical here for viewing
• appropriate collimation which will include relevance of anatomy

Quality and issues

• tissues and bones must retain shape
• asymmetric patterns which result from rotation must not occur

Common Errors

• Collination issues, must be evaluated
• avoid artifacts because jewelry and clothing affects it

Pelvic Radiography

• Correct positioning must be maintained
• Collimation is needed for viewing
• Images with less burnout and no blur is important

Anatomical Landmarks

• Check visibility and ensure they are properly visualized and there is no foreshortening
• Proper Evaluation of joint spaces and note any narrowings related
• Look out for asymmetries and fractures

Evaluation must have notes

• Radiographic projections
• AP view ensures the best image to examine
• other views are necessary
• Evaluate for Relevance ,mark properly, clinical findings aligned

Hip Joint Radiography , AP Pelvis lateral

• Good symmetry and positioning
• Structures to asses fractures

Joint Space and assessment

• Joint space as we as cartilage needs to be accessed for osteoatrhtis
• Soft and periarticular is assessed here for any abnormalities

Femural Radiograph: Pathologies

• Dislocations, as well as fractures, plus bone avascularity
• Degeneration, tumors all need proper images

Report on Radiographs and quality factors

• Ensure patient was positioned , as well as an image free of blur
• Structures all must be well-evaluated and check the hip bone

Femural Radiography : Factors

• Brightness that enables bone cortex structure is to be considered
• joints, as well as some fractures must be shown on image
• Swellings are indicated

Knee Radiographs: Identification and Details

• Verifying Patient and Image related are are important
• Proper labeling and date are required
• Details in positioning has a specific view

Analysis in Technical View

• Lateral, as well as a the sky view ,all needs to have proper exposure
• Visibility of all the key factors must not be overlooked when it comes to bone structures

Considerations for Soft tissues

• Look for calcifications, the effusions and even any abnormalities during the images review

Leg Radiography images- Image and Details

• Verify date of imaging, and the proper labeling
• Procedure must match with what's requested

Radiography: Positioning

• The entire area must be included. If not, then this could lead to another issue
• Limbs must have correct alignment
• Projection must be well-demonstrated in images

Exposure

• tissue differentiation must be possible during the contrast time
• image sharpness must have no presence of blurring
• Proper collination is mandatory for the patient and markers must identify what side the image was

Radiograph Artifacts

• the view of objects is affected by presence of an external or foreign object
• any technical artifacts must be checked to asses damage

Final recommendation for reviewing a radiograph

• Check for additional images to confirm the final details