Normal Chest Variants

Normal Variants in theChest

Adam Guttentag M.D.

Albert Einstein Medical Center

Philadelphia, PA

this shouldn't last long

nipple markers

nipple shadows

subpleural fat rt

subpleural fat left

ct med 1

ct med2

ct med 3

ct med 4

Right aortic arch

Right arch close

situs inversus pa

pectus PA

pectus lat

pectus C

cervical rib

pseudarthrosis 1st rib 1

Normal

Cervical rib

•Up to 8% incidence

•variable size

•may articulate with 1st rib

•usually Asx

•may cause “mass” or thoracic outletsyndrome

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cervical rib with pseudoarticulation

Cervical rib with pseudoarticulation with 1st rib

hypoplastic rt 1st rib

T1

pseudoarticulation of ribs

Bony bridging of ribs

pseudarthrosis 1st rib 1

pseudoarthrosis 1st rib 2

Pseudo-fracture of 1st rib

fused ribs pa

fused ribs lordotic

Fused ribs

rib forking

rib forking

absent 1st rib except cartilage

absent 1st rib except cartilage

1st rib absent except for cartilage

pa bone

oblique bone

rhomboid fossae 1

rhomboid fossae 1

Rhomboid fossa

•Attachment of costoclavicular ligamentsconnecting 1st rib to clavicle

•may simulate lung disease

rhomboid fossae 2

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Left SVC

•Found in 0.4% of normal patients

>4% of patients with CHD

•May be solitary (85%) or with separateright SVC

•empties into right atrium via coronarysinus

•differentiate from anomalous pulmonaryvein (“vertical vein”)

Left SVC CT 1

Left SVC CT 2

Left SVC CT 3

Left SVC CT 4

DSCN0104(1)

DSCN0105(1)

DSCN0106(1)

DSCN0107

Aberrant right subclavian artery

•Incidence 0.5%

•dilated origin known as diverticulum ofKommerell

•usually asymtomatic

•courses behind trachea and esophagus

aberrant RSCA CT

DSCN0004

pa close 2

ct1

ct2

ct3

DSCN0019(5)

Superior Intercostal Vein

•aka “aortic nipple”

•left sided homologue of azygos arch

connects hemiazygos system with leftsubclavian vein

•pathway of collateral flow withobstructed SVC or LBCV

Anatomy sup int vein

aortic nipple pa

aortic nipple close

ct1

ct2

ct3

DSCN0009(1)

lat

Anatomy sup int vein

Anatomy azygos arch

cisterna chyli

Lung cancer. ?mets

cisterna chyli netter drawing

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Accessory fissures

•Present in up to 50% of lungs

•Vary from superficial slits to completefissures extending to hilum

•May limit spread of disease process inunusual ways

•Mostly of academic interest:

Recognize and ignore!

Azygos fissure

•Invagination of azygosvein into RUL

•Only accessory fissureto have both visceraland parietal pleura (2layers each)

•Variable amount ofRUL isolated

•Azygos vein visible asteardrop shapednodule at the end ofthe fissure

Inferior Accessory Fissure

•Either lower lobe

•More common on right

Seen to some degree in 45% at autopsy

Seen radiographically in 8%

Seen more commonly on CT - 16%

•Separates medial basal segment fromthe rest of the lower lobe basalsegments

Left minor fissure

•Separates lingular segments from therest of the LUL

•2-8% of CXR’s

pa close before

ct4

Superior Accessory Fissure

•Separates superior segment fromremained of lower lobe

•Found on both sides

•More common on right

Accessory fissure LUL

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