1981, British Journal of Radiology, 54, 643-650

VOLUME 54 NUMBER 644 AUGUST 1981

The British Journal of Radiology

Round (helical) atelectasis

By *S.-R. Cho, M.D., *D. A. Henry, M.D., *M. C. Beachley, M.D. and f J . W. Brooks, M.D.
Departments of ^Radiology and fSurgery, Virginia Commonwealth University/Medical College of Virginia,
Richmond, Virginia, USA
{Received October 1980 and in revised form March 1981)

ABSTRACT Round atelectasis (RA) is an unusual, localized form

Round (helical) atelectasis is a little-known form of
pulmonary collapse. It is thought to occur secondary to lung of lung collapse which has only recently been dis-
compression from pleural effusion or following therapeutic cussed in the English literature (Schneider et al.,
pneumothorax. Its occurrence is favoured in patients with 1980; Hanke and Kretzschmar, 1980). These coiled,
exudative pleural effusions and extensive pleural thickening.
It presents radiographically as a pulmonary pseudotumour, mass-like lesions are seldom truly round and the
and experience with this entity and its pathogenesis are
discussed.

•Address for reprints: Shao-Ru Cho, M.D., MCV Station

Box 615, Richmond, Virginia 23298, USA.

A FIG. 1. B
(A) PA and (B) lateral views of the chest demonstrate a 4 cm mass in the superior segment of the left lower lobe. Over-
expansion of the left upper lobe with downward displacement of the left hilum is seen. There is blunting of the costophrenic
angles due to previous pleural disease.
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 VOL. 54, No. 644
S.-R. Cho, D. A. Henry, M. C. Beachley and J. W. Brooks
FIG. 1C.
A tomogram, lateral cut, at the peripheral portion of the
mass shows numerous linear stripes radiating from the mass
toward the posterior pleura.

term "helical atelectasis" is more descriptive and

recalls their pathogenesis. However, in the interest of
avoiding confusion, the term "round atelectasis"
will be used. RA presents radiographically as a
rounded, oval, angular or comma-shaped density
most commonly at the base of the lung posteriorly,
although it has been described elsewhere in the
chest (Benard et al, 1973; Brune et al, 1974;
Choffel et al, 1977; Fadhli and Derrick, 1965;
Hanke, 1971; 1972; Hanke and Kretzschmar, 1980;
Heine, 1962; Kretzschmar, 1975; R o c h e t al, 1956;
Roche and Rousselin, 1957; Schneider et al, 1980).
It does not conform to segmental or lobular orienta-
tion. RA is generally preceded by a pleural effusion,
but has been described following therapeutic pneu-
mothoraces. Recognition of this type of pulmonary
collapse and its differentiation from other patho-
logical processes which may present as a pulmonary
mass density are important to avoid unnecessary
surgery. The purpose of this report is to describe our
experience with RA and further to evaluate its
pathogenesis and radiographic appearance.

FIG. 1D.
A tomogram, lateral cut, through the middle portion of the FIG. 1E.
mass demonstrates multiple pulmonary vessels encircling Post-operative chest radiograph shows no residual mass in
the mass in a helical fashion (arrow). the lung.

Round {helical) atelectasis
CASE REPORTS
Casei
A 62-year-old black man was admitted to a local hospital
with a one-year history of intermittent gross haematuria.
The urological evaluation revealed a Grade II transitional
cell carcinoma of the bladder. The patient was transferred to
our institution for further evaluation and therapy.
Past medical history was significant in that the patient had
had spinal surgery for spur removal in 1971 and had a recent
bout of pneumonia in 1977. He has smoked heavily for many
years and admitted "bronchial trouble" and chronic short-
ness of breath on exertion.
Pertinent physical findings included moderately decreased
breath sounds over the right lower chest posteriorly as well
as a slight fullness in the left side of the lower abdomen
above the pubic symphysis. The rest of the physical ex-
amination was unremarkable.
Laboratory data included a haemoglobin of 13.3 g% and a
urinalysis which demonstrated numerous WBCs and 1 5 to
20 RBCs per high power field. The chest radiographs
demonstrated a 4 cm mass density localized in the superior
segment of the left lower lobe. Also noted was overexpansion
of the left upper lobe with downward displacement of the
left hilum (Fig. 1A, B). Comparison with a chest radiograph
one month earlier demonstrated that the mass had grown
slightly in the interval. Linear tomograms of this mass
demonstrated it to be round and well demarcated without
any significant internal features. Linear densities were noted
to extend from the mass toward the posterior chest wall
suggesting pleural involvement (Fig. 1c). The proximal
portion of the left lower lobe superior segmental bronchus
was identified and was patent. Inferior to the mass were
pulmonary vessels which entered the mass in a spiral
fashion (Fig. 1D). Due to the helical appearance of the mass
and adjacent vessels, the diagnosis of round atelectasis was
considered in addition to a primary or secondary pulmonary
neoplasm.
Bronchoscopy, mediastinoscopy and bilateral scalene node
biopsies were performed, and revealed a normal tracheo-
bronchial tree and chronic lymphadenitis of the scalene and
mediastinal lymph nodes. At surgery the left lower lobe was
found to be entrapped by pleural adhesions. The adhesions
A FIG. 2.
(A) PA and (B) lateral views of the chest reveal a 4 X 6 cm mass at the posterior portion of the right lower lobe, behind
the right Jieart border. Diffuse pleural thickening is noted as well.
645
AUGUST 1981
were lysed and decortication was performed allowing the left
lower lobe immediately to reinflate. Histological examina-
tion of portions of resected pleura revealed only inflam-
matory changes. Post-operative chest radiographs showed
no residual mass (Fig. 1E). The surgical and pathological
findings confirmed the radiographic impression of RA. The
patient recovered uneventfully and was discharged one week
after thoracotomy.
Case 2
A 52-year-old healthy white male presented to his per-
sonal physician for a routine physical examination. He had
no specific complaints. During the course of this examina-
tion a chest radiograph revealed a pulmonary mass lesion
and the patient was referred to our institution for further
evaluation.
Historically, the patient has accumulated 70 pack years of
smoking and also had a history of asbestos exposure several
years previously. He denied cough, shortness of breath,
haemoptysis, bronchitis or pneumonia. On physical exami-
nation the only pertinent findings were soft rhonchi on
auscultation and a slightly prolonged inspiratory phase.
Laboratory and ECG findings were unremarkable. A chest
radiograph demonstrated diffuse pleural thickening on the
right as well as obliteration of the right lateral and posterior
costophrenic sulci. No definite pleural calcifications were
detected. In addition there was a 4 X 6 cm mass noted
posterior and medially in the right lower lobe. It projected
behind the right heart border and was vaguely identified
over the thoracic spine on the lateral view (Fig. 2A, B).
B
VOL. 54, No. 644
S.-R. Cho, D. A. Henry, M. C. Beachley andj. W. Brooks

c FIG. 2. D
Tomograms, (c) AP and (D) lateral cuts, demonstrate an oval shaped soft tissue mass attached to the pleural surface pos-
teriorly. There are multiple pulmonary vessels encircling this mass in a coiled fashion. D = Diaphragm; H = Hilum.

Tomographic examination of this mass in both the AP and
lateral projections demonstrated a soft tissue mass which
was somewhat oval in shape and attached to the pleural sur-
faces posteriorly. There were multiple pulmonary vessels
encircling this mass in a coiled fashion (Fig. 2c, D). Round
atelectasis was the radiographic impression. However, due
to the patient's smoking history and the previous exposure
to asbestos, we felt compelled to exclude a bronchogenic
carcinoma. Bronchoscopic examination was performed and
was normal. Needle aspiration biopsy of the mass yielded no
evidence of an inflammatory process. Two Cope needle
biopsies at the same site followed and the histological diag-
nosis of chronic pleuritis and asbestosis was made. There
was no evidence of malignancy. Due to the radiographic
findings and the histological information obtained, it was
determined that this patient should be discharged and
followed in the chest clinic. His chest radiographs have
remained unchanged for one year.
Case 3
A previously healthy 54-year-old white male suffered
blunt trauma to the left side of his chest. The patient
experienced pain but did not seek medical attention at this
time. Three months after this episode on a routine physical
examination, an abnormal density was identified in the left
lower lung field on chest radiograph. He was subsequently
referred to this institution for evaluation. He had been
asymptomatic in the interval between the traumatic event
and the physical examination. Past medical history was
unremarkable except that the patient was a smoker. Physical
examination on admission was unremarkable. The examina-
tion of the chest was normal. Chest radiographs at admission
646
demonstrated a 3.5x4.5 cm oval mass localized to the
superior segment of the left lower lobe. Pleural adhesions
were identified at the left base, as was some hyperexpansion
of the left upper lobe with downward displacement of the
left hilum (Fig. 3B, C). Previous chest radiographs one-and-
a-half years before admission demonstrated only basal
pleural adhesion (Fig. 3A). AP tomographic examination
demonstrated an oval mass density posteriorly with clearly
defined air bronchograms within the mass (Fig. 3D). At
thoracotomy, the pleura was markedly thickened and
scattered areas of cholesterol and hyaline depositions were
noted. There was a massive contraction of the left lower lobe
particularly involving the superior, posterior basal and
lateral basal segments. There was marked distortion of the
lung secondary to the contraction giving rise to a mass-like
appearance. Decortication was undertaken and the lower
lobe was carefully unfolded, revealing no mass. Biopsies of
the pleura demonstrated only hyaline deposition and
fibrosis. There was no evidence of malignancy. Post-
operative chest examinations demonstrated re-expansion of
the left lower lobe. Follow-up chest examinations demon-
strated no evidence of recurrent atelectasis (Fig. 3E).
DISCUSSION
Loeschke (1928) gave the first description of
helical or rounded pulmonary atelectasis in his dis-
cussion of collapse associated with pleural effusion.
He made the key observation that the lower edge of
the lung became folded on itself due to pressure
 AUGUST 1981

Round {helical) atelectasis

9-29-7S

FIG. 3A.
PA view of chest obtained about a year and a half prior to
admission reveals non-specific chronic interstitial disease
and pleural adhesions at both bases.

exerted by the pleural fluid. Schummelfeder (1956)

confirmed this finding and concluded that the en-
folding of the lung can occur not only in an upright
and backward fashion, but also in a downward and
diaphragmatic direction as well. Roche et al. (1956;
1957) described lung opacities in patients who had
undergone therapeutic pneumothorax for tuber-
culosis. They attributed these opacities to atelectasis
secondary to neurovascular reflexes, although they
did consider the lung folding on itself. Heine (1962)
described several cases of mass-like atelectasis in
patients following therapeutic pneumothoraces,
which he either resected or successfully re-inflated
after decortication. However it is Hanke's report in
1971 that most clearly described this type of
atelectasis (Fig. 4A-D).
In the common form of atelectasis, the radio-
graphic presentation is that of a triangular area of
increased density corresponding to the lobe or
segment involved. This appearance depends on the

FIG. 3.
(B) PA and (c) lateral views of the chest on admission reveal
a 3.5 X 4.5 cm oval mass at the superior segment of the left
lower lobe (arrows). Pleural plaques at the left base are better
seen in the lateral projection. Compensatory expansion of
the left upper lobe with downward displacement of the left
hilum is noted on the PA view.
647
VOL. 54, No. 644
S.-R. Cho, D. A. Henry, M. C. Beachley and J. W. Brooks
9-29 -76
FIG. 3D.
AP tomogram demonstrates air bronchograms within the
mass (arrows).
continued contact of the parietal and visceral pleural
surfaces peripherally, as well as anchoring of the
lung at the hilum. In RA, the presence of pleural
fluid prior to the development of atelectasis permits
the pleural surfaces to separate, and isolates the
finger-like projection of lung, actually shaped like an
inverted pyramid, in the posterior costophrenic
sulcus (Fig. 4A). This isolation allows the pleural
fluid to compress all of that portion of lung except
for the base of the pyramid. Ultimately, trans-
pulmonary pressure is increased under the effusion
and eventually exceeds intraluminal airway pressure
and collapse ensues. This process is favoured at the
base of the lung due to the more positive pressure at
the base of the pleural space relative to the apex, and
648
12-2-76
FIG. 3E.
PA view of the chest taken two months after surgery shows
good expansion of the left lung with no evidence of recurrent
atelectasis.
gravity may play a role as well. A similar process
occurs in pneumothorax. Once again the pleural
surfaces are separated and portions of the lower lobe
are flattened out in finger-like projections. This
probably accounts for the appearance of this entity in
patients following therapeutic pneumothoraces.
The enfolding process begins with either a clock-
wise or counter-clockwise rotation of the lower lobe
bronchi (Fig. 4B, D). Rotatory movement is very
likely aided by diaphragmatic activity during normal
respiration. Once the rotation reaches the point at
which the airway becomes kinked, atelectasis be-
comes more complete and the collapsed portion
assumes a more flattened shape. As a result of the
rotatory process, this flattened portion of lung comes
to lie adjacent to the remaining portions of the lower
lobe, either posteriorly or inferiorly. Their visceral
pleural surfaces are juxtaposed and over a period of
time a fibrinous bond forms between these surfaces
and the nucleus of RA is formed (Fig. 4B).
As the effusion resolves and the pleural space is
cleared, adhesions and areas of pleural thickening
remain. Re-expansion of the lung, altered by the
adhesions and pleural thickening, coils the nucleus of
RA (Fig. 4c, D). Normal respiration causes the
nucleus to become further enfolded and it assumes
an oval, spherical, or angular shape. Its shape
 AUGUST 1981
Round {helical) atelectasis
depends on the elastic recoil properties of the chest compression in this process. Also the deeper the
wall and the lung and to what degree they are angle, the more likely it is that the projection of the
influenced by pleural adhesions and scarring. With lung would be influenced by diaphragmatic activity
fewer adhesions, one might expect a more rounded and displaced by the diaphragm once the rotatory
appearance. movement has begun.
The evolution of RA takes several weeks or The radiographic findings in this process include a
months. Once present, it may persist unchanged for mass density which may assume a round, oval,
a year or more, increase in size (Choffel et al., 1977), angular or comma-like shape. The mass is pleural
regress or even totally disappear (Hanke, 1971). It based. Air bronchograms may be seen within the
has also been observed to re-appear following re- mass (Fig. 3D). The bronchovascular bundles ad-
expansion via decortication (Schneider et al., 1980). jacent to the mass assume a helical arrangement as if
Factors favouring the formation of round atelect- they were being pulled into this mass density. This
asis include the presence of a pleural effusion, most is best demonstrated via lateral tomography. Radiat-
commonly an exudative effusion. Inflammation of ing linear densities originating in the area of the mass
the pleural surfaces would favour the deposition of are sometimes seen and are thought to represent
fibrin which would be important in producing the tethering of the pleura resulting from the enfolding
bond between the juxtaposed visceral surfaces in the process (Fig. 1c). Elsewhere in the hemithorax,
enfolding process. It is noteworthy that this entity there is evidence of pleural disease such as pleural
has frequently been described in the French and thickening, blunting of the costophrenic angles, a
German literature in patients with tuberculosis, or shrunken hemithorax, or pleural calcification. With-
with asbestosis as in our case and others (Schneider out obvious evidence of pleural disease, the diag-
et al., 1980; Blesovsky, 1966). The pleural effusions nosis of RA should be suspect. Other signs of
in these entities are quite similar and are both collapse may be present such as hyperaeration in the
exudative. same lobe or in other lobes. Depression of the hilum
The depth and AP dimension of the posterior on the ipsilateral side and altered position of the
costophrenic sulcus are important since the deeper fissures may also be seen. This diagnosis must be
and narrower the sulcus, the more likely it is that the considered in any pleural-based mass lesion of lung,
lung residing in such an angle would be subject to especially when associated with pleural disease and a

A B FIG. 4. C D
(A) The compression effect of the pleural effusion on the lung and the finger-like projection of the lung edge due to partial
atelectasis is seen in the posterior costophrenic angle (From Hanke (1971), with permission).
(B) The tilted lung edge is pushed against the base of the lung and a pleural groove is formed following this folding process.
When fibrin deposits cause these apposed pleural surfaces to stick together, it forms the nucleus of the round atelectasis
(From Hanke (1971), with permission).
(c) After the resolution of the pleural effusion, the re-expanding force from the adjacent normal tissue causes atelectatic por-
tion of the lung to assume a more rounded appearance. This coiling causes the helical appearance of the adjacent broncho-
vascular bundles (From Hanke (1971), with permission).
(D) The same process developing in the pulmonary base above the diaphragm is illustrated (From Hanke (1971), with permis-
sion). A=axis of rotation; CE = compensatory emphysema; HA=round (helical) atelectasis; NPR=new visceral pleural
reflection at costophrenic angle; OPR = original visceral pleural reflection at costophrenic angle; P = pachypleurisy; PG =
pleural groove; TP=tilted pleural surface.
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VOL. 54, No. 644
S.-R. Cho, D. A. Henry, M. C. Beachley and J. W. Brooks
previous effusion or pneumothorax, but requires case of a solitary pulmonary nodule. Annals of Thoracic
Surgery, 6, 753-754.
recognition of a mass density associated with a helical HANKE, R., 1971. Rundatelektasen (Kugel- und Walzen-
arrangement of adjacent bronchovascular structures atelektasen): ein Beitrag zur Differentialdiagnose intra-
in the chest (Figs. 1D, 2D). When this constellation of pulmonaler Rundherde. Fortschritte auf dem Gebiete der
Rontgenstrahlen, 114, 164-183.
radiographic findings is present, round atelectasis 1972. Rundatelektasen: ihre differentialdiagnostischen
should be considered. Merkmale gegeniiber intrapulmonalen Rundherden
anderer Genese. Kongressbericht Wissenschaftlichen Tag-
ungen Norddeutsch-Gesellschaft fiir Tuberkulose und Lun-
ACKNOWLEDGMENTS genkrankheit, 12, 174-184.
The authors would like to express their thanks for the HANKE, R. and KRETZSCHMAR, R., 1980. Rounded atelectasis.
language assistance given by Albert Amraann, M.D., Mrs. Seminars in Roentgenology, 15, 174-182.
Mary B. Ammann and Karsten Konerding, M.D., for the HEINE, F., 1962. Faltungsphanomene der Lunge. Internist,
German literature, and Robert Sims, Ph.D. for the French 3, 357-363.
literature, and the excellent secretarial help from Mrs. KRETZSCHMAR, R., 1975. Uber atelektatische Pseudotumoren
Sharron Shackleford. der Lunge. Fortschritte auf dem Gebiete der Rontgenstrahlen,
1'22, 19-29.
LOESCHKE, H., 1928. Henke-Lubarsch Handbuch der speziel-
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atelectasies rondes pseudotumorales sans antecedents SCHUMMELFEDER, N., 1956. Umfaltungen und Verwach-
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Book review
Radiology of Bone Disease. By George B. Greenfield, 3rd
edit., pp. 858, 1980 (J. B. Lippincott, Philadelphia), £3900.
ISBN 0-397-50432-2
It is a pleasure to have the opportunity to review an en-
larged third edition of a frequently used book in our depart-
mental library. The author remains faithful to his stated
aims, being to group diseases by predominantly radiographic
features, to collate recent information and to advocate a
systematic approach to diagnoses. There are accordingly
nine sections reflecting this approach including an analytical
approach to bone radiology, loss of bone density, alteration
in bone texture, changes in size and shape of bone, etc. The
volume is liberally sprinkled with illustrations, including
plain films, isotopes, CT and angiography, and contains
many full gamuts. There is a good index. A bibliography is
given with each section comprising between 100 and 150
pertinent references.
Whether or not this book is well received will depend, to
an unusual degree, on the reader's preferences. For example,
the approach used results in diseases being scattered
throughout the book in different sections. The authors'
desire to incorporate clinical, laboratory and other features
of various diseases seems sometimes excessive, with,for
example, two pages on the clinical criteria for diagnosing
rheumatoid arthritis, with perhaps some disadvantage to the
description of the radiological signs of disease. Although
liberally supplied with illustrations, a fair proportion are of
relatively poor quality on reproduction. There is virtually no
information on arthrography, myelography or venography
and disappointingly few isotopic investigations. The really
common problems such as trauma and the low back pain
syndromes are hardly mentioned. The author's view, that it
is no longer sufficient for radiology just to predict histology
of bone lesions, is reflected in the frequent use of pathology
to explain radiographic signs.
This book should be in the libraries of all training depart-
ments in radiology and will be frequently used as a bench
book by those practising bone and joint radiology. It is not a
substitute for basic texts to the training radiologist but
rather complements the other authoritative tomes which
every good department should have. Its concept is brilliant
but it may be argued that it does not quite achieve its ob-
jective in practice.
IAIN WATT.

650