Author:
Editor(s):
Updated:
ULY CLINIC
ULY CLINIC
24 Septemba 2025, 06:57:55
Ewart’s sign
Ewart’s sign is defined as the presence of bronchial breathing on auscultation and dullness on percussion heard below the angle of the left scapula. It is a compression sign typically associated with pericardial effusion, though it may also occur beneath the prominence of the sternal end of the first rib in some cases.
Pathophysiology
In pericardial effusion, the accumulation of fluid within the pericardial sac causes compression of adjacent lung tissue, particularly the left lower lobe. This mechanical compression leads to:
Reduced lung expansion and dullness to percussion.
Bronchial breath sounds due to compression bronchial breathing from collapsed alveoli near patent bronchi.
Examination Technique
Patient positioning: Have the patient sit upright or lean slightly forward.
Percussion: Tap the area below the angle of the left scapula and listen for dullness.
Auscultation: Place the stethoscope over the same region and listen for bronchial (tubular) breathing.
Comparison: Always compare with the contralateral side to confirm asymmetry.
Clinical utility
Diagnostic clue: Suggestive of pericardial effusion, particularly when combined with other signs (e.g., muffled heart sounds, cardiomegaly, pulsus paradoxus).
Localization: Helps distinguish between pulmonary consolidation and compression from extra-pulmonary causes.
Bedside sign: Useful in resource-limited settings without immediate imaging.
Differential Diagnosis
Condition | Onset | Key Feature | Associated Findings | Mechanism | Notes |
Pericardial effusion | Subacute or chronic | Dullness + bronchial breathing below left scapula | Dyspnea, muffled heart sounds, cardiomegaly | Compression of left lower lobe by effusion | Classic cause of Ewart’s sign |
Left lower lobe pneumonia | Acute | Dullness + bronchial breathing | Fever, productive cough, crackles | Alveolar consolidation | Distinguished by systemic infection signs |
Pleural effusion | Subacute | Stony dullness, absent breath sounds | Dyspnea, decreased chest expansion | Fluid in pleural space | No bronchial breathing under scapula |
Mediastinal mass | Variable | Localized dullness, displaced breath sounds | Chest pain, weight loss, compressive symptoms | Extrinsic compression | Requires imaging for confirmation |
Pediatric considerations
Rare in children; usually secondary to pericarditis or post-infectious effusion.
Signs may be subtle; ultrasound is often required for confirmation.
Geriatric considerations
More likely due to malignant pericardial effusion or chronic cardiac disease.
May coexist with pulmonary disease, complicating interpretation.
Limitations
Not specific to pericardial effusion—may mimic pneumonia or other causes of localized compression.
Reliability depends on examiner skill and patient body habitus.
Imaging (echocardiography, chest X-ray) is needed for confirmation.
Patient counseling
Explain that the finding suggests fluid around the heart.
Reassure that further imaging (e.g., echocardiogram) is needed for accurate diagnosis.
Advise on symptoms warranting urgent care: worsening shortness of breath, chest pain, syncope.
Conclusion
Ewart’s sign is a classic bedside clinical sign of pericardial effusion, characterized by dullness to percussion and bronchial breathing below the left scapular angle. While valuable in clinical assessment, it should be interpreted with caution and confirmed using echocardiography and other investigations.
References
Perloff JK. The Clinical Recognition of Congenital Heart Disease. 6th ed. Philadelphia, PA: Saunders; 2012.
Braunwald E, Zipes DP, Libby P, Bonow RO, Mann DL. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019.
Bates B. Bates’ Guide to Physical Examination and History Taking. 13th ed. Philadelphia, PA: Wolters Kluwer; 2020.
Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York, NY: McGraw-Hill; 2020.