Perspective
Lateral Chest Radiograph:
The lateral chest radiograph is a valuable source of information that has become increasingly undervalued in the era of chest computed
tomography. Optimal use of the lateral radiograph requires systematic analysis. First is an overview, followed by analysis of the airway and
major hilar structures. Next is attention to the three areas where the image darkens in the absence of visible structure edges. Last is
attention to the periphery and the upper abdomen. This communication outlines the systematic analysis and then explains in more detail
the value of the critical features of that analysis.
Key Words: Chest radiography; chest x-ray; lateral chest radiograph; routine chest radiograph; thorax radiology.
AUR, 2010
O
ver the past two or three decades, the lateral chest
radiograph has received decreasing attention, both
clinically and educationally. Routine chest radio-
graphs, especially of younger adult patients, are often confined
to frontal views; laterals are rarely ordered as a follow-up. In
modern chest imaging, if the frontal view shows the possibility
of an abnormality, many radiologists recommend chest
computed tomography (CT). The ability to perform CT
has become sufficiently convenient for this to be a practical
approach, despite the downsides of chest CT, which include
much greater radiation dose than plain radiographs and the
high incidence of false-positive findings that may require
additional evaluation.
This reasoning has led to less emphasis on the ability of
medical trainees, including radiology residents and medical
students, to become thoroughly comfortable with the analysis
of the lateral radiograph. The problem is compounded by the
fact that young radiologists have had all their training during
the era since CT became the prime imaging tool for the medi-
astinum and high-resolution CT became the imaging gold
standard for the lungs. This has led many radiologists and
other physicians to become less conversant with the details
and subtleties of normal and abnormal findings on the lateral
radiograph.
Paradoxically and unintentionally, the problem has been
compounded by the complexities of the lateral radiograph
that have often been taught in the past. The brilliant first gener-
ation of chest radiology specialists, especially Benjamin Felson
(1), studied frontal and lateral chest radiographs with such
Acad Radiol 2010; 17:15601566
From the Russell H. Morgan Department of Radiology and Radiological
Sciences, Johns Hopkins University, 601 North Caroline Street, JHOC 4233,
Baltimore, MD 21287. Received May 19, 2010; accepted July 13, 2010.
Address correspondence to: D.S.F. e-mail: dfeigin1@jhmi.edu
AUR, 2010
doi:10.1016/j.acra.2010.07.004
1560
A Systematic Approach
David S. Feigin, MD
intensity and imagination that they figured out the meaning
of each edge and the identity of every structure. They accom-
plished this without the assistance of cross-sectional imaging of
living patients as a reference. With respect to the lateral
radiograph, probably the pinnacle of these analyses were the
monographs written by Anthony Proto and John Speckman
(2,3) in 1979, in which they described the meaning of each
line and edge on the normal lateral radiograph. Learning the
lateral radiograph to that level of detail seems less useful in the
era of CT.
We thus need to take a new approach to the use of the lateral
chest film in the context of modern chest imaging. Although
some studies have shown little value to the lateral radiograph
in specific instances (46), most studies and expert opinions
continue to show how valuable it is (710). I believe that
the lateral view should be thought of as a full half of the
routine chest plain radiographic study. The lateral view
often provides key findings that are not visible on the frontal
view. It frequently clarifies questionable abnormalities by
showing more specific features. It is, in my opinion, the best
view to determine lung volumes, because the inflation of
the lungs is easier to estimate with the lungs in profile
surrounded by the chest wall and hemidiaphragms. It is
especially useful in determining whether and why the hilum
is abnormal, because the hilar vessels are not overlapped by
the mediastinum (2,3). Yet a complete search of the lateral
radiograph should take less time than that of the frontal
radiograph. Understanding the most useful features of the
lateral radiograph can be far simpler than many radiologists
and other health care professionals have been led to believe.
This communication is intended to outline a systematic
approach to the search of the lateral radiograph and the
analysis of the most common abnormalities. This approach
facilitates familiarity with the normal features and is intended
to make the lateral view easier to interpret and to teach to
others. The communication consists of two sections: (1) an
outline of a systematic search of the lateral radiograph and
Academic Radiology, Vol 17, No 12, December 2010 LATERAL CHEST RADIOGRAPH

TABLE 1. Lateral Chest Radiograph Search Pattern

1. Look briefly at the entire image for obvious abnormalities and verify the patient and date information.
2. Judge the size of the lungs and the lung markings and the shape of the diaphragms.
3. Follow the airway from the neck to the hilum.
4. Identify the principal hilar structures: left main bronchus and right and left pulmonary arteries.
5. Look down from the hilum for darkening to the diaphragms.
6. Identify the edge of the left ventricle, then note the darkening from the middle of the heart upward toward the trachea.
7. Cross the trachea and follow the spine down to the diaphragms, judging each vertebral body and looking for darkening until crossing
the diaphragms.
8. Evaluate the periphery, beginning with the upper abdominal bowel gas, then the anterior chest wall, lower neck, and posterior ribs,
finishing with the costophrenic angles.

(2) a more detailed discussion of the two critical features of the

search: the hilum and the three darkenings. My goal is to
make the lateral radiograph more approachable and thus to
encourage its continued and increased use, especially by those
first being exposed to chest imaging.

SYSTEMATIC SEARCH OF THE LATERAL CHEST

RADIOGRAPH
The following is a suggested search pattern for the lateral
radiograph. It emphasizes the features that must be included
with every case and is thus intended as a starting point for
those with no experience. It is also a checklist for those
who have experience but are not entirely comfortable with
their ability to analyze the image. The essentials are summa-
rized in Table 1, and a typical normal lateral radiograph is
shown in Figure 1.
First, look briefly at the entire image for obvious abnormal-
ities. Although this gestalt (essence of the complete form) is
often not helpful to beginners in radiology, it becomes more
useful with increased experience in interpreting chest
radiographs, as the reader becomes increasingly familiar
with the normal appearance. Be sure to verify the patient
and date information for the image, whether hard copy or
digital, if you did not do so before you studied the frontal view.
Second, judge the size of the lungs and the lung markings and
the shape of the diaphragms. The overall size of the lungs on the
lateral radiograph is usually an excellent estimate of the total
lung volume at the time the film was made. For most patients, Figure 1. Normal lateral plain radiograph.
this will correspond to the total lung volume as measured by
pulmonary function tests. If the patient is temporarily unable secondary to centriacinar emphysema of chronic obstructive
to achieve full inspiration, the apparent volume will obviously pulmonary disease (Fig 2). Rarely, the cause may be panacinar
be diminished; this is most likely to occur if the patient is weak, emphysema, as in a1-antitrypsin deficiency, methylphenidate
tired, or in pain. Low lung volumes are far less likely to be (Ritalin; Novartis Pharmaceuticals Corporation, East
caused by poor inspiratory effort. This term should be applied Hanover, NJ) toxicity, or other causes, including idiopathic
only if the technologist has informed the interpreter that the causes. Remember that the tilt of the diaphragm (typically
patient would not follow directions to take a deep breath. the anterior aspect is superior) is not important; it is the lack
Enlarged lung markings are often easier to see on the lateral of doming that matters.
than the frontal view and often suggest pulmonary venous Third, follow the airway from the neck to the hilum. The
hypertension. The degree of loss of diaphragmatic doming is trachea is, of course, the upper portion of the airway and is
the single best predictor on the plain film for the presence of generally tilted posterior as it descends into the thorax. The
emphysema. The flatter the diaphragms, the more likely it is carina is not visible on the lateral view, because the main
that there is elevated residual volume, which most often is bronchi continue in the same direction as the trachea and

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FEIGIN
Figure 2. Lateral plain radiograph of a patient with chronic obstruc-
tive pulmonary disease. Increased lung volumes and flattened
hemidiaphragms.
are superimposed on each other if the lateral film is perfectly
positioned. The carina is located just below the aortic arch.
Thus, any deviation or other abnormality of the airway below
the arch is usually an abnormality of one of the mediastinal
bronchi, not of the trachea (2,3). The location of the aortic
arch is usually visible as a vague opacity behind the airway;
the entire top of the arch may be visible (as in Fig 2), especially
if the lungs are hyperinflated (which compresses the medias-
tinum but cannot compress the aorta, thus surrounding the
aorta with air in the left lung).
Fourth, identify the principal hilar structures: left main
bronchus and right and left pulmonary arteries. The major
components of the hilum are much more clearly visible on
the lateral than on the frontal view (Fig 3). The distal end of
the left bronchus is visible as a round lucency, which is typically
located at or near the apparent center of the lungs on the lateral
film. This is true even when the lungs are abnormal in shape or
when the patient is hypoinflated or hyperinflated. If there is
more than one round lucency near the center of the lungs,
remember first that the bronchus on end must be directly
connected with the rest of the airway above. If there are two
round lucencies along the airway, the upper one is the right
upper lobe bronchus and the lower one is the left main. The
visible opacities of each normal hilum are simply the two
main branches of the pulmonary artery. The other structures
in the visible portion of the hilum are either lucencies (the
bronchi) or too small to be visible (lymph nodes, bronchial
arteries, etc). The largest pulmonary veins are not clearly
visible on either the frontal or lateral view, because only the
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superior portion of the anatomic hilum is surrounded by air
in the lungs. The hilar structures are discussed in more detail
below.
Fifth, look down from the hilum for darkening to the
diaphragms. As your eye follows the space between the back
of the left ventricle (posterior edge of the heart) and the anterior
margin of the thoracic spine, the lateral film becomes darker.
This darkening is because the middle mediastinum becomes
thinner just above the diaphragms. This is one of the three
places where the lateral film must darken, as discussed in detail
below. Your eye will cross several lines. Most of the horizontal
ones are pulmonary veins approaching the left atrium. As your
eye descends, however, it should not encounter any edges
(either lower edges or upper edges), because there are no
normal structures that would be visible as edges between the
heart and the spine.
Sixth, identify the edge of the left ventricle, then note the
darkening from the middle of the heart upward toward the
trachea. The posterior border of the heart is the left ventricle,
which is the only chamber that projects laterally from the rest
of the mediastinum and thus has sufficient air directly behind it.
The middle of the heart is the whitest part, and the
mediastinum narrows above it, where the pulmonary trunk
and aorta emerge. Therefore, the image becomes darker and
may appear totally black. The darkness becomes less marked
just in front of the trachea, where the systemic veins form
the superior vena cava.
Seventh, cross the trachea and follow the spine down to the
diaphragms, judging each vertebral body and looking for
darkening until crossing the diaphragms. The region just
posterior to the trachea and above the aortic arch (Raders
triangle) is another area of darkening in most patients, because
this is another area where the mediastinum is thin (2,3). The
darkening of the spine downward is caused by diminution
in the filtering effect of soft tissue and bones in the lower
chest compared to the upper chest. This is discussed in
greater detail below.
Eighth, evaluate the periphery, beginning with the upper
abdominal bowel gas, then the anterior chest wall, lower
neck, and posterior ribs, finishing with the costophrenic
angles. The anterior chest wall includes the sternum, which
is often well visualized. The neck is usually not well seen,
but the posterior chest wall and the turning points of the
posterior ribs are clearly visible. The costophrenic angles are
always blunted if the diaphragms are flattened, but pleural
effusions may be apparent.
CRITICAL FEATURES OF THE LATERAL SEARCH
The Hilum
The principal opacities of the normal hilum, as seen on both
the frontal and lateral plain chest images, are the two main
pulmonary arteries as they enter the lungs. The bronchi always
travel with the arteries but are filled with air if normal. All right
pulmonary arteries are anterior and lateral to their respective
Academic Radiology, Vol 17, No 12, December 2010 LATERAL CHEST RADIOGRAPH

Figure 3. (a) Close-up view of lateral hilum. (b)

Labeled image: left main bronchus (a), bronchus
intermedius (b), right pulmonary artery and inter-
lobar artery (c), and left pulmonary artery (d).

bronchi, including the interlobar artery with the bronchus

intermedius (Fig 3). All left pulmonary arteries are lateral
and posterior to their bronchi, beginning with the left main
artery, which crosses over the left main bronchus and descends
behind it. The contours of the main arteries are more predict-
able on the lateral view than on the frontal, and there are fewer
overlapping structures to obscure their edges.
The right pulmonary artery is the bright, white opacity
anterior to the airway in the center of the lungs on the lateral.
Its shape is usually either tubular or ovoid, and the posterior
margin is a sharp edge because the bronchus intermedius is
directly behind it. The left pulmonary artery is usually less
opaque as it emerges from the mediastinum just above the
left main bronchus on end. Its posterior margin curves down-
ward with the same shape as the arch of the aorta, which is
located anatomically just above it. Thus, the anterior margin
of the left pulmonary artery is its bronchus, including the
black hole of the distal end of the left main bronchus.
Hilar abnormalities are most likely to appear as enlargement
or distortion of the normal appearance of the hilar structures on
the frontal and lateral plain films. Because the shape of the
pulmonary arteries is more predictable and recognizable on
the lateral, the presence and nature of a hilar abnormality is
usually easier to evaluate. If the lateral hilum is enlarged but
normal in shape (Fig 4), the cause is usually enlargement of
the pulmonary arteries and is most often a sign of pulmonary
arterial hypertension. If, however, the shape of the hilum is dis-
torted, especially with abnormal bulges, the cause is usually
lymphadenopathy (Fig 5) or, less likely, some other pulmonary
mass. If the hilar structures are not discernable on the lateral
view, or if there is enlargement that cannot be clearly defined
as normal in shape versus distorted, chest CT may be needed. Figure 4. Close-up view of lateral hilum in a patient with pulmonary
arterial hypertension. Large pulmonary arteries are enlarged but
normal in shape.
The Three Darkenings
increasing overall lucency as one looks down the thoracic
Most radiologists and residents are familiar with the spine vertebral bodies from the neck to the diaphragms. The sign
sign, which states that the normal lateral chest film shows is principally based on the fact that the soft tissues and bones

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FEIGIN
Figure 5. Lateral radiograph of hilum in a patient with sarcoidosis.
Abnormal hilar bulges indicative of bilateral hilar lymphadenopathy.
Figure 6. Lateral radiograph of a patient with right lower lobe bron-
chogenic carcinoma. Localized mass with discrete edges overlies
lower thoracic spine.
of the chest wall are much more abundant in the shoulders
than in the flanks of the lower chest. The shoulders absorb
more of the x-ray beam, and there is a gradual darkening effect
as the soft tissues thin over the lower vertebral bodies until the
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Figure 7. Lateral view of a patient with left lower lobe collapse.
Large area of increased opacity overlies the spine with obscured
posterior edge of left hemidiaphragm.
upper edge of the higher hemidiaphragm. It is sometimes
stated that the sign is caused by the increased width of the
lower lungs, but it is less soft tissue filtering, not increased
air, that creates the difference in whiteness.
There are two different types of findings that create an
abnormal spine sign. First, there may be an extra edge of
soft tissue that abruptly interrupts the gradual darkening
downward or a localized opacity with a discrete edge (Fig
6). Any such edge, whether the top or the bottom of a soft
tissue shadow, is an abnormality. The most common cause is
a mass or consolidative pattern in either lung, but the edge
may be caused by a mediastinal mass with lung air above or
below it. The second type of finding is failure to darken grad-
ually (without an edge) above the diaphragms. The cause may
be pleural thickening or some other thin abnormal soft tissue,
but it is also a typical finding in lower lobe collapse (Fig 7). In
addition to looking for these two types of spine signs, it is vital
to evaluate the individual vertebral bodies for specific skeletal
abnormalities such as collapse, or lytic or blastic density
changes.
The other two darkenings on the lateral are both caused by
gradual narrowing of the mediastinum. The widest portion of
the entire mediastinum, and hence the whitest region on the
lateral film, is at the middle of the heart. This is approximately
the level of the tricuspid and mitral valves, where all four
chambers are near their largest diameters. From the whitest
aspect of the lateral heart, the lateral film darkens upward,
until just anterior to the trachea. The cause is the decreasing
width of the anterior mediastinum, beginning at the level of
Academic Radiology, Vol 17, No 12, December 2010
Figure 8. Lateral view of a patient with Hodgkins disease. Anterior
opacification of upper mediastinum with posterior deviation of lower
trachea.
Figure 9. Single computed tomographic transverse view of
a normal patient. Azygoesophageal recess of right lower lobe
extends medially to midline just anterior to thoracic vertebra.
the pulmonary artery and ascending aorta and progressing
upward until the region of the systemic veins that form the
superior vena cava, just anterior to the midtrachea. The lungs
often meet in front of the upper ascending aorta, creating the
anterior junction line of the frontal view. On the lateral view,
this region, just behind the manubrium, is sometimes called
LATERAL CHEST RADIOGRAPH
Figure 10. Lateral view of a patient with congenital respiratory cyst
(bronchogenic cyst). Mass between heart and spine, inferior to hilum.
the anterior clear space, even though the lungs are not
always in contact to create a truly clear space.
With regard to the spine sign, the anterior darkening may
become abnormal by either the presence of an extra edge or
by a failure to darken gradually. The top of the heart is never
visible as an edge on the lateral, because the pulmonary trunk
and the aorta emerge from the superior aspect of the heart,
and there is thus no interface with air to define the top of
any chamber. If an edge is visible over or above the heart on
the lateral view, it must represent a soft tissue interface with
air (Fig 8). That interface is usually in the lung, such as the
upper edge of a mass or a consolidative pattern in the middle
lobe, but it may also represent a mediastinal mass projecting
laterally and displacing lung air. Gradual opacification above
the heart, without an abnormal edge, is most often caused
by an anterior mediastinal mass.
The third darkening on the lateral view is between the
posterior border of the heart (the back of the left ventricle)
and the front of the vertebral bodies and downward from
the hilum to the diaphragms. This is another region where
the mediastinum narrows and the lungs may be quite close
to each other, or even touch. The largest normal structures
found in the mediastinum in this area are the esophagus and
the azygous vein, as shown in cross-section on CT (Fig 9).
It is this region between the heart and the descending aorta
where the right lung is farthest to the left, creating the
azygoesophageal edge of the frontal view. The right lower
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lobe indents, behind the bronchus intermedius, until it often
reaches the midline.
Again, an abnormality on the lateral radiograph in this third
location may present as a soft tissue edge (Fig 10) or as a failure
to darken downward. This area of the lateral contains a large
number of pulmonary vessels, especially the pulmonary veins
approaching the left atrium from behind. Thus, there are
several normal lines in this area, but no normal edges, except
for the back of the left ventricle. Most abnormal edges here are
horizontal or oblique and include the lower edge of a pulmo-
nary or mediastinal mass, or a major fissure appearing as an
edge because of lobar consolidation.
CONCLUSIONS
The value of the lateral chest radiograph cannot be underesti-
mated. There are a wide variety of abnormalities of the chest
that are located and shaped in such a manner that they are
simply more conspicuous on the lateral radiograph than on
the frontal view. In particular, the structures of the hilum
are more visible because they are not overlapped by the
mediastinal edges. If the lateral radiograph is analyzed in
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a systematic fashion, the information it provides can be appre-
ciated in a few seconds. The rewards will become obvious to
anyone who spends that time on every opportunity.
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