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Perspective

Lateral Chest Radiograph:


A Systematic Approach

David S. Feigin, MD

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 intensity and imagination that they figured out the meaning
radiograph has received decreasing attention, both of each edge and the identity of every structure. They accom-
clinically and educationally. Routine chest radio- plished this without the assistance of cross-sectional imaging of
graphs, especially of younger adult patients, are often confined living patients as a reference. With respect to the lateral
to frontal views; laterals are rarely ordered as a follow-up. In radiograph, probably the pinnacle of these analyses were the
modern chest imaging, if the frontal view shows the possibility monographs written by Anthony Proto and John Speckman
of an abnormality, many radiologists recommend chest (2,3) in 1979, in which they described the meaning of each
computed tomography (CT). The ability to perform CT line and edge on the normal lateral radiograph. Learning the
has become sufficiently convenient for this to be a practical lateral radiograph to that level of detail seems less useful in the
approach, despite the downsides of chest CT, which include era of CT.
much greater radiation dose than plain radiographs and the We thus need to take a new approach to the use of the lateral
high incidence of false-positive findings that may require chest film in the context of modern chest imaging. Although
additional evaluation. some studies have shown little value to the lateral radiograph
This reasoning has led to less emphasis on the ability of in specific instances (46), most studies and expert opinions
medical trainees, including radiology residents and medical continue to show how valuable it is (710). I believe that
students, to become thoroughly comfortable with the analysis the lateral view should be thought of as a full half of the
of the lateral radiograph. The problem is compounded by the routine chest plain radiographic study. The lateral view
fact that young radiologists have had all their training during often provides key findings that are not visible on the frontal
the era since CT became the prime imaging tool for the medi- view. It frequently clarifies questionable abnormalities by
astinum and high-resolution CT became the imaging gold showing more specific features. It is, in my opinion, the best
standard for the lungs. This has led many radiologists and view to determine lung volumes, because the inflation of
other physicians to become less conversant with the details the lungs is easier to estimate with the lungs in profile
and subtleties of normal and abnormal findings on the lateral surrounded by the chest wall and hemidiaphragms. It is
radiograph. especially useful in determining whether and why the hilum
Paradoxically and unintentionally, the problem has been is abnormal, because the hilar vessels are not overlapped by
compounded by the complexities of the lateral radiograph the mediastinum (2,3). Yet a complete search of the lateral
that have often been taught in the past. The brilliant first gener- radiograph should take less time than that of the frontal
ation of chest radiology specialists, especially Benjamin Felson radiograph. Understanding the most useful features of the
(1), studied frontal and lateral chest radiographs with such 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
Acad Radiol 2010; 17:15601566
approach to the search of the lateral radiograph and the
From the Russell H. Morgan Department of Radiology and Radiological
analysis of the most common abnormalities. This approach
Sciences, Johns Hopkins University, 601 North Caroline Street, JHOC 4233, facilitates familiarity with the normal features and is intended
Baltimore, MD 21287. Received May 19, 2010; accepted July 13, 2010. to make the lateral view easier to interpret and to teach to
Address correspondence to: D.S.F. e-mail: dfeigin1@jhmi.edu
others. The communication consists of two sections: (1) an
AUR, 2010
doi:10.1016/j.acra.2010.07.004 outline of a systematic search of the lateral radiograph and

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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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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
Figure 2. Lateral plain radiograph of a patient with chronic obstruc- and aorta emerge. Therefore, the image becomes darker and
tive pulmonary disease. Increased lung volumes and flattened may appear totally black. The darkness becomes less marked
hemidiaphragms.
just in front of the trachea, where the systemic veins form
the superior vena cava.
are superimposed on each other if the lateral film is perfectly Seventh, cross the trachea and follow the spine down to the
positioned. The carina is located just below the aortic arch. diaphragms, judging each vertebral body and looking for
Thus, any deviation or other abnormality of the airway below darkening until crossing the diaphragms. The region just
the arch is usually an abnormality of one of the mediastinal posterior to the trachea and above the aortic arch (Raders
bronchi, not of the trachea (2,3). The location of the aortic triangle) is another area of darkening in most patients, because
arch is usually visible as a vague opacity behind the airway; this is another area where the mediastinum is thin (2,3). The
the entire top of the arch may be visible (as in Fig 2), especially darkening of the spine downward is caused by diminution
if the lungs are hyperinflated (which compresses the medias- in the filtering effect of soft tissue and bones in the lower
tinum but cannot compress the aorta, thus surrounding the chest compared to the upper chest. This is discussed in
aorta with air in the left lung). greater detail below.
Fourth, identify the principal hilar structures: left main Eighth, evaluate the periphery, beginning with the upper
bronchus and right and left pulmonary arteries. The major abdominal bowel gas, then the anterior chest wall, lower
components of the hilum are much more clearly visible on neck, and posterior ribs, finishing with the costophrenic
the lateral than on the frontal view (Fig 3). The distal end of angles. The anterior chest wall includes the sternum, which
the left bronchus is visible as a round lucency, which is typically is often well visualized. The neck is usually not well seen,
located at or near the apparent center of the lungs on the lateral but the posterior chest wall and the turning points of the
film. This is true even when the lungs are abnormal in shape or posterior ribs are clearly visible. The costophrenic angles are
when the patient is hypoinflated or hyperinflated. If there is always blunted if the diaphragms are flattened, but pleural
more than one round lucency near the center of the lungs, effusions may be apparent.
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 CRITICAL FEATURES OF THE LATERAL SEARCH
upper lobe bronchus and the lower one is the left main. The The Hilum
visible opacities of each normal hilum are simply the two
main branches of the pulmonary artery. The other structures The principal opacities of the normal hilum, as seen on both
in the visible portion of the hilum are either lucencies (the the frontal and lateral plain chest images, are the two main
bronchi) or too small to be visible (lymph nodes, bronchial pulmonary arteries as they enter the lungs. The bronchi always
arteries, etc). The largest pulmonary veins are not clearly travel with the arteries but are filled with air if normal. All right
visible on either the frontal or lateral view, because only the pulmonary arteries are anterior and lateral to their respective

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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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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


Figure 5. Lateral radiograph of hilum in a patient with sarcoidosis. stated that the sign is caused by the increased width of the
Abnormal hilar bulges indicative of bilateral hilar lymphadenopathy. 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
Figure 6. Lateral radiograph of a patient with right lower lobe bron- gradual narrowing of the mediastinum. The widest portion of
chogenic carcinoma. Localized mass with discrete edges overlies the entire mediastinum, and hence the whitest region on the
lower thoracic spine.
lateral film, is at the middle of the heart. This is approximately
the level of the tricuspid and mitral valves, where all four
of the chest wall are much more abundant in the shoulders chambers are near their largest diameters. From the whitest
than in the flanks of the lower chest. The shoulders absorb aspect of the lateral heart, the lateral film darkens upward,
more of the x-ray beam, and there is a gradual darkening effect until just anterior to the trachea. The cause is the decreasing
as the soft tissues thin over the lower vertebral bodies until the width of the anterior mediastinum, beginning at the level of

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Figure 8. Lateral view of a patient with Hodgkins disease. Anterior Figure 10. Lateral view of a patient with congenital respiratory cyst
opacification of upper mediastinum with posterior deviation of lower (bronchogenic cyst). Mass between heart and spine, inferior to hilum.
trachea.
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
Figure 9. Single computed tomographic transverse view of posterior border of the heart (the back of the left ventricle)
a normal patient. Azygoesophageal recess of right lower lobe and the front of the vertebral bodies and downward from
extends medially to midline just anterior to thoracic vertebra. the hilum to the diaphragms. This is another region where
the mediastinum narrows and the lungs may be quite close
the pulmonary artery and ascending aorta and progressing to each other, or even touch. The largest normal structures
upward until the region of the systemic veins that form the found in the mediastinum in this area are the esophagus and
superior vena cava, just anterior to the midtrachea. The lungs the azygous vein, as shown in cross-section on CT (Fig 9).
often meet in front of the upper ascending aorta, creating the It is this region between the heart and the descending aorta
anterior junction line of the frontal view. On the lateral view, where the right lung is farthest to the left, creating the
this region, just behind the manubrium, is sometimes called azygoesophageal edge of the frontal view. The right lower

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lobe indents, behind the bronchus intermedius, until it often a systematic fashion, the information it provides can be appre-
reaches the midline. ciated in a few seconds. The rewards will become obvious to
Again, an abnormality on the lateral radiograph in this third anyone who spends that time on every opportunity.
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
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