Chapter 9 Skull & Sinus Radiography

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Chapter 9 Skull Sinus Radiography

• Skull Radiography can be easily done erect with
  the patient seated in a chair or often time
  standing. It is easier to check for rotation with
  the patient seated.
• Sinus studies should always be done erect to see
  air and fluid levels in the sinuses.
• Sinus views can also be used to evaluate the
  facial bone and orbits.

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Skull Sinus Radiography

• All skull or sinus views should be taken using
  the small focal spot. This will provide the best
  possible geometric resolution.
• Skull films are taken on 10 x 12 regular speed
  cassettes.
• Sinus films are taken on 8 x 10 regular speed
  cassettes.

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Why do I need this?

• Cranial pathologies may show up on cervical spine
  views.
• Doctor needs to be able to further evaluate the
  pathology.
• If patient presents withy neurological signs, you
  need to evaluate them.

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Mini Case Study

• 27 year old male with complaints of head aches.
• Full spine series performed in clinic.

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Lat Cervical APOM
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Air Fluid Level seen in maxillary Sinus
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Waters Projection

• Waters projection demonstrates
• Cloudy maxillary sinuses worse on left.
• Sinus infection that needed antibiotics.

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9.1 P-A Skull

• Measure A-P at the Glabella
• Protection Full coat apron with lead to back or
  half apron draped over back of chair.
• SID 40 Bucky
• No tube angle
• Film 10 x 12 regular I.D. down (portrait)

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P-A Skull

• Patient seated or standing facing the Bucky.
• Nose and forehead touching the Bucky to get the
  canthomeatal line perpendicular to film.

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P-A Skull

• Horizontal CR exit through the glabella.
• Vertical CR mid-sagittal plane
• Center film to horizontal CR
• Collimation slightly less than film size.
• Breathing Instructions Suspended respiration

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P-A Skull

• Make exposure and let patient relax.
• Note If the patient is done seated, place Bucky
  tray in the lower Bucky slot. This will allow the
  patient to get their legs under the Bucky.

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P-A Skull Film

• The entire skull should be on the film.
• There should be no rotation.
• The petrous ridges will be superimposed with the
  orbits.
• To clear the ridges, the Caldwell view can be
  taken.

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9.2 Chamberlain-Townes

• The Townes Projection is part of a routine skull
  series.
• The tube is angled to throw the anterior part of
  the skull away from the occipital region of the
  skull.

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Chamberlain-Townes

• Measure A-P at Glabella
• Protection Half apron or Coat Apron
• SID 40 Bucky
• Tube angle 35 degrees Caudal
• Film 10 x 12 regular I.D. Down (portrait)

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Chamberlain-Townes

• Patient is seated facing the tube.The chin is
  tucked into the chest until the canthomeatal line
  is perpendicular to film. A chair the allows some
  reclining will make this easier for the patient.

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Chamberlain-Townes

• Horizontal CR Through the EAM. The Horizontal CR
  will usually pass through the hair line.
• Vertical CR mid-sagittal
• Film centered to horizontal CR
• Collimation slightly less than film size or soft
  tissue of skull

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Chamberlain-Townes

• Breathing Instructions Suspended respiration
• Make exposure
• Let patient breathe and relax

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Chamberlain-Townes Film

• The entire skull and especially the occipital
  region of the skull must be on the film.
• Structure seen include the foramen magnum,
  petrous ridges, IACs and TM Joints
• No rotation of skull

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9.3 Skull Lateral

• Measure Lateral at EAM
• Protection Full coat apron or half apron draped
  over back of chair
• SID 40 Bucky
• Tube angle none but may be angled parallel to
  interpupillary line.
• Film 12 x 10 I.D. to face (landscape)

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Skull Lateral

• Patient seated of standing facing the Bucky.
  Rotate the body into an oblique position.
• Turn skull so the affected side is next to the
  Bucky.
• The interpupillary line must be perpendicular to
  film and tube.
• Mid sagittal plane parallel to the film.

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Skull Lateral

• Horizontal CR 3/4superior to EAM
• Vertical CR 3/4 anterior to EAM or mid skull
• Center film to horizontal CR.
• Collimation slightly less than film size
• Breathing Instructions Suspended respiration
• Make exposure and let patient relax.

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Skull Lateral Film

• Entire skull must be on the film.
• There should be no rotation of the skull, orbits
  and mandible ramus superimposed.
• The facial bones are sinuses will be dark (over
  exposed).
• Usually both lateral views are taken.

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9.5 Base Posterior Skull

• Routine skull view that can be used to evaluate
  the upper cervical spine.
• Provides an axial view of C-1 and C-2 as well as
  the foramen magnum.

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9.5 Base Posterior Skull

• Measure A-P at Glabella
• Protection Half apron
• SID 40 Bucky
• Tube Angle None but if patient cannot extend
  head back far enough to get inferior orbital
  meatal line perpendicular to horizontal CR tube
  angle may be needed.

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Base Posterior Skull

• Film Size 10 x 12 regular I.D. down (Portrait)
• Patient is seated in a reclining chair. The chair
  is placed about 6 to 10 from Bucky.
• Patient is asked to extend neck back until
  inferior orbital meatal line is parallel to film
  with top of skull touching the Bucky.

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Base Posterior Skull

• Horizontal CR EAM
• Vertical CR mid-sagittal
• Center film to horizontal CR
• Collimation slightly less than film size or skin
  of skull
• Breathing Instructions suspended respiration
• Make exposure

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Base Posterior Skull

• Assist patient get out of the position. Be very
  careful that the patient does not hit face on
  x-ray tube.
• The ability of the patient to lay back in the
  chair will make the view much easier for all
  concerned.

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Base Posterior Skull Films

• This basilar view of skull has the patients head
  not extended back far enough. The mandible and
  frontal skull should be superimposed.
• The I.D. Blocker is on the skull.
• The skull is rotated.

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Base Posterior Skull Films

• If the upper cervical spine or mastoid processes
  and internal auditory canals are the areas of
  interest, it is appropriate to cone down to
  this area.
• Note the ear ring left on the patient.
• There is some rotation.

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Base Posterior Skull Films

• The entire skull is visualized.
• The mandible and frontal region of skull are
  superimposed.
• With a bright light, the zygomatic arches can
  usually be seen.

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9.6 Schullers Projection

• The Schullers Projection can be used to evaluate
  the temporal mandibular joints and mastoid air
  cells and inner ear.

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9.6 Schullers Protection

• Measure lateral at EAM
• Protection Lead apron
• SID 40 Bucky
• Tube angle 25 degrees caudal
• Film size 8 x 10 I.D. up (portrait)

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Schullers Protection for TMJ

• Patient is seated facing the Bucky. Head is
  turned to place the affected TMJ next to Bucky.
• Skull should be in a true lateral position. Align
  the TMJ to the center line of the Bucky.
• The vertical CR should be aligned with TMJ away
  from film.

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Schullers Protection for TMJ

• If the affected TMJ and the side away from the
  Bucky is aligned with the Center of the Bucky and
  Vertical CR, the skull will be in the true
  lateral position.
• The horizontal CR is aligned with the Affected
  TMJ (closest to film).

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Schullers Protection for TMJ

• Center film to horizontal CR.
• Collimation 5 x 5
• Breathing instructions Keep mouth closed and
  dont breathe move or swallow.
• Make exposure.
• Let patient breathe but remain in the position.

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Schullers Protection for TMJ

• Change cassettes to a new 8 x 10
• Ask patient to open mouth as far as possible.
• Recheck positioning.
• Breathing Instructions With mouth wide open,
  dont breathe move or swallow.
• Make exposure and let patient relax.

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Schullers Protection for TMJ

• Open and closed mouth view are taken of both TM
  joints.
• The TMJ closest to the Bucky will be the one seen
  at the center or top of the film.
• Accurate positioning is essential to being able
  to compare joints.

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9.7 Caldwell Sinus Projection

• The Caldwell Projection will have the petrous
  ridges below the orbits.
• Positioning is exactly like the P-A skull with
  the exception of the use of a 15 degree caudal
  tube angle to lower the petrous ridges.

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9.7 Caldwell Sinus Projection

• Measure A-P at Glabella
• Protection Coat apron backwards or half apron
  draped over back of chair.
• SID 40 Bucky
• Tube angle 15 degrees caudal
• Film 8 x 10 Regular I.D. Down (portrait)

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Caldwell Sinus Projection

• Patient is seated facing Bucky. Their legs should
  be under the Bucky. Get chair as close to the
  Bucky as possible.
• Ask patient to place their nose and forehead on
  center line of Bucky.
• Check for rotation.

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Caldwell Sinus Projection

• Horizontal CR exits through the Glabella or
  Nasion
• Vertical CR mid-sagittal
• Center film to horizontal CR
• Collimation 6 or 7 square.
• Breathing Instructions Suspended Respiration

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Caldwell Sinus Projection Film

• This view will provide a clear view of the
  frontal and ethmoid sinuses.
• The super orbital rims can be evaluated for
  fracture when facial bone are of interest.
• To project the petrous ridges farther down,
  increase angle to 25 degrees

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9.8 Waters Projection Sinus

• The most important view for sinus problems or
  injury involving the maxilla or orbits.
• By taking the view erect, fluid levels within the
  maxillary sinuses can be seen.

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9.8 Waters Projection Sinus

• Measure A-P at Glabella
• Protection Half apron over back of chair or coat
  apron backwards
• SID 40 Bucky
• No tube angle
• Film 8 x 10 regular I.D. Down (portrait)

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Waters Projection Sinus

• Patient is seated facing the Bucky. Get the chair
  as close to the Bucky as possible. Patient may
  spread legs to get chair as close as possible.
  May also be taken standing.
• Mentomeatal line should be perpendicular to film
  with mouth closed.

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Waters Projection Sinus

• The nose will be one to two centimeters from
  Bucky with chin resting on Bucky.
• The mouth may be opened to see the sphenoid
  sinus. When this is done, the canthomeatal line
  should be 35 to 40 degrees to the Bucky.

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Waters Projection Sinus

• Horizontal CR exit through the base of nose or
  acantha.
• Vertical CR mid-sagittal
• Center film to horizontal CR
• Collimation 6 or 7 square
• Breathing Instructions Suspended Respiration

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Waters Projection Sinus Film

• This is an example of the open mouth waters view.
• The facial bones and sinuses should be on the
  film.
• There should be no rotation.
• The petrous ridges must be below the floor of the
  maxilla.

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Waters Projection Sinus Film

• The facial bones and sinuses should be on the
  film.
• There should be no rotation.
• The petrous ridges must be below the floor of the
  maxilla.

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9.9 Sinus Lateral

• The lateral view of the sinuses and facial bones
  will under exposed for the skull.
• This view is very useful for seeing fluid levels
  in all of the sinuses.

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9.9 Sinus Lateral

• Measure Lateral at EAM
• Protection Coat apron or half apron draped over
  back of chair.
• SID 40 Bucky
• No Tube Angle
• Film 8 x 10 regular I.D. down (portrait)

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Sinus Lateral

• Patient is seated or standing facing the Bucky.
  Turn patient toward the affected side. Turing the
  body will make it easier for the patient.
• Patients skull should be in a true lateral
  position. The interpupillary line perpendicular
  to film.

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Sinus Lateral

• Horizontal CR Outer canthus of the eye with mid
  sagittal plane parallel to film.
• Vertical CR Outer canthus of eye
• Center film to horizontal CR.

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Sinus Lateral

• Collimation Top to Bottom Frontal Sinuses to
  Mandible
• Collimation Side to side Nose to EAM
• Breathing Instructions suspended respiration
• Make exposure and let patient relax

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Sinus Lateral

• There should be no rotation of the patients
  skull.
• The orbits, sella, maxilla and visualized
  mandible should be superimposed.

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9.10 Basilar View of Sinuses

• The base view of the sinuses is positioned just
  like the base posterior view.
• The horizontal CR is moved to the center of the
  facial bones and sinuses.
• The positioning view demonstrates a patient that
  cannot extend their neck.

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9.10 Basilar View of Sinuses

• Measure A-P at glabella
• Protection Half or coat apron
• SID 40 Bucky
• Tube angle none if patient can extend neck until
  the inferior orbital-meatal line is parallel to
  film.

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Basilar View of Sinuses

• If patient cannot extend back far enough, angle
  tube to get the CR perpendicular to the inferior
  orbital-meatal line.
• Film 8 x 10 regular I.D. down (portrait)

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Basilar View of Sinuses

• Position chair about 6 to 10 from Bucky.
  Patient seated facing the tube.
• Have patient lean back or recline in chair.
• Patient extend neck as far as possible until the
  inferior orbital-meatal line is parallel to film.

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Basilar View of Sinuses

• Horizontal CR 1.5 superior to EAM or middle of
  mandible.
• Vertical CR mid-sagittal plane
• Center film to horizontal CR.
• Collimation slightly less than film size or skin
  of facial region

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Basilar View of Sinuses

• Breathing Instructions Suspended respiration
• Make exposure
• Carefully assist patient raise head without
  hitting head on x-ray tube.

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Basilar View of Sinuses

• Mandible and frontal bone should be superimposed.
• No rotation of skull
• Maxilla, sphenoid and ethmoid sinuses and
  mandible will be seen.

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10.1 Basics of Extremity Radiography

• All extremity studies must include the proximal
  and distal articulations. Long bones may require
  additional views to see both articulations.
• The patient measurement will be generally be at
  the location of the horizontal central ray.
  Exceptions lateral scapula and heel

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Basics of Extremity Radiography

• Views can be taken standing, seated or recumbent.
  Bucky views can be taken using the upright Bucky,
  Table Bucky or a stationary grid on cassette.
• When taking upper extremity views table top,
  never have the patients legs under table.
  Unnecessary exposure to femurs and bone marrow
  will be the result.

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Basics of Extremity Radiography

• More than one view can be taken on the film for
  small extremities. Lead blockers are used to
  control scatter radiation when multiple views are
  taken non-Bucky on the same film. Exposed film is
  very sensitive to fogging from secondary
  radiation.

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Basics of Extremity Radiography

• Proper Collimation is extremely important with
  extremity radiography. Collimation that is too
  tight will net demonstrate both articulations The
  operator must understand the location of the
  essential anatomy. Collimation that is too large
  will result in darker films or overlap of images.

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Basics of Extremity Radiography

• Extremity Cassettes with fine detail screens are
  used on small extremities that typically measure
  less than 10 cm thick.
• Extremity cassettes are not placed in the Bucky.
• Knees are generally taken Bucky because of the
  density of the distal femur.

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Basics of Extremity Radiography

• Typically speaking when one part of an extremity
  is in the A-P or lateral position, the rest of
  extremity will also be in the same position.
• For lower extremities, you are instructed to
  internally rotate the limb 15 degrees. In the
  standard anatomical position, the extremity is
  externally rotated 15 degrees. This will get the
  limb into an A-P position.

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Basics of Extremity Radiography

• Landmarks on the cassettes can be used when
  dividing the film for multiple views on the same
  film.
• The rivets can be used when doing three across
  when using the landscape format.

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Basics of Extremity Radiography

• The center of the cassette is marked horizontally
  and vertically by arrows.
• The arrows are used to divide the cassette into
  quarters or halves when using the portrait
  orientation.

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Cassette divided to get all needed anatomy on
the film.

• For elbows, Hands and ankle views the film is
  turned 12 x 10 for two views.
• Landscape orientation.
• Lead blockers protect the film from scatter
  radiation.

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Cassette divided to get all needed anatomy on the
film.

• For foot views the film is oriented 10 x 12 to
  allow us to get from the toes to the heel on the
  film. Portrait orientation.
• The cassette is divided in halves.

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Cassette divided to get all needed anatomy on the
film.

• For the wrist, the cassette is oriented 10 x 12
  and divided into quarters. Portrait orientation
• This gives us more film area for each view
  compared to three across.

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