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.

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.

Mini Case Study

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

Lat Cervical & APOM

Air Fluid Level seen in maxillary Sinus

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

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.

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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 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.

Skull Lateral

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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: midsagittal 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 orbitalmeatal 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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 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

10.1 Basics of Extremity Radiography

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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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End of Lecture
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