Lec1222509slideshare

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Lec1222509slideshare

  1. 1. Chapter 22 Paranasal Sinuses <ul><li>Lesson 1 </li></ul><ul><li>Anatomy and Procedures </li></ul><ul><li>of the Paranasal Sinuses </li></ul>Prof. Z. Vinokur
  2. 2. Paranasal Sinuses <ul><li>Defined as the air-filled cavities located in the frontal, ethmoid, and sphenoid bones of the cranium, as well as the maxillae of the face </li></ul><ul><li>So named because of their formation from the nasal mucosa and their continued communication with the nasal fossas </li></ul>Prof. Z. Vinokur
  3. 3. Functions <ul><li>Serve as resonating chamber for the voice </li></ul><ul><li>Decrease weight of skull </li></ul><ul><li>Aid in warming and moisturizing inhaled air </li></ul><ul><li>Act as shock absorbers in trauma </li></ul><ul><li>Possibly control the immune system </li></ul>Prof. Z. Vinokur
  4. 4. Development <ul><li>Begins in fetal life </li></ul><ul><li>Maxillary sinuses are usually the only ones developed enough to be demonstrated radiographically at birth </li></ul><ul><li>By 6 to 7 years of age, frontal and sphenoid are distinguishable from ethmoids </li></ul><ul><li>Ethmoids do not fully develop until </li></ul><ul><li>17 to 18 years of age </li></ul>Prof. Z. Vinokur
  5. 5. Maxillary Sinuses <ul><li>Largest and most symmetric </li></ul><ul><li>Paired (one in each facial bone) </li></ul><ul><li>Vary in size and shape but are roughly pyramidal in shape </li></ul>Prof. Z. Vinokur
  6. 6. Frontal Sinuses <ul><li>Second largest </li></ul><ul><li>Paired </li></ul><ul><li>Located between vertical plates of frontal bone </li></ul><ul><li>Vary greatly in size and shape </li></ul><ul><li>Occasionally absent </li></ul><ul><li>Rarely symmetric </li></ul>Prof. Z. Vinokur
  7. 7. Prof. Z. Vinokur
  8. 8. Ethmoid Sinuses <ul><li>Located within lateral masses of labyrinths </li></ul><ul><li>Comprised of varying number of air cells, which are divided into three main groups </li></ul><ul><ul><li>Anterior (2 to 8) </li></ul></ul><ul><ul><li>Middle (2 to 8) </li></ul></ul><ul><ul><li>Posterior (2 to 6) </li></ul></ul>Prof. Z. Vinokur
  9. 9. Prof. Z. Vinokur
  10. 10. Sphenoid Sinuses <ul><li>Normally paired </li></ul><ul><li>Occupy body of sphenoid bone </li></ul><ul><li>Often only one sinus develops, but never more than two </li></ul><ul><li>Vary in size and shape </li></ul><ul><li>Usually asymmetric </li></ul><ul><li>Located below sella and extend between dorsum and posterior ethmoids </li></ul>Prof. Z. Vinokur
  11. 11. Prof. Z. Vinokur
  12. 12. Prof. Z. Vinokur
  13. 13. Essential Projections <ul><li>Lateral </li></ul><ul><li>PA axial (Caldwell method) </li></ul><ul><li>Parietoacanthial (Waters method) </li></ul><ul><li>Parietoacanthial (Waters) open-mouth modification </li></ul><ul><li>Submentovertical </li></ul>Prof. Z. Vinokur
  14. 14. Technical Considerations <ul><li>Density most critical to demonstrate pathology </li></ul><ul><li>Upright position necessary to demonstrate fluid levels </li></ul><ul><li>CR should remain horizontal </li></ul><ul><li>Shielding must be used on pregnant patients and pediatric patients </li></ul><ul><li>Proper collimation critical in reducing scatter radiation and patient dose </li></ul>Prof. Z. Vinokur
  15. 15. Lateral Projection Prof. Z. Vinokur Demonstrates <ul><li>All four sets of sinuses </li></ul><ul><li>AP and superoinferior dimensions of paranasal sinuses </li></ul><ul><li>Thickness of frontal bone </li></ul><ul><li>Detail of side closer to IR </li></ul>
  16. 16. Lateral Projection <ul><li>Patient position </li></ul><ul><ul><li>Seated erect in anterior oblique position </li></ul></ul><ul><li>Part position </li></ul><ul><ul><li>MSP of head parallel with IR plane </li></ul></ul><ul><ul><li>IPL perpendicular to IR plane </li></ul></ul><ul><ul><li>IOML parallel to transverse axis of cassette </li></ul></ul>Prof. Z. Vinokur
  17. 17. Lateral Projection <ul><li>CR </li></ul><ul><ul><li>Horizontal and perpendicular to IR </li></ul></ul><ul><ul><li>Enters ½  to 1  (1.3 to 2.5 cm) posterior to outer canthus </li></ul></ul><ul><ul><li>Center IR to CR </li></ul></ul>Prof. Z. Vinokur
  18. 18. Prof. Z. Vinokur
  19. 19. Prof. Z. Vinokur
  20. 20. PA Axial Projection (Caldwell Method) Prof. Z. Vinokur Demonstrates <ul><li>Frontal sinuses above frontonasal suture </li></ul><ul><li>Anterior ethmoid air cells </li></ul><ul><li>Sphenoid sinuses seen through nasal fossa below or between ethmoids </li></ul><ul><li>Petrous pyramids in lower third of orbits </li></ul>
  21. 21. PA Axial (Caldwell Method) <ul><li>Angled Grid Technique </li></ul><ul><li>Patient position </li></ul><ul><ul><li>Seated upright facing Bucky </li></ul></ul><ul><ul><li>MSP centered to midline </li></ul></ul>Prof. Z. Vinokur
  22. 22. PA Axial (Caldwell Method) <ul><li>Patient position </li></ul><ul><ul><li>Tilt vertical Bucky down 15 degrees </li></ul></ul><ul><ul><li>Rest patient’s forehead and nose on device </li></ul></ul><ul><ul><li>Center nasion to IR </li></ul></ul><ul><ul><li>MSP and OML perpendicular to IR plane </li></ul></ul>Prof. Z. Vinokur
  23. 23. Prof. Z. Vinokur
  24. 24. PA Axial (Caldwell Method) <ul><li>Vertical Grid Technique </li></ul><ul><li>Position patient’s OML at 15-degree angle to horizontal CR </li></ul><ul><li>Center nasion to IR </li></ul><ul><li>MSP perpendicular </li></ul><ul><li>Radiolucent support may be needed at forehead </li></ul><ul><li>This method is not preferred due to increased OID, which results in decreased resolution </li></ul>Prof. Z. Vinokur
  25. 25. PA Axial (Caldwell Method) <ul><li>CR </li></ul><ul><ul><li>Horizontal </li></ul></ul><ul><ul><li>Exits nasion </li></ul></ul><ul><ul><li>Center IR and CR </li></ul></ul>Prof. Z. Vinokur
  26. 26. Parietoacanthial Projection (Waters Method) Prof. Z. Vinokur Demonstrates <ul><li>Maxillary sinuses </li></ul><ul><li>Petrous pyramids lying inferior to maxillary floor </li></ul><ul><li>Frontal and ethmoid sinuses are distorted </li></ul>
  27. 27. <ul><li>Patient position </li></ul><ul><ul><li>Seated erect facing Bucky </li></ul></ul><ul><ul><li>MSP centered to midline </li></ul></ul><ul><li>Part position </li></ul><ul><ul><li>Hyperextend neck to place OML at 37-degree angle from IR plane </li></ul></ul><ul><ul><li>MSP and MML perpendicular to IR plane </li></ul></ul>Parietoacanthial Projection (Waters Method) Prof. Z. Vinokur
  28. 28. <ul><li>CR </li></ul><ul><ul><li>Horizontal </li></ul></ul><ul><ul><li>Exits acanthion </li></ul></ul>Parietoacanthial Projection (Waters Method) Prof. Z. Vinokur
  29. 29. Parietoacanthial Projection (Open-Mouth Waters Method) Prof. Z. Vinokur Demonstrates <ul><li>Sphenoid sinuses through open mouth </li></ul><ul><li>Maxillary sinuses </li></ul><ul><li>Petrous pyramids lying inferior to maxillary floor </li></ul>
  30. 30. <ul><li>Patient position </li></ul><ul><ul><li>Seated erect facing Bucky </li></ul></ul><ul><ul><li>MSP centered to midline </li></ul></ul><ul><li>Part position </li></ul><ul><ul><li>Hyperextend neck to place OML at 37-degree angle from IR plane </li></ul></ul><ul><ul><li>MSP and MML perpendicular to IR plane </li></ul></ul><ul><ul><li>Open mouth wide while holding position </li></ul></ul>Parietoacanthial Projection (Open-Mouth Waters Method) Prof. Z. Vinokur
  31. 31. <ul><li>CR </li></ul><ul><ul><li>Horizontal </li></ul></ul><ul><ul><li>Exits acanthion </li></ul></ul>Parietoacanthial Projection (Open-Mouth Waters Method) Prof. Z. Vinokur
  32. 32. Prof. Z. Vinokur
  33. 33. Prof. Z. Vinokur
  34. 34. Prof. Z. Vinokur
  35. 35. SMV Projection Prof. Z. Vinokur Demonstrates <ul><li>Sphenoid and ethmoid sinuses </li></ul><ul><li>Mandible </li></ul><ul><li>Bony nasal septum </li></ul>
  36. 36. SMV Projection <ul><li>Patient position </li></ul><ul><ul><li>Upright </li></ul></ul><ul><li>Part position </li></ul><ul><ul><li>Hyperextend neck and rest vertex of head on vertical grid device </li></ul></ul><ul><ul><li>MSP perpendicular to IR plane </li></ul></ul><ul><ul><li>Neck extended to place IOML parallel to IR plane </li></ul></ul>Prof. Z. Vinokur
  37. 37. SMV Projection <ul><li>CR </li></ul><ul><ul><li>Horizontal and perpendicular to IOML </li></ul></ul><ul><ul><li>Enters MSP ¾  (1.9 cm) anterior to level of EAM </li></ul></ul>Prof. Z. Vinokur
  38. 38. Prof. Z. Vinokur
  39. 39. Prof. Z. Vinokur
  40. 40. Image Critique Criteria for Essential Projection Slide
  41. 41. Lateral Projection <ul><li>All four sinus groups </li></ul><ul><ul><li>Sphenoid of primary importance </li></ul></ul><ul><li>No rotation of sella turcica </li></ul><ul><li>Superimposed orbital roofs </li></ul><ul><li>Superimposed mandibular rami </li></ul><ul><li>Clearly visible sinuses </li></ul><ul><li>Close beam restriction </li></ul><ul><li>Clearly visible air-fluid levels, if present </li></ul>Prof. Z. Vinokur
  42. 42. Lateral Projection Prof. Z. Vinokur
  43. 43. Prof. Z. Vinokur L LATERAL SKULL CORONAL SUTURE LAMBOID SUTURE INT. & EXT. OCCIPITAL PERTUBERANCE MASTOID AIR CELLS HARD PALATE NASOPHARYNX ANTERIOR CLINOID POSTERIOR CLINOID MANDIBULAR CONDYLE FLOOR OF THE CRANIAL FOSSA SELLA TURCICA FRONTAL SINUS MAXILLARY SINUS SPHENOID SINUS ETHMOID SINUS
  44. 44. PA Axial (Caldwell Method) <ul><li>No rotation </li></ul><ul><ul><li>Equal distance between lateral border of skull and lateral border of orbits </li></ul></ul><ul><ul><li>Petrous ridges symmetric </li></ul></ul><ul><li>Petrous ridge lying in lower third of orbit </li></ul><ul><li>Frontal sinuses above frontonasal suture and anterior ethmoidal air cells above petrous ridges </li></ul>Prof. Z. Vinokur
  45. 45. PA Axial (Caldwell Method) <ul><li>Frontal and anterior ethmoidal air cells </li></ul><ul><li>Clearly visible air-fluid levels, if present </li></ul><ul><li>Close beam restriction </li></ul>Prof. Z. Vinokur
  46. 46. Prof. Z. Vinokur SINUS CALDWELL VIEW FRONTAL SINUS SPHENOID BONE MAXILLARY SINUS INFERIOR TURBINATE MANDIBLE HARD PALATE MASTOID AIR CELLS ORBIT ETHMOID
  47. 47. Prof. Z. Vinokur ETHMOID SINUS NASAL SEPTUM MASTOID AIR CELLS MAXILLARY SINUS MAXILLA GREATER WING OF SPHENOID AP SKULL
  48. 48. PA Axial (Caldwell Method) Prof. Z. Vinokur
  49. 49. <ul><li>Petrous pyramids immediately inferior to floor of maxillary sinuses </li></ul><ul><li>No rotation </li></ul><ul><ul><li>Equal distance between lateral border of skull and lateral border of orbit </li></ul></ul><ul><ul><li>Orbits and maxillary sinuses symmetric </li></ul></ul><ul><li>Maxillary sinuses </li></ul><ul><li>Close beam restriction </li></ul><ul><li>Clearly visible air-fluid levels, if present </li></ul>Parietoacanthial Projection (Waters Method) Prof. Z. Vinokur
  50. 50. Prof. Z. Vinokur Sinus WATERS VIEW MANDIBLE FRONTAL SINUS ETHMOID SINUS MAXILLARY SINUS ZYGOMA ZYGOMATIC ARCH INFERIOR ORBITAL MARGIN ORBIT NASAL SEPTUM ZYGOMATICAL –FRONTAL SUTURE ODONTOID
  51. 51. Prof. Z. Vinokur Sinus AP FRONTAL SINUS ETHIMOID SINUS ORBIT NASAL SEPTUM GREATER WING OF SPHENOID MAXILLARY SINUS
  52. 52. Parietoacanthial (Waters) Prof. Z. Vinokur
  53. 53. <ul><li>Petrous pyramids immediately inferior to floor of maxillary sinuses </li></ul><ul><li>No rotation </li></ul><ul><ul><li>Equal distance between lateral border of skull and lateral border of orbit </li></ul></ul><ul><ul><li>Orbits and maxillary sinuses symmetric </li></ul></ul><ul><li>Maxillary sinuses </li></ul>Parietoacanthial Projection (Open-Mouth Waters Method) Prof. Z. Vinokur
  54. 54. <ul><li>Close beam restriction </li></ul><ul><li>Clearly visible air-fluid levels, if present </li></ul><ul><li>Sphenoid sinuses projected through open mouth </li></ul>Parietoacanthial Projection (Open-Mouth Waters Method) Prof. Z. Vinokur
  55. 55. Parietoacanthial (Waters) Prof. Z. Vinokur
  56. 56. SMV Projection <ul><li>No tilt </li></ul><ul><ul><li>Equal distance from lateral border of skull to mandibular condyles on both sides </li></ul></ul><ul><li>Anterior frontal bone superimposed by mental protuberance </li></ul><ul><ul><li>Indicates IOML is parallel (full extension) </li></ul></ul><ul><li>Mandibular condyles anterior to petrous pyramids </li></ul><ul><li>Clearly visible air-fluid levels, if present </li></ul>Prof. Z. Vinokur
  57. 57. SMV Projection Prof. Z. Vinokur
  58. 58. Prof. Z. Vinokur
  59. 59. Prof. Z. Vinokur SKULL TOWNE VIEW MANDIBLE MASTOID AIR CELLS PETROUS TEMPORAL BONE FORAMEN MAGNUM PARIETAL BONES LAMBDOID SUTURE LAMBDOID SUTURE
  60. 60. Prof. Z. Vinokur SKULL TOWNE VIEW MANDIBLE MASTOID AIR CELLS PETROUS TEMPORAL BONE FORAMEN MAGNUM PARIETAL BONES LAMBDOID SUTURE LAMBDOID SUTURE
  61. 61. Prof. Z. Vinokur ODONTOID PROCESS (DENS) ETHMOID SINUS SPHENOID SINUS MAXILLARY SINUS LAT. PTYERGOID PLATE FORAMEN OVALE ARCH OF C-1 EXT. AUDITORY CANAL MASTOID AIR CELLS BASE OF THE SKULL
  62. 62. Prof. Z. Vinokur FRONTAL SINUS LATERAL NASAL BONE NASAL BONES
  63. 63. Prof. Z. Vinokur FRONTAL SINUS MAXILLARY SINUS MANDIBLE MAXILLA ETHMOID SINUS SELLA TURCICA SPHENOID SINUS LATERAL FACIAL STRUCTURES
  64. 64. Prof. Z. Vinokur AIRWAY EPIGLOTTIS HYOID BONE CALCIFIED TRACHEAL CARTILAGE RINGS THYROID CARTILAGE CRICOID CARTILAGE
  65. 65. Prof. Z. Vinokur ARTERIOGRAM CAROTID SYPHON OCCIPITAL ARTERY INTERNAL CAROTID ARTERY EXTERNAL CAROTID ARTERY COMMON CAROTID ARTERY MAXILLARY ARTERY MIDDLE CEREBRAL ARTERY ANTERIOR CEREBRAL ARTERY FACIAL ARTERY
  66. 66. What is it supposed to look like Prof. Z. Vinokur http://www.jeffersonhospital.org/webcast/sinus/index.html
  67. 67. Prof. Z. Vinokur
  68. 68. links Prof. Z. Vinokur http://classes.kumc.edu/som/radanatomy/results2.asp?RegionID=1&PathologyID=2

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