Skull positions for radiologists. Important for radiology residents and radiographers.

1. C.N.S.
Skull Positions
Mohamed M.A. Zaitoun, MD
Interventional Radiology Consultant, Zagazig University Hospitals, Egypt
FINR-Switzerland
zaitoun82@gmail.com

3. Dedication
To the memory of my late father, Prof Ashraf
Zaitoun Interventional
Radiology Unit,
Zagazig University,
Egypt

4. Knowing as much as possible
about your enemy precedes
successful battle and learning
about the disease process
precedes successful management.

5. *Preparation in general :
1-Remove any radio-opaque shadow inducing
material e.g. hair pins
2-Avoid vaseline & zinc paints
3-10 days rule in females
4-Protection by lead waist apron

6. 1-Lateral view
-Patient position :
*Prone + turn head in the dead lateral position
over a bucky table ( the affected side is in
contact with the film )
*Sagittal plane will be in parallel to film & intra-
orbital line perpendicular to it

7. -Center :
5 cm above & ant. To E.A.M.
-Aim of the view :
*Profile for the base of the skull
*Sella turicica ( best view )
*Profile for all sinuses ( esp. sphenoid )
*Post. Aspect of nasopharynx
*Detection of any calcification
*Cranial & facial bones are superimposed on each other
*Bones of the vault
*Sutures & vascular markings
*Meningeal diploic veins

11. 2-Coldwall ( 15 degress angulation )
-Patient position :
*Prone + nose & forehead are in contact with midline of the table
*sagittal plane is perpendicular on film , inter pupillary line is parallel
-Center:
2.5 cm above the external occipital protuberance to the nasion
-Aim :
PNS ( frontal & ethmoidal )
Nasal bone & septum
Foramen rotundum
Lesser & greater wings of sphenoid

14. 3-Town’s view ( 30 degrees angulation )
-Patient position :
*Supine with chin on chest , sagittal plane &
orbito-meatal line perpendicular to the film
*EAM is equidistant on both sides of the film
-Center :
Hair line or 5 cm above the gabella

15. -Aim :
*Occipital bone , post. Cranial fossa
*Foramen magnum
*Petrous bones & temporal bones are seen on each side of the
foramen magnum above the orbits
*Post. Clinoid process seen within the foramen magnum
*Mastoid air cells are seen on the lateral termination of petrous
bone
*Zygomatic arch
*TMJ

18. 4-Occipito mental
-Patient position :
*Erect with the Nose & chin in contact with the film , median sagittal plane is
perpendicular to the film
*No tube tilt >> closed mouth : orbit + max. & frontal sinuses
open mouth : water’s view : as above + sphenoidal
*With tube tilt >> 10 degrees caudalic : petrous bone
30 degrees caudalic: fracture ant. Orbital roof , maxillary
& frontal sinuses
-Center
1.5 inch above the external occipital protuberance in the midline
-Aim :
*To view the orbit
*Sinuses

22. 5-Submentovertex >> Skull base
-Patient position :
Sit the patient facing the x-ray tube , fully extend the neck & rest the vertex of the skull in
contact with the vertical bucky in the midline
-Center :
In the midline , midway between the angles of the mandible
-Aim :
*Base of the skull with its different foramina
*Petrous bone , mastoid & mandibles
*Ossicles of the ear ( RT & LT )
*Internal auditory canal & ext. auditory canal
*Foramen magnum
*Sphenoidal & post. Ethmoidal
-Modifications :
SMV with 20 degrees angulation >> shows ant. Ethmoid , part of frontal sinus

23. N.B. >> Vertico submental for PNS
-Sit the patient facing the cassette , neck is
hyperextended
-Center : through the vertex pass between angles
of jaw

27. 6-Lateral oblique ( Schuller’s & Law’s ) = TMJ+ mastoid
-Patient position :
*Schuller’s :Lateral + 25 degrees tube caudalic + open mouth & closed mouth
for sublaxation
*Law’s : the same but tube is 15 degrees
-Center point :
5 cm above TMJ
-Aim :
*TMJ
*Mastoid
*Parotid
*IAC & EAC

31. 7- AP oblique of the mastoid process
-Patient position :
Supine + back of the head on the film + rotate the head
35 degrees away from side under examination
-Center :
Root of mastoid process remote from the film through
the ear pinna

34. 8-Mayer’s view = Mastoid
-Patient position :
As A.P. oblique + tube 45 degrees caudalic
-Center :
fronto-parietal region of the remote side , so the rays pass
via EAM nearest to the film
-Aim :
*Petrous bone
*Mastoid
*Middle ear structures

35. 9-Occipito-vertical
-Patient position :
The patient faces the film with the head flexed forward
with the chin in contact with the chest to bring the
vertex in contact with the film
-Center :
Midway between mastoid process
-Aim :
Mastoid air cells appear on both sides of foramen
magnum

36. 10-Rhese’s view ( oblique view )
-Patient preparation :
Patient face the film with head & nose in contact with the film ,
rotate the head to LT or RT to make the baseline forming 30
degrees with the vertical
-Center :
4 inches above & behind the EAM of opposite side
-Aim :
*Optic foramen
*Post. Ethmoidal sinus
*Greater & lesser wings of sphenoid

39. A-Optic canal
B-Optic structures
C-superior orbital fissure
D-Ethmoid sinus
E-Planum sphenoidale
F-Greater wing of sphenoid

40. 11-Stenver’s view
-Patient’s method :
Patient prone + tip of nose & outer canthus in contact with the film >>
B.L. perpendicular to film , M.S.P. 45 degrees with the film + tube 12 degrees cephalic
angulation
-Center :
Midway between Ext. occipital protuberance & EAM of the side away from the film
-Aim :
*I.A. canal
*Mastoid air cells
-Modified stenver’s :
*Supine + center ( fronto-parietal region ) + 12 degrees caudalic

43. 12-Tangential ( Sup. Inf. View ) = Nose
*Patient preparation :
-Patient is sitting or supine
-Film is occlusal film in the mouth between teeth with its
longitudinal axis along MSP & 2/3 of films outside the
mouth
-Beam is directed tangentially from above nasal bone in
midline
*Center :
Nasal bone above the vertex

45. 13-Occipito frontal oblique view of optic foramen
-Patient preparation :
*Prone + orbit of the side under exam. In contact with the couch top + cheek ,
nose & chin also in contact
*Adjust the head so that MSP & B.L. are both at 35 degrees to the vertical >> as
the optic canal that ends at optic foramen passes forwards & lateral 35
degrees with MSP & downwards 35 degrees to O. Meatal plane
-Center :
Through the orbit nearest to the film
-Detect :
Tumors >> glomus jagulare optic nerve glioma

46. 14-Intra-ocular F.B.
Plain film
U/S
CT orbit
MRI orbit
Limbal ring localization
Multi-section linear tomography
Bone free technique

47. *Plain x-rays :
-Lateral skull film ( center on outer canthus )
For localization of radio-opaque F.B. in the region of the
globe , if no F.B. stop looking
-If present >> proceed to use another view >> O.M.
with have half the exposure factors (mAs) with the eye
fixed upwards & half the exposure on the same film &
the same position with the eye looking downward
If a moving F.B. >> intra-ocular

49. *U/S :
-Ocular U/S >> post. Segment
-UBM ( ultra bio microscopy ) >> ant. Segment
-Only method for localization of non radio-
opaque I.O.F.B.
-Whether the F.B. is intra or extra ocular

50. *C.T. orbit :
-Axial & coronal
-As brain CT
-Starts from the floor >> just above the roof
-Take every 3-5 mm
-Metallic & glass >> radio-opaque
-Wood >> translucent ( radio-lucent )

51. *MRI orbit :
-After exclusion of metallic F.B.
-As brain MRI
*Limbal ring localization :
-12 mm diameter ring fixed to the limbus of the cornea
by 4 carrying conjunctival sutures
-3 views : PA , Lateral & Eye moving lateral film
*Multi-section linear tomography

52. *Bone free technique :
-Done for very small F.B. not visible in normal
plain film due to >> bone shadow overlap
-We use dental film placed in the inner canthus
with the tube centered behind the outer canthus
-Value >> diagnosis of ant. Located F.B. taking
only less than a quarter of the globe

53. 15-Mandible
-P.A.
-Oblique
-Lateral
-Orthopantograom ( OPG )