Skull Radiography techniques and reporting

1. RADIOLOGY OF SKULL-
TECHNIQUES AND
REPORTING
-DR. BHAVANA

2. THE SKULL

3. SKULL – ANTERIORVIEW

4. SKULL – ANTERIORVIEW

5. SKULL – LATERALVIEW

6. SKULL – LATERALVIEW

7. SKULL –BASALVIEW

8. SKULL –BASALVIEW

9. SKULL – SAGITTAL SECTION

10. SKULL – SAGITTAL SECTION

11. PARANASAL SINUSES

12. SKULLTOPOGRAPHY

13. EXPOSURETABLES
As per WHO manual of diagnostic imaging

14. PATIENT PREPARATION
• Ensure that all metal objects are removed from the patient, e.g. hair clips and
hairpins.
• Bunches of hair often produce artefacts and thus should be untied.
• False teeth containing metal and metal dental bridges should be removed.

15. USEFUL ACCESSORIES

16. CRANIUM
• LATERAL
• PA
• PA- AXIAL (CALDWELL)
• AP-AXIAL (TOWNE)

17. CRANIUM - LATERAL
• Semiprone
IOML is parallel to cassette
Central ray : perpendicular ,
5cm superior to EAM

18. CRANIUM – LATERAL DORSAL
DECUBITUS
• Position : supine
Interpupillary line perpendicular
to cassette
Central ray: perpendicular 5cm
superior to EAM

19. CHECKLIST
• SHAPE AND SIZE
• THETHREE LAYERS INNERTABLE, DIPLOEAND
OUTERTABLE.
• MINERALIZATION- CIRCUMSCRIBED DENSITIES,
DECALCIFICATION
• VASCULAR MARKINGS
• CONTOURS –ANY SPICULES / DISCONTINUITIES
• CRANIAL SUTURES
• CRANIAL CAVITY- CALCIFICATIONS?
• SKULL BASE – ANTERIOR, MIDDLEAND
POSTERIOR CRANIAL FOSSA ; AND SELLA
• FRONTAL SINUS, ETHMOID SINUS, MAXILLARY
SINUS, SPHENOID SINUS, MASTOIDAIR CELLS
• FACIAL BONES – ORBIT, NASAL CAVITY, PALATE
• CERVICAL SPINE – POSITIONAND DENS
• SOFTTISSUES.

20. CRANIUM – AP PROJECTION
• Position : supine
IOML perpendicular to
cassette
Central ray :perpendicular 5cm
above nasion

21. CHECKLIST
• SHAPE AND SIZE
• THETHREE LAYERS INNERTABLE, DIPLOEAND
OUTERTABLE.
• MINERALIZATION,CIRCUMSCRIBED DENSITIES,
DECALCIFICATION,CONVOLUTIONAL MARKINGS
• VASCULAR MARKINGS
• CONTOURS –ANY SPICULES / DISCONTINUITIES
• CRANIAL SUTURES
• CRANIAL CAVITY- CALCIFICATIONS?
• CRISTA GALLI
• DORSUM SELLAE
• FACIAL BONES – ORBITS FILLED BY PETROUS
PYRAMID, MAXILLARY SINUS, NASAL CAVITY
,FRONTAL SINUSESAND POSTERIOR ETHMOIDAIR
CELLS
• DENS
• SOFTTISSUES.

22. CALDWELL METHOD
• PA AXIAL projection
• Position : prone/seated
OML perpendicular to cassette
Central ray - directed to exit
nasion 15 degree caudad

23. • PETROUS PYRAMID
PROJECTED IN LOWER
THIRD OF ORBITS
• POSTERIOR ETHMOID AIR
CELLS
• CRISTA GALLI
• FRONTAL SINUSES

24. CRANIAL BASE
• SUBMENTOVERTICAL PROJECTION (SCHULLER’S METHOD)

25. CRANIAL BASE -SCHULLER METHOD
• Submentovertical projection
position: IOML parallel to cassette
Central ray -perpendicular to IOML
between angles of the mandible
2cm anterior to level EAM

26. • PETROUS BONES
• MASTOID PROCESSES
• MAXILLARY SINUSES
• SPHENOID SINUS
• DENS
• FORAMEN OVALE
• MANDIBLE
• ZYGOMATIC
• SOFTTISSUES

27. SELLATURCICA
• LATERAL PROJECTION

28. SELLATURCICA
• LATERAL PROJECTION
• Position: semiprone/ seated
• IOML parallel to cassette
• Central ray : perpendicular 2 cm anterior
and superior to EAM

29. • SHAPE OF SELLA , DORSUM
SELLA AND CLINOID
PROCESSES.
• SPHENOID SINUS
• NEUROCRANIUM FOR
CALCIFICATION

30. ORBIT
• PARIETO-ORBITAL OBLIQUE PROJECTION (RHESE METHOD)

31. ORBITPARIETO-ORBITAL OBLIQUE
PROJECTION (RHESE METHOD)
• Position : semiprone / seated
• AML perpendicular to cassette
• Mid-sagittal plane 53 degree
with cassette
• Central ray :perpendicular, 2.5
cm superior and posterior to
upsideTEA

32. • SUPERIOR ORBITAL MARGIN
• LATERAL ORBIT MARGIN
• OPTIC CANAL AND FORAMEN
• MEDIAL ORBITAL MARGIN
• LESSERWING OF SPHENOID
• ETHMOID SINUS
• INFERIOR ORBITAL MARGIN

33. FACIAL BONES
• LATERAL PROJECTION
• PARIETO-ACANTHAL PROJECTION (WATER’S)

34. FACIAL BONES- LATERAL
• Position: semiprone / seated
• Mid-sagittal plane parallel to
cassette
• Central ray : perpendicular,
between outer canthus and
EAM

35. • FRONTAL SINUS
• NASAL BONE
• SELLATURCICA
• MAXILLARY SINUS
• EXTERNAL AUDITORY
MEATUS
• MANDIBLE

36. Facial bones-WATER’S METHOD
• Parieto canthal projection
• WATERS method
• Position: prone / seated
• Neck hyperextended, OML 37
degree with cassette
• Central ray: perpendicular,
exit the acanthion

37. • FRONTAL SINUS
• ORBITS
• ZYGOMATIC ARCH
• PETROUS RIDGE
• MAXILLARY SINUS
• MAXILLA
• NASAL SEPTUM
• MANDIBLE
• DENS

38. NASAL BONES
• LATERAL PROJECTION
• TANGENTIAL PROJECTION

39. NASAL BONES- LATERAL
• Position : seated / semiprone
• Mid-sagittal plane parallel to
cassette
• Central ray : perpendicular to
bridge of nose , 1.3 cm distal
to nasion

40. • NASAL BONE
• FRONTONASAL SUTURE
• ANGLE BETWEEN NASAL AND
FRONTAL BONES
• DENSITIES/ LUCENCIES
• CONTOURS
• SOFTTISSUE

41. NASAL BONES-TANGENTIAL
• Position: seated / recumbent
• Inclined cassette
• Central ray: parallel to
glabelloalveolar line

42. • Septal cartilage
• Nasal bone

43. PARANASAL SINUSES
• PA AXIAL PROJECTION- CALDWELL
• PARIETOCANTHAL PROJECTION- WATER’S
• PARIETOCANTHAL PROJECTION –WATER’S WITH OPEN MOUTH

44. CALDWELL METHOD
• PA axial projection
• CALDWELL METHOD
• Position : extend patient’s
head
IOML forms 15 degree with
horizontal central ray
Central ray : horizontal – exit at
nasion

45. • FRONTAL SINUS
• ETHMOIDAL SINUS
• PETROUS RIDGE
• SPHENOIDAL SINUS
• MAXILLARY SINUS

46. Maxillay sinuses –WATERS METHOD
• Parietocanthal projection
• Position:hyperextend patient’s
neck
• OML forms 37 degree to cassette
• MML is perpendicular to cassette
• Central ray: perpendicular- exit at
the acanthion

47. • FRONTAL SINUS
• ETHMOIDAL SINUSES
• MAXILLARY SINUSES
• PETROUS RIDGE
• MASTOID AIR CELLS
• ORBIT

48. Maxillary and ethmoidal sinuses- OPEN
MOUTHWATER’S
• Parietocanthal projection
• OPEN MOUTHWATERS
• Position: OML 37 degree to
cassette
• MML not perpendicular
• Mouth open
• Central ray: : perpendicular- exit
acanthion

49. • MAXILLARY SINUS
• SPHENOIDAL SINUSES

50. ZYGOMATICARCH
• SUBMENTOVERTICAL PROJECTION
• TANGENTIAL PROJECTION –MAY METHOD

51. ZYGOMATIC ARCH-SUBMENTOVERTICAL
PROJECTION
• Position: upright/ supine
• Hyperextend neck-IOML
parallel to cassette
• Central ray : perpendicular
to IOML
2.5cm posterior to outer
canthi

52. • SHAPE – A LOW ARCH BROADENED
AT BOTH ENDS
• STRUCTURE AND CONTOUR OFTHE
ZYGOMATIC ARCH
• SKULL AND FACIAL SKELETON
• SOFTTISSUE

53. MAY METHOD
• Tangential projection/ MAY method
• Position: prone/upright
Neck extended-rest chin on cassette
Mid-sagittal plane rotated 15 degree
away from side being examined
Central ray : perpendicular to IOML-
3.8cm posterior to outer canthus

54. • SHAPE AND STRUCTURE OF
ZYGOMATIC ARCH
• SOFTTISSUES

55. MANDIBLE
• AXIOLATERAL OBLIQUE PROJECTION

56. MANDIBLE -AXIOLATERAL OBLIQUE
PROJECTION
• Position: long axis of of
mandibular body parallel to
cassette
• Central ray : 25 degree cephalad-
to pass through the mandible
region of interest

57. • RAMUS: head in true lateral
position
• BODY : rotate head – 30 degree
towards cassette
• SYMPHYSIS : rotate head – 45
degree toward cassette

58. • MANDIBLE SHAPE,WIDTH , ANGLE,
MANDIBULAR CANAL AND
CONDYLES
• MAXILLA, MAXILLARY SINUS
• NASAL CAVITY
• DENTITION
• SOFTTISSUES

59. Temporomandibular joint
• AP axial projection
• Axiolateral oblique projection

60. TEMPOROMANDIBULAR JOINT
AP AXIAL PROJECTION
• Position : flex neck – OML is
perpendicular to cassette
• Central ray : 35 degree caudad ,
midway betweenTMJs, 7.5 cm
above nasion

61. • Condyle
• Ramus of mandible

62. TEMPEROMANDIBULAR JOINT
-AXIOLATERAL OBLIQUE PROJECTION
• Position : mid-sagittal plane
15 degree toward cassette
• Central ray : 15 degree
caudad – 3.8 cm superior to
EAM

63. • Mandibular fossa
• Articular tubercle
• External auditory meatus
• Condyle of the mandible

64. ORTHOPANTOMOGRAPHY
• Panoramic tomography, pan
tomography, and rotational
tomography
• The x-ray tube and the IR rotate in
the same direction around the
seated and immobilized patient

65. • ORBITS AND ZYGOMA
• JAWS- HARMONIOUS CURVE
• NOSE – SEPTUM
• MAXILLARY SINUSES
• TEMPOROMANDIBULAR JOINT AND MANDIBULAR ANGLE
• DENTITION
• SOFTTISSUES

66. PETROMASTOID
• AXIOLATERAL (SCHULLER’S METHOD)
• AP AXIAL (TOWNE METHOD)
• AXIOLATERAL OBLIQUE (LAWS METHOD)
• AXIOLATERAL OBLIQUE- POSTERIOR PROFILE (STENVERS
METHOD)

67. PETROMASTOID PORTION – SCHULLER’S
METHOD
• Axial lateral projection
Position: Prone or supine
IOML parallel to cassette
Central ray : Directed to exit
EAM closest to cassette 25
degree caudad.

68. • MASTOIDANTRUM
• INTERNALAND EXTERNALACOUSTIC
MEATUS
• PETROUS PYRAMID- SUPERIOR RIDGE,
CITELLIANGLE, PNEUMATIZATION,
SIGMOID SINUS
• MASTOID PROCESS
• TEMPOROMANDIBULAR JOINT –
GLENOID FOSSA , ARTICULAR
TUBERCLEAND MANDIBULAR
CONDYLE
• SOFTTISSUES

69. PETROMASTOID PORTION –TOWNE
METHOD
• AP Axial
• Position: Supine/Upright, neck
flexed
• OML perpendicular to cassette
• Central ray 300 caudad to OML

70. • DORSUM SELLA
• ARCUATE EMINENCE
• INTERNAL ACOUSTIC
CANAL
• LABYRINTH
• MASTOID AIR CELLS

71. PETROMASTOID PORTION- LAWSVIEW
• AXIOLATERAL OBLIQUE
• Position- head in a true lateral.
• IOML parallel to cassette.
• Central ray -Directed at an angle of 15
degrees caudad and 15 degrees
anteriorly

72. • MASTOID ANTRUM
• MASTOID AIR CELLS
• SUPERIMPOSED INTERNAL AND
EXTERNAL ACOUSTIC MEATUSES
• MANDIBULAR CONDYLE
• MASTOID PROCESS
• SOFTTISSUES

73. PETROMASTOID PORTION -STENVERS
VIEW
• AXIOLATERAL OBLIQUE-
POSTERIOR PROFILE
• prone position, or seated . Head 45
degrees to the cassette
• Central ray-Directed 12 degrees
cephalad.

74. • CALVARIA
• PETROUS BONE
• EXTERNAL ACOUSTIC MEATUS
• INTERNAL ACOUSTIC CANAL
• ARCUATE EMINENCE
• MASTOID CELL AND MASTOID PROCESS
• MANDIBULAR CONDYLE
• SOFTTISSUES

75. Styloid process –CAHOON METHOD
• PA axial
• Rest forehead on cassette
• OML perpendicular to cassette
• Central ray : nasion – 25 degree
cephalad

76. • STYLOID PROCESS
• RAMUS OFTHE MANDIBLE

77. BIBLIOGRAPHY
• Ballinger Philip, Frank Eugene, Merill’s Atlas of Radiographic positions and
Radiologic Procedures , 9th edition , Missouri , Mosby Publication 1999 , 1-
44, 380-465.
• Whitley Stewart, Sloane Charles, Hoadle Graham, Moore Adrian , Clark’s
Positioning in Radiography 12th edition, London, Arnold publication
2005,20-47
• Adam A, Dixon A K, Grainger and Allison’s Diagnostic radiology, A textbook
of Medical Imaging, 5th edition, China, Elsevier Churchill Livingstone,2008
• Moeller BTorston, Normal findings in Radiology, New york ,Thieme,2000,P
1-34.

78. THANKYOU.