Skull

Radiography
Cranial bones (8)
Skull Cap (calvarium):
1 Frontal
2 Parietal (R,L)
1 Occipital
Skull Base (floor):
2 Temporal (R,L)
1 Sphenoid
1 Ethmoid
Facial bones (14)
2 Maxillary
2 Zygomatic
2 Lacrimal
2 Nasal
2 Palatine
2 Inferior nasal conche
1 Vomer
1 Mandible

Frontal
Parietal
Temporal
Zygoma
Nasal
Vomer
Maxilla
Mandible
Frontal View
Frontal
Nasal
Zygoma
Maxilla
Mandible
Parietal
Sphenoid
Temporal
Occipital
External Auditory Meatus
Mastoid Process
Lateral View
Vomer
Frontal
Parietal
Occipital
Temporal
Foramen
Magnum
Sphenoid
Superior View
Frontal
(Coronal)
Sagittal
Squamous
Lambdoid
Sutures
Sagittal
Lambdoid
Sutures
Frontal
Superior Aspect
9
Skull Landmarks
1. Vertex
2. External Occipital Protuberance (E.O.P.)
3. External Auditory Meatus
4. Outer Canthus Of Eye.
5. Infra-orbital point
6. Nasion
7. Glabella
The Anthropological line
The Isometric Baseline which runs from the inferior orbital margin to the upper border of the external auditory Meatus (EAM)
The Orbital- Meatal Line
The original Baseline which runs from the Nasion through the outer Canthus of the eye to the centre of the external auditory
Meatus.
The Interpupillary line
The line connects the centers of the orbits and is at 90 degree to the median Sagittal plane.
The Auricular Line
This line passes at 90 degrees to the anthropological line through the centre of the external auditory meatus.
( Note: there is a difference of 10 to 15 degrees between the Orbital-Meatal line and the anthropological line.)
1
2 3
4
1
2
3
4
Skull positioning lines
Cranial Topography
Glabella: raised triangular area bet. eyebrows.
Nasion: depression at the bridge of the nose.
Acanthion: nose and upper lip meet
Tragus: cartilage. flap covering ear opening.
Gonion: angle of mandible.
Inion: prominent point of EOP.
Some Indications for skull Imaging

Linear fractures
Depressed fractures
Basal skull fractures
Gunshot wounds
Metastases
osteoplastic lesions
Multiple myeloma
Pituitary adenomas
Acoustic neuroma
Sinusitis
Para nasal sinuses polyps
Otitis media
15
TECHNICAL ASPECTS
Sitting erect positions are preferred to exclude any air-fluid
levels within the cranial cavities or sinuses.
Patient comfort and skull immobilization are necessary.
Exposure factors range between 75 -85 KVp. A small
focus is to be used with short times and high mA.
A grid (40 lines/inch) must be used.
Good collimation (Narrow cone for small parts) and non-repeats
helps in minimizing the radiation exposure to the patient.
A contact shield should be used over the neck and chest to reduce
the exposure to the thyroid .
Common Positioning Errors
Rotation and tilt are two of the most common positioning errors.
A. Rotation occurs when the median Sagittal plane is not parallel to the film.
B. Tilt occurs when the Interpupillary line is not at 90 to the film.
17
PA Skull (0 Occipital-frontal) projection B
For frontal bone, #s and neoplastic processes of the
cranium, Pagets disease, orbits (obscured by
petrous temporal), I.A.M, frontal and ethmoidal
sinuses, dorsum sellae.
Patient nose and forehead against the couch center,
neck flexed so that OML is 90 to the couch, MSP
90 to couch center, head not rotated, EAMS
equidistant from the couch top.
Film: HD 24x30 cm
CR: 0 (that is 90) to film center ( for frontal bone)
CP: Exits at the glabella
NB/ AP is not recommended as it exposed eyes to
more dose



18
PA Skull (15

Caldwell) projection B

For #s, neoplastic processes of frontal, parietal and
facial bones, and for cranium and an unobstructed
view of the orbits, I.A.M, frontal and ethmoidal
sinuses, clinoids, dorsum sellae, zygomatic bones.
Same position as for PA
Film: HD 24x30 cm
CR: 15 caudal (for showing the petrous ridges).
CP: Exits at the naison.

25 - 30 gives better view of orbital rim and floors
and superior orbital fissure.



19
PA Axial Skull (Haas projection ) B

An alternate projection for the Townes view if the
patient cannot flex his neck sufficiently
It results in reduced doses to facial structures and to
the thyroid.
It is not recommended, however, for the occipital
bone because of the magnification it produces.
Same position as for PA
Film: HD 24x30 cm
CR: 25 cephalic to OML
CP: Through level of EAMs


20
PA (or PA Axial) Skull (for mandible ) B

Best for the body of mandible for #s,
inflammatory and neoplastic processes.
PA axial well shows rami and elongated
view of condyloid process.
Patient positioned as for PA (0),
chin tucked so that OML is 90 to film, MSP
90 to the couch top, head not rotated.
Film: HD 24x30 cm
CR and CP :
PA: 90 to film center (CP to junction of the
lips).
PA axial: 20- 25 cephalic (CP to the
acanthion)
21
AP Axial (Townes projection) B
For occipital bone, cranial #s, neoplasm's, and
Pagets disease. Also for AP dorsum sellae, and
advanced pathology of the temporal bone ,anterior
clinoids, foramen magnum, mastoids,
Patient supine, or in erect AP sitting, chin is
depressed (OML 90 to film), no rotation of the head
Film: HD 24x30 cm
CR: 30 caudal to orbitomeatal line
37 to infraoribtomeatal line
CP: (2 cm superior to level of EAMs).

22
Submentovertex (SMV) B

For base of the skull (Basilar view), occipital
bone, mandible, foramen ovale and foramen
magnum, TMJs, orbits, zygomatic arches,
sphenoid, maxillary sinuses and mastoid
processes.
Patient supine or erect sitting, chin raised,
neck hyper extended till IOML is parallel to
film, MSP 90 to couch top. A pillow under
patients back allows for sufficient extension.
Film: HD 24x30 cm.

CR: 90 to IOML.
CP: (2cm anterior to level of EAMs)
Midway between angles of mandible
23
Submentovertex (SMV) (for mandible) S
Entire mandible.( head .neck ,coronoid and
condyloid processes)

Patient supine or erect sitting, chin raised,
neck hyper extended till IOML is parallel to
film, MSP 90 to couch top. A pillow under
patients back allows for sufficient extension.

Film: HD 18x24 cm
CR: 90 to IOML.
CP: Midway between angles of mandible
(4 cm inferior to mandibular symphysis).
24
Submentovertex (SMV) (for zygomatic arches) B

For zygomatic arches
(usually taken as a soft-tissue technique).

Patient supine or erect sitting, chin raised, neck
hyper extended till IOML is parallel to film, MSP
90 to couch top. A pillow under patients back
allows for sufficient extension.
Film: HD 18x24 cm
CR: 90 to film.
CP: Midway between zygomatic arches
(4cm inferior to mandibular symphysis).

25
Oblique Inferosuperior Tangential (for zygomatic arches) S

For zygomatic arch. Specially useful in case of
depressed zygomatic arches (skull trauma).
Patient positioned as for the SMV, head rotated 15
toward side of interest, then chin tilted 15 toward
side of interest.

Film: HD 18x24 cm
CR: 90 to IOML.
CP: Zygomatic arch of interest.
26
Lateral Skull (general) B

Same indication as for PA (0). A horizontal
beam is used for trauma cases to show air-fluid
levels in the sphenoid sinus

Patient in a semi prone (Sims position),
recumbent or erect sitting, head in a true lateral
(required side close to the film), MSP parallel
and IPL 90 to couch top.

Film: HD 18x24 cm
CR: 90 to film center .
CP: 5 cm ( 2 inch )superior to EAM .
27
Lateral Skull (for lateral Sella Turcica) B

To show evidence of pituitary adenomas.
Same position as for the lateral skull (as in
Sims position), chin adjusted so that both IPL is
90 and MSP parallel to couch top.
Film: HD 18x24 cm
CR: 90 to film center
CP: 2 cm anterior and 2 cm superior to EAM.
NB/
(1) Both laterals may be done with stress on
macro radiography.
(2) A long narrow (slender) cone should be
used.
28
Lateral Skull (for lateral facial bones) B
For fractures, neoplastic or inflammatory processes
of facial bones, orbits, and the mandible.

Head in true lateral (same position as for lateral
skull as in Sims position), chin adjusted so that
both IPL is 90 and MSP parallel to couch top.

Film: HD 18x24 cm
CR: 90 to film center
CP: Zygoma (midway between the outer canthus
and EAM)
29
Lateral Skull (for sinuses) B

For inflammatory conditions: e.g. :sinusitis, and
sinus polyps
For sphenoid, frontal, ethmoidal, and maxillary
sinuses.

Patient erect sitting, head in true lateral (IPL 90
and MSP parallel to IR)

Film: HD 18x24 cm
CR: 90 horizontal to film center
CP: Midway between outer canthus and EAM
30
Lateral Skull (for nasal bones) B
For nasal bone fractures.
Head in true lateral (same position as for lateral skull as in Sims position)

Film: HD 18x24 cm
CR: 90 to film center
CP: 1.25 cm(.5 inch) inferior to naison
NB/ A long narrow cone should be used.
31
Tangential Superoinferior (Axial) (nasal bones) S

For fractures of the nasal bones.

Patient prone or in the erect sitting, chin
extended and rested on cassette, angle
support under film, glabelloalvolar line (GAL)
90 to cassette, long narrow cone used
Film: HD 18x24 cm (or occlusal film).
CR: Angle as needed to ensure CR is
parallel to GAL.
CP: Naison (parallel to GAL).
32
Axiolateral (Schller for mastoids) S

For pathology of the mastoid air cells.
Patient prone or erect, head in the true lateral,
IPL 90 to film, MSP parallel to the film.

Film: HD 18x24 cm
CR: 25 - 30 caudal.
CP: downside mastoid tip
(4 cm superior, 4 cm posterior to upside EAM).

33
Lateral 15 (Modified Law for TMJs) S

For pathology of the mastoid process.
Patient prone or erect, head in lateral,
IPL 90 to film.
Face( and MSP) parallel , then rotated
15 toward the film.

Film: HD 18x24 cm
CR: 15 caudal to pass through the
downside TMJ.
CP: 4 cm superior to upside EAM
34
Axiolateral Oblique (Modified Law for mastoids) B
For advanced pathology of mastoids.
Patient prone or erect, each auricle taped
forward, head in lateral, then rotated 15
oblique toward the film, IPL 90 to couch, side
of interest down.
Film: HD 18x24 cm
CR: 15 caudal
CP: Exit downside mastoid tip
(1 inch posterior, 1 inch superior to
upside EAM).

35
PA Axial Skull (Caldwell projection for sinuses ) B

Good for sinuses (frontal and anterior ethmoidal
sinuses). Also shows other inflammatory
conditions such as sinus polyps).

Patients nose and forehead against film, neck
extended so that OML is 15 from the horizontal
Film: HD 18x24 cm
CR: 90 horizontal to film center (or 15 caudal
with OML 90 to the film).
CP: exit at Naison


36
Parietoacanthial (OM) (Waters Method for sinuses ) B
Best for maxillary and frontal sinuses and nasal
Fossa.
Patient erect, neck extended, chin and nose against
couch, head adjusted till MML is 90 to the film, OML
makes 37 with film.
A long narrow cone should be used.
Film: HD 18x24 cm
CR: 90 horizontal to film center
CP: Exit at the acanthion.
37
Parietoacanthial (OM) (Open-Mouth Waters for sinuses ) B

Same as for Waters..

Same position as for Waters view, but with
open mouth (patient drops his jaw without
moving the head).

Film: HD 18x24 cm.

CR: 90 horizontal to film center

CP: Exit at the acanthion.
38
AP Axial (Townes projection for AP Sella Turcica) B

Detects pituitary adenomas in the sella turcica. Also
shows dorsum sellae, posterior clinoids, occipital
bone, petrous pyramids, the foramen magnum,
mastoids air cells, and zygomatic arches
Same position as for Towne (AP)
Film: HD 18x24 cm
CR: 37 caudal (for the dorsum sellae and the
posterior clinoids
30 caudal (for anterior clinoids)
CP: 4 cm above superciliary arch

39
AP Axial (Townes projection for mandible) B

For #s, neoplastic or inflammatory processes of the
condyloid processes of the mandible.

Same position as for Towne AP (OML 90 to couch
top.
Film: HD 18x24 cm
CR: 35- 40 caudal
CP: Glabella (To pass through midway between
EAMs and angles of the mandible

40
Lateral 25 - 30 (Axiolateral) (for mandible) B

For #s, neoplastic, or for inflammatory
processes of the mandible (both sides are
done for comparison) .

Head in true lateral with MSP parallel to the
film, side of interest placed against the film,
mouth closed, head then rotated in oblique
30 (for the body),
45 (for mentum),
10 - 15 for a (general survey).
Film: HD 18x24 cm
CR: 25 cephalic.
CP: Mandibular region of interest (body,
ramus, .).
41
Axioanterior Oblique (Stenvers for mastoids) B

For advanced pathology of temporal bone,
e.g., acoustic neuroma. Both sides are to be
examined.

Patient prone or erect, IOML 90 to film, chin
adjusted so that head is rotated 45 oblique
with the couch, side of interest down,
downside mastoid region centered to film.

Film: HD 18x24 cm
CR: 12 cephalic.
CP: 3-4 inch posterior, and .5 inch inferior
to upside EAM to exit through downside
mastoid process.
42
Parieto-orbital (Rhese View) for optic foramina S

For bony abnormalities of the optic foramen.
Both sides must be done for comparison.
Patient prone or erect, chin, cheek, and nose
against couch, head adjusted so that the
MSP makes 53 with the couch top, the
acanthiomeatal line AML makes 90 to the
film, a long narrow cone should be used.
Film: HD 18x24 cm
CR: 90 to IOML
CP: Downside orbit (7 cm above and 7 cm
behind the up EAM).

Note
Correct position project the optic foramen
into the lower outer quadrant of orbit

43
ORTHOPANTOMOGRAPHY (tomography of the mandible) S

For #s of the mandible and TM joint.

Tube and film attached at starting position, chin rest
raised to same level as patients chin, chin rested on
a sterile bite block, patient as close as possible to
the tube stand, chin adjusted until IOML is parallel
with the floor, occlusal plane declines 10 from
posterior to anterior, patients lips placed together,
tongue on roof of the mouth.

Film: HD 23x30 cm, or curved non-grid cassette
CP: Fixed CR and FFD. For TMJ, another film
must be done with open mouth.