Radiology in ENT-1

Radiology
In
Otorhinolaryngology
Dr.Digvijay Singh Nargave
ENT Senior Resident
Positioning of the Skull
The key to a good exam is to take the

images correctly and produce the expected view
of the anatomy.
PLAIN X-RAYS OF THE
PARANASAL SINUSES
Occipitomental Occipitofrontal
Water’s View
• Waters' view (also known as the occipitomental view) is a radiographic view of
the skull.
• It is commonly used to get a better view of the maxillary sinuses.
• An x-ray beam is angled at 45° to the orbitomeatal line.
• The rays pass from behind the head and are perpendicular to the radiographic
plate.
• Another variation of the waters places the orbitomeatal line at a 37° angle to the
image receptor.
• It is named after the American radiologist Charles Alexander Waters.
Waters' view can be used to best visualise a number of structures in the skull.
•Maxillary sinuses.
•Frontal sinuses, seen with an oblique view.
•Ethmoidal cells.
•Sphenoid sinus, seen through the open mouth.
•Odontoid process, where if it is just below the mentum, it confirms adequate
extension of the head.
Pathology Observation
• Odontoid process lies exactly below mentum.
None (Normal)
• Maxillary sinuses are more radiolucent than orbits.
• Maxillary sinus shows radiopacity.[2]

• Mucous membrane shows thickening. [2]
• Air-fluid level may be observed if the radiograph is taken in
Maxillary sinusitis [2]
"head-up" position.[2] It is not seen in radiograph taken in
lying down position. The concavity of fluid opacity points
upwards.
Differentiating pathology in maxillary sinus • Maxillary sinus shows radiopacity; which is present despite
Polyp of the position in which the radiograph is taken.
• Usually, the radiopacity has convexity pointing upward.
• Sinus is radioopaque.
• Sometimes, destruction of walls of sinus is seen and is
diagnostic of malignancy
• Distance between antero-lateral wall of maxilla
Malignancy and coronoid process of the mandible is measured. If it is
increased on one side, it indicates involvement
of infratemporal fossa by the malignancy. This is
called Handousa's sign. Prognosis of malignancy is
determined by position of tumour on basis Onhgren's line.
OCCIPITOMENTAL VIEW
(WATER’S VIEW)
Modified Parietoacanthial
(Modified Waters)
• OML 55 degrees to the IR

• Chin and nose on table
• Petrous pyramids are seen mid-maxillary sinus
• CR exits acanthion
• Blowout Fractures
Modified Waters Radiograph
• Petrous ridges projected
immediately below the inferior
border of the orbits
• Equal distance from lateral

orbit to lateral skull on both
sides
Reverse Waters
• Supine
• Extend neck so OML is 37 degree

with plane of IR
• MML perp
• Suspend respiration
• CR perpendicular and enters

acanthion
Caldwell View
• Caldwell's view (or Occipitofrontal
view) is a radiographic view of skull,
where X-ray plate is perpendicular to
the orbitomeatal line.
• The rays pass from behind the head and
are angled at 15-20° to the radiographic
plate.
• It is commonly used to get better view of
the ethmoid and frontal sinuses.
• It is named after the noted American
radiologist Eugene W. Caldwell, who
described it in 1907.
Structures seen
•Frontal sinus
•Ethmoidal sinus
•Orbit
•Orbital rim
•Medial orbital wall
•Zygomatic bone
•Nasal bone
•Nasal septum
•Mandible
Pathology Observation
• Different pneumatisation patterns of frontal sinus are observed in
population.
Normal • The frontal sinuses can be asymmetric in normal individual.
• Usually, frontal sinus shows radiolucent shadow and individual
cells are made out, giving it a scalloping or clove-like appearance.
• Increased frontal sinus opacity.

Chronic frontal sinusitis
• Normal scalloping absent.
Osteoma • Marked radiopacity is seen. (Denser than bone)
• Hypopneumatisation (decreased pneumatisation) is common

finding in Sickle cell anemia and Beta thalassemia.
Erythroblasticanemia
• Hyperpneumatisation (increased pneumatisation ) is common
finding in Acromegaly and Sturge-Weber syndrome.
OCCIPITO-FRONTAL VIEW
(CALDWELL VIEW)
LATERAL VIEW
Occipito mental Occipito frontal
Lateral
Acute and Chronic Sinusitis
Mucosal thickening
Fluid Level
Complete opacity
Schuller’s View
• Schuller's view is a lateral radiographic view of skull principally used for
viewing mastoid cells.
• The central beam of X-rays passes from one side of the head and is at angle of
25° caudad to radiographic plate.
• This angulation prevents overlap of images of two mastoid bones.
• Radiograph for each mastoid is taken separately.
Structures seen
•Mastoid air cells
•External auditory canal
•Tympanic cavity
•Temporomandibular joint
•Dural plate
•Sinus plate
•Dense bone of labyrinth
Observation Description
• Air cells cover mastoid
Pneumatic
• Air cells seen beyond dural and sinus plates
• Air cells cover mastoid
Moderate
• Air cells not seen beyond dural and sinus plates
• Absence of air cells
• Whole antrum appears small in size
Sclerotic • Marked radiopacity
• Can be seen in individuals suffering from chronic otitis media as well as in
normal individuals
• Single radiolucent shadow is seen. It can be present in sclerotic as well
as normal mastoid
• Differential diagnosis:
• Cholesteatoma
• Operated mastoidectomy
• Large antral cell
Radiolucent mastoid • Large peri-antral cell
• Malignancy
• Chronic mastoiditis with granulations
• Eosinophilic granuloma
• Tuberculosis
• Multiple myeloma
• Skull metastases from kidney, bronchus, breast etc.
TYPES OF MASTOID AEREATIONS
Cellular Diploic Acellular (Sclerotic)

Neck Lateral View
Normal Lateral Plain X-rays Neck
PLAIN X-RAYS NECK & PHARYNX
Pharyngeal or retropharyngeal
Normal swelling
Lateral View nasopharynx
Normal Nasopharynx Soft tissue swelling

Nasopharynx
Forgein Body
Normal View
• GOOD POSITIONING
• MAKES EVERYONE HAPPY!

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Radiology

The key to a good exam is to take the

• Maxillary sinus shows radiopacity.[2]

• OML 55 degrees to the IR

• Equal distance from lateral

• Extend neck so OML is 37 degree

• CR perpendicular and enters

• Increased frontal sinus opacity.

• Hypopneumatisation (decreased pneumatisation) is common

Cellular Diploic Acellular (Sclerotic)

Normal Nasopharynx Soft tissue swelling

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