PARANASAL SINUSES

The paranasal sinuses (called the paranasal sinuses because of their

formation from the nasal mucosa and their continued communication
with the nasal fossae) usually consist of four paired air-filled spaces that
circumscribe the nasal structures. They have several functions of which
reducing the weight of the head is the most important. Other functions are air
humidification and aiding in voice resonance. They are named for the facial
bones in which they are located:

 Frontal sinuses: The right and left frontal sinuses are located over and
around your eyes. Specifically, they’re situated near the center of your
forehead just above each eye. They are paired structures located within
the frontal bone adjacent to the fronto-nasal articulation. They are very
variable in size, and in some individuals they may be absent.
 Maxillary sinuses: They are paired, pyramidal-shaped structures
located within the maxillary bone either side of the nasal cavity. They
are the largest of the sinuses. They’re positioned behind your
cheekbones near your maxillae, or upper jaws.
 Sphenoid sinuses: The sphenoid sinuses are located behind your
skull, near your optic nerve and pituitary gland. These structures lie
immediately beneath the sella turcica and are posterior to the ethmoid
sinuses.
 Ethmoid sinuses: These are labyrinth of small air spaces that
collectively form part of the medial wall of the orbit and the upper lateral
walls of the nasal cavity These sinuses are situated between your eyes
and the bridge of your nose. Ethmoid sinuses consist of a collection of 6
to 12 small air cells that open independently into your nasal passage.
They’re divided into front, middle, and rear groups.

The paranasal sinuses are subject to marked variation between individuals

and between sides in the same individual, regarding size (aeration) and bony
septations. Total paranasal sinus agenesis (failure of the sinus to develop
during embryonic growth and development) is very rare. Isolated frontal
sinus agenesis, on the other hand, is common.

Functions of the paranasal sinuses

1. Serve as a resonating chamber for the voice

2. Decrease the weight of the skull by containing air
3. Help warm and moisten inhaled air 
4. Act as shock absorbers in trauma (as airbags do in automobiles)
5. Possibly control the immune system

A sinus X-ray (or sinus series) is an imaging test that uses a small amount of
radiation to visualize details of your sinuses.
FIG. 22-1 A, Anterior aspect of paranasal sinuses, showing lateral relationship to each other and to
surrounding parts. B, Schematic drawing of paranasal sinuses, showing AP relationship to each other
and surrounding parts.

Occipito-mental/water’s view-Best for maxillary sinus and sphenoidal

(if done with open mouth)
This projection is designed to project the petrous part of the temporal bone below the floor of the
maxillary sinuses so that fluid levels or pathological changes in the lower part of the sinuses can be
visualized clearly.

Position of patient and cassette

• The projection is best performed with the patient seated facing the skull unit cassette holder or
vertical Bucky.

• The patient’s nose and chin are placed in contact with the midline of the cassette holder. The head is
then adjusted to bring the orbito-meatal baseline to a 45-degree angle to the cassette holder.

• The horizontal central line of the Bucky or cassette holder should be at the level of the lower orbital
margins.

• Ensure that the median sagittal plane is at right-angles to the Bucky or cassette holder by checking that
the outer canthi of the eyes and the external auditory meatuses are equidistant.

• The patient should open the mouth as wide as possible before exposure. This will allow the posterior
part of the sphenoid sinuses to be projected through the mouth.

Direction and centring of the X-ray beam

• The central ray of the skull unit should be perpendicular to the cassette holder and by design will be
centred to the middle of the image receptor. If this is the case and the above positioning is performed
accurately, then the beam will already be centred.

• If using a Bucky, the tube should be centred to the Bucky using a horizontal beam before positioning is
undertaken. If the above positioning is performed accurately and the Bucky height is not altered, then
the beam will already be centred.

• To check the beam is centred properly, the cross-lines on the Bucky or cassette holder should coincide
with the patient’s anterior nasal spine.

• Collimate to include all of the sinuses.

Essential image characteristics

• The petrous ridges must appear below the floors of the maxillary sinuses.

• There should be no rotation. This can be checked by ensuring

that the distance from the lateral orbital wall to the outer skull margins is equidistant on both sides.

Occipito-frontal 15 degrees caudad (Caldwell view)

This projection is used to demonstrate the frontal and ethmoid

sinuses.
Position of patient and cassette
• The patient is seated facing the vertical Bucky or skull unit cassette holder so the median sagittal plane
is coincident with the midline of the Bucky and is also perpendicular to it.

• The head is positioned so that the orbito-meatal baseline is raised 15 degrees to the horizontal.

• Ensure that the nasion is positioned in the centre of the Bucky.

• The patient may place the palms of each hand either side of the head (out of the primary beam) for
stability.

• An 18 24-cm cassette is placed longitudinally in the Bucky tray. The lead name blocker must not
interfere with the final image.

Direction and centering of the X-ray beam

• The central ray is directed perpendicular to the vertical Bucky along the median sagittal plane so the
beam exits at the nasion.

• A collimation field or extension cone should be set to include the ethmoidal and frontal sinuses. The
size of the frontal sinuses can vary drastically from one individual to another.

Essential image characteristics

• All the relevant sinuses should be included within the image.

• The petrous ridges should be projected just above the lower orbital margin.

• It is important to ensure that the skull is not rotated. This can be assessed by measuring the distance
from a point in the midline of the skull to the lateral orbital margins. If this is the same on both sides of
the skull, then it is not rotated.
Lateral- for all sinuses
Position of patient and cassette
• The patient sits facing the vertical Bucky or skull unit cassette holder. The head is then rotated, such
that the median sagittal plane is parallel to the Bucky and the inter-orbital line is perpendicular to the
Bucky.

• The shoulders may be rotated slightly to allow the correct position to be attained. The patient may grip
the Bucky for stability.

• The head and Bucky heights are adjusted so that the centre of the Bucky is 2.5 cm along the orbito-
meatal line from the outer canthus of the eye.

• Position an 18 24-cm cassette longitudinally in the erect Bucky, such that its lower border is 2.5 cm
below the level of the upper teeth.

• A radiolucent pad may be placed under the chin for support.

Direction and centring of the X-ray beam

• A horizontal central ray should be employed to demonstrate fluid levels.

• The tube should have been centred previously to the Bucky, such that the central ray will now be
centred to a point 2.5cm posterior to the outer canthus of the eye.

Common faults and remedies

This is not an easy position for the patient to maintain. Check the position of all planes immediately
before exposure, as the patient probably will have moved.

Essential image characteristics

• A true lateral will have been achieved if the lateral portions of the floors of the anterior cranial fossa
are superimposed.

Technical Considerations

Radiographic density is probably more critical and more misleading in the sinuses than in any other
region of the body. Overpenetration of the sinuses diminishes or completely obliterates existing
pathologic conditions, and underpenetration can simulate pathologic conditions that do not exist.