Radiographic

technique of
orbit/temporal
bone
Puja Adhikari
Bsc.MIT 1st year
Nams, Bir Hospital
Contents
1. Introduction
2. Anatomy
3. Indication
4. Patient preparation
5. Equipment
6. References
7. Questions
Introduction

• The importance of plain radiography of skull has diminished in recent years due
to the widespread availability of other imaging modalities, i.e. computed
tomography (CT) and magnetic resonance imaging (MRI).
• The specificity of both modalities does allow for a faster and more definite
diagnosis than plain radiography.
• Consequently, a significant number of referrals are still received from the
accident and emergency.
• In order to produce high quality diagnostic images of the skull and minimum
risk, i.e. radiation dose for the patient, the radiographer must have good
understanding of relevant anatomy, position landmarks and equipment used for
image
Anatomy

• The anatomy of the skull is very complex, and specific attention to detail is
required of the technologist.
• The skull, or bony skeleton of the head, rests on the superior end of the vertebral
column and is divided into two main sets of bones
i.e 8 cranial bones and 14 facial bones.
Contd….
• Cranial bones
1. Calvarium (Skullcap)
• Frontal
• Right parietal
• Left parietal
• Occipital
2. Floor
• Right temporal
• Left temporal
• Sphenoid
• Ethmoid
Temporal bone
• The temporal bones are irregular in shape and are situated on each side of the
base of the cranium between the greater wings of the sphenoid bone and the
occipital bone.
• The temporal bones form a large part of the middle fossa of the cranium and a
small part of the posterior fossa.
• Each temporal bone consists of a squamous portion, a tympanic portion, a
styloid process, a zygomatic process, and a petromastoid portion (the mastoid
and petrous portions) that contains the organs of hearing and balance
• The squamous portion is the thin upper portion of the temporal bone. It forms a
part of the side wall of the cranium and has a prominent arched process, the
zygomatic process, which projects anteriorly to articulate with the zygomatic
bone of the face and complete the zygomatic arch.
• The tympanic portion is situated below the squama and in front of the mastoid
and petrous portions of the temporal bone. This portion forms the anterior wall,
the inferior wall, and part of the posterior walls of the EAM. The EAM is
approximately 1 2 inch (1.3 cm) in length and projects medially, anteriorly, and
slightly superiorly
• The styloid process, a slender, pointed bone of variable length, projects
inferiorly, anteriorly, and slightly medially from the inferior portion of the
tympanic part of the temporal bone.
Petromastoid portion

• The petrous and mastoid portions together are called the petromastoid portion.
The mastoid portion, which forms the inferior, posterior part of the temporal
bone, is prolonged into the conical mastoid process.
• The petrous portion, often called the petrous pyramid, is conical or pyramidal
and is the thickest, densest bone in the cranium. This part of the temporal bone
contains the organs of hearing and balance.
Contd..
• The first of the mastoid air cells to develop is situated at the upper anterior part of
the process and is termed the mastoid antrum. This air cell is quite large and
communicates with the tympanic cavity.
• The internal carotid artery in the carotid canal enters the inferior aspect of the
petrous portion, passes superior to the cochlea, then passes medially to exit the
petrous apex.
• Near the petrous apex is a ragged foramen called the foramen lacerum. The
carotid canal opens into this foramen, which contains the internal carotid artery.
• At the center of the posterior aspect of the petrous portion is the internal acoustic
meatus (IAM), which transmits the vestibulocochlear and facial nerves. The upper
border of the petrous portion is commonly referred to as the petrous ridge
Ear
• The ear is the organ of hearing and balance
• EXTERNAL EAR:
1. the auricle
2. the external acoustic meatus (EAM), a sound conducting canal
• The TEA is a reference point for positioning the lateral cervical spine.
MIDDLE EAR
1. Tympanic membrane
2. Tympanic cavity
3. Auditory ossicles i.e malleus, incus and stapes
• They bridge the middle ear cavity for the transmission of sound vibrations from
the tympanic membrane to the internal ear
INTERNAL EAR
• The internal ear contains the essential sensory apparatus of hearing and
equilibrium and lies on the densest portion of the petrous portion immediately
below the arcuate eminence.
• Consists bony labyrinth and membranous labyrinth
• Bony labyrinth consists of cochlea(used for hearing), vestibule and three semi
circular canals (involved in equilibrium)
ORBITS
• Each orbit is composed of seven different bones (Fig. 20-34). Three of
these are cranial bones: frontal, sphenoid, and ethmoid.
• The other four bones are the facial bones: maxilla, zygoma, lacrimal,
and palatine.
• The circumference of the orbit, or outer rim area, is composed of
three of the seven bones
—frontal, zygoma, and maxilla.
• The remaining four bones compose most of the posterior aspect of
the orbit.
November 19, 2024 Skull Radiography 16
Orbit
 General image quality and radiation
protection
• Should have visually sharp reproduction of all relevant structures of the skull
• Appropriate marker like open & closed mouth, lt. rt. etc. should be provided, but out
of the diagnostic image
• no rotation, tilting and extention of the skull.
• A 400 (regular) speed imaging system is recommended (regular conventional
film/screen combination).
• Use 70–85 kV with 10 x 12 sq.inch IR Plate
• Whenever possible, use an PA rather than an AP technique with tight collimation,
since this vastly reduces the radiation dose to the eyes ( sometimes thyroid), and
avoid repeat radiographs

November 19, 2024 Skull Radiography 17

Patient preparation
• Remove all metal/radio-opaque objects from the patient e.g. hair pins or clips,
goggles ,and other object that interfere the diagnostic image.
• Bunches of hair often produce artefacts and thus should be loosened.
• Technique must be explained to the patient with demonstration which help in
better patient positioning to avoid repetition of the examination
 For orbits
• Trauma
o Lateral Orbit (Lateral View)
o Waters' View (Occipitomental View)
o Caldwell's View (Posteroanterior View)
o Submentovertex View
• Foreign body
• Orbital pathology(Orbital Masses or Tumors, Orbital Infections such as sinusitis)
• Water’s view
• Caldwell’s view
For temporo-mandibular joint
Projections
1. AP axial (modified Towne method)
2. Axiolateral oblique (modified Law method)
3. Axiolateral (Schuller method)
Indications
• TMJ pain
• erodic degenerative changes ( erosion, flattening, sclerosis,
subchondral cysts, and osteophytes)
Posterior profile projection for mastoids.
 AP axial projection: TMJs
Modified Towne’s Method

• Clinical Indications
• Fractures and abnormal relationship
or range of motion between condyle
and TM fossa
Contd…
• Patient Position:
Remove all metallic or plastic objects from head and neck. Position patient erect or
supine.
Part Position
Rest patient’s posterior skull against table/upright imaging device surface.
Tuck chin, bringing OML perpendicular to table/imaging device surface or bringing
IOML perpendicular and increasing CR angle by 7°.
Align MSP perpendicular to midline of the grid or the table/ upright imaging device
surface to prevent head rotation or tilt
CR

Angle CR 35° caudad from OML or 42° from IOML.

Direct CR 3 inches superior to the nasion.
Center IR to projected CR.
 Contd..
1. Evaluation Criteria:
Anatomy Demonstrated:
Condyloid processes of mandible and TM fossae are demonstrated.
2. Position:
Correctly positioned patient, with no rotation, is indicated by the following: condyloid
processes visualized symmetrically, lateral to the cervical spine; clear visualization of
condyle and TM fossae relationship.
Collimation to area of interest.
3. Exposure:
Contrast and density (brightness) are sufficient to visualize condyloid process and TM
fossa.
Sharp bony margins indicate no motion.
AXIOLATERAL OBLIQUE PROJECTION: TMJS
MODIFIED LAW METHOD
Clinical Indications
Abnormal relationship or range of motion between condyle and TM fossa
Generally, images are obtained in the open mouth and closed mouth positions.
• Patient Position: erect or semiprone (erect is
preferred if patient’s condition allows). Rest lateral
aspect of head against table/upright imaging device
surface, with side of interest closest to IR
• Part Position: Prevent tilt by maintaining IPL
perpendicular to IR. MSP is parallel to IR to start.
Align IOML perpendicular to front edge of IR. From
lateral position, rotate face toward IR 15° (with MSP
of head rotated 15° from plane of IR)
CR
Angle CR 15° caudad, centered to 11 2 inches (4 cm) superior to upside EAM (to
pass through downside TMJ).
Center IR to projected CR.
Minimum SID is 40 inches (102 cm).
Recommended Collimation: Collimate on four sides to anatomy of interest.
 Evaluation Criteria
• Anatomy Demonstrated:
TMJ nearest IR is visible. Closed mouth image demonstrates condyle within
mandibular fossa; the condyle moves to the anterior margin (articular tubercle) of
the mandibular fossa in the open mouth position.
Position:
Correctly positioned images demonstrate TMJ closest to IR clearly, without
superimposition of opposite TMJ (15° rotation prevents superimposition). TMJ of
interest is not superimposed by cervical spine.
Collimation to area of interest.
Exposure: Contrast and density (brightness) are sufficient to visualize TMJ. Sharp
bony margins indicate no motion
AXIOLATERAL PROJECTION:
TMJ SCHULLER METHOD
Patient Position:
erect or semiprone. Place the head in a true lateral position, with side of interest
nearest IR.
Part Position
Adjust head into true lateral position and move patient’s body in an oblique
direction, as needed for patient’s comfort.
Align IPL perpendicular to IR.
Align MSP parallel with table/imaging device surface.
Position IOML perpendicular to front edge of IR.
CR
Angle CR 25° to 30° caudad, centered to 1 2 inch (1.3 cm) anterior and 2 inches (5
cm) superior to upside EAM.
Center IR to projected TMJ.
 Evaluation Criteria
Anatomy Demonstrated:
TMJ nearest IR is visible. Closed mouth image demonstrates the condyle within the
mandibular fossa; the condyle moves to the anterior margin (articular tubercle) of
fossa in the open mouth position.
Position: TMJs are demonstrated without rotation, as evidenced by superimposed
lateral margins.
Collimation to area of interest.
Exposure:
Contrast and density (brightness) are sufficient to visualize TMJ. • Sharp bony
margins indicate no motion
• This projection results in greater elongation of the condyle compared with the
modified Law method
PARIETO-ORBITAL OBLIQUE PROJECTION:
OPTIC FORAMINA (RHESE METHOD )
Clinical Indications
Bony abnormalities of the optic foramen.
Demonstrate lateral margins of orbits and foreign bodies within eye.
 Cont…
• Patient Position:
Remove all metallic or plastic objects from head and neck. Position patient erect or supine.
Part Position:
As a starting reference, position patient’s head in a prone position with MSP
perpendicular to IR.
Adjust flexion and extension so that AML(acanthomeatal line) is perpendicular to IR.
Adjust the patient’s head so that the chin, cheek, and nose touch the table/upright
imaging device surface.
Rotate the head 37° toward the affected side. The angle formed between MSP and plane of
IR measures 53°. (An angle indicator should be used to obtain an accurate angle of 37°
from CR to MSP.)
• CR
Align CR perpendicular to IR at the midportion of the downside orbit.

• Recommended Collimation
Collimate on all sides to yield a field size of approximately 4 inches (10 cm)
square.
 Evaluation Criteria
• Anatomy Demonstrated:
Bilateral, non-distorted view of the optic foramen. Lateral orbital margins are
demonstrated.
Position:
Accurate positioning projects the optic foramen into the lower outer quadrant of
the orbit.
Proper positioning results when AML is correctly placed perpendicular to IR and
correct rotation of skull. Collimation to area of interest.
Exposure:
Contrast and density (brightness) are sufficient to visualize the optic foramen.
Sharp bony margins indicate no motion.
MODIFIED PARIETOACANTHIAL
PROJECTION MODIFIED WATERS METHOD
• Clinical Indications
Orbital fractures (e.g., blowout) and neoplastic or inflammatory processes
Foreign bodies in the eye
• Patient Position
Remove all metallic or plastic objects from the head and neck. Patient position is
erect or prone (erect is preferred if patient’s condition allows).
Part Position
Extend neck, resting chin and nose against table/upright imaging device surface.
Adjust head until LML is perpendicular; OML forms a 55° angle with IR.
Position MSP perpendicular to midline of grid or table/upright imaging device
surface. Ensure no rotation or tilt of head.
Contd..

• CR
Align CR perpendicular, centered to exit at acanthion.
• Evaluation Criteria
Anatomy Demonstrated:
Orbital floors (plates) are perpendicular to IR, which also provides a less distorted view
of the orbital rims than a parietoacanthial (Waters) projection.
Position:
Correct position/CR angulation is indicated by petrous ridges projected into the lower
half of the maxillary sinuses, below the IOMs.
No rotation of the cranium is indicated by equal distance from the midlateral orbital
margin to the lateral cortex of the cranium. Collimation to area of interest.
Exposure: Contrast and density (brightness) are sufficient to visualize the orbital floors.
Sharp bony margins indicate no motion
PA AXIAL PROJECTION;
CALDWELL METHOD
• Patient Position
Remove all metallic or plastic objects from head and neck. Patient position is erect
or prone (erect is preferred if patient’s condition allows).
• Part Position
Rest patient’s nose and forehead against tabletop. • Tuck chin, bringing OML
perpendicular to IR.
Align MSP perpendicular to midline of grid or table/imaging device surface.
Ensure no rotation or tilt of head.
• CR
Angle CR 30° caudad, to project the petrous ridges below the IOM.
Evaluation criteria
• Anatomy Demonstrated:
Orbital rim, maxillae, nasal septum, zygomatic bones, and anterior nasal spine.
Position:
No rotation of cranium is indicated by equal distance from midlateral orbital
margin to the lateral cortex of the cranium; superior orbital fissures are
symmetric.
Exposure:
Contrast and density (brightness) are sufficient to visualize maxillary region and
orbital floor.
Sharp bony margins indicate no motion
Petrous rigdes projected
below inferior orbital
margin
 LATERAL POSITION—RIGHT OR LEFT
LATERAL
• Patient Position
Remove all metallic or plastic objects from head and neck. Patient position is erect or
recumbent semi-prone.
• Part Position
Rest lateral aspect of head against table or upright imaging device surface, with side of
interest closest to IR .
Adjust head into a true lateral position and oblique body as needed for patient’s comfort.
Palpate external occipital protuberance posteriorly and nasion or glabella anteriorly to
ensure that these two points are equidistant from tabletop. Place support sponge under
chin if needed.
Align MSP parallel to IR.
Align IPL perpendicular to IR.
Adjust chin to bring IOML perpendicular to front edge of IR.
• CR
Align CR perpendicular to IR.
Center CR to zygoma (prominence of the cheek), midway between
outer canthus and EAM.
Center IR to CR.
 Evaluation Criteria
• Anatomy Demonstrated:
Superimposed facial bones, greater wings of the sphenoid, orbital roofs, sella turcica, zygoma
are demonstrated
• Position:
An accurately positioned lateral image of the facial bones demonstrates no rotation or tilt.
Rotation is evident by anterior and posterior separation of symmetric vertical bilateral
structures such as the greater wings of the sphenoid. Tilt is evident by superior and inferior
separation of symmetric horizontal structures such as the orbital roofs (plates) and greater
wings of sphenoid. Collimation to area of interest.
• Exposure:
Contrast and density (brightness) are sufficient to visualize the maxillary region.
Sharp bony margins indicate no motion.
Orbital Emphysema
REFRENCES:-
• Clark’s positioning in radiography, 13th Edition by A. S. Whitley, G. Jefferson, K.
Holmes, C. Sloane, C. Anderson, G. Hoadley.
• Merrill`s Atlas of Radiographic Positions 10th Edition by Philip W. Ballinger,
Eugene D. Frank.
• Bontrager's Textbook of Radiographic Positioning and Related Anatomy
• Website too………….
 Questions
1. What is the recommended radiographic positioning for obtaining an optimal view of the orbits
and temporal bones?
2. What are the key anatomical landmarks used to guide the positioning of radiographs for the
orbits and temporal bones?
3. what are the indications for orbit radiography?
4. What are the common radiographic projections used to visualize the frontal and ethmoidal
sinuses in relation to the orbits?
5. What are the recommended radiographic projections for assessing the superior orbital fissure
and optic foramen?
6. How can radiographic positioning be adjusted to minimize distortion and superimposition of
anatomical structures when imaging the orbits and temporal bones?
7. Why is typical Caldwell’s method modified in case of orbit radiography?
8. What are the indications for temperomandibular joint?
9. Mention the radiographical line used while performing orbit radiography?
1. includes the posteroanterior (PA) projection, lateral projection, and various specialized
projections such as the modified Waters, Caldwell, and Towne methods
2.Glabella, nasion, external auditory meatus, external occipital protuberance, acanthion,
mastoid process, inferior orbital rim etc
3.Fractures, foreign body, orbital pathologies like masses or tumours,orbital emphysema etc
4.Waters view (parietoacanthial projection) and the lateral view.
5.modified Towne's view and the lateral view with the head positioned in true lateral
orientation.
6.To minimize distortion and superimposition, proper patient positioning and alignment with
the image receptor are crucial. Collimation should be used to restrict the X-ray beam to the
area of interest, and technique factors must be adjusted based on patient size and anatomical
density variations.
7.modified Caldwell projection is done by giving 30 degrees caudal angulation rather tha 15
degrees to visualize petrous ridge below the orbital floor.
8. TMJ pain, erodic degenerative changes like erosion, flattening, sclerosis, subchondral cysts,
and osteophytes.
9. infra orbital line, orbito meatal line, intra pupillary line, infra orbito meatal line, acanthio
meatal line, lips meatal line