Week 1 skull & sinus & intro to digital 105

1

Skull & Sinus Radiography

• Skull Radiography can be easily done erect with the patient seated in a chair or often time standing. It is easier to check for rotation with the patient seated.

• Sinus studies should always be done erect to see air and fluid levels in the sinuses.

• Sinus views can also be used to evaluate the facial bone and orbits.

2

Skull & Sinus Radiography

• All skull or sinus views should be taken using the small focal spot. This will provide the best possible geometric resolution.

• Skull films are taken on 10” x 12” regular speed cassettes.

• Sinus films are taken on 8” x 10” regular speed cassettes.

3

Why do I need this?

• Cranial pathologies may show up on cervical spine views.

• Doctor needs to be able to further evaluate the pathology.

• If patient presents with any neurological signs, you need to evaluate them.

4

Mini Case Study

• 27 year old male with complaints of head aches.

• Full spine series performed in clinic.

5

Lat Cervical & APOM

6

Air Fluid Level seen in maxillary Sinus

7

Waters Projection

• Waters projection demonstrates:– Cloudy maxillary

sinuses worse on left.– Sinus infection that

needed antibiotics.

8

9.1 P-A Skull

• Measure: A-P at the Glabella

• Protection: Full coat apron with lead to back or half apron draped over back of chair.

• SID: 40” Bucky• No tube angle• Film: 10” x 12” regular

I.D. down

9

P-A Skull

• Patient seated or standing facing the Bucky.

• Nose and forehead touching the Bucky to get the canthomeatal line perpendicular to film.

10

P-A Skull

• Horizontal CR: exit through the glabella.

• Vertical CR: mid-sagittal plane

• Center film to horizontal CR

• Collimation: slightly less than film size.

• Breathing Instructions: Suspended respiration

11

P-A Skull

• Make exposure and let patient relax.

• Note: If the patient is done seated, place Bucky tray in the lower Bucky slot. This will allow the patient to get their legs under the Bucky.

12

P-A Skull Film

• The entire skull should be on the film.

• There should be no rotation.

• The petrous ridges will be superimposed with the orbits.

• To clear the ridges, the Caldwell view can be taken.

13

9.2 Chamberlain-Townes

• The Townes Projection is part of a routine skull series.

• The tube is angled to throw the anterior part of the skull away from the occipital region of the skull.

14

Chamberlain-Townes

• Measure: A-P at Glabella• Protection: Half apron or

Coat Apron• SID: 40” Bucky• Tube angle: 35 degrees

Caudal• Film: 10” x 12“ regular

I.D. Down

15

Chamberlain-Townes

• Patient is seated facing the tube.The chin is tucked into the chest until the canthomeatal line is perpendicular to film. A chair the allows some reclining will make this easier for the patient.

16

Chamberlain-Townes

• Horizontal CR: Through the EAM. The Horizontal CR will usually pass through the hair line.

• Vertical CR: mid-sagittal• Film centered to

horizontal CR• Collimation: slightly less

than film size or soft tissue of skull

17

Chamberlain-Townes


• Make exposure• Let patient breathe and

relax

18

Chamberlain-Townes Film

• The entire skull and especially the occipital region of the skull must be on the film.

• Structure seen include the foramen magnum, petrous ridges, IAC’s and TM Joints

• No rotation of skull

19

9.3 Skull Lateral

• Measure: Lateral at EAM• Protection: Full coat

apron or half apron draped over back of chair

• SID: 40” Bucky• Tube angle: none but

may be angled parallel to interpupillary line.

• Film: 12” x 10” I.D. to face

20

Skull Lateral

• Patient seated of standing facing the Bucky. Rotate the body into an oblique position.

• Turn skull so the affected side is next to the Bucky.

• The interpupillary line must be perpendicular to film and tube.

• Mid sagittal plane parallel to the film.

21

Skull Lateral• Horizontal CR:

3/4”superior to EAM• Vertical CR: 3/4”

anterior to EAM• Center film to

horizontal CR.• Collimation: slightly

less than film size• Breathing

Instructions: Suspended respiration


22

Skull Lateral Film

• Entire skull must be on the film.

• There should be no rotation of the skull, orbits and mandible ramus superimposed.

• The facial bones are sinuses will be dark (over exposed).

• Usually both lateral views are taken.

23

9.5 Base Posterior Skull

• Routine skull view that can be used to evaluate the upper cervical spine.

• Provides an axial view of C-1 and C-2 as well as the foramen magnum.

24

9.5 Base Posterior Skull

• Measure: A-P at Glabella• Protection: Half apron• SID: 40” Bucky• Tube Angle: None but if

patient cannot extend head back far enough to get inferior orbital meatal line perpendicular to horizontal CR tube angle may be needed.

25

Base Posterior Skull

• Film Size: 10” x 12” regular I.D. down

• Patient is seated in a reclining chair. The chair is placed about 6” to 10” from Bucky.

• Patient is asked to extend neck back until inferior orbital meatal line is parallel to film with top of skull touching the Bucky.

26


• Horizontal CR: EAM• Vertical CR: mid-sagittal• Center film to

horizontal CR• Collimation: slightly less

than film size or skin of skull

• Breathing Instructions: suspended respiration

• Make exposure

27


• Assist patient get out of the position. Be very careful that the patient does not hit face on x-ray tube.

• The ability of the patient to lay back in the chair will make the view much easier for all concerned.

28

Base Posterior Skull Films

• This basilar view of skull has the patient’s head not extended back far enough. The mandible and frontal skull should be superimposed.

• The I.D. Blocker is on the skull.

• The skull is rotated.

29


• If the upper cervical spine or mastoid processes and internal auditory canals are the areas of interest, it is appropriate to cone down to this area.

• Note the ear ring left on the patient.

• There is some rotation.

30


• The entire skull is visualized.

• The mandible and frontal region of skull are superimposed.

• With a bright light, the zygomatic arches can usually be seen.

31

9.6 Schullers Projection

• The Schullers Projection can be used to evaluate the temporal mandibular joints and mastoid air cells and inner ear.

32

9.6 Schullers Protection

• Measure: lateral at EAM• Protection: Lead apron• SID: 40” Bucky• Tube angle: 25 degrees

caudal• Film size: 8” x 10” I.D. up

33

Schullers Protection for TMJ

• Patient is seated facing the Bucky. Head is turned to place the affected TMJ next to Bucky.

• Skull should be in a true lateral position. Align the TMJ to the center line of the Bucky.

• The vertical CR should be aligned with TMJ away from film.

34


• If the affected TMJ and the side away from the Bucky is aligned with the Center of the Bucky and Vertical CR, the skull will be in the true lateral position.

• The horizontal CR is aligned with the Affected TMJ (closest to film).

35


• Center film to horizontal CR.

• Collimation: 5” x 5”

• Breathing instructions: Keep mouth closed and don’t breathe move or swallow.

• Make exposure.

• Let patient breathe but remain in the position.

36


• Change cassettes to a new 8” x 10”

• Ask patient to open mouth as far as possible.

• Recheck positioning.• Breathing Instructions:

With mouth wide open, don’t breathe move or swallow.


37


• Open and closed mouth view are taken of both TM joints.

• The TMJ closest to the Bucky will be the one seen at the center or top of the film.

• Accurate positioning is essential to being able to compare joints.

38

9.7 Caldwell Sinus Projection

• The Caldwell Projection will have the petrous ridges below the orbits.

• Positioning is exactly like the P-A skull with the exception of the use of a 15 degree caudal tube angle to lower the petrous ridges.

39

9.7 Caldwell Sinus Projection

• Measure: A-P at Glabella• Protection: Coat apron

backwards or half apron draped over back of chair.

• SID: 40” Bucky• Tube angle: 15 degrees

caudal• Film: 8” x 10” Regular

I.D. Down

40

Caldwell Sinus Projection

• Patient is seated facing Bucky. Their legs should be under the Bucky. Get chair as close to the Bucky as possible.

• Ask patient to place their nose and forehead on center line of Bucky.

• Check for rotation.

41

Caldwell Sinus Projection

• Horizontal CR: exits through the Glabella or Nasion

• Vertical CR: mid-sagittal• Center film to horizontal

CR• Collimation: 6” or 7”

square.• Breathing Instructions:

Suspended Respiration

42

Caldwell Sinus Projection Film

• This view will provide a clear view of the frontal and ethmoid sinuses.

• The super orbital rims can be evaluated for fracture when facial bone are of interest.

• To project the petrous ridges farther down, increase angle to 25 degrees

43

9.8 Waters Projection Sinus

• The most important view for sinus problems or injury involving the maxilla or orbits.

• By taking the view erect, fluid levels within the maxillary sinuses can be seen.

44

9.8 Waters Projection Sinus

• Measure: A-P at Glabella• Protection: Half apron

over back of chair or coat apron backwards

• SID: 40” Bucky• No tube angle• Film: 8” x 10” regular I.D.

Down

45

Waters Projection Sinus

• Patient is seated facing the Bucky. Get the chair as close to the Bucky as possible. Patient may spread legs to get chair as close as possible. May also be taken standing.

• Mentomeatal line should be perpendicular to film with mouth closed.

46


• The nose will be one to two centimeters from Bucky with chin resting on Bucky.

• The mouth may be opened to see the sphenoid sinus. When this is done, the canthomeatal line should be 35 to 40 degrees to the Bucky.

47


• Horizontal CR: exit through the base of nose or acantha.

• Vertical CR: mid-sagittal• Center film to horizontal

CR• Collimation: 6” or 7”

square• Breathing Instructions:

Suspended Respiration

48

Waters Projection Sinus Film

• This is an example of the open mouth waters view.

• The facial bones and sinuses should be on the film.


• The petrous ridges must be below the floor of the maxilla.

49

Waters Projection Sinus Film

• The facial bones and sinuses should be on the film.


• The petrous ridges must be below the floor of the maxilla.

50

9.9 Sinus Lateral

• The lateral view of the sinuses and facial bones will under exposed for the skull.

• This view is very useful for seeing fluid levels in all of the sinuses.

•

51

9.9 Sinus Lateral

• Measure: Lateral at EAM• Protection: Coat apron

or half apron draped over back of chair.

• SID: 40” Bucky• No Tube Angle• Film: 8” x 10” regular I.D.

down

52

Sinus Lateral

• Patient is seated or standing facing the Bucky. Turn patient toward the affected side. Turing the body will make it easier for the patient.

• Patient’s skull should be in a true lateral position. The interpupillary line perpendicular to film.

53

Sinus Lateral

• Horizontal CR: Outer canthus of the eye with mid sagittal plane parallel to film.

• Vertical CR: Outer canthus of eye


• Collimation: 6” or 7” square

54

Sinus Lateral

• Collimation Top to Bottom: Frontal Sinuses to Mandible

• Collimation Side to side: Nose to EAM

• Breathing Instructions: suspended respiration

• Make exposure and let patient relax

55

Sinus Lateral

• There should be no rotation of the patient’s skull.

• The orbits, sella, maxilla and visualized mandible should be superimposed.

56

9.10 Basilar View of Sinuses

• The base view of the sinuses is positioned just like the base posterior view.

• The horizontal CR is moved to the center of the facial bones and sinuses.

• The positioning view demonstrates a patient that cannot extend their neck.

57

9.10 Basilar View of Sinuses

• Measure: A-P at glabella• Protection: Half or coat

apron• SID: 40” Bucky• Tube angle: none if

patient can extend neck until the inferior orbital-meatal line is parallel to film.

58

Basilar View of Sinuses

• If patient cannot extend back far enough, angle tube to get the CR perpendicular to the inferior orbital-meatal line.

• Film: 8” x 10” regular I.D. down

59


• Position chair about 6” to 10” from Bucky. Patient seated facing the tube.

• Have patient lean back or recline in chair.

• Patient extend neck as far as possible until the inferior orbital-meatal line is parallel to film.

60


• Horizontal CR: 1.5” superior to EAM or middle of mandible.

• Vertical CR: mid-sagittal plane


• Collimation: slightly less than film size or skin of facial region

61



• Make exposure• Carefully assist patient

raise head without hitting head on x-ray tube.

62


• Mandible and frontal bone should be superimposed.

• No rotation of skull• Maxilla, sphenoid and

ethmoid sinuses and mandible will be seen.

63

Introduction to Digital Radiography

The use of the equipment in our clinic.

64

What is the difference?

• The AGFA CR35 Digital Radiography System replaces the Kodak Cassettes, radiographic film, Kodak M35 film processor and view boxes.

65

What is the difference?

• The technical factors are basically the same as what was used with film.

• This means that the patient exposure starts as the same as film.

• Fewer retakes reduces the exposure.

66

Basic procedure changes

• We use only two film sizes:– 35 CM x 43 CM or 14” x 17”– 24 CM by 30 CM

• We use one phosphor or cassette type. The computer program determines the speed and image resolution.

• Only one image is put on each cassette.

67

Cassette

• The back of the cassette is red.

• A clip shows the orientation marker or I.D. blocker on the back.

• The front is black and the I.D. is a non-textured rectangle.

68

Cassette

• The I.D. is used to orient the cassette and not for patient demographics.

• The patient demographics is not on the digital image.

• Cassette orientation is important for image manipulation on the viewing station.

69

Cassette orientation

• The I.D. is down or towards the patient’s feet for Wall Bucky and Table Bucky examinations.

• It is up only on the special A-P full spine exam holder.

• This is much more simple than with film.

70

Digital Imaging Sequence Changes

• The patient demographics is entered into the computer instead of typed on a flash card.

• The patient demographics is entered on the cassette either before or after the image is taken. This is called the I.D. process.

• It must be entered before the cassette is processed.

71

Patient data entry screen

• We start by entering the patient into the computer.

• CAPITAL FONTS ARE USED.

• The file number starts with a zero and ends with CA for our patients except for old Benton Clinic which starts with a five and ends with CA.

• The Date of Birth is entered

• The ordering clinician is also entered.

72

Digital sequence

• One the patient data is completed, click the “OK” or touch the “OK” to move to the next step.

• Be careful with data entry as errors are hard to correct after the exam is completed.

73

Select the Body Region

• Next we must tell the system what region we are imaging.

• Below the title, the information entered before will be displayed.

• When finished, click “OK” or touch “OK”

74

Select Views

• Next we must tell the system what views we are taking.

• Click or touch each view to be taken to complete the procedure.

• They will appear in the black window on the right.

• When finished click “OK”

75

Select image to be taken

• Touch or “left click” the view or image that you want to take.

• Select the correct cassette size.

• Slide it into the I.D. slot with the I.D. Slot down and black side toward the monitor.

76

Identify the Cassette

• “Left click” or touch the I.D. button on the monitor.

• When the cassette is identified, I.D. will be seen on the image in the right window.

• You can also put the cassette in first and then touch I.D.

77

Identify the Cassette

• If the wrong view is selected, the cassette can be over written and a new image will appear in the view window.

• The cassette is now ready to be used.

• The image may be taken before the identification. process but it must be identified before the image is processed.

78

Cassette orientation

• The cassette orientation will be displayed on the monitor based upon the image selected.

• It will either be landscape or portrait.

• Remember the I.D. orientation is down for all exams except for the A-P full spine.

79

Radiograph taken

• Just like with film, the patient will be positioned and the image taken. We will discuss the room operation after the digital process is covered.

80

Image Processing

• Make sure the green light is on the digitizer.

• The exposed cassette is now placed inside the digitizer.

• The latches (wheels) are down.

81

Processing the image

• The digitizer will pull the cassette in and start the processing of the image.

• The phosphor is removed from the cassette, exposed to a high intensity laser and the image captured.

• Bright light is used to erase the phosphor before it is reloaded in the cassette.

82

Processing the image

• The erased cassette is returned to the loading slot and is ready to be reused.

• The entire process takes only about one minute.

83

Image Quality Check

• The image can be checked at the work station.

• The LGM is a number that represents exposure. Ideally it should be between 1.90 and 2.20.

• The image orientation is wrong.

84

Image rotation change

• By using the arrows, the image may be rotated to the correct orientation but this may impact analysis tools.

• Markers may also be added and the image flipped.

85

Image Edit Functions

• When the image is displayed on the monitor, you may also select the Edit functions.

• This may only be done when the system is not processing another image.

86


• The greatest advantage to digital radiography is image manipulation.

• The contrast and brightness may be edited in the edit function.

• Doing it here will reduce viewing station edit functions unless the image is “saved as new”.

87



• The image may be reversed.


88



• The image may be magnified.


89

Using the edit function

• Occasionally the computer will not correctly sense the collimation borders. This can cause artifacts on the image such as two tone images or image reversal.

• Use the collimation function in the edit mode to correct this.

90

End Exam

• When you are satisfied with the images or ready to have them viewed by the clinician, touch the close and send button.

• After this point, errors in demographics or images are very hard to fix.

91

End Exam

• The images will be transferred to the viewing station in the viewing room.

• A radiologist work station is located there with many analysis tools and high resolution monitors.

92

Special Imaging AP Full Spine

• Our digital system is equipped to perform the A-P Full Spine.

• Three special 14” x 17” cassettes are used.

• These cassettes are stored next to the digitizer and are numbered.

93


• A special film holder is installed on the opposite side of the x-ray room.

• The #1 cassette goes in the top slot; #2 in the middle and # 3 in the bottom.

• They are identified and processed in numerical order.

94


• Remember the I.D. is up on the full spine.

• The red handle releases the lock to raise or lower the unit. The other handle is uses to move the unit.

• Place the bottom of the cassette two inches below the gluteal folds.

95

10.1 Basics of Extremity Radiography

• All extremity studies must include the proximal and distal articulations. Long bones may require additional views to see both articulations.

• The patient measurement will be generally be at the location of the horizontal central ray. Exceptions lateral scapula and heel

96

Basics of Extremity Radiography

• Views can be taken standing, seated or recumbent. Bucky views can be taken using the upright Bucky, Table Bucky or a stationary grid on cassette.

• When taking upper extremity views table top, never have the patient’s legs under table. Unnecessary exposure to femurs and bone marrow will be the result.

97


• More than one view can be taken on the film for small extremities. Lead blockers are used to control scatter radiation when multiple views are taken non-Bucky on the same film. Exposed film is very sensitive to fogging from secondary radiation.

98


• Proper Collimation is extremely important with extremity radiography. Collimation that is too tight will net demonstrate both articulations The operator must understand the location of the essential anatomy. Collimation that is too large will result in darker films or overlap of images.

99


• Extremity Cassettes with fine detail screens are used on small extremities that typically measure less than 10 cm thick.

• Extremity cassettes are not placed in the Bucky.

• Knees are generally taken Bucky because of the density of the distal femur.

100


• Typically speaking when one part of an extremity is in the A-P or lateral position, the rest of extremity will also be in the same position.

• For lower extremities, you are instructed to internally rotate the limb 15 degrees. In the standard anatomical position, the extremity is externally rotated 15 degrees. This will get the limb into an A-P position.

101


• Landmarks on the cassettes can be used when dividing the film for multiple views on the same film.

• The rivets can be used when doing three across.

102


• The center of the cassette is marked horizontally and vertically by arrows.

• The arrows are used to divide the cassette into quarters or halves.

103

Cassette divided to get all needed anatomy on the film.

• For elbows, Hands and ankle views the film is turned 12” x 10” for two views.

• Lead blockers protect the film from scatter radiation.

104


• For foot views the film is oriented 10” x 12” to allow us to get from the toes to the heel on the film.

• The cassette is divided in halves.

105


• For the wrist, the cassette is oriented 10” x 12” and divided into quarters.

• This gives us more film area for each view compared to three across.

Education

Week 1 skull & sinus & intro to digital 105