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Review of Positioning Standards for the Skull and
Facial Bones
Stephen Weber, R.T.(R)
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Objectives • The participant (you) will learn the nuances of
skull and facial bones radiography • To gain a better understanding of the criteria
for proper radiographic appearances of skull and facial bones radiography
• To review common positioning errors and how to correct them
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Skull Anatomy
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Skull Morphology: Mesocephalic
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Skull Morphology: Brachycephalic
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Skull Morphology: Dolichocephalic
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• Supraorbital Groove • Superciliary Ridge (Arch) • Supra and Infraorbital Margin • Inner and Outer Canthus
Skull Topography:
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Skull Topography:
Occiput
Vertex
Inion
Glabella
Nasion
Acanthion
Mental Point Gonion
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Skull Topography:
Auricle
TEA
Tragus
EAM
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Skull Baselines:
GML OML IOML
AML
MML
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GML: Glabellomeatal Line OML: Orbitalmeatal Line
– There is an 8 degree difference between the GML and the OML
IOML: Infraorbitomeatal Line – AKA Reid’s Base Line – There is a 7 degree difference between the
OML and the IOML
Skull Baselines:
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AML: Acanthiomeatal Line MML: Mentomeatal Line
– There is a 53 degree difference between the OML and the MML
Interpupillary Line
Skull Baselines:
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Calvarium or Skull Cap Frontal Two Parietals Occipital
Floor of the Cranium Two Temporals Sphenoid Ethmoid
Cranial Bones (8):
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Two Maxillae Two Zygomas Two Lacrimals Two Nasal Bones Two Inferior Nasal Conchae Two Palatine Bones Vomer Mandible
Facial Bones (14):
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Cranial Bones Frontal Sphenoid Ethmoid
Facial Bones Maxilla Zygoma Lacrimal Palatine
Base of Orbits (14):
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• Consists of the perpendicular plate of the ethmoid and the vomer
Bony Nasal Septum:
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Maxillary (2) AKA antra of highmore
Frontal (usually 2) Become aerated at age 6
Ethmoid (consists of many air cells within the labyrinth)
Sphenoid (1 or 2) All sinuses become aerated at age 17 or 18
Paranasal Sinuses:
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Paranasal Sinuses:
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Positioning Considerations
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Positioning Considerations: • May be done upright or recumbent
– Upright allows patient to be positioned quickly – Upright visualizes existing air/fluid levels within the
cranial or sinus cavities
• Ensure patient comfort • Hygiene
– Disinfect table/bucky surface before and after use
• Exposure factors – Medium kV 75-85 – Minimum SID is 40”
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Radiation Protection: • Best techniques for minimizing radiation
exposure – Use good collimation practices – Minimize repeats
• Gonadal shielding is not always needed – No detectable exposure to gonadal area during skull
radiography – However, lead shields may be used to reassure the patient
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Causes of Positioning Errors: • Human body is expected to be symmetric
bilaterally… This is not always true – Ears, Nose, and Jaw are often asymmetric
• Use patient’s eyes as opposed to their nose as a positioning landmark
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Correct Positioning: • Bony parts such as mastoid tips and orbital
margins are safer landmarks to use • Look at the various facial features and palpate
anatomic landmarks for accurate positioning
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Positioning Errors: The do NOT’s of palpating your patient during positioning…
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Positioning:
A more appropriate means to palpating and positioning your patient for their exam
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5 Common Positioning Errors: • Rotation
–Almost always results in a retake • Tilt • Excessive Flexion • Excessive Extension • Incorrect CR angle
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Skull: No Rotation or Tilt
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Skull: Rotation
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Skull: Tilt
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Skull: Rotation vs. Tilt
None Rotation Tilt
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Pediatric Applications:
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Pediatrics Applications: • Communication
– Clear explanation of the procedure – Obtain trust and cooperation of the patient
and guardian • Immobilization
– Use of positioning immobilization devices reduces the need of patient being held
– Guardian can hold, provide them with shielding
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Pediatric Immobilization Devices:
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Skull Radiography
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Routine Skull Positioning Routine Skull Positions:
1. PA 2. AP Axial (Towne) 3. Both Laterals 4. Submentovertex (SMV) or Full Basal
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PA Skull: SID 40”
IR Size 24 x 30 cm Lengthwise
Tube Angle None
CR Center to Glabella
Collimation Collimate on four sides
Positioning Place patient’s forehead and nose against IR with OML and MSP perpendicular to IR
Breathing Suspend
Additional Comments
The patient’s arms and hands are by their head for support if done on the table. Can also be done AP. Mark correct side.
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PA Skull:
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• Positioning Accuracy: • Distance from outer
canthus and lateral margin of skull must be equal on both sides
• Petrous Ridges must fill the orbits
PA Skull:
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• Angle central ray so it forms a perpendicular angle with the OML
• If petrous ridges are below the supra orbital rim: – The chin is too high – Will appear like a PA Axial (Caldwell) view
• If petrous ridges are above the supra orbital rim: – The chin is too low – Will appear like an AP Axial (Towne) view
PA Skull positioning:
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SID 40”
IR Size 24 x 30 cm Lengthwise
Tube Angle 30 degrees caudal to OML CR Center 2.5” above Glabella
Collimation Collimate on four sides
Positioning Have patient tuck chin to place OML and MSP perpendicular to IR
Breathing Suspend
Additional Comments
Place a small sponge behind patients head to help tuck chin. Angle 37 degrees if IOML is perpendicular to IR
AP Axial (Towne) Skull:
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AP Axial (Towne) Skull:
• Positioning Accuracy: • Petrous Ridges must be
symmetrical • The dorsum sellae must
be found within the foramen magnum
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Lateral Skull: SID 40” IR Size 24 x 30 cm Crosswise Tube Angle None CR Center 2” above the EAM Collimation Collimate on four sides Positioning Oblique pt. & place affected
side against IR in a true lateral position. Interpupillary line is perpendicular to IR. MSP is parallel to IR. IOML is perpendicular to edge of IR
Breathing Suspend Additional Comments
Use sponge under chin or head to prevent tilt
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Lateral Skull:
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L
Positioning Accuracy: •Orbital Plates must be superimposed •Angles of the mandible must be superimposed
Lateral Skull:
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Submentovertex (SMV) or Full Basal: SID 40” IR Size 24 x 30 cm Lengthwise
Tube Angle None
CR CR will be perpendicular to IOML and enter midway between the gonia
Collimation Collimate on four sides
Positioning/Planes & Baselines
Pt. raises chin to place IOML parallel and MSP perpendicular to IR
Breathing Suspend
Additional Comments
Base of the cranium, petrous pyramids, mandible, zygomatic arches, and sphenoid sinuses all best demonstrated
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Submentovertex (SMV) or Full Basal:
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Submentovertex (SMV) or Full Basal:
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Submentovertex (SMV) or Full Basal:
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Submentovertex (SMV) or Full Basal:
Positioning Accuracy: • Mandible must be symmetrical • Condyles of the mandible must be anterior to the petrous ridges
L
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1. PA Axial (Caldwell) 2. PA Axial (Haas) aka Reverse Towne’s
Optional Skull Positions:
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PA Axial (Caldwell) Skull: SID 40”
IR Size 24 x 30 cm Lengthwise
Tube Angle 15 degrees caudal
CR Center at the nasion
Collimation Collimate on four sides
Positioning Place patient’s forehead and nose against IR with OML and MSP perpendicular to IR
Breathing Suspend
Additional Comments
Mark correct side
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PA Axial (Caldwell) Skull:
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L Positioning Accuracy: • Petrous Ridges must fill the lower 1/3 of the orbits • Distance from outer canthus and lateral margin of skull must be equal on both sides
PA Axial (Caldwell) Skull:
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SID 40” IR Size 24 x 30 cm Lengthwise Tube Angle
25 degrees Cephalic to OML
CR Center 1.5” below inion (between EAM)
Collimation
Collimate on four sides
Positioning PA: Have patient tuck chin to place OML and MSP perpendicular to IR
Breathing Suspend Additional Comments
Angle 37 degrees if IOML is perpendicular to IR
PA Axial (Haas) Skull:
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L
Positioning Accuracy: •Petrous Ridges must be symmetrical •The dorsum sellae must be found within the foramen magnum
PA Axial (Haas) Skull:
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Facial Bones Radiography
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Routine Facial Bones Positioning: Routine Facial Bones Positions:
1. Parietoacanthial or Waters 2. PA Axial or Caldwell 3. Lateral of the Affected Side 4. Submentovertex (SMV) or Full Basal * Best if done upright
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Parietoacanthial or Waters: SID 40”
IR Size 24 x 30 cm Lengthwise
Tube Angle None CR Exiting the acanthion
Collimation Collimate on four sides Positioning/Planes & Baselines
Have patient raise chin and place against IR, MML and MSP are perpendicular to IR, OML forms a 37 degree angle to bucky
Breathing Suspend Additional Comments
Best demonstrates orbits, zygomas, and maxillae.
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Parietoacanthial or Waters:
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Positioning Accuracy: • Petrous Ridges must be below the maxillary sinuses • Distance from outer canthus and lateral margin of skull must be equal on both sides
Parietoacanthial or Waters:
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Chin is raised too high Chin is not raised high enough
Parietoacanthial or Waters:
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PA Axial (Caldwell) Facial Bones: SID 40”
IR Size 24 x 30 cm Lengthwise
Tube Angle 15 degrees caudal
CR Center at the nasion
Collimation Collimate on four sides
Positioning/Planes & Baselines
Place patient’s forehead and nose against IR with OML and MSP perpendicular to IR
Breathing Suspend
Additional Comments
Mark correct side
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Positioning Accuracy: • Petrous Ridges must fill the lower 1/3 of the orbits • Distance from outer canthus and lateral margin of skull must be equal on both sides L
PA Axial (Caldwell) Facial Bones:
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Petrous Ridges Troubleshooting: • Positioning Accuracy for PA Axial (Caldwell): • Petrous Ridges must fill the lower 1/3 of the
orbits – If the Petrous Ridges are in the upper portion
either a) raise the chin or b) increase the CR angle – If the Petrous Ridges are inferior to the orbital
rims either a) lower the chin or b) decrease the CR angle
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Petrous Ridges Troubleshooting: • The Petrous Ridges move with the back of the
head in the PA position – Raising the chin moves the Petrous Ridges down – Lowering the chin moves the Petrous Ridges up
• The central ray moves the orbits – Increasing the CR angle moves the orbits down – Decreasing the CR angle moves the orbits up
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Lateral Facial Bones: SID 40” IR Size 24 x 30 cm Lengthwise Tube Angle None CR Center to the malar bone Collimation Collimate on four sides Positioning/Planes & Baselines
Oblique pt. & place affected side against IR in a true lateral position. Interpupillary line is perpendicular to IR. MSP is parallel to IR. IOML is perpendicular to edge of IR
Breathing Suspend Additional Comments
Use sponge under chin or head to prevent tilt
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Lateral Facial Bones:
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Lateral Facial Bones:
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• Positioning Accuracy: • Orbital Plates must be superimposed • Angles of the mandible must be superimposed
Lateral Facial Bones:
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• Positioning Accuracy: • Detecting Tilt:
• Orbital roofs • EAM • Lesser wings of sphenoid
• Detecting Rotation: • Mandibular rami • EAM • Greater wings of sphenoid
Lateral Facial Bones:
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Modified Parietoacanthial (Modified Water’s): SID 40” IR Size 24 x 30 cm Lengthwise
Tube Angle None CR Exiting the acanthion
Collimation Collimate on four sides Positioning/Planes & Baselines
Have patient place chin and nose against IR, MML is not perpendicular to IR, OML forms a 55 degree angle to bucky
Breathing Suspend Additional Comments
Best demonstrates floor of the orbits, and used to r/o a blow-out fracture of orbit
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Positioning Accuracy: • Petrous Ridges are projected into the maxillary sinuses • Distance from outer canthus and lateral margin of skull must be equal on both sides
Modified Parietoacanthial (Modified Water’s):
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• Orbital fracture (blowout) and neoplastic/inflammatory processes are shown • Foreign bodies in eye may be demonstrated in this position
Modified Parietoacanthial (Modified Water’s):
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Additional Studies
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VP Shunt Radiography • Ventriculo-Peritoneal Shunt • Thin tube placed inside the brain’s ventricle
and tunneled underneath the skin to the peritoneum
• Reduces pressure of Cerebral Spinal Fluid in the brain
• Drains to the abdominal area • Series of overlapping radiographs taken to
image the entire VP Shunt
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VP Shunt Radiography
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The Codman Hakim Shunt • Programmable ventricular shunt valve system
used to treat hydrocephalus • It is necessary to radiographically check
ventricular shunt valves following MR studies –Shunt valve has susceptibility to MR fields
• X-Ray film taken in relation to the valve and not to the patient’s anatomy
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Shunt Valve Radiography:
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Shunt Valve Radiography:
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In Closing… • Reviewed the nuances of skull and facial
bones radiography • Analyzed the criteria for proper radiographic
appearance of the skull and facial bones • Discussed common positioning errors and
methods on how to correct them • Now you can apply this knowledge towards
your clinical setting
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Demonstrate Confidence… The ER just order Skull and Facial Bones X-Rays…
…and your co-workers let you know they got your back
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How the patient encounter should go:
VS. What’s really about to go down…
Expectations:
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The X-Ray Technologist:
What my family thinks I do What ER patients thinks I do
What entire hospital sees me do
What X-Ray students think I do
What nurses thinks I do
What I really do