Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Plain films of the orbit

Gregory M. Sulkowski, Harvard Medical School Year IV

Gillian Lieberman, MD

January 26, 2004

2

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Why learn about orbital films?

• After all, they are no longer commonly used• Most often indicated to assess for ocular

metal fragments in a noncommunicative patient who requires MRI

• Nevertheless, studying these films provides a useful review of anatomy and is a good exercise in deducing complex 3 dimensional structure which has been collapsed to 2D

3

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

The orbit is hard to visualize!

• Very complex arrangement of curving bones

www.uth.tmc.edu/.../test/er_primer/ face/images/fct16.html

4

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

The orbit is hard to visualize!

• Petrous portion of temporal bone lies posteriorly

www.meddean.luc.edu/.../neurovasc/ navigation/icpetr.htm

5

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

The orbit is hard to visualize!

• eyeballs lie in front of an intricately textured sphere of bone

courses.washington.edu/.../ amniote_skull_photos2.htm

6

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Sinuses and cavities help ...

• Can use these spaces to reveal the orbits on X-ray ucsu.colorado.edu/~schutzh/ Anatomy.html

7

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

5 views in the “Orbital Series”

• Lateral• Caldwell• Waters• Submentovertex (aka Base)• Rhese (aka Oblique or Foramen)

8

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Lateral view

• Side view of orbits and sinuses

Courtesy of Dr. Michael G. Morley

9

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Lateral view

• Sphenoid sinus

• Sella turcica

• Cribriform plate

http://www.amershamhealth.com/medcyclopaedia/medical/volume%20ii/skull%20base.asp#Fig.12

10

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Caldwell view

• Projects petrous portions of temporal bones just beneath the orbits

Courtesy of Dr. Michael G. Morley

11

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Caldwell view

• Shows orbits, ethmoid sinuses, frontal sinuses

• Can demonstrate medial (ethmoid) blowout fractures

Courtesy of Dr. Michael G. Morley

12

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Caldwell view

• Orbital floor fx extending to lateral orbital wall

Courtesy of Dr. Michael G. Morley

13

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Waters view

• Projects petrous portion of temporal bones just beneath the maxillary sinuses

Courtesy of Dr. Michael G. Morley

14

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Waters view

Shows: • orbits• maxillary

sinuses• zygomatico-

frontal suture

Courtesy of Dr. Michael G. Morley

15

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Waters view

Tripod fx:• arch of the

zygomatic bone

• zygomatic process of frontal bone

• zygomatic process of maxillary bone

Courtesy of Dr. Michael G. Morley

16

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

• Waters (notice clear view of maxillary sinuses - shows an orbital floor fx)

• Caldwell (petrous pyramids obscure maxillary sinuses)

Courtesy of Dr. Michael G. Morley

17

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Submentovertex or Base view

• Zygomatic arch

• Lateral wall of orbit

• Sphenoid sinuses

Courtesy of Dr. Michael G. Morley

18

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Submentovertex or Base view

Underpenetrated or “light” view is best for zygomatic arch fx

Courtesy of Dr. Michael G. Morley

19

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

• Directs beam through optic canal

Rhese/Oblique/Foramen view

Courtesy of Dr. Michael G. Morley

20

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Rhese/Oblique/Foramen view

• can show unilateral foramen enlargement (e.g., aneurysm, tumor, or rarely fx)

Courtesy of Dr. Michael G. Morley

21

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

• Can better localize fragments, extent of fxs

Postscript: CT is much better ...

www.uth.tmc.edu/.../test/er_primer/ face/images/fct16.html

22

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

http://www.littledoll.com/petite_fantasy/gallery/eyelesson/eye_paint_diagram.htm

23

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

References

• Medcyclopaedia Professional Edition online: http://www.amershamhealth.com/medcyclopaedia

• Netter, FH. Atlas of human anatomy. Summit, N.J. : CIBA- GEIGY Corp., 1995.

• Novelline, RA. Squire's fundamentals of radiology, 5th ed. Cambridge: Harvard University Press, 1997.

24

Gregory M. Sulkowski, HMS IVGillian Lieberman, MD

Acknowledgements

Thanks to:• Michael G. Morley, MD for plain films and

diagrams• Larry Barbaras our Webmaster• Gillian Lieberman, MD• Pamela Lepkowski• Sunana Sohi for screening the talk