Al-Azhar University-Gaza

Faculty of Applied Medical Sciences

Medical Imaging Department

Radiographic Positioning of Cranium,

Facial Bone & Paranasal Sinuses
Lecturer: Husam Mansour
Master of Public Health
Master of Medical Imaging

General Anatomy and Radiographic

Positioning Considerations of Cranium
Radiographic Anatomy
• The skull, or bony skeleton of the head, rests on the superior end
of the vertebral column. Divided into two main sets of bones:

8 cranial bones
14 facial bones

Cranial Bones (8)

The eight bones of the cranium are divided into the calvaria
(skullcap) and the floor. Each of these two areas primarily
consists of four bones:
Calvaria (Skullcap)
Floor
1. Frontal
5. Right temporal
2. Right parietal
6. Left temporal
3. Left parietal
7. Sphenoid
4. Occipital
8. Ethmoid
Cranial Topography Surface Landmarks:
1. Outer canthus of the eye: the point where the upper
and lower eyelids meet laterally.
2. Infra-orbital margin/point: inferior rim of the orbit,
lower margin of the eye socket and the maxillary part of the
margin of the orbit.
3. Nasion: the articulation between the nasal and frontal
bones.
4. Glabella: a bony prominence found on the frontal bone
immediately superior to the nasion.
5. Acanthion: A point lying near the base of the nose;
specifically, the point at the base of the anterior nasal spine
6. Vertex: the highest point of the skull in the median sagittal
plane.
7. External occipital protuberance (inion): a bony
prominence found on the occipital bone, usually coincident
with the median sagittal plane.
8. External auditory meatus: the opening within the ear
that leads into the external auditory canal.

Cranial Positioning Lines

1. Inter-orbital (inter-pupillary) line: joins the centre of the two
orbits or the centre of the two pupils when the eyes are looking
straight forward.
2. Infra-orbital line: joints the two infra-orbital points.
3. Anthropological baseline: passes from the infra-orbital point to
the upper border of the external auditory meatus (also known as
the Frankfurter line).
4. Orbito-meatal base line (radiographic baseline): extends
from the outer canthus of the eye to the centre of the external
auditory meatus. This line is angled approximately 10 degrees to the
anthropological baseline.
Cranial Positioning Planes
1. Median sagittal plane: divides the skull into right and left
halves. Landmarks on this plane are the nasion anteriorly
and the external occipital protuberance (inion) posteriorly.
2. Coronal planes: these are at right-angles to the median
sagittal plane and divide the head into anterior and
posterior parts.

1. Anthropological plane: a horizontal plane containing the

two anthropological baselines and the infra-orbital line. It is
an example of an axial plane. Axial planes are parallel with
this plane.
2. Auricular plane: perpendicular to the anthropological
plane. Passes through the centre of the two external
auditory meatuses. It is an example of a coronal plane.

Note: The median sagittal, anthropological and coronal planes are

mutually at right-angles.
Positioning Considerations
Erect versus Recumbent
• Projections of the skull may be taken with the patient in the
recumbent or erect position, depending on the patient's condition.
• Images can be obtained in the erect position with the use of a
standard x-ray table in the vertical position or an upright Bucky )A
Bucky is a component of x-ray units that holds the x-ray film
cassette (.
• The erect position allows the patient to be quickly and easily
positioned and permits the use of a horizontal beam.
• A horizontal beam is necessary to visualize any existing air-fluid
levels within the cranial or sinus cavities.
Patient preparation
Before the procedure:
1. All metal objects are removed.
2. Bunches of hair produce artifacts and thus should be untied.
3. If the area of interest includes the mouth, then false teeth
containing metal should be removed.
4. Clear explanation of movements and film positions to the
patient.

Hygiene
• Cranial and facial radiography may require the patient's face to be
in direct contact with the technologist's hands and the
table/upright Bucky surface.
• Therefore, it is important that proper hand washing techniques and
surface disinfectants be used before and after the examination.

Exposure Factors
Film/Screen
KV mAs FFD Focus Grid
combination
80 40 100 Fine Yes Regular
SID ) Source-to-Image Distance(
• The minimum SID with the image receptor in the table or upright
Bucky is 40 inches (100 cm).
Radiation Protection
The best techniques for minimizing radiation exposure to the patient
in skull radiography are to
(1) Use good collimation practices,
(2) Immobilize the head when necessary, minimizing repeats
(3) Center properly.
Gonadal shielding
• Generally, with accurate collimation, no detectable contribution to
gonadal exposure occurs during radiography of the skull. However,
lead shields should be used to reassure the patient.

Five Common Positioning Errors

• Five potential positioning errors related to cranial, facial
bone, and paranasal sinus positioning are as follows:
1. Rotation
2. Tilt
3. Excessive neck flexion
4. Excessive neck extension
5. Incorrect CR angle
Rotation—MSP is rotated, not parallel to tabletop and IR.

Tilt—MSP is tipped or slanted, not parallel to tabletop

 A:Excessive neck extension and B:Excessive neck flexion

PA Projection 0° CR
Pathology Demonstrated
• Skull fractures (medial and lateral displacement)
Technical Factors
• Minimum SID 40 inches (102 cm)
• IR size 24 × 30 cm (10 × 12 inches), lengthwise
• Grid
Patient Position
• Place the patient in a prone or seated position.
• Center the midsagittal plane of the patient’s body to the midline of
the grid.
• Rest the patient’s forehead and nose on the table or against the
upright Bucky.
• Flex the patient’s elbows, and place the arms in a comfortable
position.
Part Position
• Rest patient's nose and
forehead against table/Bucky
surface.
• Flex neck, aligning OML
perpendicular to IR.
• Align midsagittal plane
perpendicular to midline of
table/Bucky to prevent head
rotation and/or tilt (EAMs
same distance from table/Bucky
surface).

CR
• CR is perpendicular to IR (parallel to OML) and is centered to exit
at glabella.
Recommended Collimation
• Collimate on four sides to anatomy of interest. Adjust to 10 × 12
inches (24 × 30 cm) on the collimator
Respiration
• Suspend respiration during exposure.
Evaluation Criteria
Anatomy Demonstrated:
• Frontal bone, crista galli, internal auditory canals, frontal and
anterior ethmoid sinuses, petrous ridges, greater and lesser wings of
sphenoid, and dorsum sellae are shown.
Position:
• No rotation is evident, as indicated by equal distance bilaterally from
lateral orbital margin to lateral cortex of skull.
• Petrous ridges fill the orbits and level of the supraorbital margin.
• Posterior and anterior clinoids are visualized just superior to
ethmoid sinuses.
Exposure:
• Density (brightness) and contrast are sufficient to visualize frontal
bone and surrounding bony structures.
• Sharp bony margins indicate no motion.
PA Axial Projection: 15° CR (Caldwell Method) or
25° to 30° CR
Technical Factors
• Minimum SID 40 inches (102 cm)
• IR size 24 × 30 cm (10 × 12 inches), lengthwise
• Grid
Patient Position
• Place the patient in a prone or seated position.
• Center the midsagittal plane of the patient’s body to the midline of
the grid.
• Rest the patient’s forehead and nose on the table or against the
upright Bucky.
• Flex the patient’s elbows, and place the arms in a comfortable
position.

Part Position
• Rest patient's nose and forehead against table/Bucky surface.
• Flex neck, aligning OML perpendicular to IR.
• Align midsagittal plane perpendicular to midline of table/Bucky to
prevent head rotation and/or tilt (EAMs same distance from
table/Bucky surface).
• CR
• Angle CR 15° caudad, and center to exit at nasion.
• Alternative with CR 25° to 30° caudad, and center to exit at nasion.
Alternative AP axial projection
• For patients who are unable to be positioned for a PA projection
(e.g., trauma patients), an AP axial projection may be obtained with
the use of a 15° cephalic angle, with OML positioned perpendicular
to IR.
Evaluation Criteria
Anatomy Demonstrated:
• Greater and lesser sphenoid wings, frontal bone, superior orbital
fissures, frontal and anterior ethmoid sinuses, supraorbital margins, and
crista galli are demonstrated.
• PA with 25° to 30° Caudad Angle:
• In addition to the structures mentioned previously, the foramen
rotundum adjacent to each IOM is visualized, and the superior orbital
fissures are visualized within the orbits.
Position:
• No tilt with the MSP perpendicular to IR.
• No rotation as assessed by equal distance from the midlateral orbital
margins to the lateral cortex of the cranium on each side, superior
orbital fissures symmetric within the orbits, and correct extension of
neck (OML alignment).
Example: If the distance between the right lateral orbit and lateral
cranial cortex is greater than the left side, the face is rotated toward
the left side.
PA with 15° Caudad Angle:
• Petrous pyramids are projected into the lower one-third of the
orbits.
• Supraorbital margin is visualized without superimposition.

PA with 25° to 30° Caudad Angle:

• Petrous pyramids are projected at or just below the IOM to allow
visualization of the entire orbital margin.
• Collimation to area of interest.
Exposure:
• Density (brightness) and contrast are sufficient to visualize the
frontal bone and sellar structures without overexposure to perimeter
regions of skull.
• Sharp bony margins indicate no motion.
 Superior orbital fissures (black arrows),
the foramen rotundum (small white
arrows)

AP Projection Fronto-occipital View

• When the patient cannot be positioned for a PA projection, a similar but
magnified image can be obtained with an AP projection
Position of patient and part
• Patient lies supine on a Bucky table.
• Head is adjusted to bring the median sagittal plane at right angles to the
IR.
• The external auditory meatuses are equidistance from the IR
• The orbito meatal baseline should be perpendicular to the IR
Central ray
• Central ray is directed perpendicular to the IR along the medial sagittal
plane and throw nasion.
• The field should be set to include the vertex of the skull superiorly and
base of the occipital bone inferiorly.
Structures shown
• The structures shown on the AP projection are the same as
the structures shown on the PA projection.
• On the AP projection, the orbits are considerably magnified
because of the increased object–to–image receptor distance
(OID).
• Petrous pyramids filling orbits with a 0-degree central ray
angulation.
AP Axial Projection 15º Cephalic
Its alternative to PA Axial Projection 15° CR (Caldwell Method)
when the patient cannot be positioned for a PA projection, a similar
but magnified image can be obtained with an AP Axial projection
Position of patient and part
• The same in AP Projection
Central ray
• Central ray is directed to the nasion at an angle 15 degrees
cephalad
Structures shown
• Petrous pyramids lying in lower third of orbit
AP Axial Projection Towne Method
Position of patient and part
• Depress chin, bringing OML perpendicular to IR.
• For patients unable to flex the neck to this extent, align IOML
perpendicular to IR.
• Add radiolucent support under the head if needed
• Align MSP to CR and to midline of the grid or the table/imaging
device surface.
• Ensure that no head rotation or tilt exists.
• Ensure that the vertex of the skull is within collimation field.

Central ray
• Angle CR 30° caudad to OML, or 37° caudad to IOML
• Center at MSP 2.5 inches (6.5 cm) above the glabella to pass through the
foramen magnum at the level of the base of the occiput.
• Center IR to projected CR.
• NOTE: If patient is unable to depress the chin sufficiently to bring
OML perpendicular to IR even with a small sponge under the head,
IOML can be placed perpendicular instead and the CR angle increased
to 37° caudad.
• This maintains the 30° angle between OML and CR and demonstrates
the same anatomic relationships. (A 7° difference exists between
OML and IOML.)
Essential image characteristics

• The sella turcica is projected

with in the foramen magnum.

• Include all the occipital bone

and posterior parts of
parietal bone, and the
lambdoidal suture should be
visualized clearly.
Evaluation Criteria
Anatomy Demonstrated:
• Occipital bone, petrous pyramids, and foramen magnum are
demonstrated with the dorsum sellae and posterior clinoids
visualized in the shadow of the foramen magnum.
Position:
• Petrous ridges should be symmetric, indicating no rotation.
• Dorsum sellae and posterior clinoids visualized in the foramen
magnum indicate correct CR angle and proper neck
flexion/extension.

• Under angulation of CR or insufficient flexion of neck projects the

dorsum sellae superior to the foramen magnum.
• Over angulation of CR or excessive flexion superimposes the
posterior arch of C1 over the dorsum sellae within the foramen
magnum and produces foreshortening of the dorsum sellae..
• Shifting of the anterior or posterior clinoid processes laterally
within the foramen magnum indicates tilt.
• Collimation to area of interest.
Exposure:
• Density (brightness) and contrast are sufficient to visualize occipital
bone and sellar structures within foramen magnum.
• Sharp bony margins indicate no motion
PA Axial Projection: Haas Method
• This is an alternative projection for patients who cannot flex the
neck sufficiently for AP axial (Towne).
• It results in magnification of the occipital area but in lower doses
to facial structures and the thyroid gland.
• This projection is not recommended when the occipital bone is the
area of interest because of excessive magnification.
• Position of patient
• Adjust the patient in the prone or seated-upright position, and
center the midsagittal plane of the body to the midline of the grid.
• Flex the patient’s elbows, place the arms in a comfortable position,
and adjust the shoulders to lie in the same horizontal plane.

Position of part
• Rest the patient’s forehead and nose on the table, with the
midsagittal plane perpendicular to the midline of the grid.
• Adjust the flexion of the neck so that the OML is perpendicular to
the IR.
• For a localized image of the sellar region or the petrous pyramids,
or both, adjust the position of the IR so that the midpoint coincides
with the central ray; shift the IR cephalad approximately 3 inches
(7.6 cm) to include the vertex of the skull.
Central ray
• Angle CR 25° cephalad to OML.
• Center CR to MSP to pass through level of EAM and exit 1½
inches (4 cm) superior to the nasion.
Evaluation Criteria
Anatomy Demonstrated:
• Occipital bone, petrous pyramids, and foramen magnum are
demonstrated, with the dorsum sellae and posterior clinoid
processes visualized in the shadow of the foramen magnum.
Position:
• No rotation is evident, as indicated by bilateral symmetric
petrous ridges.
• Dorsum sellae and posterior clinoid processes are visualized
in the foramen magnum, which indicates correct CR angle
and proper neck position.
• No tilt as evidenced by correct placement of anterior
clinoid processes within the middle of the foramen magnum
Exposure:
• Density and contrast are sufficient to visualize occipital
bone and sellar structures within foramen magnum.
• Sharp bony margins indicate no motion.
Lateral Position: Right and Left Lateral
Position of patient
• Place the patient in the anterior oblique position, seated
upright or recumbent.
• If recumbent anterior oblique position is used, have the patient
rest on the forearm and flex the knee of the elevated side.
Position of part
• The side of interest closest to the IR.
• Adjust the patient’s head so that the midsagittal plane is
parallel to the plane of the IR.

• If necessary, place a support under the side of the mandible.

• Adjust the flexion of the patient’s neck so that the IOML
should be parallel to the long axis of the IR.
• GAL is parallel to front edge of IR.
• Check the head position so that the interpupillary line is
perpendicular to the IR.
Central ray
• Perpendicular, entering 2 inches (5 cm) superior to the EAM
• Center the IR to the central ray.
Recumbent Anterior
Oblique Position

Upright Anterior
Oblique Position
Evaluation Criteria
Anatomy Demonstrated:
• Entire cranium visualized and superimposed parietal bones
of cranium.
• The entire sella turcica, including anterior and posterior
clinoid processes and dorsum sellae, is also demonstrated.
• The sella turcica and clivus are demonstrated in profile.
Position:
• No rotation or tilt of the cranium is evident.
Lateral Position: Dorsal decubitus or supine lateral
position: R or L position
Dorsal decubitus
• With the patient supine, adjust the shoulders to lie in the
same horizontal plane.
• After ruling out cervical injury, place the side of interest
closest to the vertically placed grid IR.
• Elevate the patient’s head enough to center it to the IR, and
then support it on a radiolucent sponge.

• Adjust the patient’s head so that the midsagittal plane is

vertical and the interpupillary line is perpendicular to the
IR.
• Direct the central ray perpendicular to the IR, and center
it 2 inches (5 cm) superior to the EAM.
• Using the dorsal decubitus lateral projection to show
traumatic sphenoid sinus effusion.
• They stated that this finding may be the only clue to the
presence of a basal skull fracture.
Supine lateral
• Place the patient in a supine or recumbent posterior
oblique position, and turn the head toward the side being
examined.
• Elevate and support the opposite shoulder and hip enough
that the midsagittal plane of the head is parallel and the
interpupillary line is perpendicular to the IR.
• Support the patient’s head with a radiolucent sponge.
• Direct the central ray perpendicular to enter 2 inches (5
cm) superior to the EAM.
• • Center the IR to the central ray.
Submentovertical Projection: SMV : Schüller Method
Warning: Rule out cervical spine fracture or subluxation on
trauma patient before attempting this projection.
Positioning of patient :
• The success of the submentovertical (SMV) projection of the
cranial base depends on placing the IOML as nearly parallel with
the plane of the IR as possible and directing the central ray
perpendicular to the IOML.The following steps are taken:
• Place the patient in the supine or the seated-upright position; the
latter is more comfortable.

• If a chair that supports the back is used, the upright position

allows greater freedom in positioning the patient’s body to
place the IOML parallel with the IR.
• If the patient is seated far enough away from the vertical grid
device, the head can usually be adjusted without placing great
pressure on the neck.
• When the patient is placed in the supine position, elevate the
torso on firm pillows or a suitable pad to allow the head to
rest on the vertex with the neck in hyperextension.
• Flex the patient’s knees to relax the abdominal muscles.
• Place the patient’s arms in a comfortable position, and adjust the
shoulders to lie in the same horizontal plane.
• Do not keep the patient in the final adjustment longer than is
absolutely necessary because the supine position places
considerable strain on the neck.
• Position of part
• With the midsagittal plane of the patient’s body centered to the
midline of the grid, extend the patient’s neck to the greatest
extent as can be achieved, placing the IOML as parallel as possible
to the IR.
• Adjust the patient’s head so that the midsagittal plane is
perpendicular to the IR.

NOTE: Patients placed in the supine position for the cranial

base may have increased intracranial pressure. As a result, they
may be dizzy or unstable for a few minutes after having been
in this position. Use of the upright position may alleviate some
of this pressure
Central ray
• Directed through the sella turcica perpendicular to the IOML.
• Center 1½ inch (4 cm) inferior to the mandibular symphysis
• Center the IR to the central ray. The IR should be parallel to the
IOML.
Evaluation Criteria
Anatomy Demonstrated:
• Foramen ovale and spinosum, mandible, sphenoid and posterior
ethmoid sinuses, mastoid processes, petrous ridges, hard palate,
foramen magnum, and occipital bone are demonstrated.
Position:
• Correct extension of neck and relationship between IOML and
CR as indicated by mandibular mentum anterior to the ethmoid
sinuses.
• No rotation evidenced by the MSP parallel to edge of IR.
• No tilt evidenced by equal distance between mandibular ramus
and lateral cranial cortex..

EXAMPLE: If the distance on the left side between the

ramus and lateral cranium is greater on the left than the right,
the cranial vertex is tilted to the left.
Exposure:
• Density (brightness) and contrast are sufficient to visualize
clearly outline of ethmoid and sphenoid sinuses and cranial
foramen.
• Sharp bony margins indicate no motion.
Radiographic Positioning of Facial
Bone
Facial Bones
• The 14 facial bones contribute to the shape and form of a
person’s face.
• In addition, the cavities of the orbits, nose, and mouth are
largely constructed from the bones of the face.
• Of the 14 bones that make up the facial skeleton, only 2 are
single bones.
• The remaining 12 consist of six pairs of bones, with similar
bones on each side of the face.

• Facial Bones
• 2 Maxillae
• 2 Zygomatic bones
• 2 Lacrimal bones
• 2 Nasal bones
• 2 Inferior nasal conchae
• 2 Palatine bones
• 1 vomer
• 1 mandible
Lateral Position: Facial Bones Right and Left Lateral
This is the same basic position that is used for the lateral
skull position.
Position of patient
• Place the patient in the anterior oblique position, seated upright or
recumbent.
• If recumbent anterior oblique position is used, have the patient rest
on the forearm and flex the knee of the elevated side.
Position of part
• With the side of interest closest to the IR
• Adjust head into a true lateral position.

• Adjust the patient’s head so that the midsagittal plane is parallel to

the plane of the IR.
• Check the head position so that the interpupillary line is
perpendicular to the IR.
Central ray
• Perpendicular, enters lateral zygomatic bone ½ way between outer
canthus and EAM.
• Center the IR to the central ray.
Evaluation Criteria
Anatomy Demonstrated:
• Superimposed facial bones, greater wings of the sphenoid,
orbital roofs, sella turcica, zygoma, and mandible are
demonstrated.
• Position:
• Collimation to area of interest.
• 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
mandibular rami and 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.
Exposure:
• Density (brightness) and contrast are sufficient to visualize
bony detail of bony structures and surrounding skull.
• Sharp bony margins indicate no motion.
Parietoacanthial Projection: Facial Bones Waters
Method
Technical Factors
• Minimum SID 40 inches (102 cm)
• IR size 24 × 30 cm (10 × 12 inches), lengthwise
• Grid
Patient Position
• Place the patient in a prone or seated position.
• Center the midsagittal plane of the patient’s body to the midline
of the grid.
Part Position
• Rest the patient’s head on the tip of the extended chin.
Hyperextend the neck so that the orbitomeatal line (OML)
forms a 37-degree angle with the plane of the IR.

• The mentomeatal line (MML) is approximately perpendicular

to the plane of the IR; the average patient’s nose is about 3/4
inch (1.9 cm) away from the grid device.
• Adjust the head so that the midsagittal plane is
perpendicular to the plane of the IR.
• Center the IR at the level of the acanthion.
• Immobilize the head.
Central ray
• Perpendicular to exit the acanthion.
Respiration
• Suspend respiration during exposure.
Evaluation Criteria
Anatomy Demonstrated:
• IOMs, maxillae, nasal septum, zygomatic bones, zygomatic arches,
and anterior nasal spine.
Position:
• Correct neck extension demonstrates petrous ridges just inferior
to the maxillary sinuses.
• No patient rotation exists, as indicated by equal distance from the
mid lateral orbital margin to the lateral cortex of cranium on each
side.
• Collimation to area of interest
Exposure:
• Density (brightness) and contrast are sufficient to visualize frontal
bone and surrounding bony structures.
• Sharp bony margins indicate no motion.
PA Axial Projection: Facial Bones Caldwell
Method
Technical Factors
• Minimum SID 40 inches (102 cm)
• IR size 24 × 30 cm (10 × 12 inches), lengthwise
• Grid
Patient Position
• Place the patient in a prone or seated position.
• Center the midsagittal plane of the patient’s body to the
midline of the grid.
• Rest the patient’s forehead and nose on the table or against
the upright Bucky.
Part Position
• Rest patient's nose and forehead against table/Bucky surface.
• Flex neck, aligning OML perpendicular to IR.
• Align midsagittal plane perpendicular to midline of
table/Bucky to prevent head rotation and/or tilt (EAMs same
distance from table/Bucky surface).
Central ray
• Direct the central ray to exit the nasion at an angle of 15
degrees caudad.
• To show the orbital rims, in particular, the orbital floors, use
a 30-degree caudal angle (sometimes referred to as the
exaggerated Caldwell).
Evaluation Criteria
Anatomy Demonstrated:
• Orbital rim, maxillae, nasal septum, zygomatic bones, and
anterior nasal spine
Position:
• Correct patient position/CR angulation is indicated by
petrous ridges projected into the lower one-third of orbits
with 15° caudad CR.
• If the orbital floors are the area of interest, 30° caudad angle
projects the petrous ridges below the IOMs.

• 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.
• Collimation to area of interest
Exposure:
• Density (brightness) and contrast are sufficient to visualize
the frontal bone and sellar structures without
overexposure to perimeter regions of skull.
• Sharp bony margins indicate no motion.
Modified Parietoacanthial Projection: Facial
Bones Modified Waters Method
Technical Factors
• Minimum SID 40 inches (102 cm)
• IR size 24 × 30 cm (10 × 12 inches), lengthwise
• Grid
Patient Position
• Place the patient in a prone or seated position.
• Center the midsagittal plane of the patient’s body to the midline
of the grid.
Part Position
• Rest the patient’s head on the tip of the extended chin.
• Hyperextend the neck so that the orbitomeatal line (OML)
forms a 55 degree angle with the plane of the IR.
• Adjust head until LML is perpendicular to the plane of the
IR.
• Adjust the head so that the midsagittal plane is
perpendicular to the plane of the IR.
• Center the IR at the level of the acanthion.
• Immobilize the head.
Central ray
• Perpendicular to exit the acanthion.
Respiration
• Suspend respiration during exposure.
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.
• Exposure:
• Density (brightness) and contrast are sufficient to visualize frontal
bone and surrounding bony structures.
• Sharp bony margins indicate no motion.
Acanthioparietal Projection Reverse Waters
Method
• The reverse Waters method is used to show the facial bones
when the patient cannot be placed in the prone position.
Position of patient
• With the patient in the supine position, center the midsagittal
plane of the body to the midline of the grid.
Position of part
• Bringing the patient’s chin up, adjust the extension of the neck
so that the OML forms a 37-degree angle with the plane of
the IR.

• If necessary, place a support under the patient’s shoulders to

help extend the neck.
• The MML is approximately perpendicular to the plane of the
IR.
• Adjust the patient’s head so that the midsagittal plane is
perpendicular to the plane of the IR.
• Immobilize the head.
• Respiration: Suspend.
• Central ray
• Perpendicular to enter the acanthion and centered to the IR.
Structures shown
• The reverse Waters method shows the superior facial bones. The
image is similar to that obtained with the Waters method, but the
facial structures are considerably magnified.
• Evaluation Criteria
• Entire orbits and facial bones should be clearly shown.
• No rotation or tilt, demonstrated by: Distances between lateral
borders of the skull and orbits equal on each side. MSP of head
aligned with long axis of collimated field
• Petrous ridges projected below maxillary sinuses
• Brightness and contrast demonstrate soft tissue and bony trabecular
detail.
Acanthioparietal Facial Bones: Reverse Waters
Method with central ray parallel to MML.
• Trauma patients are often unable to hyperextend the neck far
enough to place the OML 37 degrees to the IR and the MML
perpendicular to the plane of the IR.
• In these patients, the acanthioparietal projection, or the
reverse Waters projection, can be achieved by adjusting the
central ray so that it enters the acanthion while remaining
parallel with the MML
Lateral Position: Nasal Bones Right and Left Lateral
Clinical Indications
• Nasal bone fractures
• Both sides should be examined for comparison, with side closest to
IR best demonstrated.
Technical Factors
• Minimum SID 40 inches (102 cm)
• IR size 18 × 24 cm (8 × 10 inches), lengthwise
• Non Grid
Position of patient
• Place the patient in the anterior oblique position, seated upright or
recumbent.
Position of part
• Position nasal bones to center of IR.
• With the side of interest closest to the IR
• Adjust head into a true lateral position.
• Adjust the patient’s head so that the midsagittal plane is parallel to
the plane of the IR.
• Check the head position so that the interpupillary line is
perpendicular to the IR.
Central ray
• Align CR perpendicular to IR.
• Center CR to 1/2 inch (1.25 cm) distal to the nasion.
Evaluation Criteria
Anatomy Demonstrated:
• Nasal bones with soft tissue nasal structures, the frontonasal
suture, and the anterior nasal spine are demonstrated.
• Position:
• Nasal bones are demonstrated without rotation.
• Collimation to area of interest.
Exposure:
• Density (brightness) and contrast are sufficient to visualize
nasal bony detail from the surrounding skull.
• Sharp bony margins indicate no motion.
Superoinferior Tangential (Axial) Projection: Nasal
Bones
Clinical Indications
• Fractures of the nasal bones (medial or lateral displacement)
Patient Position
• Patient is seated erect in a chair at end of table or in the prone
position on table.
Part Position
• Extend and rest chin on IR. Place angled support under IR, as
demonstrated, to place IR perpendicular to GAL.
• Align MSP perpendicular to CR and to IR midline
 Central ray
Center CR to nasion and angle as needed to ensure that it is parallel
to GAL.

Evaluation Criteria
Anatomy Demonstrated:
• Tangential projection of mid nasal and distal nasal bones (with little
superimposition of the glabella or alveolar ridge) and nasal soft
tissue. Petrous ridges are inferior to maxillary sinuses.
• Position:
• No patient rotation is evident, as indicated by equal distance from
anterior nasal spine to outer soft tissue borders on each side.
• Incorrect neck position is indicated by visualization of alveolar ridge
(excessive extension) or visualization of too much glabella
(excessive flexion).
Exposure:
• Density (brightness) and contrast are sufficient to visualize nasal
bones and nasal soft tissue.
Submentovertical Projection: SMV Zygomatic Arches
This projection is similar to the submentovertical (SMV) projection
described in the Skull Radiography section.
Warning: Rule out cervical spine fracture or subluxation on
trauma patient before attempting this projection.
Positioning of patient :
• The success of the submentovertical (SMV) projection of the
cranial base and Zygomatic Arches depends on placing the IOML
as nearly parallel with the plane of the IR as possible and directing
the central ray perpendicular to the IOML. The following steps are
taken:
• Place the patient in the supine or the seated-upright position; the
latter is more comfortable.
• If a chair that supports the back is used, the upright position allows
greater freedom in positioning the patient’s body to place the IOML
parallel with the IR.
• If the patient is seated far enough away from the vertical grid device,
the head can usually be adjusted without placing great pressure on
the neck.
• When the patient is placed in the supine position, elevate the torso
on firm pillows or a suitable pad to allow the head to rest on the
vertex with the neck in hyperextension.
• Flex the patient’s knees to relax the abdominal muscles.

• Place the patient’s arms in a comfortable position, and adjust the

shoulders to lie in the same horizontal plane.
• Do not keep the patient in the final adjustment longer than is
absolutely necessary because the supine position places considerable
strain on the neck.
• Position of part
• With the midsagittal plane of the patient’s body centered to the
midline of the grid, extend the patient’s neck to the greatest extent
as can be achieved, placing the IOML as parallel as possible to the IR.
• Adjust the patient’s head so that the midsagittal plane is
perpendicular to the IR.
NOTE: Patients placed in the supine position for the cranial base may
have increased intracranial pressure. As a result, they may be dizzy or
unstable for a few minutes after having been in this position. Use of
the upright position may alleviate some of this pressure

Central ray
• Directed through the sella turcica perpendicular to the IOML.

• Center 1½ inch (4 cm) inferior to the mandibular symphysis

• Center the IR to the central ray. The IR should be parallel to the

IOML.
Evaluation Criteria
Anatomy Demonstrated:
• Zygomatic arches are demonstrated laterally from each mandibular
ramus.
Position:
• Correct IOML/CR relationship, as indicated by superimposition of
mandibular symphysis on frontal bone
• No patient rotation, as indicated by zygomatic arches visualized
symmetrically.
Exposure:
• Sufficient contrast and density (brightness) to visualize zygomatic
arches.
• Sharp bony margins indicate no motion.
Oblique Inferosuperior (Tangential) Projection: Zygomatic
Arches
Positioning of patient :
• Place the patient in the supine or the seated-upright position; the
latter is more comfortable.
• Hyperextend the patient’s neck, and rest the head on its vertex.
• Adjust the position of the patient’s head so that the IOML is as
parallel as possible with the plane of the IR.
• Rotate head 15° toward side to be examined; also tilt chin 15°
toward side of interest.
• Central ray:
• Perpendicular to the IOML and centered to the zygomatic arch at a
point approximately 1 inch (2.5 cm) posterior to the outer canthus
Evaluation Criteria
Anatomy Demonstrated:
• Single zygomatic arch, free of superimposition, is shown.
• Position:
• Correct patient position provides for demonstration of zygomatic
arch without superimposition of parietal bone or mandible.
• Exposure:
• Sufficient contrast and density (brightness) to visualize zygomatic
arche.
• Sharp bony margins indicate no motion.
AP Axial Projection Zygomatic Arches: Modified Towne
Method
Position of patient and part
• Depress chin, bringing OML perpendicular to IR.
• For patients unable to flex the neck to this extent, align IOML
perpendicular to IR.
• Align MSP to CR and to midline of the grid or the table/imaging
device surface.
• Ensure that no head rotation or tilt exists.
Central ray
• Angle CR 30° caudad to OML, or 37° caudad to IOML
• Directed to enter the glabella approximately 1 inch (2.5 cm) above
the nasion.
Evaluation Criteria
Anatomy Demonstrated:
• Bilateral zygomatic arches, free of superimposition, are shown.
• Position:
• Zygomatic arches are visualized without patient rotation as
indicated by symmetric appearance of arches bilaterally.
Exposure:
• Density (brightness) and contrast are sufficient to visualize
zygomatic arches.
• Sharp bony margins indicate no motion
Parieto-orbital Oblique Projection: Optic Foramina
Clinical Indications
• Bony abnormalities of the optic foramen
• Demonstrate lateral margins of orbits and foreign bodies within eye
Notes: CT is the preferred modality for a detailed investigation of the
optic foramina. Radiographs of both sides generally are taken for
comparison.
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 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)
Center Ray
• Align CR perpendicular to IR at the midportion of the downside
orbit.
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.
• Exposure:
• Sufficient contrast and density (brightness) to visualize optic
foramen.
• Sharp bony margins indicate no motion.
PA Projection : Mandibular Rami
Patient Position
• Place the patient in a prone or seated position.
• Center the midsagittal plane of the patient’s body to the midline of
the grid.
• Rest the patient’s forehead and nose on the table or against the
upright Bucky.
• Flex neck, aligning OML perpendicular to IR.
• Note: For trauma patients, this position is best performed supine.
Center Ray
• Align CR perpendicular to IR, centered to exit at junction of lips.
Structures shown
• PA projection shows the mandibular body and rami. The central
part of the body is not well shown because of the superimposed
spine.
• This radiographic approach is usually employed to show medial or
lateral displacement of fragments in fractures of the rami.
Evaluation Criteria
• Evidence of proper collimation
• No rotation or tilt, demonstrated by: Mandibular body and rami
symmetric on each side. MSP of head aligned with long axis of
collimated field
• Brightness and contrast demonstrating soft tissues and bony
trabecular detail.
PA Axial Projection : Mandibular Rami
Patient Position
• Place the patient in a prone or seated position.
• Center the midsagittal plane of the patient’s body to the midline of
the grid.
• Rest the patient’s forehead and nose on the table or against the
upright Bucky.
• Flex the patient’s elbows, and place the arms in a comfortable
position.
• Flex neck, aligning OML perpendicular to IR.
• Note: For trauma patients, this position is best performed supine.
• Center Ray
• Directed 20 or 25 degrees cephalad to exit at the acanthion.
Structures shown
• PA axial projection shows the mandibular body, rami and condylar
processes. The central part of the body is not well shown because
of the superimposed spine.
• This radiographic approach is usually employed to show medial or
lateral displacement of fragments in fractures of the rami.
Evaluation Criteria
• Evidence of proper collimation
• No rotation or tilt, demonstrated by: Mandibular body and rami
symmetric on each side. MSP of head aligned with long axis of
collimated field
• Brightness and contrast demonstrating soft tissues and bony
trabecular detail.
PA Projection : Mandibular Body
Patient Position
• Place the patient in a prone or seated position.
• Center the midsagittal plane of the patient’s body to the midline of
the grid.
• With the midsagittal plane of the patient’s head centered to the
midline of the IR, rest the head on the nose and chin so that the
anterior surface of the mandibular symphysis is parallel with the
plane of the IR.
• This position places the acanthiomeatal line (AML) nearly
perpendicular to the IR plane.
• Center Ray
• Align CR perpendicular to IR, centered to exit at junction of lips.
Structures shown
• This image shows the mandibular body
• Evaluation Criteria
• The following should be clearly shown:
• Evidence of proper collimation
• Entire mandible
• No rotation or tilt, demonstrated by:
1. Mandibular body and rami symmetric on each side.
2. MSP of head aligned with long axis of collimated field
• Brightness and contrast demonstrating soft tissues and bony
trabecular detail.
PA Axial Projection : Mandibular Body
Patient Position
• Place the patient in a prone or seated position.
• Center the midsagittal plane of the patient’s body to the midline of
the grid.
• With the midsagittal plane of the patient’s head centered to the
midline of the IR, rest the head on the nose and chin so that the
anterior surface of the mandibular symphysis is parallel with the
plane of the IR.
• This position places the acanthiomeatal line (AML) nearly
perpendicular to the IR plane.
• Center Ray
• Directed midway between the temporomandibular joints (TMJs) at
an angle of 30 degrees cephalad.
Structures shown
• This image shows the mandibular body and TMJs
• Evaluation Criteria
• The following should be clearly shown:
• Evidence of proper collimation
• Entire mandible
• No rotation or tilt, demonstrated by:
1. Mandibular body and rami symmetric on each side.
2. MSP of head aligned with long axis of collimated field
• Brightness and contrast demonstrating soft tissues and bony
trabecular detail.
Submentovertical Projection: SMV Mandible
Positioning of patient :
• The success of the submentovertical (SMV) projection depends on
placing the IOML as nearly parallel with the plane of the IR as
possible and directing the central ray perpendicular to the IOML.
• Place the patient in the supine or the seated-upright position; the
latter is more comfortable.
• If a chair that supports the back is used, the upright position allows
greater freedom in positioning the patient’s body to place the IOML
parallel with the IR.
• When the patient is placed in the supine position, elevate the torso
on firm pillows or a suitable pad to allow the head to rest on the
vertex with the neck in hyperextension.

• Place the patient’s arms in a comfortable position, and adjust the

shoulders to lie in the same horizontal plane.
• Do not keep the patient in the final adjustment longer than is
absolutely necessary because the supine position places considerable
strain on the neck.
• Position of part
• With the midsagittal plane of the patient’s body centered to the
midline of the grid, extend the patient’s neck to the greatest extent
as can be achieved, placing the IOML as parallel as possible to the IR.
• Adjust the patient’s head so that the midsagittal plane is
perpendicular to the IR.
Central ray
• Center CR to a point midway between angles of mandible or at a
level 1½ inch (4 cm) inferior to mandibular symphysis.
Evaluation Criteria
Anatomy Demonstrated:
• Entire mandible and coronoid and condyloid processes are
demonstrated.
• Position:
• Correct neck extension is indicated by the following: mandibular
symphysis superimposing frontal bone; mandibular condyles
projected anterior to petrous ridges.
• No patient tilt as evidenced by equal distance from mandible to
lateral border of skull. No patient rotation as evidenced by
symmetric mandibular condyles.
• Exposure:
• Sufficient contrast and density (brightness) to visualize mandible
superimposed on the skull. Sharp bony margins indicate no motion.
• AP Axial Projection Mandible:Towne Method
• Position of patient and part
• Patient position is erect or supine.
• Rest patient’s posterior skull against table/upright imaging device
surface.
• Depress chin, bringing OML perpendicular to IR.
• For patients unable to flex the neck to this extent, align IOML
perpendicular to IR.
• Align MSP to CR and to midline of the grid or the table/imaging
device surface.
• Ensure that no head rotation or tilt exists.
• Central ray
• Angle CR 35° caudad to OML, or 42° caudad to IOML. Directed to
enter the glabella
Evaluation Criteria
Anatomy Demonstrated:
• Condyloid processes of mandible and TM fossae.
Position:
• A correctly positioned image with no rotation demonstrates the
following: condyloid processes visualized symmetrically, lateral to
the cervical spine; clear visualization of condyle/TM fossae
relationship, with minimal superimposition of the TM fossae and
mastoid portions.
Exposure:
• Density (brightness) and contrast are sufficient to visualize
condyloid process and TM fossa.
• Sharp bony margins indicate no motion.
Axiolateral and Axiolateral Oblique Projection
Patient Position
• Place the patient in the seated, semi-prone, or semi-supine position.
Position of part
• Place the patient’s head in a lateral position with the interpupillary
line perpendicular to the IR. The mouth should be closed with the
teeth together.
• Extend the patient’s neck enough that the long axis of the
mandibular body is parallel with the transverse axis of the IR to
prevent superimposition of the cervical spine.

• If the projection is to be performed on the tabletop, position the IR

so that the complete body of the mandible is on the IR.
• Adjust the rotation of the patient’s head to place the area of
interest parallel to the IR, as follows.
Ramus
• Keep the patient’s head in a true lateral position.
Body
• Rotate the patient’s head 30 degrees toward the IR.
Symphysis
• Rotate the patient’s head 45 degrees toward the IR.
• General survey of the mandible
• 10° to 15° rotation best provides
NOTE: When the patient is in the semi-supine position, place the IR
on a wedge device or wedge sponge. Ensure that combined CR angle
and midsagittal plane tilt equals 25 degrees.
Center Ray
• Directed 25 degrees cephalad to pass directly through the
mandibular region of interest.
• Center the IR to the central ray for projections done on upright
grid units.
Collimation
• •Adjust to 8 × 10 inches (18 × 24 cm) on the collimator.

Axiolateral mandibular ramus Axiolateral oblique mandibular body

Axiolateral oblique mandibular Semi-supine axiolateral oblique
symphysis mandibular body and symphysis.

Horizontal beam trauma Erect—15° head tilt toward IR

projection—25° cephalad; 5° to and 10° CR angle.
10° posteriorly; left lateral.
Structures shown
• Each axiolateral oblique projection shows the region of the
mandible that was parallel with the IR.
Evaluation Criteria
• The following should be clearly shown:
Ramus and Body
• No overlap of the ramus by the opposite side of the mandible.
• No elongation or foreshortening of ramus or body.
• No superimposition of the ramus by the cervical spine.
Symphysis
• No overlap of the mentum region by the opposite side of the
mandible.
• No foreshortening of the mentum region.

Axiolateral oblique mandibular ramus

Axiolateral oblique mandibular symphysis

Axiolateral (general survey)

• AP Axial Projection Mandible:Towne Method
• Position of patient and part
• Patient position is erect or supine.
• Rest patient’s posterior skull against table/upright imaging device
surface.
• Depress chin, bringing OML perpendicular to IR.
• For patients unable to flex the neck to this extent, align IOML
perpendicular to IR.
• Align MSP to CR and to midline of the grid or the table/imaging
device surface.
• Ensure that no head rotation or tilt exists.
• Central ray
• Angle CR 35° caudad to OML, or 42° caudad to IOML. Directed to
enter 3 inches (7.6 cm) superior to the nasion
Evaluation Criteria
Anatomy Demonstrated:
• Condyloid processes of mandible and TM fossae.
Position:
• A correctly positioned image with no rotation demonstrates the
following: condyloid processes visualized symmetrically, lateral to
the cervical spine; clear visualization of condyle/TM fossae
relationship.
Exposure:
• Density (brightness) and contrast are sufficient to visualize
condyloid process and TM fossa.
• Sharp bony margins indicate no motion.

AP axial TMJs: mouth closed AP axial TMJs: mouth open

Axiolateral Projection: Schuller 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.
• Examine both sides for comparison.
Patient Position
• Place the patient in the seated, semi-prone, or semi-supine position.
• Place the head in a true lateral position, with side of interest
nearest IR

Position of part
• 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.
• Center Ray
• 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.
• Exposure:
• Contrast and density (brightness) are sufficient to visualize TMJ.
• Sharp bony margins indicate no motion.

Closed mouth Open mouth

Axiolateral Oblique Projection: 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.
• Examine both sides for comparison.
Patient Position
• Place the patient in the seated, semi-prone, or semi-supine position.
• Place the head in a true lateral position, with side of interest
nearest IR

Position of part
• 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.
• From lateral position, rotate face toward IR 15° (with MSP of head
rotated 15° from plane of IR).
• Center Ray
• Angle CR 15° caudad, centered to 11/2 inches (4 cm) superior to
upside EAM (to pass through downside 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:
• 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.
• Exposure:
• Contrast and density (brightness) are sufficient to visualize TMJ.
• Sharp bony margins indicate no motion.

Closed mouth Open mouth

 Radiographic Positioning of
Paranasal Sinuses

Paranasal Sinuses
• The large, air-filled cavities of the paranasal sinuses are sometimes
called the accessory nasal sinuses because they are lined with
mucous membrane, which is continuous with the nasal cavity.
• These sinuses are divided into four groups, according to the bones
that contain them:
1. Maxillary (2) Maxillary (facial) bones

2. Frontal (usually 2) Frontal (cranial) bones

3. Ethmoid (many) Ethmoid (cranial) bones

4. Sphenoid (1 or 2) Sphenoid (cranial) bone

• Only the maxillary sinuses are part of the facial bone structure.
• The frontal, ethmoid, and sphenoid sinuses are contained within
their respective cranial bones.
• The paranasal sinuses begin to develop in the fetus, but only the
maxillary sinuses exhibit a definite cavity at birth.
• The frontal and sphenoid sinuses begin to be visible on radiographs
at age 6 or 7y.
• The ethmoid sinuses develop last.
• All the paranasal sinuses generally are fully developed by the late
teenage years.
 Technical Factors
• A medium kV range of 70 to 80 is commonly used to provide
sufficient contrast of the air-filled paranasal sinuses.
• A small focal spot should be used for maximum detail.
• As with cranial and facial bone imaging, gonadal shielding is not
useful in reducing gonadal exposure, but shields over the pelvic
area may be used for patient reassurance.
• Close collimation and elimination of unnecessary repeats are the
best measures for reducing radiation dose in sinus and temporal
bone radiography.

Lateral Position: Sinuses Right and Left Lateral

Clinical Indications
• Inflammatory conditions (sinusitis, secondary osteomyelitis)
• Sinus polyps or cysts
Position of patient
• Seat the patient before a vertical grid device with the body placed
in the RAO or LAO position so that the head can be adjusted in a
true lateral position. This is the same basic position that is used for
the lateral skull and facial bone positions.
• Position of part
• With the side of interest closest to the IR
• Adjust head into a true lateral position.
• Adjust the patient’s head so that the midsagittal plane is parallel to
the plane of the IR.
• Check the head position so that the interpupillary line is
perpendicular to the IR.
Central ray
• Align horizontal Cr perpendicular to IR.
• Center CR to a point midway between outer canthus and EAM or
½ to 1 inch (1.3 to 2.5 cm) posterior to the outer canthus
• Center the IR to the central ray.
NOTES:
• To visualize air-fluid levels, an erect position with a horizontal beam
is required.
• Fluid within the paranasal sinus cavities is thick and gelatin-like,
causing it to cling to the cavity walls.
• To visualize this fluid, allow a short time (at least 5 minutes) for the
fluid to settle after patient’s position has been changed (i.e., from
recumbent to erect).
• If patient is unable to be placed in the upright position, the image
may be obtained with the use of a horizontal beam, similar to
trauma lateral facial bones

Evaluation Criteria
Anatomy Demonstrated:
• All four paranasal sinus groups are shown.
Position:
• Accurately positioned cranium without rotation or tilt.
• Rotation is evident by anterior and posterior separation of
symmetric bilateral structures such as the mandibular rami and
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
Exposure:
• Density (brightness) and contrast are sufficient to visualize sphenoid
sinuses through the cranium without overexposing the maxillary
and frontal sinuses.
• Sharp bony margins indicate no motion.
PA Axial Projection: Sinuses Caldwell Method
• Because sinus images should always be obtained with the patient in
the upright body position and with a horizontal direction of the
central ray, the Caldwell method is easily modified when a head unit
or other vertical grid device capable of angular adjustment is used.
• For the modification, all anatomic landmarks and localization planes
remain unchanged.
Patient Position
• Seat the patient facing a vertical grid device.
• Center the midsagittal plane of the patient’s body to the midline of
the grid
Part Position
Angled grid technique
• Before positioning the patient, tilt the vertical grid device down so
that an angle of 15 degrees is obtained.
• Rest the patient’s nose and forehead on the vertical grid device, and
center the nasion to the IR.
• Adjust the midsagittal plane and orbitomeatal line (OML) of the
patient’s head perpendicular to the plane of the IR.
• This positioning places the OML perpendicular to the angled IR and
15 degrees from the horizontal central ray.
Vertical grid technique
• When the vertical grid device cannot be angled, extend the patient’s
neck slightly, rest the tip of the nose on the grid device, and center
the nasion to the IR.
• Position the patient’s head so that the OML forms an angle of 15
degrees with the horizontal central ray.
• For support, place a radiolucent sponge between the forehead and
the grid device.
• Adjust the midsagittal plane of the patient’s head perpendicular to
the plane of the IR.
Evaluation Criteria
Anatomy Demonstrated:
• Frontal sinuses projected above the frontonasal suture are
demonstrated.
• Anterior ethmoid air cells are visualized lateral to each nasal bone,
directly below the frontal sinuses.
Position:
• Accurately positioned cranium with no rotation or tilt is indicated
by the following:
1. Equal distance from the lateral margin of the orbit to the lateral
cortex of the cranium on both sides.

2. Equal distance from the MSP (identified by the crista galli) to the
lateral orbital margin on both sides; superior orbital fissures
symmetrically visualized within the orbits.
3. Correct alignment of OML and CR projects petrous ridges into
lower one-third of orbits.
• Collimation to area of interest.
• Exposure:
• Density (brightness) and contrast are sufficient to visualize the
frontal and ethmoid sinuses.
• Sharp bony margins indicate no motion
Parietoacanthial Projection: Sinuses Waters Method
Patient Position
• Place the patient seated in an upright position, facing the vertical
grid device.
• Center the midsagittal plane of the patient’s body to the midline
of the grid device.
Part Position
• Because this position is uncomfortable for the patient to hold,
have the IR and equipment in position so that the examination
can be performed quickly.
• Hyperextend the patient’s neck to approximately the correct
position, and then center the IR to the acanthion.
• Rest the patient’s chin on the vertical grid device and adjust it so
that the midsagittal plane is perpendicular to the plane of the IR.
• Using a protractor as a guide, adjust the head so that the OML
forms an angle of 37 degrees from the plane of the IR.
• As a positioning check for the average shaped skull, the
mentomeatal (MML) line should be approximately perpendicular to
the IR plane.
• Immobilize the head.
Respiration
• Suspend respiration during exposure.
Central ray
• Horizontal to the IR and exiting the acanthion
 Proper positioning diagram. Improper positioning diagram.
Petrous ridges are projected Petrous ridges are superimposed
below maxillary sinuses. on maxillary sinuses.

Evaluation Criteria
Anatomy Demonstrated:
• Maxillary sinuses with the inferior aspect visualized free from
superimposing alveolar processes and petrous ridges, the inferior
orbital rim, and an oblique view of the frontal sinuses.
• Position:
• No rotation of the cranium is indicated by the following: equal
distance from MSP (identified by the bony nasal septum) to lateral
orbital margin on both sides; equal distance from the lateral orbital
margin to the lateral cortex of the cranium on both sides.
• Adequate extension of neck demonstrates petrous ridges just
inferior to the maxillary sinuses.
Exposure:
• Density and contrast are sufficient to visualize maxillary sinuses
• Sharp bony margins indicate no motion.
Parietoacanthial Projection: Sinuses Open-mouth
Waters Method
• This method provides an excellent demonstration of the sphenoidal
sinuses projected through the open mouth.
• For patients who cannot be placed in position for the
submentovertical (SMV) projection, the open-mouth Waters
method and lateral projections may be the only techniques to show
the sphenoidal sinuses.
• Because the open-mouth position is uncomfortable for the patient
to hold, the radiographer must have the IR and equipment in
position to perform the examination quickly.
Patient Position
• Place the patient seated in an upright position, facing the vertical
grid device.
• Center the midsagittal plane of the patient’s body to the midline of
the grid device.
Part Position
• Hyperextend the patient’s neck to approximately the correct
position, and then position the IR to the acanthion.
• Rest the patient’s chin on the vertical grid device, and adjust it so
that the midsagittal plane is perpendicular to the plane of the IR.

• Using a protractor as a guide, adjust the patient’s head so that the

OML forms an angle of 37 degrees from the plane of the IR. The
MML would not be perpendicular.
• Have the patient slowly open the mouth wide open while holding
the position.
• Immobilize the head.
Respiration
• Suspend respiration during exposure.
Central ray
• Horizontal to the IR and exiting the acanthion
Evaluation Criteria
Anatomy Demonstrated:
• Maxillary sinuses with the inferior aspect visualized, free from
superimposing alveolar processes and petrous ridges, the inferior
orbital rim, an oblique view of the frontal sinuses, and the sphenoid
sinuses visualized through the open mouth.
Position:
• No rotation of the cranium is indicated by the following: equal
distance from the MSP (identified by the bony nasal septum) to the
lateral orbital margin on both sides; equal distance from the lateral
orbital margin to the lateral cortex of the cranium on both sides;
accurate extension of the neck demonstrating petrous ridges just
inferior to the maxillary sinuses.
Exposure:
• Density and contrast are sufficient to visualize maxillary sinuses
• Sharp bony margins indicate no motion.
Submentovertical SMV Projection: Sinuses
Patient Position
• The success of the SMV projection depends on placing the IOML as
nearly parallel as possible with the plane of the IR and directing the
central ray perpendicular to the IOML.
• The upright position is recommended for all paranasal sinus images
and is more comfortable for the patient.
• The following steps are observed:
• Use a chair that supports the patient’s back to obtain greater
freedom in positioning the patient’s body to place the IOML parallel
with the IR.
• Seat the patient far enough away from the vertical grid device that
the head can be fully extended.
• If necessary to examine short-necked or hypersthenic patients,
angle the vertical grid device downward to achieve a parallel
relationship between the grid and the IOML.
• The disadvantage of angling the vertical grid device is that the
central ray is not horizontal, and air-fluid levels may not be shown
as easily as when the central ray is truly horizontal.

Part Position
• Hyperextend the patient’s neck as far as possible, and rest the head
on its vertex.
• If the patient’s mouth opens during hyperextension, ask the patient
to keep the mouth closed to move the mandibular symphysis
anteriorly.
• Adjust the patient’s head so that the midsagittal plane is
perpendicular to the midline of the IR.
• Adjust the tube so that the central ray is perpendicular to the
IOML.
• Immobilize the patient’s head. In the absence of a head clamp, place
a suitably backed strip of adhesive tape across the tip of the chin and
anchor it to the sides of the radiographic unit.
• Do not put the adhesive surface directly on the patient’s skin.
Respiration
• Suspend respiration during exposure.
Central ray
• Horizontal and perpendicular to the IOML through the sella turcica.
• The central ray enters on the midsagittal plane approximately 3/4
inch (1.9 cm) anterior to the level of the external acoustic meatus.
OR: The central ray centered midway between angles of mandible, at a
level 11/2 to 2 inches (4 to 5 cm) inferior to mandibular symphysis
Evaluation Criteria
Anatomy Demonstrated:
• Sphenoid sinuses, ethmoid sinuses, nasal fossae, and maxillary
sinuses are demonstrated.
• Position:
• Accurate IOML and CR relationship is demonstrated by the
following:
• Correct extension of neck and relationship between IOML and CR
as indicated by mandibular mentum anterior to ethmoid sinuses.
• No rotation evidenced by MSP parallel to edge of IR.
• No tilt evidenced by equal distance between mandibular ramus and
lateral cranial cortex.
• Exposure:
• Density and contrast are sufficient to visualize sphenoid and
ethmoid sinuses. Sharp bony margins indicate no motion.