UNDERGRADUATE ENT

RADIOLOGY

DR. DAVIS THOMAS PULIMOOTTIL

7 THINGS TO MENTION IN EACH X-
RAY:

1. Plain / contrast
2. X-ray / CT / MRI
3. Part of body (both mastoids / nose and PNS)
4. View (Law’s view / Water’s view/ AP view)
5. Normal structures (list anterior -posterior or
superior –inferior)
6. Abnormal pathology or anatomical variant
7. Probable diagnosis
 PLAIN X-RAY BOTH
MASTOIDS LAWS VIEW
PLAIN X-RAY BOTH MASTOIDS
LAWS VIEW
 PLAIN X-RAY BOTH MASTOIDS LAWS
VIEW
 Why take X-ray of both mastoids?
 To compare the normal anatomy of the 2 sides

 What is Law’s view?

 15° lateral oblique view

 Why take Law’s view?

 To prevent superimposition of one mastoid over the opposite
mastoid
 To cause superimposition of the external and internal auditory
canal
 PLAIN X-RAY BOTH MASTOIDS LAWS
VIEW
 Types of pneumatisation of mastoid:
 Cellular: 80% of the normal population
 Diploeic: 15% of normal population
 Sclerotic: 5% of normal population

 If Xray mastoids shows bilateral sclerotic mastoids,

what is the diagnosis?
 It may be either bilateral CSOM or may be a normal
variant as 5% of normal population have sclerotic
mastoids
 PLAIN X-RAY BOTH MASTOIDS LAWS
VIEW
 Normal structures seen on X-ray both mastoids
Law’s view (from anterior to posterior):
 Condyle of mandible
 Glenoid fossa
 External and internal auditory canals superimposed
upon each other
 Tegmen plate (corresponds to middle fossa dura)
 Sinus plate (corresponds to sigmoid sinus)
 Sinodural angle (Citelli’s angle)
 Mastoid air cells
PLAIN X-RAY BOTH MASTOIDS
LAWS VIEW
 PLAIN X-RAY BOTH MASTOIDS LAWS
VIEW
 Differences between Cholesteatoma cavity and
post-mastoidectomy cavity:
Cholesteatoma cavity Post-mastoidectomy cavity

Margins are regular Margins are irregular (due to new bone

formation)

Sclerosis of margins present (due to No sclerosis of margins

ongoing inflammatory process)

Cotton-wool appearance of -
cholesteatoma in the centre of the
cavity
Rim of air between the cotton-wool -
appearance and the margin of the
cavity
 PLAIN X-RAY BOTH MASTOIDS
LAWS VIEW
 Differential diagnosis of cavity on X-ray
mastoids:
 1. Cholesteatoma cavity
 2. Post-mastoidectomy cavity
 3. Mega-antrum
 4. Dehiscent high rising jugular bulb
 5. Forward lying sigmoid sinus
 6. Eosinophilic granuloma
 7. Cholesterol granuloma
 8. Tuberculosis
 9. Malignancy temporal bone
 10. Long-standing / retained foreign body in mastoid
 PLAIN X-RAY NOSE AND
PARANASAL SINUSES WATER’S
VIEW
PLAIN X-RAY NOSE AND PARANASAL
SINUSES WATER’S VIEW
PLAIN X-RAY NOSE AND PARANASAL
SINUSES WATER’S VIEW
PLAIN X-RAY NOSE AND PARANASAL
SINUSES WATER’S VIEW
PLAIN X-RAY NOSE AND PARANASAL
SINUSES WATER’S VIEW
PLAIN X-RAY NOSE AND PARANASAL
SINUSES WATER’S VIEW

 Occipitomental view with mouth open

 Nose-chin position

 Advantage: All the sinuses can be visualized

in a single X-ray
 PLAIN X-RAY NOSE AND PARANASAL
SINUSES WATER’S VIEW

 Normal structures visualized:

 Frontal sinus
 Ethmoid sinuses
 Maxillary sinuses
 Spheniod sinus
 Bony septum
 Inferior turbinate
 Nasal cavity
 Orbit
 Zygomatic process
 PLAIN X-RAY NOSE AND PARANASAL
SINUSES WATER’S VIEW
 When will you say there is sinus haziness?
 By comparing the sinus haziness with the orbital haziness – if the
sinus haziness is more than that of the orbital haziness, sinus
haziness is said to be there.

 Kernel sign / Cut coconut appearance:

 It is circumferential mucosal thickening of the maxillary sinuses
seen in Allergic rhinitis.

 Sites of attachment of maxillary antral polyps:

 Floor of maxillary sinus
 Lateral wall of maxillary sinus
 PLAIN X-RAY SOFT TISSUE
NASOPHARYNX LATERAL VIEW
 PLAIN X-RAY SOFT TISSUE
NASOPHARYNX LATERAL VIEW
 PLAIN X-RAY SOFT TISSUE
NASOPHARYNX LATERAL VIEW
 PLAIN X-RAY SOFT TISSUE
NASOPHARYNX LATERAL VIEW
 PLAIN X-RAY SOFT TISSUE
NASOPHARYNX LATERAL VIEW
 PLAIN X-RAY SOFT TISSUE
NASOPHARYNX LATERAL VIEW

 Normal structures visualized:

 Nasal cavity
 Hard palate
 Soft palate
 Roof and posterior wall of nasopharynx
 PLAIN X-RAY SOFT TISSUE
NASOPHARYNX LATERAL VIEW

 What is the endoscopic grading of adenoid

hypertrophy?
 Grade I: Adenoid occupying >25% of the choanal
area
 Grade II: Adenoid occupying 25-50% of the choanal
area
 Grade III: Adenoid occupying 50-75% of the choanal
area
 Grade IV Adenoid occupying 75-100% of the choanal
area
 PLAIN X-RAY SOFT TISSUE
NASOPHARYNX LATERAL VIEW

 What is crescent sign?

 This sign is used to differentiate between a mass
arising from the nasopharynx and a nasal mass
extending to the nasopharynx
 On a Plain Xray soft tissue nasopharynx lateral view, if
a crescent air is present anterior to a nasopharyngeal
soft tissue mass, it implies a nasopharyngeal mass.
 If the crescent of air is present posterior to the mass,
it implies a nasal mass extending to the nasopharynx.
PLAIN X-RAY SOFT TISSUE
NECK LATERAL VIEW
PLAIN X-RAY SOFT TISSUE NECK
LATERAL VIEW
 PLAIN X-RAY SOFT TISSUE NECK
LATERAL VIEW
 Normal structures visualized are:
 Base of tongue
 Vallecula
 Epiglottis
 Hyoid bone
 Laryngeal and tracheal airway
 Prevertebral soft tissue shadow
 Cervical spine
 PLAIN X-RAY SOFT TISSUE NECK
LATERAL VIEW
 Features of Acute Retropharyngeal Abscess on
plain X-ray soft tissue neck are:
 Pre-vertebral soft tissue widening (more than 1/3rd –
½ of the diameter of the body of the corresponding
vertebra)
 Straightening of cervical spine (due to paraspinal
muscle spasm)
 Presence of gas shadows in the prevertebral soft
tissue shadow (due to gas-forming organisms)
 Presence of air-fluid level (in case of abscess)
 PLAIN X-RAY SOFT TISSUE NECK
LATERAL VIEW
 Causes of pre-vertebral soft tissue widening:

 Retropharyngeal abscess
 Infected foreign body
 Post-cricoid malignancy
PLAIN X-RAY SOFT TISSUE NECK
LATERAL VIEW
 PLAIN X-RAY SOFT TISSUE NECK
LATERAL VIEW
 How to describe a foreign body:

 Radio-opaque
 Radio-lucent
 Radio-dense
 PLAIN X-RAY SOFT TISSUE NECK
LATERAL VIEW
 How to describe the level of the foreign body:

 By counting the cervical spine from below

upwards
 The last cervical spine is C7
PLAIN X-RAY NECK AND CHEST –
AP AND LATERAL VIEWS
PLAIN X-RAY NECK AND CHEST – AP
AND LATERAL VIEWS
How to differentiate between tracheal
and oesophageal foreign bodies
AP view Lateral view
Trachea Edge on view Face-on view
Oesophagus Face-on view Edge-on view

Trachea (superior view) Oesophagus (superior view)

PLAIN X-RAY NECK, CHEST
AND ABDOMEN – AP VIEW
PLAIN X-RAY NECK, CHEST AND
ABDOMEN – AP VIEW
 Halo sign / Double ring sign

 Button battery shows a

double-ring sign or a
halo sign in AP view
and step-off sign in the
lateral view .

 However, two
overlapping coins may
simulate a ‘halo’ sign
on X-ray 
THANK YOU