D

Radiology in ENT
Dr. Vion Guzman | February 17, 2022
Trans by: Dammay, Palattao, Sabado

OUTLINE • It could also be a cancer site.

• Sphenoid sinus
I. Imaging of Nose and D. Ultrasound
Paranasal Sinuses → Located at the approximate center of the skull above the
II. Oral Cavity
A. Conventional nasopharynx. [Probst et al, 2006]
III. Salivary Glands
Radiographs → It relates laterally to the cavernous sinus, the internal carotid
IV. Ear
B. CT artery, and cranial nerves II–VI, and it is very closely related
V. References
C. MRI to the optic canal. [Probst et al, 2006]
▪ In the optic canal, you’ll find the optic nerve. That is why
I. IMAGING OF THE NOSE AND PARANASAL SINUSES tumors in the sphenoid sinus has a poor prognosis
compared to the other sinuses. Anatomically, it is also
closely related to the pituitary gland.
• Frontal sinus
→ Located in the frontal bone, its floor forming the medial portion
of the orbital roof.
→ Bounded behind by the anterior cranial fossa
→ Inflammations of the frontal sinus can give rise to serious
complications because of its close proximity to the orbit and
cranial cavity (orbital cellulitis, epidural or subdural abscess,
meningitis)
A. CONVENTIONAL RADIOGRAPHS
• Minsan it is not very conclusive. There are x-ray clinics or x-ray
labs that do not have a clear copy or production of this type of X-
rays so mahirap gawan ng conclusion basing from this X-rays.
[Doc]

Figure 1. The Paranasal Sinuses [Probst et al, 2006]

• Maxillary sinus
→ Is present at birth and is closely related to the
maxilla/dentition.
→ It is located superiorly to the maxillary dentition, hence, Figure 2. Occipitomental projection (Waters view) [Probst et al, 2006]
patients who present with dental infections usually has • WATERS VIEW (Occipitomental Projection)
concomitant maxillary swelling because of their close → Other structures seen in Figure 2:
relationship. ▪ Nasal bones (Septum, Right and left nasal cavities)
→ The floor of the maxillary sinus is closely related to the roots ▪ Sphenoid and maxillary sinus
of the second premolar and first molar teeth which creates a ▪ Dentition
potential route for the spread of dentogenic infections, and a ▪ Orbit
tooth extraction may create a communication between the oral ▪ Mastoid pneumatization
cavity and maxillary sinus (oroantral fistula). [Probst et al, 2006] ▪ Arch of zygoma
→ Behind the maxillary sinus is the pterygopalatine fossa, ▪ Mandible
which is traversed by the maxillary artery along with • CALDWELL VIEW (Occipitofrontal)
branches of the trigeminal nerve and autonomic nervous
system. [Probst et al, 2006]
▪ Any malignancy of the maxillary sinus could spread to
these areas
• Functions of the sinuses:
→ Humidification of inspired air
→ Mucus production
• Drainage of the sinuses:
→ Middle meatus
▪ Maxillary sinus
▪ Frontal sinus
▪ Anterior ethmoid cells
→ Superior meatus
▪ Posterior ethmoid cells
• The paranasal sinuses have many pathologies. Any area of
obstruction can lead to inflammation/sinusitis, mass formation, Figure 3. Occipitofrontal projection (Caldwell) [Probst et al, 2006]
polyps.
Trans # 1 Radiology in ENT 1 of 7
 → Forehead-nose view
→ Structures that can be best seen in this view:
▪ Nasal bone, ethmoid, frontal, maxilla, and lamina
papyracea
▪ Indications:
− Suspected fracture (maxilla trauma, zygoma)
o to identify areas of bleeding in the presence of trauma
or if there are any collections of blood, bone breakage
or bone discontinuity or hindi kulay itim na itim yung
maxillary sinus kasi mayroon ng collection of blood
inside your sinus. [Doc]
− In cases of trauma that needs medico-legal part kasi
kunyari magwiwitness ka sa court, you have a proof na
there is an injury that happened and this was
documented with x-ray. [Doc]
• Kunyari nasa ER ka na tapos hindi mo talaga maevaluate kung
may skull base fracture ba ito or may CSF leak na ba and the
patient is already deteriorating at hindi na siya ganun ka-stable.
So we have a choice to step up if may pera si patient or the
hospital is capable of providing us another modality. So next step
would be CT Scan. The superiority of CT scan over the
conventional radiographs is walang super imposed structures.
Makikita mo na mga axial and coronal. Para siyang 3-D level. [Doc]
Figure 4. Skull Lateral [Probst et al, 2006]
• Structures that are seen here are your sphenoid sinus and the
posterior ethmoids and the frontal sinus (anterior and posterior
table). [Doc]
• There is better view of the anterior cranial fossa as it is closely
related to your frontal sinus. [Doc]
Figure 5. Ethmoid roof & cribriform plate [Probst et al, 2006]
Trans # 1 Radiology in ENT
• Crista galli is continuous with the septum
• Middle turbinate is closely connected to your cribriform plate
• Lamina papyracea
→ forms the medial boundary of your orbit.
→ supports the wall of the orbit.
→ this is a good landmark when you do surgeries sa ilong..
→ attached to this is the lateral lamina of cribriform plate.
→ kunyari may mga infections within your frontal or ethmoid
sinuses so tinitignan yung level ng cribriform plate.
• Cribriform plate
→ Transmits olfactory nerve. [Doc]
→ This is evaluated when you have nasal bone fracture. [Doc]
→ Lateral lamina of cribriform plate[Doc]
▪ What do you evaluate considering the height of lateral
lamina? What are you protecting? [Doc]
− It is a structure between or midway between your cranial
fossa and nasal cavity. [Doc]
− It delineates the sharpness of anterior cranial fossa or
kung nagproprotrude ba or mababa yung anterior crania
fossa, which is your brain. Tinitignan doon kung
masiyadong mababa yung level ng skull base as
compared to your nasal cavity kasi when you are doing
sinus surgeries or endoscopy, yun yung iingatan mo
which is the level of your anterior skull base because
when you are doing scopes and insrumentation
pwedeng matusok yung skull base. [Doc]
B. COMPUTED TOMOGRAPHY (CT)
• Best evaluate the bones. [Doc]
• Indications:
→ Malformations meningocele, congenital malformations),
→ Chronic rhinosinusitis (hindi nasiya gumagaling sa gamot and
the px experiences symptoms of rhinosinusitis)
→ Trauma (skull base, frontobasal fractures).
→ Tumors (polyp, one sided lang yung may polyp)
• We only request for plain CT. Madalang nirerequest ang contrast
CT unless indicated. (Doc]
Figure 6. Normal CT Scan [Probst et al, 2006]
• Normally, aerated sinuses would exhibit density in a CT scan that
is why air densities in your maxillary sinus it would appear black
and the bones will appear white. [Doc]
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 C. MAGNETIC RESONANCE IMAGING (MRI) II. ORAL CAVITY
• Since the anatomical structures of the oral cavity are easily
accessible, the diagnosis can often be established by clinical
examination alone (inspection, palpation, biopsy or local excision
of a suspected tumor). As a result, imaging procedures tend to
have a limited role in diseases of the lips and oral cavity.
Nevertheless, there are various clinical situations.
• Only B-mode instruments are useful for ultrasound examinations
of the oral floor and tongue and real-time scanning is preferred.
• In tumors and cancers, CT Scan of the oral cavity is used. [Doc]
• Indications:
→ Pronounced inflammatory changes
→ Tumors
▪ To determine tumor extent, depth of invasion, and spread
across the midline are important parameters in selecting
the optimum treatment modality, especially for lesions
Figure 7. MRI of the paranasal sinuses [Probst et al, 2006] involving the tongue and floor of the mouth
• Mas concentrated sa soft tissue discrimination. Between soft → Masses inside the tongue or palate
tissue and a mass. So ganun siya kaeffective at ganun din • As a rule, mas pangit yung prognosis kapag pumagitna yung
kamahal. [Doc] tumor. [Doc]
• Mahirap gawin sa mga bata so usually sinesedate pa namin
when we do the procedure. [Doc]
• It is indicated in diseases that involve the paranasal sinuses in
addition to the cranial cavity or orbit (e.g tumors and congenital
malformations such as encephaloceles).
→ Most common na pwede mo ievaluate sa cranial cavity?
anterior and middle cranial fossa. [Doc]
• It can also supply information that is useful in differentiating soft-
tissue lesions within the paranasal sinuses (mucocele, cyst,
polyp), and it can distinguish between solid tumor tissue and
inflammatory perifocal reaction.
• Contraindications: electrically controlled devices (cardiac
pacemaker, insulin pump, cytostatic pump, or cochlear implant.)
By contrast, modern internal fixation materials such as titanium
are usually nonmagnetic and therefore MRI-compatible. Figure 8. Oral floor abscess (Ludwig’s Angina) [Probst et al, 2006]
• In terms of thickness, ang MRI hindi nageexceed ng 3-4mm. • We also request for CT Scan when we are evaluating abscesses
Kahit gaano kaliit na structure maka-catch ni MRI. [Doc] or inflammatory changes. [Doc]
• Imaging of the frontal skull base, orbit, parapharyngeal space, • There is a swelling in the submental area of the child. A CT scan
and pterygopalatine fossa requires the highest possible spatial is requested and there is an abscess within the floor of the mouth
resolution with a thin slice thickness (3 mm). extending downwards. [Doc]
• If there are small tissues, it will be clearly indentified through an
MRI. Ganun kasuperior among other studies. .[Doc]
D. ULTRASOUND
• The paranasal sinuses can also be visualized with ultrasound (A
and B mode).
• Advantages:
→ Ultrasound is particularly useful in the follow-up of acute
inflammatory processes, as it can eliminate the need for extra
radiographic views. It is also used in children and pregnant
women for the same reason.
• Disadvantages:
→ Ultrasound yields much less detailed images than CT and
MRI, and it cannot provide three-dimensional rendering.
• It is used kapag ayaw mo talaga maexpose to radiation yung
patient like for pregnant women.[Doc]
• Ano yung hindi mo pwedeng iultrasound na sinus? Ano yung
hindi magiging accessible? Sphenoid. [Doc] Figure 9. Computed tomography of the pharynx: Normal Findings [Probst et al, 2006]

• Indications: • In this picture, when we see the maxillary sinus is it normal or

→ Frontal and maxillary sinuses are most easily accessible to abnormal? Yung maxillary sinus niya there suspicion of mass or
ultrasound imaging. cystic structure (arrow) within the right. [Doc]
→ Scanning the middle and posterior ethmoid cells by the • When reading CT scan, the technique is you compare it to the
transocular route is extremely challenging and requires a other side.[Doc]
highly experienced examiner.
→ The sphenoid sinus is inaccessible to ultrasound imaging
because of its location.

Trans # 1 Radiology in ENT 3 of 7

 Figure 12. Retro-pharyngeal abscess. [Probst et al, 2006]
• This is a case of retropharyngeal abscess. The abscess is clearly
delineated by black color. As a result, abscesses that arise at this
area is closely related to your parapharyngeal areas and
prevertebal areas. [Doc]
• This is life-threatening because it can cause difficulty of breathing
Figure 10. Juvenile Angiofibroma [Probst et al, 2006]
especially kapag bata yung patient. [Doc]
• In Juvenile Angiofibroma, reddish structure is seen in the
nasopharynx. There is a presence of enhancing mass (upper
right) within the nasopharynx. [Doc]
• Usually kapag juvenile angiofibroma, we request for angiography
para makita mo what are the vessels that are involved. [Doc]

Figure 13. Tonsillar carcinoma [Doc’s ppt]

• Mass seen in the left tonsil. An MRI was done and the mass was
clearly identified. The area of oropharynx is already narrowed
because of the mass. [Doc]
III. SALIVARY GLANDS

Figure 11. Postrhinoscopic endoscopy demonstrates a mass that has obstructed

the nasopharynx. [Probst et al, 2006]

• There is fungating mass so makikita mo rin siya sa CT scan or

MRI. [Doc] Figure 14. Major Salivary Glands [Probst et al, 2006]

• What are your 3 salivary glands? [Doc

→ Parotid, Submandibular and Sublingual [Doc
• These glands have ducts. What are those ducts? [Doc]
→ Parotid duct (Stensen duct)
▪ Connects the parotid gland to the upper second molar. [Doc]
▪ This excretory duct leaves the parotid gland in its anterior
superior third and passes forward over the masseter
muscle. It winds around the anterior border of the muscle
and pierces the buccinator muscle and buccal mucosa. It
Trans # 1 Radiology in ENT 4 of 7
 opens opposite the second upper molar, forming an orifice → MAGNETIC RESONANCE IMAGING
with slightly raised edges.
→ Submandibular duct (Wharton duct)
▪ Exits the floor of the mouth [Doc]
▪ The excretory duct of the submandibular gland passes with
the sublingual process of the gland to the sublingual plane
of the oral floor and runs forward beneath the mucosa. It
crosses over the lingual nerve & opens at the sublingual
caruncle.
→ Sublingual

• What is the function of the salivary glands? [Doc]

→ Production of saliva.
→ Yung saliva pupunta sa oral cavity through those ducts for the
purpose of lubrication of food, protection etc. [Doc]
→ May mga lysozyme siya and immunoglobulins that are Figure 16. Magnetic resonance image of a lymphangioma of the left parotid
present. [Doc] gland [Probst et al, 2006]
• This is an MRI picture that shows a tumor within the parotid
A. IMAGING STUDIES
gland. Ang tinitignan natin na involvement would be the
• When we do radiographic studies of the salivary gland we utilize structures (maxillary sinus, nasopharyngeal areas, external
the following: [Doc] auditory canal) near to it. [Doc]
→ ULTRASOUND
▪ Has proved to be a well-tolerated and rewarding study for
investigating the salivary glands.
▪ It can differentiate among normal glandular parenchyma,
inflammatory processes (with or without liquefaction),
tumors, lymph nodes, and calculi.
▪ Generally, this is the first imaging procedure used. It can
be combined with fine-needle aspiration biopsy.
→ SIALOGRAPHY
▪ Indications: detection of small stones in the excretory
ducts, anomalies of the excretory ducts, sialadenosis, and
chronic inflammation.
▪ Contraindication: Acute inflammation
▪ This is done by having those ducts cannulated and
injected with dyes. [Doc]
▪ The most commonly evaluated are submandibular and the
parotid gland. [Doc]
▪ Locate the opening of the ducts and then inject the dye.
▪ Why do we put dye? To check if there are strictures or
obstruction. [Doc]

Figure 17. Algorithm for the investigation of salivary gland disease [Probst et al, 2006]

Figure 15. CT scan of an abscess in the left parotid gland [Probst et al, 2006]

→ CT SCAN
▪ On this CT scan (left), you could identify an abscess that is
located within the left parotid gland as compared to the
other picture (right). [Doc]
▪ When we evaluate parotid abscesses consider its location
or its proximity to the structures like external and internal
carotid arteries.[Doc]
▪ Tignan mo if it nagkakaroon ng involvement yung pterygoid
muscle or masseter muscle. [Doc]
▪ Ano ba ang clinical presentation kapag may involvement
ng masseter at pterygoid muscle? It can produce trismus
or spasm of the jaw muscle. [Doc]
▪ And what do you call these muscles? Muscles of
mastication. [Doc]
Figure 18. Barium Swallow [Probst et al, 2006]
• Patient is asked to swallow a contrast media to evaluate for
obstruction. [Doc]
• Barium Swallow: ginagamit ito when you are suspecting for a
foreign bodies (food particles, dentures) or diffuse esophageal
obstruction o kaya hindi siya makalunok for how many days na.
• In the picture (left), the contrast passes from the oropharynx to
the hypopharynx. It is like a stripping wave. [Doc]
• Napakatedious nito kasi titignan mo kung paano magfoflow yung
dye. [Doc]

Trans # 1 Radiology in ENT 5 of 7

• Moments later (center), the contrast is push off the oropharynx IV. EAR
up to the level of base of the tongue. Normally at the level of the
epiglottis, there is stasis. [Doc]
• With the relaxation of the cricopharyngeus, on this level is the
cricopharyngeal opening or your upper esophageal sphincter.
The contrast media have already passed that area then the
contrast passes through your esophagus. [Doc]
• Ineevaluate mo dito yung obstruction or stasis. For example,
circumferential yung obstruction, makikita mo talaga na hindi
bumababa yung dye sa mga subsequent images. [Doc]
• Hindi lang siya tatlong images. Kapag masipag yung radtech,
there will be a lot of cut/images. The surgical significance of that?
When you do extraction of the foreign body you will know where
is the proximate location of the foreign body or kung hanggang
saan siya nakablocked or nakaobstruct. [Doc] Figure 21. Normal [Probst et al, 2006]
B. SAMPLE CASES • When we request for X-ray of the ear, we request for mastoid
series. [Doc]
1. CASE 1:
• You can see a normal aeration of mastoid air cells, the TMJ which
• This 4-year old child had severe bilateral tonsillitis with appear normal and there are no lesions or bony disruption. [Doc]
symptoms of a left peritoneal abscess.
A. MASTOID SERIES

Figure 19. [Probst et al, 2006]

• In the picture, there are hypodensities or fluid collections
(red) in your left tonsil. This is a case of an abscess.
Confined lang siya on your left tonsil. There are no
involvement of the other structures. Parapharyngeal area
(blue) is not involved. [Doc]
2. CASE 2:
• Patient having a cold and fever with a rapidly progressive red
swelling of the neck and inspiratory stridor.

Figure 22. Towne’s View [Probst et al, 2006]

• TOWNE’S VIEW: an anteroposterior view with 30-degree tilt
from above that allows comparison of both petrous pyramids and
mastoids on same film.

Figure 20. [Probst et al, 2006]

• The airway is already narrowed and there is an abscess
extending into the hypopharyngeal area with subsequent
compression of your hypopharyngeal area that is why it
causes stridor. [Doc]
• Mas maliit na yung mga structures compared sa mga non-
affected side indicating the involvement of jugular vein on the
left (green). [Doc]

Trans # 1 Radiology in ENT 6 of 7

 Figure 23. Law’s View [Probst et al, 2006]
• LAW’S VIEW: lateral view with the sagittal plane of the skull
parallel to the plate and 15 degree cephalocaudal angulation of
the x-ray beam.
→ Ito lang yung may lateral projection sa Mastoid Series. [Doc]
Figure 24. Schuller’s View [Probst et al, 2006]
• SCHULLER’S VIEW is like Law’s view
→ With a 30 degree cephalocaudal angulation of the beam. It
shows the antrum and the attic better than the Law’s view and
give an excellent view of the extent of pneumatization of the
mastoid.
Figure 25. Mayer’s View [Probst et al, 2006]
• MAYER’S VIEW: head is rotated 45 degrees toward the side
examined and the central ray passes through the external
auditory canal nearest at the film at an angle of 45 degrees.
→ It also shows a bit of distortion of the picture, but gives an axial
view of the petrous bone and mastoid cells.
• TRANSORBITAL VIEW: the film is paced in the occiput of the
patient and with the head rotated near the orbitomeatal plane is
perpendicular to the plate.
Trans # 1 Radiology in ENT
Figure 26. Stenver’s View [Probst et al, 2006]
• STENVER’S VIEW is obtained with patient facing the film with
head rotated toward the opposite side. The x-ray beam is
angulated 14 degrees caudad. The IAM appears foreshortened
because of the rotation.
Figure 27. Submentovertical View (Basal View) [Probst et al, 2006]
• SUBMENTOVERTICAL VIEW is taken from under the chin and
shows both temporal bones for comparison.
→ It also shows the base of the skull structures.
Figure 28. Bony labyrinth [Probst et al, 2006]
• This is the more toxic part. You have your mastoid air cells here
(yellow). You have your ossicles (blue). [Doc]
• In evaluating CT Scan, we take note of the degree of
pneumatization of your mastoid air cells and if there are presence
of masses within your mastoid or cholesteatoma.
• Makikita mo rin yung cochlea or snail-shape (green) and the
entrance to your internal auditory canal.
V. REFERENCE
• Probst, R. et. al., (2006). Basic Otorhinolaryngology. Germany: Appl,
Wemding.
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