ENT X-RAYS

PREPARED BY
DEBASISH GANGULY
MEDICAL COLLEGE, KOLKATA
 WILHELM KONRAD ROENTGEN
FIRST RECIPIENT OF THE NOBEL PRIZE IN PHYSICS IN 1901 FOR DISCOVERY
OF X-RAYS
(1) • X-RAY MASTOID LATERAL
OBLIQUE VIEW

(2) • X-RAY PNS OCCIPITO-MENTAL

VIEW

(3) • X-RAY SOFT TISSUE

NASOPHARYNX LATERAL VIEW
X-RAY MASTOID
LATERAL
OBLIQUE VIEW
 VIEWS OF TEMPORAL BONE IN X-RAY
1. LAW’S VIEW
2. SCHULLER’S VIEW
3. STENVER’S VIEW
4. TOWNE’S VIEW
5. TRANSORBITAL VIEW
6. SUBMENTOVERTICAL VIEW

BOTH LAW’S VIEW AND SCHULLER’S

VIEW ARE LATERAL OBLIQUE VIEWS.
IN BOTH CASES, PATIENT IS
POSITIONED IN SUCH A WAY THAT
SAGITTAL PLANE OF THE SKULL IS
PARALLEL TO THE FILM.
IN LAW’S VIEW, THE X-RAY BEAM IS
PROJECTED 15° CEPHALOCAUDAL.
IN SCHULLER’S VIEW, THE X-RAY BEAM
IS PROJECTED 30 °
CEPHALOCAUDAL.
IN LAW’S VIEW, THE KEY AREA OF THE MASTOID, THAT IS, ATTIC, ADITUS, ANTRUM ARE NOT
WELL SEEN. ON THE OTHER HAND, IN SCHULLER’S VIEW, THE KEY AREA OF THE MASTOID IS
WELL APPRECIATED. HENCE, SCHULLER’S VIEW IS MOST PREFFERED FOR VISUALIZATION OF
THE MASTOID.
THE UTILITY OF LATERAL OBLIQUE VIEW IS THAT-----ON
TAKING A LATERAL OBLIQUE VIEW, THE MASTOID OF THE
OTHER SIDE WILL NOT SUPERIMPOSE AND OBSCURE THE
VIEW OF THE SIDE BEING OBSERVED.

THUS,
FOR APPRECIATING ANY PATHOLOGY, BILATERAL MASTOID X-RAY IS
DESIRABLE
 X-RAY MASTOID LATERAL
OBLIQUE(SCHULLER’S) VIEW
SHOWING-
1. CONDYLE OF MANDIBLE
2. EXTERNAL ACOUSTIC
MEATUS SUPERIMPOSED
ON INTERNAL ACOUSTIC
MEATUS
3. MASTOID ANTRUM
MASTOID ANTRUM 4. SINUS PLATE
5. DURAL PLATE
6. SINO-DURAL/ CITELI’S
ANGLE

THE MASTOID IN THIS CASE

SCLEROTIC
Temporomandibular joint

External
acoustic
meatus
superim
posed
on int
acoustic
meatus
 Tegmen
tympani/ Dural
plate

Sinus plate

Angle between sinus

plate and dural plate
is known as sinodural
angle
X-RAY MASTOID LEFT SIDE
LATERAL OBLIQUE VIEW
SHOWING
FLUFFY OPACIFICATION
WHICH IS PROBABLY A LYTIC LESION
DUE TO CHOLESTEATOMA
LYTIC
LESION
THERE IS A LYTIC LESION (AREA
OF RAIOLUCENCY) IN THE LEFT
MASTOID. THIS CAN BE DUE TO—
1. NORMAL ANTRUM
2. POST OPERATIVE
3. CHOLESTEATOMA
4. MALIGNANCY
5. TUBERCULOSIS

SINCE THE MARGIN OF THE

ADJOINING RADIOPAQUE
PORTION IS SMOOTH AND
THE MASTOID DOES NOT
APPEAR TO BE EXCESSIVELY
LARGE, THIS IS PROBABLY DUE
TO CHOLESTEATOMA.
HERE ALSO, THERE
IS AN AREA OF
RADIOLUCENCY IN
THE MASTOID.
HOWEVER IF WE
OBSERVE THE
MARGIN OF THE
ADJOINING
OPAQUE REGION,
WE WILL SEE THAT
IT IS IRREGULAR,
WITH SOME
HONEY-
COOMBING.
HENCE THIS
MASTOID IS
DIPLOIC.
THE
PARASINUSOIDAL
CELLS ARE
PROBABLY
PNEUMATIC IN
THIS MASTOID.
AREA OF
RADIOLUCENCY,
A DIPLOIC
MASTOID
 HIGHLY
PNEUMATIZED
MASTOID

THE PRESENCE OF SUCH

EXTENSIVE PNEUMATIZATION OF
THE MASTOID IMPLIES THAT THE
EUSTACHIAN TUBE IS PATENT.
THE VARIOUS MASTOID AIR CELLS
ARE-
1. MASTOID ANTRUM (THE MOST
CONSTANT OF ALL MASTOID
AIR CELLS)
2. PERISINUSOIDAL
3. SINODURAL CELLS
4. PERIANTRAL CELLS
5. TIP CELLS
6. PERIFACIAL
7. PERITUBAL
8. AT PETROUS APEX (APICAL)
9. SUPRA LABYRYNTHINE
10. RETRO LABYRYNTHINE
11. INFRA LABYRYNTHINE
12. SQUAMOUS
13. OCCIPITAL
14. ZYGOMATIC
IMPORTANCE OF X-RAY MASTOID SCHULLER’S VIEW
BEFORE TAKING THE PATIENT FOR SURGERY-

1. TO KNOW THE STATUS OF THE MASTOID BECAUSE WE HAVE TO DRILL IN

THIS AREA, AND HENCE WE NEED TO KNOW HOW DEEP WE HAVE TO GO

2. THE LEVEL OF THE DURAL PLATE AND SINUS PLATE. SOMETIMES WE CAN
HAVE A LOW LYING DURAL PLATE OR AN ANTERIORLY LYING SINUS PLATE,
WHICH HAS TO BE TAKEN CARE OF WHILE WE OPERATE.

3. IF THERE IS CHOLESTEATOMA, IT CAN ERODE THE DURAL PLATE AND

HENCE WE CAN HAVE AN IDEA ABOUT THE COMPLICATIONS THE PATIENT
MIGHT BE GOING INTO.
 WHENEVER GIVEN AN X-RAY
LATERAL VIEW OF NECK,
REMEMBER THAT YOU HAVE
TO LOOK FOR SOME PROBLEM
IN THE AIRWAY
X-RAY SOFT
TISSUE
NASOPHARYNX
LATERAL VIEW
WITH OPEN
MOUTH
SHOWING A
SOFT TISSUE
MASS
ORIGINATING
FROM THE
ROOF OF THE
NASOPHARYNX
–PROBABLY AN
ENLARGED
ADENOID
SOFT TISSUE MASS ARISING
FROM ROOF OF
NASOPHARYNX...PROBABLY
HYPERTROPHIED ADENOID
 SOFT PALATE

TRACHEA

AS WE CAN SEE, THE AIRWAY CAN BE

TRACED FROM THE EXTERNAL NARES
UPTO THE TRACHEA, SO DESPITE
ADENOID HYPERTROPHY, THE PATIENT
WILL NOT HAVE MUCH DIFFICULTY IN
BREATHING THROUGH THE NOSE
 IN THIS CASE, THE
ADENOID HAS BEEN
SO ENLARGED THAT
THE AIRWAY IS
TOTALLY OBSTRUCTED
AT THE LEVEL OF THE
NASOPHARYNX
IN THIS CASE, THE
CHILD WILL BE
INCAPABLE OF
BREATHING THROUGH
THE NOSE, BECAUSE
OF WHICH HE WILL
START BREATHING
THROUGH THE
MOUTH
THIS WILL RESULT IN
DEVELOPMENT OF
ADENOID FACIES
NB- ACTUALLY, NO COMMENT SHOULD BE MADE REGARDING PATENCY OF THE AIRWAY, SINCE
THE X-RAY HAS NOT BEEN DONE IN APPROPRIATE POSITION. X-RAY SOFT TISSUE
NASOPHARYNX LATERAL VIEW MUST BE DONE WITH THE NECK EXTENDED AS WE SEE IN THE
PREVIOUS X-RAYS.
XRAY SOFT TISSUE NASOPHARYNX CAN ALSO BE USED TO
DIFFERENTIATE AN ANTROCHOANAL POLYP FROM A JUVENILE
NASOPHARYNGEAL ANGIFIBROMA

AC POLYP GROWS FROM FORWARD TO BACKWARD

JNA GROWS FROM BACKWARD TO FORWARD

IN CASE OF AC POLYP, A CRESCENTRIC SPACE OF AIR IS PRESENT

BETWEEN THE POLYP AND THE POSTERIOR NASOPHARYNGEAL
WALL.THIS IS KNOWN AS DODD SIGN/CRESCENT SIGN.
DODD SIGN IS NEGATIVE IN JNA.
RED ARROW SHOWS
THE LOWER END OF THE
AC POLYP.
THE CRESCENTRIC SPACE
OF AIR IN BETWEEN
THIS POLYP AND THE
POSTERIOR
PHARYNGEAL WALL IS
CALLED DODD SIGN.
DODD SIGN IS NEGATIVE
IN JNA.
X-RAY PNS WATERS VIEW/ OCCIPITO-MENTAL VIEW-
•NOSE AND CHIN OF THE PATIENT TOUCH THE FILM WHILE X-RAY BEAM IS
PROJECTED FROM BEHIND
•MOUTH OF THE PATIENT SHOULD BE OPEN SO THAT SPHENOID SINUSES CAN BE
SEEN
•ALL PARA NASAL SINUSES CAN BE SEEN EXCEPT POSTERIOR ETHMOIDAL AIR
CELLS

OTHER VIEWS FOR THE VISUALISATION OF PARA NASAL AIR SINUSES-

1. CALDWELL VIEW(OCCIPITO FRONTAL VIEW)
2. LATERAL VIEW
3. SUBMENTOVERTICAL VIEW
4. RIGHT AND LEFT OBLIQUE VIEWS

FRONTAL SINUSES ARE BEST SEEN IN CALDWELL VIEW

MAXILLARY SINUSES ARE BEST SEEN IN WATER’S VIEW

POSTERIOR ETHMOIDAL AIR CELLS CAN BE SEEN IN ALL THE VIEWS EXCEPT
WATER’S VIEW. THEY ARE BEST SEEN IN RIGHT AND LEFT OBLIQUE VIEWS.
Nasal septum deviated
to the left side with a
prominent spur
Radio density of left
maxillary sinus is
more than that of
orbits, which
indicates that it may
be any 1 of the
following
1. Fluid(unlikely here as
air fluid level not seen)
2. Pus
3. Blood
4. Tumour
5. Polyp
6. Hypertrophied
mucosa
Ethmoidal polyp/ tumour

Nasal septum
deviated towards
the left side with a
spur arising from the
lower part of the
septum, directed
towards the left
XRAY PNS OCCIPITO-
MENTAL/ WATER’S VIEW,
SHOWING
•OPACIFICATION OF BOTH
THE MAXILLARY SINUSES
DUE TO MUCOSAL
THICKENING
•FRONTAL AND
ANTERIORETHMOIDAL
SINUSES ARE NORMAL
•SPHENOID SINUSES ARE
NOT VISIBLE
•NASAL SEPTUM IS IN THE
MIDLINE
XRAY PNS
OCCIPITO-
MENTAL/ WATER’S
VIEW, SHOWING
OPACIFICATION OF
BOTH MAXILLARY
SINUSES, PROBABLY
DUE TO MUCOSAL
THICKENING,
ALSO SOME
OPACIFICATION OF
BOTH FRONTAL
SINUSES,
NASAL SEPTUM IS
IN MIDLINE,
SPHENOID SINUSES
ARE NOT VISIBLE
XRAY PNS OCCIPITO-MENTAL/
WATER’S VIEW SHOWING
•BOTH MAXILLARY SINUSES
•BOTH SPHENOID SINUSES
•BOTH FRONTAL SINUSES
•B/L ANTERIOR ETHMOIDAL
SINUSES
THIS BEING THE XRAY OF A 2
YEAR OLD CHILD, THE SINUSES
ARE NOT YET FULLY MATURE
THE TEETH OF THE UPPER JAW
ARE DEEPLY EMBEDDED WITHIN
THEIR SOCKETS
Bilateral maxillary sinus opacity

Nasal septum deviated towards

the right
X-ray pns occipito mental/
water’s view showing
1. Frontal sinus
2. Maxillary sinus
3. Anterior ethmoidal
sinus
4. Sphenoid sinus

There is bilateral maxillary

sinus opacity which
may be due to
fluid/pus/blood/tumo
ur/hypertrophied
mucosa, along with
the nasal septum
deviated towards the
right side
 OPACITY OF THE
LEFT MAXILLARY
OPACITY OF SINUS, AN AIR-
THE RIGHT FLUID LEVEL CAN
MAXILLARY BE SEEN, SO
SINUS THERE IS
PROBABLY FLUID
ACCUMULATIION
AP AND LATERAL VIEW X-RAY OF NECK, CHEST AND UPPER PART OF ABDOMEN, SHOWING
•ROUND RADIOOPAQUE FOREIGN BODY IN AP VIEW
•SLIT LIKE RADIOOPAQUE FOREIGN BODY IN LAT VIEW
THUS, THE FOREIGN BODY IS PRESENT IN THE ESOPHAGUS, AT THE LEVEL 0F C6-C7.
 FOREIGN BODY IN ESOPHAGUS VS
TRACHEA
FB IN ESOPHAGUS FB IN TRACHEA
• LIES IN THE CORONAL • LIES IN THE SAGITTAL
PLANE PLANE DUE TO-THE
GLOTTIC CHINK IS
SAGITALLY ORIENTED AND
AS THE TRACHEALIS
MUSCLE IS PRESENT ON
THE POSTERIOR ASPECT OF
TRACHEA, ONLY IF A FB
LIES ALONG THE SAGITTAL
PLANE WILL IT GET AMPLE
SPACE
 TRACHEA

X-ray NECK AND CHEST, IN AP AND LATERAL VIEW, SHOWING

1. LINEAR RADIO OPAQUE FOREIGN BODY IN THE ESOPHAGUS IN LATERAL VIEW (C5/6 LEVEL)
2. NO FOREIGN BODY CAN BE SEEN IN AP VIEW
THUS, THERE IS A LINEAR RADIO OPAQUE FOREIGN BODY IN THE ESOPHAGUS AT THE C5/6 LEVEL
X-RAY NECK, CHEST AND ABDOMEN
IN AP VIEW SHOWING A ROUNDED,
RADIO OPAQUE FOREIGN BODY
WITHIN THE ESOPHAGUS, AT THE
LEVEL OF C6/C7

A FOREIGN BODY WHICH APPEARS

ROUNDED IN AP VIEW IS PRESENT
IN THE ESOPHAGUS
WHILE, A FOREIGN BODY WHICH
APPEARS ROUNDED IN LATERAL
VIEW IS IN THE TRACHEA
X-RAY OF SKULL AND
NECK IN LATERAL VIEW
SHOWING A LINEAR
RADIO OPAQUE FOREIGN
BODY IN THE ESOPHAGUS,
AT THE LEVEL OF C6/C7
FISTULOGRAM
SHOWING THE
TYROGLOSSAL DUCT,
AFTER INJECTING A
RADIO-OPAQUE DYE.
THE TRACT OF THE
THYROGLOSSAL DUCT
CAN BE TRACED UPTO
THE TONGUE.
FISTULOGRAM
SHOWING A PRE
AURICULAR SINUS
ON THE LEFT SIDE,
FOLLOWING
INJECTION OF A
RADIO OPAQUE DYE.
SPECIAL THANKS TO-

1. DR. SHAONI SANYAL

2. DR. TITAS KAR
3. SUSHMITA MISRA
4. MEGHDEEPA SENGUPTA
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PREPARED BY
DEBASISH GANGULY
MEDICAL COLLEGE,KOLKATA
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