Oto-rhino-laryngologic

illustrations
By
Prof.Dr. Ahmed Allam
Prof. & Head of ENT Department
Benha Faculty of Medicine

Prof. Dr. Mossad Elsisy

Prof. of ENT
Benha Faculty of Medicine
 Plain
CT Scan MRI
X Ray

Demonstrates
Accurately demonstrates VIII nerve
• External ear Brain
Of limited value
• Middle ear Great vessels Demonstrates
• Surrounding structures Mastoid air cells
 • lateral Oblique (Mastoid)view

Locate the Temporo-mandibular joint •

the external auditory canal (EAC)
which is a complete circle

• The mastoid air cells are behind and

above the EAC
 • lateral Oblique (Mastoid)

TMJ

External auditory
canal

Pneumatised mastoid:
air spaces separated
by bony partitions
• The mastoid cells (white arrow) are
obscured, and not air-containing,
due to chronic otitis media.

External

auditory canal
TMJ
• Schüller view: Well-developed normally
pneumatized mastoid air cells can be observed
in the picture on the left side (double arrow).
• In the picture on the right side, the mastoid cells
(arrow) are obscured, and not air-containing, due
to chronic otitis media.

TMJ
Sinodural angle

EAC
 External auditory
TMJ
canal
• There is a clean
cavity behind and
above the external
auditiry canal not
surrounded by
sclerosis
• Diagnosis:
surgical cavity of
mastoidectomy
 Petrous bone

• Axial CT scan, the destructed apex of the

petrous bone can be observed (white arrow),
which is caused by ? cholesteatoma.
• Axia CT scans:
• The mastoid cells on the right side (green arrow)
are totally obscured, which proves mastoiditis.
• On the left side (blue arrow), an intact status can
be seen.
• Axial CT scans:
Transverse temporal bone fracture (arrows).
 Plain
CT Scan • MRI
X Ray

Accurately demonstrates
Mainly for limited value
• Nose
Surrounding soft Screening of sinuses
• Paranasal sinuses
tissue structures Medico-legal
• Surrounding
IN NASAL BONE
structures FRACTURE
• Patient facing the
film
• Radiologic base
line tilted 450
• Beam horizontal ,
directed to
external occipital
protuberance
 Frontal
sinus

orbit

• septum

Maxillary Maxillary
sinus sinus

Sphenoid
sinus
NB
• Radiologic Examination of sinuses
should be:
- In erect position
- Sphenoid is seen in occipitomental
view with open mouth
Frontal Sinus
Ethmoid Sinus
Maxillary Sinus
Soft Palate
Nasopharynx
Sphenoid Sinus
Sella Turcica
Clinoid Process
• Occipito-mental view of the sinuses
showing partial opacification of the right
maxillary sinus, with an air-fluid level

• Acute Sinusitis
• Acute Sinusitis
 NASAL FRACTURE

• Loss of continuity
of nasal bone with
displacement of
distal fragment
• Axial view
• Coronal view
 Coronal CT scan
Normal findings
• The sinuses
normally contain air
which is seen in
black color

• The frontal sinus :

- Above the orbit
- Seen in the anterior
• ORBIT •
cuts ORBIT

- May be absent
Ethmoid sinuses
- 15 to 20 air cells in
• ORBIT
each side Ethmoid

- Medial to Lamina
paparycea Maxillary Maxillary

Maxillary sinus
- Below the orbit
 Sphenoid Sinus
- Divided by a
septum into right
and left sinuses Sphenoid

- The floor of the

sinus is the roof of
the nasopharynx
 Orbit

Bulla
Ethmoidalis

Middle
Maxillary Sinus
Turbinate
Middle Meatus Uncinate
process

Inferior Turbinate

Inferior Meatus
PATHOLOGICAL FINDINGS
CORONAL CT
SHOWING
THICKENING OF
THE FRONTAL
SINUS MUCOSA
Osteoma. A left frontal osteoma ( arrow) is
visible anteriorly in this coronal CT scan.
Note its increased density, characteristic
of the lesion.
• Coronal CT scan showing normal
ostiomeatal complex. Patent ostia are
visible on both sides, and sinuses are well
ventilated.
• Coronal CT scan
• Total ethmoid opacity ( ethmoidal polypi)
• Fluid level in the left maxillary sinus
• Diagnosis : bilateral ethmoid sinusitis Left
maxillary sinusitis
• Coronal CT scan
• Blocked osteomeatal complex
• Opacity of right ethmoidal air cells
• Fluid level in the left maxillary sinus
• Thickened mucosa of right maxillary sinus
• Diagnosis : bilateral Maxillary sinusitis, right ethmoid sinusitis
Coronal CT scan
Blocked ostiomeatal complex

Maxillary
sinus Maxillary
sinus
• A coronal CT scan
• Moderate bilateral maxillary sinus mucosal thickening with
blockage of both ostiomeatal complexes
• Chronic sinusitis
• A coronal CT scan.
• Complete opacification of the right maxillary sinus
• Mucosal thickening of the left maxillary sinus
• Chronic sinusitis
• Coronal CT scan
• Concha bullosa i.e pneumatized middle
turbinate
• A deviated nasal septum.
Concha bullosa i.e pneumatized middle
turbinate ( red arrow).

orbit
orbit

Maxillary
sinus
Pardoxical middle turbinates.
• Coronal CT scan
• Bilateral total opacity of ethmoid sinuses
• Bilateral Ethmoidal polypi
• Coronal CT scan showing right maxillary sinus
opacification. Also, note the septal deviation to
the right and the hypertrophy of the left inferior
turbinate (yellow arrow)
• Coronal CT scan of
the sinuses showing
bilateral maxillary
sinusitis.
• The opacification is
more prominent on
the left side (arrow).
 Oroantral fistula
• Enumerate 3 causes starting with the most
common cause
Comment
• Complete right maxillary sinus opacity
• Opacity and Widening of the right
osteomeatal complex
• Soft tissue opacity in the nasopharynx
Inverted Papilloma

• Soft tissue mass in the

• nasal
Differential
cavity and left
Diagnosis
maxillary and ethmoidal
sinusespapilloma
Inverted
•Antrochoanal
The left middle meatus
polyp
and medial
Squamous wall of the
cell
left maxillary sinus are
carcinoma
absent.
• There is mucosal
thickening of the right
maxillary sinus
• Coronal CT scan
• Bilateral
sphenoidal sinus
opacity
• Diagnosis:
Bilateral Sphenoid
sinusitis
 There is soft-tissue
Axial CT scan thickening
left Frontal sinuses
over the expanded?? Right Frontal Sinus
expansion
are partially opacified
of the
by Right Frontal
mucoperiosteal sinus.
thickening
Hyperdense sinus secretions. This axial CT
scan shows hyperdense secretions in the left
maxillary antrum. fungal sinusitis.
Sinonasal polyposis.
Note the polypoid changes with opacification and
expansion of the right Nasal cavity, right maxillary
sinusitis coexists.
MRI
• Coronal MRI
scan showing
opacification of
the left maxillary
and ethmoid
sinuses
• Axial MRI scan
showing
opacification of the
left maxillary sinus
 Barium Plain
CT Scan
swallow X Ray

Accurately demonstrates limited value

• Pharynx The lumen ++ demonstrates
• Surrounding srtucture Lumen of pharynx
• with LN
• Lateral soft tissue X ray
of the head and neck
• Soft tissue shadow
arising from the roof
and posterior wall of
the nasopharynx
indenting the
nasopharyngeal airway
(green arrow)
• Suggesting adenoid
( blue arrow)
 Lateral view of the Neck
• Look for
- The vertebral column
( for any destruction
e.g in Pott’s disease)
- The pre-vertebral
space (3/4 the width
of the body of the
vertebra)
- The airway
• Widening of the radiological pre-vertebral space
• Acute Retropharyngeal abscess
wide prevertebral space (blue arrow)
pushing the airway anteriorly (yellow
arrow) in the lower half of the neck
Hypopharyngeal mass
 Retropharyngeal abscess
• Notice the markedly
thickened prevertebral soft
tissue space (between
arrows)

• Notice the destruction of 5th

&6th cervical vertebra
• Pott’s Disease
Pott’s Disease
• Safety pin in hypopharynx
• Coins are probably the most commonly
ingested foreign bodies in children
• AP and lateral plain films showing a
metallic foreign body in the upper
esophagus. Most foreign bodies are found
at the level of the cricopharyngeus muscle
• Chest X-Ray showing the metallic hook of the
partial denture (right). The rest of the plate is
radiolucent.
• Coin shaped shadow is seen in the lower neck
and above the level of the clavicle. Swallowed
Coin is seen by esophagoscopy
• Lateral radiograph of the neck reveals metalic
foreign body in the hypopharynx
• A pouch in the lower neck filled with radio-
opaque dye

Pharyngeal pouch
 Barium Plain
CT Scan
swallow X Ray

Accurately demonstrates Radio-opaque

demonstrates
• The esophagus foreign body
The lumen +++
• Surrounding srtucture
• with LN
 Barium Swallow
• Look for
Stricture
- length
- regular or irregular
- beginning,( e.g conical , shouldering
- Site ( at or high above the cardia)
Pre-stenotic dilatation( small, moderate
or huge dilatation)
 Achalasia
The stricture is
1-smooth
2- conical
3- at the cardia
Pre-stenotic
dilatation is huge
 Achalasia
• This 63 year old man
presented with a long history
of dysphagia, regurgitation of
undigested food and a
nocturnal cough.

• Barium swallow shows

marked dilatation of the
esophagus above the
smooth tapering lower end

• Endoscopy showed a large

volume of food residue
within the oesophagus. The
mucosa appeared normal.
Carcinoma of
oesphagus

The stricture is
-irregular
-short
-shouldering
prestenotic
dilatation is
moderate
• 71-year-old man with
distal esophageal
stricture shows
malignant-appearing
stricture (arrows) in
distal esophagus.

• Narrowed segment
has markedly
irregular contour +
shouldering
Post corrosive
stenosis

The stricture is
- Long segment
- Conical beginning
- High above the
cardia
The pre-stenotic
dilatation is small
• Child with croup. Note the pencil sign of the
proximal trachea evident on this anteroposterior
film
• The majority of children who aspirate a foreign
body are in the pre-school age group (1 to 5
years).
• The most common foreign bodies are nuts but
any other objects about the size of a peanut
can be inhaled (eg beads, plastic toys).
• Many children will not have a history of a
choking episode, however, a history of acute
choking, cough, breathlessness or wheeze
may all indicate inhalation of a foreign body.
• Chest radiograph of a child with no
abnormality identified
• PA chest,

• Diagnosis : Right lung collapse

• ? FB in the right main bronchus
• Complete right lung atelectasis
• Foreign body • Same child after
• Collapsed left lung extraction of the
foreign body showing
re-expansion of the
left lung
• Expiratory chest radiograph. Air trapping in the left
lung prevents air being expelled during expiration so
the left lung remains more lucent (darker) and the
mediastinum shifts to the right as the right lung
decreases in volume normally.
• A tooth (molar) was
dislodged during
intubation. The
patient developed a
lobar pneumonia
from the tooth,
• Aspirated foreign body (backing to an
earring) lodged in the right main stem
bronchus
• Clinical presentation:
Child admitted with breathing problems after playing with
plastic toy and a small piece is now missing.
• The right lung volume is increased and has herniated
across the mid-line. The left lung is compressed by the
displaced heart and mediastinum.
• This patient was able to speak, in
spite of the fact that she had an
uncapped tracheostomy tube. A
suction catheter could not be
introduced more than a few inches
before meeting resistance.

• The picture above is a sagittal

reformatting of a neck CT scan that
shows the tracheotomy cannula in
a false tract, outside the trachea.

• The axial CT scan picture below

shows the same tracheostomy
cannula anterior to the trachea.