Radiology Self-study Tutorial

Head & Neck Region

Neuroscience System 2015

Structures to be identified on the following radiographic

images appear when pressing the down arrow or space
bar. The answer appears after pressing the down arrow or
space bar a second time. Hyperlinks are included in many
of the images to provide useful relationships and atlas
images for clearer interpretation of the radiographs.
 Lateral View - Plain Film of Skull

1. Middle meningeal a. groove

2. Orbital roof

3. Hard palate

4. Neck of mandible
8
2 1 11
5. Petrosal ridge
9
6. Sphenoid sinus

7. Sella turcica
7 5
8. Frontal sinus
6
9. Auricle (external ear) 10
4
10. Pterygopalatine fossa
3
11. Diploic bone (last item)
 What is wrong with these patients?

Both show linear skull fractures. Note the similarities and

differences between these radiolucent lines and the
radiolucent groove for the middle meningeal artery shown
in the preceding slide.
 Head MRI – Mid-sagittal

1. Sphenoid sinus
4
2. Frontal sinus

3. Nasopharynx

4. Lambdoid suture 2
1
5. Genioglossus

6. Epiglottis 3
7
7. Soft palate (last item)
5
6
 AP View – Plain Film of Skull

1. Lambdoid suture

2. Frontal sinus 1
3. Orbital margin

4. Superior orbital fissure

2 3
5. Inferior concha (turbinate)

6. Maxillary sinus 8 4

7. Head of Mandible in TMJ

6 7
8. Petrosal ridge
5
11
9. Hard palate
9
10. Angle of mandible

11. Styloid process (last item)

10
 What is the abnormality in each Patient?

Fracture thru neck & body of mandible Bilateral TMJ dislocation

 Axial CT – Orbit and Nasal Cavity

1 optic nerve

2 lateral rectus *
5 5
3 medial rectus *

1 5 5
4 sphenoid sinus ** 3
2
5 5
5 ethmoid air cells

6 nasal septum
(last item)
4

* Key Relationships ** Key Relationships

 Axial MRI – Orbit and Nasal Cavity

1. Optic nerve
5
2. Lateral rectus 5
3 5
3. Medial rectus 1 5
2 5

5 5
4. Sphenoid sinus 5

5. Ethmoid air cells

(last item) 4
 Coronal CT – Orbit and Nasal Cavity
10 What structures are most closely related to
the bone indicated by the arrows?
1 inferior rectus *

2 superior oblique ** 3
2
3 Levator palpebrae
superioris 8 9
8
4 middle turbinate 1 8 8
5 inferior meatus
4 7
6 hard palate

7 maxillary sinus 5

8 ethmoid air cells

6
9 optic nerve

10 olfactory bulbs
(last item)

* Key Relationships ** Key Relationships

What is wrong with this patient?

Blowout fracture of left orbital floor

* Orbital emphysema (air in orbit)
Anatomical & Clinical Correlations
 Coronal MRI – Orbit and Nasal Cavity

1. Maxillary sinus
2. Medial rectus muscle 5
4
3. Inferior oblique
4. Superior oblique
7 2
5. Levator superioris and superior
rectus 3
6
6. Middle turbinate and meatus 1
8
7. Ethmoid air cells
8. Zygomatic arch 9
9. Genioglossus of tongue 10

10. Buccinator muscle (last item)

 What is wrong with this patient?

Right maxillary sinus infection

 Axial MRI – Infratemporal (level 1)

7
1. Masseter muscle

2. Ramus of mandible
6
3. Medial pterygoid muscle 1
2
3
4. Nasopharynx/oropharynx border 4
5. Dens of C2 5
6. Uvula of soft palate

7. Buccinator muscle (last item)

 Axial MRI – Infratemporal (level 2)

1 lateral pterygoid muscle *

2 condyle or neck of mandible *

9 3
3 middle turbinate (concha) 6
7 5
4 nasopharynx
4 1
5 opening of auditory tube 2

6 masseter muscle
8
7 Temporalis muscle

8 mastoid air cells

9 maxillary sinus (last item)

* Key relationships
 Axial MRI – Base of Skull (level 1)

1 Mastoid process

2 Neck of mandible

3 Nasopharynx
4
4 Maxillary sinus 7
8
5 Styloid process 9
3
6 Dens of C-2 2
7 Nasolacrimal duct

8 Lateral pterygoid plate 1 5

6
9 Coronoid process (last item)
 What are the two pathologies shown below?

Epidural Hematoma Subdural Hematoma

Explanations
 Axial MRI – Base of Skull (Level 2)

1. Zygomatic arch

2. Foramen ovale 4

3. Head (condyle)of mandible

2
4. Middle turbinate
1
5. External auditory meatus 8
3
6. Foramen magnum
5
7. Mastoid process (last item) 7
6
8. Foramen spinosum
 Axial MRI – Base of Skull (level 3)

1. Sphenoid sinus

2. Internal auditory meatus

5 7
3. Head of malleus
1
4. Incus in middle ear cavity * 3
5. Ethmoid air cell

6. Lambdoid suture 2
4
7. Temporalis muscle (last item)
6
* Relationships
 Coronal CT – Infratemporal & Orbit

1. temporalis muscle

2. maxillary sinus
1 3
3. inferior rectus muscle

4. inferior concha 5
2
4
5. Zygomatic arch 6
6. Masseter muscle
7
7. Hard palate (last item)
 Axial MRI – Larynx and Neck

Key relationships for this level

1 sternocleidomastoid

2 internal jugular vein

6 5
3 common carotid artery 1 7
3
4 vertebral artery in 2
transverse foramen

5 thyroid cartilage 4

6 glottis 8

7 cricoid cartilage

8. Trapezius muscle (last

item)
 Carotid Arteriogram

1. Common carotid artery

2. Internal carotid artery
3. Maxillary artery
4. Occipital artery
5. Superior thyroid artery 7

6. Facial artery
8
4
7. Internal carotid artery in
cavernous sinus
8. Middle meningeal artery 3

2
End of Tutorial
6 5 1
In an axial image, when the full circumference of the eyeball is seen, as in
the radiograph, the structure projecting posteriorly from the center of the
eyeball must be the optic nerve. If it was either a superior or inferior
rectus muscle, the eyeball circumference would be much smaller. Also, the
only two ocular muscles seen at the “equator” of the eyeball are the medial
and lateral rectus muscles. All other muscles are either above or below the
plane of this section.

Back to radiograph Next image in tutorial

When examining a series of axial CT images, it is difficult to distinguish the
sphenoid sinus from the nasopharynx. The key is to determine if the image shows
turbinates, or ethmoid air cells and orbit. If ethmoid air cells and orbit are present
then the sphenoid sinus is the radiolucent area immediately posterior to the sinuses.
If turbinates are present then the radiolucent area immediately posterior to the
conchae is the nasopharynx .

Sphenoid sinus

Nasopharynx

Return to CT Scan Next radiographic image in tutorial

 * Key relationships for inferior
rectus versus inferior oblique
When the eyeball (orb) is seen in a Superior
coronal MRI or CT, the inferior oblique
oblique muscle is seen as shown in
the Netter figure to the right. The
inferior rectus can also be seen but
closer to the eyeball.
Superior
When the optic nerve is seen in a rectus
coronal MRI and CT (as is the case
in the image shown in this tutorial),
only the inferior rectus is seen and
not the inferior oblique, which is an
Inferior
anterior muscle. oblique

** Key relationships for superior

oblique vs. medial rectus
The belly of the superior oblique and the
medial rectus parallel each other adjacent
to the medial wall of the orbit, with the
superior oblique being superior to the medial
rectus.
Back to coronal CT Next image in radiographic tutorial
The internal jugular vein (IJV) lies immediately deep to the
sternocleidomastoid (SCM) muscle and lateral to the common carotid
artery. The IJV is often larger than the common carotid.

The thyroid cartilage is a V-shaped Arytenoid

structure that over lies the glottis Thyroid cartilage
and arytenoid cartilages. cartilage
Common
carotid
The vertebral arteries ascend in
the neck through the bony
transverse foramina.
SCM

IJV

Return to CT scans
Vertebral artery in
transverse foramen
The short process of the incus points posteriorly and directly at the entry
(aditus) to the mastoid air cells.

Right Middle Ear Cavity as Seen from Above

Anterior

Foot-plate Head of malleus

of stapes

Medial
The head of the malleus,
which appears quite Lateral

spherical, is immediately
anterior to the incus. CN VII Short process
of incus
VII & VIII entering
internal auditory meatus
Return to MRI
Posterior

Next Image in tutorial

Mastoid air cells just deep to star
The lateral pterygoid muscle attaches to the condyle and neck of the
mandible and is positioned horizontally in the infratemporal fossa. Thus,
both the muscle and the condyle lie in the same horizontal plane. The
absence of the ramus of the mandible is an additional clue that the plane of
section is at the superior aspect of the infratemporal fossa.

Return to MRI image Next image in tutorial

 Epidural versus Subdural Hematomas

Epidural hematomas are usually due to tears in the middle meningeal artery.
Because the blood accumulates between skull and dura, the contour of
hemorrhage on CT is smooth and lenticular-shaped with the convexity facing
the brain.

Go to next image
Return to CT image

Subdural hematomas on the other hand bleed between dura and arachnoid.
Thus, on CT they appear with an irregular border facing the brain. They also
can be larger than an epidural because the spread of blood in epidurals is
limited by suture lines where the dura is more firmly anchored to bone.
 Orbital Blowout Fractures

The thinnest bones of the orbit are the located on the

floor (orbital plate of maxilla1) and the medial wall
2 3
(orbital plate of ethmoid2 and the lacrimal3).
1

Orbital blowout fractures are the second most commonly

encountered midfacial fractures, second to nasal
fractures. Such fractures are secondary to a sudden
increase in orbital pressure. A high-velocity object, such
as a ball or fist, that impacts the globe results in pressure
with a downward and medial vector usually targeting the
infraorbital grove.

Most fractures occur where the bone is thinnest, which is

the medial wall and floor of the orbit. The inferior rectus
is often entrapped in fractures of the floor, leading to
diplopia and the globe tethered with an inability to gaze
upward. Fractures of the floor communicate with the
underlying maxillary sinus. The infraorbital nerve is also
commonly damaged.

Return to CT Go to next image in tutorial