4SINUSES Nasal Septum Frontal Sinus Maxillary Sinus Ethmoid Sinus PA viewNasal SeptumFrontal SinusMaxillary SinusEthmoid SinusInferior TurbinateSuperior orbital fissure26431Comparing the skull x-ray and a specimen structures deep to the bony surface are visible.5
51- Superior orbital fissure 2- Inferior orbital foramen 3- Mental foramen121Here we have made a 3-D model from CT sections and present it as compared with specimen. Note the corresponding foramen labeled.23Fissures and foramen havenerves that show on labpracticals.3
6OPTIC CANALHere on this oblique view the optic canal is seen along the medial border of the superior orbital fissure.
7AP WATERS VIEW SINUSES 1 2 3 4 1. Frontal sinus 2. Zygomatic-Frontal Suture3. Maxillary Sinus4. Inferior orbital margin1234This view is angled to project the maxillary sinuses free of the petrous ridge.
8Note the opacified right maxillary sinus with fluid layering dependently indicating sinusitis
9WHAT RECTUS MUSCLE CAN BE INJURED BY EYE TRAUMA?SuperiorInferiorMedialLateralInferior
10Arrow points to bone fragment ORBITAL FLOOR FRACTUREArrow points to bone fragmentdisplaced into orbit. The inferior rectus muscle can become entrapped in fracture
11CT FACIALCORONAL SCANHere the trauma shows the inferiorly displaced floor of the orbit which can entrap the inferior rectus muscle.CT scans redemonstrate fracture and edema at site.
121. Frontal Sinus 2. Maxillary Sinus 3. Ethmoid Sinus 4. Sphenoid Sinus The lateral x-ray and the specimen compared.LATERAL SINUS & SKULL
13Middle meningeal artery The middle meningeal artery, a branch of the maxillary artery runs in a groove along the innner table of the skull.A fracture through the skull can injure the middle meningeal artery and the bleeding here can cause an epidural hematoma causing mass effect on the subjacent brain.
15Cause: Laceration of the meningeal artery adjacent to inner table. EPIDURALHEMATOMAFRACTUREThe fracture extends through the skull at the site of the middle meningeal artery.The arterial blood disects the dura (periosteum) from the inner table due to the higher arterial pressure and creates a convex mass.Cause: Laceration of the meningeal artery adjacent to inner table.15
16Normal skullThe pituitary gland is seen in the sella inferior to the arrow. The pituitary stalk connects the brain to the pituitary gland. The optic chiasm is above the gland.Sella
17CAROTID CANALJUGULAR FORAMENHere on the CT section the carotid and jugular canals are seen.CT SKULL BASE
18PINNAMANDIBULARCONDYLEA more cephalad section shows condyles and mastoid air cells. The pinna is seen on the left. Mastoid air cells show small bony septa and air density indicating normal ventilation.MASTOID AIR CELLSCT SKULL BASE
19SKULL BASEFRACTUREOn the left the fracture is seen and the mastoid air cells are opacified with the bleeding and edema from the fracture Skull base fracture can lead to cerebral spinal fluid leak and risk of meningitis.The purple ecchymosis behind the ear is called Battle sign described as a clinical finding with basilar fractures here. The blood from the fracture tracks superficially to the skin over the mastoid air cells.
20“RACCOON EYES”Periorbital ecchymosis is a sign of a basal skull fracture. Blood tracks along the periosteum and can collect in soft tissues of the orbital lid.Blood may track anteriorly from other skull base fractures and pool in soft tissues of the orbit from a basilar skull fracture and show Raccoon eyes.
21ZYGOMATIC ARCHEXTERNALAUDITORY CANALFurther cephaladCT SKULL BASE
22FORAMEN OVALEPETROUS CAROTID CANALFORAMENSPINOSUMThe foramen ovale and spinosum, petrous portion of carotid artery and the clivus.CLIVUSCT SKULL BASE
23INTERNAL AUDITORY CANAL CAROTID CANALOSSICLESThe carotid canal continues through the skull base to lie adjacent to the sella. The 7th and 8th cranial nerves enter the IAC. The skull specimen is viewed from the top looking inside.IACINTERNAL AUDITORY CANALCT SKULL BASE
24Acoustic neuroma is a slow growing tumor that develops on the 8th cranial nerve. Symptoms include unilateral loss of hearing, Tinnitus-ringing in ears. dizziness and vertigo.Here the MR scan shows a mass at the internal auditory canal on the right compared with the left side.A tumor of the 8th cranial nerve called an Acoustic Neuroma or Schwannoma.
25SINUS AND ORBIT ANATOMY To now look in more detail at sinus and orbit anatomy with CT.
27SINUSES AP WATERS VIEW Frontal sinus 2. Zygomatic-Frontal Suture 3. Maxillary sinus4. Inferior orbital margin1234This view is angled to project the maxillary sinuses free of the petrous ridge. The Frontal and Maxillary sinuses are seen on the Waters view.The Ethmoid and Sphenoid sinuses are obscurred by boneThis view is angled to project the maxillary sinuses free of the petrous ridge.
29Scans start superiorly and are shown going inferiorly CT- SINUSAXIAL VIEW11. Frontal SinusWe have a series of sections starting cephalad and working caudad. The skull xray and line shows the level of the section.Scans start superiorly and are shown going inferiorly
30CT SINUS AXIAL SCAN normal The opacified sinus can cause bone destruction with the chronic bacterial/fungal infection. This can lead to meningitis and abscess formation.Note the destroyed posterior wall of the left frontal sinus due to bacterial invasion.
31CT- SINUS 1. Ethmoid sinus 2. Sphenoid sinus 3. Carotid canal AXIAL VIEW1As we move inferiorly, we now see we are at the level of the orbits1. Ethmoid sinus2. Sphenoid sinus3. Carotid canal23
32CT- SINUS Maxillary sinus Med. & Lat. Pterygoid plate Nasopharynx AXIAL VIEW1Maxillary sinusMed. & Lat. Pterygoid plateNasopharynxNasal septumInferior turbinate45Below the orbits we are now at the level of the maxilla on the next two sections.23
33Coronal sections extending from anterior to posterior CT- SINUSCoronal sections extending from anterior to posterior2Fronto-nasal sutureFrontal sinusNasal bones1On these sections we are creating coronal images viewed as though the patient is looking at us. Most anteriorly, we can see the nasal bones3
34CT- SINUS 1. Ethmoid sinus 2. Maxillary sinus 3. Middle turbinate CORONAL VIEW131. Ethmoid sinus2. Maxillary sinus3. Middle turbinateMore posteriorly we are now behind the globes. Note the thin cribiform plate separarating the ethmoid roof from the anterior cranial fossa
35CT- SINUS CORONAL VIEW Maxillary sinus This image of the maxillary sinuses in a different patient shows the ostea of the sinuses draining.Maxillary sinus
36CT- SINUS Sphenoid sinus Hard palette Anterior clinoid CORONAL VIEW 3 1Sphenoid sinusHard paletteAnterior clinoidNow we can see the sphenoid sinuses and the anterior clinoid processes.2
37CT ORBIT Retro orbital fat Medial rectus Lens Lateral rectus AXIAL SCANRetro orbital fatMedial rectusLensLateral rectusOptic nerve24135Here axial sections through the orbits are viewed at a soft tissue level to see the muscles, nerve and orbital fat. Note the bony detail is not as well seen as on the sinus/bone images.
38MR SCAN AXIAL SCAN CORONAL SCAN Optic nerves Chiasm Further cephalad shows the two optic nerves extend through the optic canal and converge to form the chiasm. The coronal scan shows the CHIASM with the pituitary stalk and gland inferiorly.MR SCAN38
39In Biblical liturature who showed a knowledge of cranial nerve anatomy?MosesNoahDavidGoliathDavid
40NormalSella MassThe mass impinges on the optic chiasm to create the visual disturbance. Pituitary tumors can secrete growth hormone and lead to gigantism.Goliath, the giant of Biblical history may have been one. His pituitary tumor pressure on the chiasm caused a visual field defect “tunnel vision” –bitemporal hemianopsia which allowed his foe- David to get close enough by staying in the peripheral visual where he could not be seen.Compare the normal with the enlarged pituitary adenoma. The mass impinges on the optic chiasm to create the visual disturbance.
41NECK ANATOMYTo now move to more soft tissue anatomy of the oral cavity and neck
42LATERAL NECK Hard palate Soft palate Nasopharynx Oropharynx Epiglottis 3LATERAL NECKHard palateSoft palateNasopharynxOropharynxEpiglottis1245On this lateral view the air outlines soft tissue structures. A mid line MR is shown for comparison.
43AIRWAY LATERAL VIEW OF NECK Calcified tracheal cartilage rings Hyoid boneEpiglottisThyroid cartilageCricoid cartilage3254Cartilage in the neck can calcify normally and this aids visualizationHere they are outlined1LATERAL VIEW OF NECK
44LATERAL VIEW OF NECK AIRWAY Calcified tracheal cartilage rings 3AIRWAYCalcified tracheal cartilage ringsHyoid boneEpiglottisThyroid cartilageCricoid cartilage2541LATERAL VIEW OF NECK
45Where do you insert the tube at an emergency tracheostomy? Cricothyroid membrane
46Emergency tracheostomy is performed at the thyro-cricoid ligament Emergency tracheostomy is performed at the thyro-cricoid ligament. Here a chest xray with a tracheostomy tube in postion.LATERAL VIEW OF NECK
47Sections from the skull base extending inferiorly through the neck. LTMAXILLARY SINUSESSCAN LEVELZYGOMAZYGOMASPHENOIDSINUSThese are a set of axial sections through the neck from the skull base going inferiorly. There is a corresponding lateral x-ray to show the level of sectionSections from the skull base extending inferiorly through the neck.
48LT SCAN LEVEL MANDIBULAR CONDYLE MAXILLA EXTERNAL AUDITORY MEATUS NASOPHARYNXMASTOIDSContinuing inferiorly over the next several sections.
49LT SCAN LEVEL MANDIBLE MASSETER MUSCLE MASSETER MUSCLE PTERYGOID MUSCLESPAROTIDGLANDNote the parotid glands are of lower density than the surrounding muscles due to the fat present within the gland.
50LT SCAN LEVEL SUBMANDIBULAR GLAND EPIGLOTTIS STERNOCLEIDOMASTOID MUSCLEAgain note the difference in fat compared with soft tissue muscle.SUBCUTANEOUSFAT
51LT SCAN LEVEL HYOID BONE VALLECULA PYRIFORM SINUS JUGULAR VEIN JUGULAR COMMON CAROTIDARTERIESIodinated contrast was injected during the exam and it opacifies the carotid and jugular vessels
52LT SCAN LEVEL STERNOCLEIDOMASTOID MUSCLE THYROID CARTILAGE VOCAL CORD The calcified thyroid cartilage is seen anteriorly
53LT SCAN LEVEL THYROID CARTILAGE COMMON CAROTID ARTERY CRICOID JUGULARVEINNow inferiorly the cricoid cartilage is seen.
54LT SCAN LEVEL THYROID GLAND CLAVICLE CLAVICLE FAT FAT ESOPHAGUS TRACHEAAir posterior to the trachea is in the esophagus. Typically the esophagus is collapsed unless eructation occurs.
55Note hyoid bone moves anteriorly and superiorly with swallowing. SWALLOWING STUDY12Here successive images at 2 frames per second show barium propelled into the esophagus.43Note hyoid bone moves anteriorly and superiorly with swallowing.
56THYROID SCAN Nuclear Medicine Nuclear medicine can evaluate tissue for function based on abiltiy to take up iodine. Here a radioactive iodine I-123 is administered.
57SAGITTALTHYROID SCANThe superficial location of the thyroid makes readily accessible to ultrasound for evaluation of questionable palpable findings.
58SAGITTAL SCANS LEFT LOBE RIGHT LOBE Ultrasound can assess palpable nodules and direct biopsy if needed. A nodule in the Rt. Lobe is marked
59NUCLEAR MEDICINE THYROID SCAN Normal Hypo-functional Here are the normal thyroid scan made with radioactive Iodine shows relatively symmetric activity in the right and left lobes. The hypofunctional gland shows a large cold nodule inferiorly in the right lobe. This indicates non functioning thyroid tissue along with some mass effect. This is not a specific pathology but more suspicious for malignancy
60PATIENT PRESENTS WITH WHEEZING AND NECK MASS IN MIDLINE AT STERNAL NOTCH
61THYROID SCAN Nuclear Medicine Chest x-ray showing superior Mediastinal mass with displacement of the trachea to the right. Nuclear Medicine I123 thyroid scan shows lobular mass extending inferiorly from the thyroid indicating a thyroid goiter accounting for displacement on chest x-ray.Here in a different patient: Chest x-ray showing superior Mediastinal mass with displacement of the trachea to the right. Considerations would include enlarged thyroid tissue or tortuous vessels. Nuclear Medicine I123 thyroid scan shows lobular mass extending inferiorly of the thyroid indicating a thyroid goiter accounting for displacement on chest x-ray.THYROIDSCANNuclear Medicine
62CORONAL CT SCANS SHOWS THYROID LESION. CT scan shows left thyroid mass at the level of the clavicles displacing the trachea to the right.
63ARTERIOGRAM Internal carotid artery Intracranial carotid Maxillary arteryOccipital arteryExternal carotid arteryCommon carotid arteryFacial artery234Here is a lateral image from a carotid angiogram. Iodinated contrast has been injected in a catheter with its tip in the common carotid artery. The contrast outlines the vascular tree. The catheter was placed from a femoral artery puncture and advanced retrograde into the aorta and into the common carotid artery.7156
64WHAT VESSEL HAS TO BE LIGATED OR EMBOLIZED TO CONTROL EPISTAXIS IF PACKING NOSE FAILS? MaxillaryFacialLingualSuperficial temporalMaxillary64
65normal Maxillary artery Here injection into the external carotid shows extravasation of blood from a branch of the maxillary artery compared with the normal.normalMaxillary artery65
66EMBOLIZATIONRadiologist has directed a coil through the catheter to occlude vessels that were bleeding.66
68NormalAbnormalUltrasound can measure lumen size of carotid artery and velocity of flow to indicate significant stenosis.
69Ultrasound and arteriogram show high grade narrowing NormalArteriogram is used for more anatomic detail to plan for surgery if a significant stenosis is found with ultrasound.Ultrasound and arteriogram show high grade narrowingof internal carotid artery due to atherosclerosis.
71ASPIRATIONA small amount of barium has extending anteriorly with aspiration into the airway. This can irritate the vocal cords and cause hoarsness.NORMALA small amount of barium has spilled anteriorly with aspiration into the airway.71
72Hiatal hernia and reflux. Reflux from the stomach due to hiatal hernia can lead to aspiration with vocal cord irritation and hoarseness. Here a hiatal hernia is shown.
73Here two patients with masses in their chest have involvement of the Here two patients with a mass in their chest have involvement of the recurrent laryngeal nerve causing hoarseness due to vocal cord paralysis.Here two patients with masses in their chest have involvement of therecurrent laryngeal nerve causing hoarseness due to vocal cord paralysis.
74LARGE THORACIC ANEURYSM Here the aneuysm of the Aortic arch is stretching the recurrent laryngeal nerve causing damage leading to vocal cord dysfunction.
75LUNG MALIGNANCYThe lung cancer affects the nerve similarly leading to dysfunction. The patient may present to physician with the hoarsness as the initial complaint.
76Aspiration into airway Mosquito bite Ethmoid transmission Amoebic meningitis can be contracted in southern states from swimming in warm lake water in summer by what route?Ear infectionAspiration into airwayMosquito biteEthmoid transmissionEthmoid transmission76
77The thin cribiform plate can allow for transmission of nasal fluid. 77