AP AXIAL: TOWNE METHOD Collimation
● Collimate on all four sides to include the
skull anatomy of interest.
Respiration
● Suspend respiration during exposure.
Position (Evaluation Criteria)
Minimum SID: 40 inches (102cm) • Symmetry of petrous ridges indicates no
IR: Lengthwise rotation.
Patient position: Erect or Supine
• Dorsum sellae and posterior clinoids within
Part Position the foramen magnum indicate correct CR
angle and neck flexion/extension.
● Depress the chin to bring the OML
perpendicular to the IR. • Underangulation or insufficient neck flexion:
dorsum sellae projected superior to foramen
○ If the patient cannot flex the neck, magnum.
align IOML perpendicular to the
• Overangulation or excessive neck flexion:
IR and use radiolucent support if
posterior arch of C1 superimposed on dorsum
needed.
sellae, causing foreshortening.
● Align the MSP to the CR and the midline
• Lateral shift of anterior/posterior clinoid
of the grid/table.
processes: head tilt present.
● Ensure no head rotation or tilt. • Proper collimation to area of interest.
● Include the vertex of the skull in the
collimation.
Central Ray (CR)
● Angle: 30° caudad to OML or 37° caudad
to IOML.
● Centering: MSP, 2½ inches (6.5 cm)
above the glabella, passing through the
foramen magnum at the base of the
occiput.
● Center IR to the projected CR.
LATERAL POSITION: RIGHT OR LEFT • Align IPL perpendicular to IR.
• Adjust neck flexion so IOML is perpendicular
to the front edge of IR (GAL parallel to the front
edge of IR).
Central Ray (CR)
• Perpendicular to IR.
• Center 2 inches (5 cm) superior to EAM, or
halfway between the glabella and inion
(depending on skull shape).
• Center IR to CR.
Respiration
• Suspend respiration during exposure.
Clinical Indications
• Skull fractures Evaluation Criteria
• Neoplastic processes
Anatomy Demonstrated:
• Paget’s disease
• Entire cranium visualized with superimposed
• Trauma routine: Horizontal beam lateral may
parietal bones.
show air-fluid levels in the sphenoid sinus,
• The entire sella turcica, including anterior and
which can indicate a basal skull fracture if
posterior clinoid processes and dorsum sellae, is
intracranial bleeding is present.
demonstrated.
• The sella turcica and clivus are shown in
profile.Position:
Technical Factors • No rotation or tilt of the cranium.
• SID: 40 inches (102 cm) • Rotation is evident by anterior and posterior
• IR Size: 24 × 30 cm (10 × 12 inches), separation of symmetric vertical bilateral
crosswise structures such as the EAM, mandibular rami,
• Grid: Required and greater wings of the sphenoid.
• Analog kV range: 70–80 kV • Tilt is evident by superior and inferior
• Digital systems: 80–85 kV separation of symmetric horizontal structures
such as the orbital roofs (plates) and greater
wings of the sphenoid.
• Collimation must include the area of interest.
Shielding
• Shield radiosensitive tissues outside the region
of interest.
Patient Position
• Remove all metal, plastic, or removable objects
from the head.
• Position the patient erect or recumbent
semiprone.
Part Position
• Place the head in a true lateral position, with
the side of interest closest to IR.
• Align MSP parallel to IR, ensuring no rotation
or tilt.
PA AXIAL: CALDWELL METHOD use 15° cephalic angle with OML perpendicular
to IR.
Anatomy Demonstrated:
• Greater and lesser sphenoid wings
• Frontal bone
• Superior orbital fissures
• Frontal and anterior ethmoid sinuses
• Supraorbital margins
• Crista galli
PA with 25° to 30° Caudad Angle:
• In addition to the above structures, the foramen
Technical Factors rotundum adjacent to each IOM is visualized.
• SID: 40 inches (102 cm) • The superior orbital fissures are seen within
• IR Size: 24 × 30 cm (10 × 12 inches), the orbits.
lengthwise
• Grid: Required Position:
• Analog kV range: 70–80 kV • No rotation: Equal distance from midlateral
• Digital systems: 80–85 kV orbital margins to the lateral cortex of the cranium
on both sides; superior orbital fissures symmetric
Part Position within orbits; correct neck extension (OML
• Rest nose and forehead against the table or alignment).
imaging device.
• Flex the neck as needed to align the OML ● Example: If the distance between the
perpendicular to the IR. right lateral orbit and lateral cranial cortex
• Align MSP perpendicular to midline of the grid is greater than the left side, the face is
or table to prevent rotation or tilt. rotated toward the left side.
• Center IR to CR. • No tilt: MSP is perpendicular to IR.
PA with 15° Caudad Angle:
• Petrous pyramids are projected into the lower
Central Ray (CR) one-third of the orbits.
• Angle CR 15° caudad and center to exit at the • Supraorbital margin is visualized without
nasion. superimposition.
• Alternative: Angle CR 25° to 30° caudad,
center to exit at the nasion (better visualization of PA with 25° to 30° Caudad Angle:
superior orbital fissures, foramen rotundum, and • Petrous pyramids are projected at or just
inferior orbital rims). below the IOM, allowing visualization of the
entire orbital margin.
Respiration
• Suspend respiration during exposure.
Alternative Views
• 25° to 30° caudad angle: Visualizes superior
orbital fissures, foramen rotundum, and inferior
orbital rim region.
• AP Axial (Reverse Caldwell): For trauma
patients or those unable to be positioned PA —
PA PROJECTION: 0 CR Recommended Collimation
• Collimate on four sides to anatomy of interest.
Respiration
• Suspend respiration during exposure.
Evaluation Criteria
Anatomy Demonstrated
• Frontal bone, crista galli, internal auditory
canals (IACs), frontal and anterior ethmoid
sinuses, petrous ridges, greater and lesser wings
of sphenoid, and dorsum sellae are shown.
Technical Factors
• Minimum SID: 40 inches (102 cm)
• IR Size: 24 × 30 cm (10 × 12 inches),
lengthwise Position
• Grid: Required • No rotation is evident, as indicated by equal
• Analog kV range: 70–80 kV distance bilaterally from the lateral orbital margin
• Digital systems: 80–85 kV to the lateral cortex of the skull.
• Petrous ridges fill the orbits and are at the level
of the supraorbital margin.
• Posterior and anterior clinoids are visualized
Shielding just superior to the ethmoid sinuses.
• Shield radiosensitive tissues outside the region • Collimation to area of interest.
of interest.
Patient Position
• Remove all metallic or plastic objects from the
head and neck.
• Take exposure with the patient in the erect or
prone position.
Part Position
• Rest nose and forehead against the table or
imaging surface.
• Flex neck to align OML perpendicular to IR.
• Align MSP perpendicular to the midline of the
table/imaging device to prevent head rotation or
tilt (EAM equal distance from table on both sides).
• Center IR to CR.
Central Ray (CR)
• CR is perpendicular to IR (parallel to OML).
• Center CR to exit at the glabella.
SMV Note: This position is uncomfortable
for patients. Perform the exposure
quickly.
Central Ray (CR)
• CR perpendicular to IOML.
• Center 1½ inches (4 cm) inferior to
mandibular symphysis, or midway between
gonions.
• Center IR to CR.
Anatomy Demonstrated:
Technical Factors
• Foramen ovale and foramen spinosum.
• Mandible.
• Minimum SID: 40 inches (102 cm).
• Sphenoid and posterior ethmoid sinuses.
• IR size: 24 × 30 cm (10 × 12 inches),
• Mastoid processes and petrous ridges.
lengthwise.
• Hard palate.
Erect Position: • Foramen magnum and occipital bone are
– Easier for the patient and can be performed clearly demonstrated.
using an upright imaging device or erect table.
Position:
– A wheelchair may be used for greater support
• Correct neck extension and accurate CR
and stability
alignment with IOML are indicated when the
mandibular mentum is anterior to the ethmoid
Part Position
sinuses.
• No rotation is evident if the MSP is parallel to
• Raise the patient’s chin and hyperextend the
the edges of the IR.
neck (if possible) until the IOML is parallel to the
• No tilt is evident when the distance between
IR (see Notes).
the mandibular ramus and lateral cranial
• Rest the patient’s head on the vertex.
cortex is equal on both sides.
• Align MSP perpendicular to the midline of the
grid or imaging table to avoid rotation or tilt.
● Example: If the left ramus appears farther
from the lateral cranium than the right, the
Supine:
cranial vertex is tilted to the left.
– Extend the patient’s head over the end of the
• Collimation must be limited to the area
table.
of interest
– Support both the grid cassette and head,
keeping IOML parallel to the IR and perpendicular
to the CR.
– If the table does not tilt, place a pillow under
the patient’s back to achieve sufficient neck
extension.
Erect (if limited neck extension):
– Angle the CR to remain perpendicular to the
IOML.
– IR may also be angled to maintain
perpendicularity with CR (e.g., with an adjustable
upright imaging device).
PA AXIAL: HAAS METHOD Part Position
● Rest the nose and forehead against the
table/imaging device surface.
● Flex neck, aligning OML perpendicular to
IR.
● Align MSP to CR and to the midline of the
grid or table/imaging device surface.
● Ensure no rotation or tilt (MSP
perpendicular to IR).
Clinical Indications Central Ray (CR)
● Skull fractures (medial and lateral ● Angle CR 25° cephalad to OML.
displacement), neoplastic processes, and
Paget’s disease. ● Center CR to MSP to pass through the
level of EAM and exit 1½ inches (4 cm)
● This is an alternative projection for superior to the nasion.
patients who cannot flex the neck
sufficiently for AP axial (Towne). ● Center IR to the projected CR.
● It results in magnification of the Evaluation Criteria
occipital area but delivers lower doses
to facial structures and the thyroid Anatomy Demonstrated:
gland.
● Occipital bone, petrous pyramids, and
foramen magnum are demonstrated.
● Not recommended when the occipital
bone is the area of interest due to
● Dorsum sellae and posterior clinoid
excessive magnification.
processes are visualized within the
shadow of the foramen magnum.
Technical Factors
● Minimum SID: 40 inches (102 cm). Position:
● IR size: 24 × 30 cm (10 × 12 inches), ● No rotation is evident, as indicated by
lengthwise. bilateral symmetric petrous ridges.
● Grid: Use grid. ● Dorsum sellae and posterior clinoid
processes are visualized in the foramen
● Analog: 70 to 80 kV range. magnum, confirming correct CR angle and
proper neck flexion/extension.
● Digital systems: 80 to 85 kV range.
● No tilt is present, as shown by correct
Patient Position placement of anterior clinoid processes
within the middle of the foramen magnum.
● Remove all metallic or plastic objects from
the patient’s head and neck.
● Position patient erect or prone.
Key Differences Between PA and AP Quick Trick:
Skull Radiographs:
If you compare an AP and PA skull radiograph
1. Direction of the X-Ray Beam side by side, the AP will have bigger, less sharp
orbits and facial structures (due to
● PA Projection: X-ray beam enters magnification), while the PA will look more “true
through the back of the skull (posterior) size”.
and exits the front (anterior).
● AP Projection: X-ray beam enters
through the front of the skull (anterior) and
exits the back (posterior).
2. Magnification of Facial Structures
● In AP projections, the orbits and facial
bones appear magnified because they
are farther from the IR.
● In PA projections, facial structures are
closer to the IR, resulting in less
magnification and sharper detail.
3. Positioning Clues
● PA Projection: Usually taken with the
nose and forehead (or just nose and
chin) against the IR (e.g., Caldwell).
● AP Projection: Usually taken with the
back of the head against the IR (e.g.,
reverse Caldwell or AP axial).
4. Petrous Ridges
● The position of the petrous ridges
relative to the orbits can help you identify
Caldwell (PA axial) vs. reverse Caldwell
(AP axial).
The angulation might be the same, but
AP projections tend to show slightly
larger orbits due to magnification.
