Mayer X-Ray View (Axial Oblique): Mastoid & Attic Positioning Notes

The Mayer X-Ray View Method (AP Axial Oblique Projection) is a specialized temporal bone projection designed to demonstrate the external acoustic meatus (EAM), tympanic cavity (middle ear), epitympanic recess (attic), mastoid antrum, and ossicular area in an unobstructed axial-oblique profile.

By rotating the head 45⁰ toward the affected side and directing the central ray with a 45⁰ caudal angulation, the petrous pyramid of interest is projected end-on/axially, casting the petrous apex, middle ear cavity, and mastoid cells free from superimposition of the dense calvarium and contralateral temporal bone.

1. Clinical Indications & Contraindications

Detailed Indications:

• Atticoantral Disease & Cholesteatoma:
  • Detection of early expansile bone erosion within the attic (epitympanic recess) and aditus ad antrum.
  • Visualization of sclerotic margins and destruction of the lateral attic wall (scutum).
• Chronic Suppurative Otitis Media (CSOM) & Mastoiditis:
  • Assessment of bone resorption, trabecular breakdown, and opacification within the mastoid antrum and middle ear cleft.
• Ossicular Chain & Middle Ear Pathology:
  • Evaluation of ossicular discontinuity, dislocation (e.g., incudomalleolar disruption), or erosion resulting from chronic infection or trauma.
• Auditory Canal & Labyrinthine Assessment:
  • Evaluation of the external auditory canal in axial profile and assessment of petrous bone lesions encroaching on the middle ear cavity.

Contraindications & Limitations:

• Unstable Cervical Spine Trauma: Absolute contraindication for standard positioning involving head rotation or neck flexion.
• Fine Spatial Resolution Limitations: While the Mayer view provides high bone contrast for plain film protocols, modern high-resolution temporal bone CT (HRCT) is preferred for delicate surgical staging of the ossicles and facial nerve canal.

2. Technical Factors & Exposure Physics

3. Step-by-Step Patient & Part Positioning

              [ X-ray Tube Angled 45° Caudad ]
                      \
                       \  45° Caudad Tube Tilt
                        ▼
                (Enters Frontal Area above Orbit)
                 ───────┬───────
               /        │        \
              │   IOML  │         │ ◄── IOML ⟂ Transverse Axis of IR
              │ ───────┼──────── │
               \  MSP   │        /  ◄── Mid-Sagittal Plane Rotated 45° toward Affected Side
                 ───────┴───────
                 [ Image Receptor ]

• Patient Preparation: Remove all metallic and radiopaque objects (earrings, hearing aids, hairpins, spectacles, dentures, and necklaces). Tape the auricle (pinna) of the affected ear forward flat against the cheek if necessary to prevent its soft tissue shadow from superimposing over the mastoid cells.
• Base Posture: Patient lies supine on the radiographic table with the posterior skull (occiput) resting against the table surface. (Alternatively, the patient can be seated erect facing the X-ray tube with occiput on the vertical Bucky).
• Alignment of Reference Lines & Planes:
  1. Head Rotation (MSP): Rotate the patient’s head 45⁰ toward the affected side (side of interest down).
  2. Infraorbitomeatal Line (IOML): Adjust neck flexion/extension until the IOML is strictly perpendicular (90⁰) to the transverse/horizontal axis of the IR.
  3. Receptor Alignment: Center the image receptor to the projected central ray pathway at the level of the downside external auditory meatus.

4. Central Ray (CR), Tube Angle & Collimation

• Central Ray (CR) Tube Angle:45⁰ Caudad (angled downwards toward the feet).
  • Rationale: The combination of a 45⁰ head turn toward the affected side and a 45⁰ caudal tube angle isolates the petrous pyramid in an axial-oblique perspective, projecting the mastoid antrum and middle ear cavity clear of the occiput and mandibular condyle.
• CR Entry Point: Enters the frontal area of the skull approximately 5 cm (2 inches) superior to the contralateral (upside) superciliary arch / orbit.
• CR Exit Point: Passes obliquely through the cranium to exit directly through the affected (downside) external acoustic meatus (EAM) resting against the IR.
• Collimation: Four-sided tight collimation restricted to a a 7.5 × 7.5 cm (3 × 3 inches) field over the downside temporal bone.

5. Positioning Errors & Corrective Actions

6. Radiographic Anatomy & Quality Evaluation Criteria

+───────────────────────────────────────────────────────────────────────────+
|                                                                           |
|                               [ Cranium ]                                 |
|                                                                           |
|                  /─────────────────────────────────────\                  |
|                 │                                       │                 |
|   Petrous ────► │     [ Petrous Apex (Axial End-on) ]   │                 |
|    Apex         │                                       │                 |
|                 │        [ ATTIC / EPITYMPANUM ]        │ ◄── Epitympanic |
|                 │         (Aditus ad Antrum)            │      Recess     |
|                 │                 │                     │                 |
|   External ───► │          (O) ───┴─── (======)         │ ◄── MASTOID     |
|   Auditory      │         [ EAM ]     [ Tympanic ]      │      ANTRUM     |
|    Meatus       │                       [ Cavity ]      │                 |
|                  \                                     /                  |
|                   \___________________________________/                   |
|                             [ Mandibular Condyle ]                        |
|                               (Projected Away)                            |
+───────────────────────────────────────────────────────────────────────────+

• Attic & Mastoid Antrum Isolation (Primary Quality Hallmark):
  • The epitympanic recess (attic), aditus ad antrum, and mastoid antrum are clearly visualized in axial profile, free of superimposition from the dense occipital bone.
• External Auditory Meatus & Middle Ear Cleft:
  • Clear, open demonstration of the external acoustic meatus (EAM) and the radiolucency of the tympanic cavity.
• Petrous Pyramid Axial Profile:
  • Petrous pyramid projected end-on with distinct bony boundaries of the tegmen tympani and mastoid process.
• Contrast & Detail:
  • High-contrast resolution that clearly defines the thin cortical bony septa of the mastoid cells and the bony walls of the attic with no motion blur.