Waters View For Skull / Facial Bones

Waters View (Parietoacanthial Projection)

The Waters View for the skull and facial bones is the gold standard for visualizing the facial bones and maxillary sinuses. It requires a specific extension of the neck to shift the dense petrous ridges out of the area of interest. When done correctly, it provides a clear, unobstructed view that is vital for medical review.

Purpose

The primary goal of the Waters View is to visualize the facial bones, particularly the maxillary sinuses, zygomatic arches, and the orbits. This projection is essential for demonstrating anatomical alignment and visualizing potential trauma or fluid levels within the sinuses. By providing a clear “unobstructed” view, you help clinicians make fast, confident decisions without the interference of the petrous pyramids.

Patient Positioning

Orientation: The patient is typically positioned upright (standing or sitting) against the image receptor (IR) to demonstrate fluid levels in the sinuses, though it can be performed prone if necessary.
Body Alignment: Center the midsagittal plane (MSP) to the midline of the Bucky. Ensure there is no rotation or tilt of the head.
Baselines: Extend the patient’s neck, placing the chin against the IR. The mentomeatal line (MML) should be adjusted so it is approximately perpendicular to the plane of the IR. For most patients, the nose will be about 1 to 2 centimeters away from the Bucky surface.
Arms: Relax the arms at the sides or hold onto the Bucky handles for stability.

Richie’s Tip: The “secret sauce” to a perfect Waters view is the chin extension. You want the OML (Orbitomeatal Line) to form a 37-degree angle with the plane of the IR. If you don’t have a protractor in your pocket, just remember: lift the chin until the MML is perpendicular. This move is what “drops” those thick petrous ridges down below the maxillary sinuses where they belong.

Central Ray (CR)

Angle: The CR is perpendicular to the IR (0 degrees).
Horizontal Centering: Align the CR to exit at the acanthion (the area right under the nose, above the upper lip).
Vertical Centering: Ensure the CR is aligned with the MSP.

SID & Breathing

SID: 40 inches.
Breathing: Suspended. Have the patient hold their breath to ensure there is no blurring of the fine facial bone structures.

Common Errors

Under-extension: If the chin isn’t lifted enough, the petrous ridges will overlap the bottom of the maxillary sinuses. If you see those thick bones “creeping” into the sinuses, you need more extension.
Rotation: Check the distance from the bony lateral borders of the orbits to the edge of the skull. If one side is wider than the other, the head is rotated.
Tilt: If the MSP isn’t vertical, the facial structures will appear skewed. Ensure the eyes (interpupillary line) are level.

What Image Should Demonstrate

A technically sound Waters View should demonstrate the maxillary sinuses projected above the petrous pyramids. The distance from the lateral orbital borders to the lateral cortex of the cranium should be equal on both sides, confirming no rotation. The bony nasal septum should be centered, and the orbital rims should be clearly visualized.

Richie’s “Why It Matters” Note

Richie’s Tip: Accuracy on the Waters view is a huge win for the patient. Because we are looking for very fine details—like tiny fractures or fluid levels—getting the petrous ridges out of the way on the first shot is key. It prevents unnecessary repeats and ensures the provider has the best possible technical data to make an accurate clinical evaluation. Precision positioning is your best tool for patient advocacy!