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

Parameter	Recommended Specification	Radiographic Rationale
Patient Posture	Supine (Preferred) or Erect (Seated)	Supine provides better stabilization for the 45⁰ head rotation and 45⁰ tube angle
Image Receptor (IR)	18 × 24 cm (Portrait)	Small format tightly centered on the affected temporal bone
SID	100 to 115 cm ( 40 to 44 inches)	Standard focal distance balances spatial resolution and beam divergence
Grid Ratio	8: 1 to 12 : 1 focused grid	Essential to absorb scatter from dense cranial bones
Tube Potential (kVp)	70 – 80 kVp	High tissue-to-air contrast resolution for small middle ear cavities
mAs Range	25 – 35 mAs	Calibrated based on temporal bone thickness; center AEC cell active
Focal Spot	Small (0.6 mm)	High spatial sharpness required to visualize delicate attic and antral margins
Breathing	Suspended respiration	Eliminates respiratory and motion blur

3. Step-by-Step Patient & Part Positioning

Mayer Method – Positioning Card

Mayer Method: Patient Positioning

AP Axial Oblique (45°/45°)

Central Ray: 45° Caudad Tube Tilt
Enters frontal area ~2″ above contralateral orbit

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MSP Rotated 45° Toward Affected Side
(Profiles middle ear and antrum end-on)

IOML ⟂ Transverse Axis of IR (90°)

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[ Image Receptor Surface ]
CR exits through downside EAM

45° Caudal Tube Angle

Throws the dense superimposing calvarium inferiorly to expose the epitympanic attic.

45° Head Rotation

Rotates the temporal bone toward the downside to project the mastoid antrum end-on.

IOML Baseline (90°)

Keeps the infraorbitomeatal baseline perpendicular to the transverse cassette axis.

Exit Landmark

The central beam exits directly through the external auditory meatus (EAM) of the affected side.

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

Error Type	Radiographic Sign on Film	Clinical Impact	Correction
Under-Rotation (< 45⁰ Head Turn)	The mandibular condyle and facial bones superimpose over the middle ear cavity.	Obscures the external auditory canal and attic.	Rotate the head a full 45⁰ toward the affected side.
Over-Rotation (> 45⁰ Head Turn)	Petrous pyramid is projected in lateral profile; the mastoid antrum superimposes over the labyrinth.	Fails to achieve an axial view of the attic and antrum.	Rotate the head back to restore the 45⁰ angle.
Insufficient Caudal Angle (< 45⁰)	The dense occipital bone superimposes over the mastoid antrum and attic.	Obscures bone erosion from cholesteatoma.	Increase the caudal tube angle to a full 45⁰.
Improper Neck Flexion (IOML not 90⁰)	Petrous apex appears tilted; mastoid air cells overlap the mandibular ramus.	Distorts the spatial relationship between the EAM and middle ear.	Realign the IOML perpendicular to the transverse axis of the IR.

6. Radiographic Anatomy & Quality Evaluation Criteria

Mayer Method Anatomical Evaluation Diagram

Mayer Method: Radiographic Anatomy & Quality Criteria

AP Axial Oblique 45°/45°

Axial-Oblique Profile of Middle Ear & Mastoid Antrum

Diagnostic Quality Criteria

Attic

Epitympanic Recess & Aditus

Clear axial demonstration of the attic and aditus ad antrum free of superimposition from the dense occipital squama.

Antrum

Mastoid Antrum & Air Cells

Delineation of the mastoid antrum and tegmen tympani, profiling cortical erosion or sclerosis from chronic otitis media.

Canal

EAM & Tympanic Cavity

External auditory meatus and middle ear cleft are visualized in open profile without mandibular ramus overlap.

Apex

Axial End-On Petrous Pyramid

Petrous apex is projected end-on, confirming accurate simultaneous 45° head rotation and 45° caudal tube tilt.

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.