From the Guidelines
To rule out zygoma and orbital fractures, a CT maxillofacial without IV contrast is the most appropriate initial imaging study, as it provides superior visualization of complex facial fractures and is particularly valuable for surgical planning if a fracture is identified 1. When ordering the CT scan, it is essential to clearly document the mechanism of injury, point of impact, and specific symptoms like facial asymmetry, periorbital ecchymosis, or sensory changes.
Key Considerations
- The CT maxillofacial scan should be performed without IV contrast, as it does not aid in the detection of facial injury 1.
- The scan should include thin cuts (1-2mm) to allow for the detection of subtle nondisplaced fractures of the facial skeleton 1.
- CT provides high image resolution with thin-section acquisitions and offers multiplanar and 3-D image reconstructions, allowing for better characterization of complex fractures 1.
Limitations of Radiographs
- Radiographs may miss subtle orbital floor or rim fractures and have limitations related to inaccuracies, especially with small or fine structures, associated with the superimposition of adjacent anatomic structures and the lack of technical skill resulting from disuse and a lack of training 1.
- CT is more sensitive in confirming the clinical suspicion of nasal bone fracture and is superior to radiography for the evaluation of mandibular fractures 1.
Importance of Proper Diagnosis
- Untreated zygoma or orbital fractures can lead to functional and cosmetic complications, including diplopia, enophthalmos, or facial asymmetry.
- Proper diagnosis and treatment are crucial to prevent these complications and ensure the best possible outcome for the patient.
From the Research
Ordering a Facial X-ray to Rule Out Zygoma and Orbital Fracture
To order a facial x-ray for ruling out zygoma and orbital fracture, consider the following steps:
- Evaluate the patient's symptoms and medical history to determine the necessity of imaging studies 2, 3
- Consider using computed tomography (CT) scans for accurate assessment of the zygomatic complex and orbital floor defects 2, 4
- In cases where intraoperative CT scans are available, utilize them to assess the accuracy of reduction and confirm implant position in zygomatico-orbital fractures 4, 5
- Follow established algorithms for the treatment of zygomatico-orbital fractures, such as the ZYGOMAS protocol, to guide the appropriate utilization of intraoperative 3-Dimensional imaging 5
Imaging Modalities
- CT scans are recommended for evaluating the zygomatic complex and orbital floor defects due to their high accuracy and ability to provide detailed images 2, 4
- Intraoperative CT scans can be used to assess the reduction of fractures and confirm implant position, reducing the need for secondary corrective surgery 4, 5
- 3D segmentation on CT scans can be used to assess symmetry of the zygomatic bone and guide reconstructive maxillofacial surgery 6
Clinical Considerations
- Patients with severe diplopia, restriction, or malpositioning of the globe may require exploration and repair of the orbit 2
- The treatment of zygomatico-orbital fractures can be sequential, using an algorithm to avoid unnecessary surgical approaches and procedures 3
- Intraoperative CT scans can help reduce the number of patients requiring internal orbital reconstruction 3, 5