Immediate Diagnostic Imaging with CT Maxillofacial
This patient requires urgent CT maxillofacial imaging to evaluate for a zygomaticomaxillary complex fracture with possible soft tissue entrapment or hematoma, and the facial weakness suggests facial nerve injury that must be fully characterized before any intervention. 1
Clinical Presentation Analysis
The combination of persistent facial weakness (inability to lift left side of face) and a palpable mass near the nasal and cheek area two weeks post-trauma is highly concerning for:
- Zygomaticomaxillary complex fracture - the second most common isolated facial fracture, particularly from blunt trauma like baseball impact 2
- Possible entrapped orbital fat or soft tissue creating the palpable mass 1
- Facial nerve injury causing the persistent weakness 1
- Potential hematoma or developing mucocele if there is sinus involvement 1
Immediate Next Steps
1. Obtain CT Maxillofacial Without Contrast (First Priority)
CT maxillofacial is the definitive initial imaging modality for facial trauma, providing high-resolution delineation of osseous and soft-tissue structures with multiplanar and 3-D reconstructions critical for surgical planning. 1, 2
- CT offers superb detection of subtle nondisplaced fractures and characterizes complex fracture patterns 1
- 3-D reformations are critical for preoperative planning in complex facial injuries 1
- IV contrast does not aid in detection of facial injury and should not be used 1
2. Comprehensive Facial Nerve Examination
Document the specific pattern of facial weakness:
- Test all facial nerve branches systematically 1
- Assess for complete versus incomplete paralysis 1
- Evaluate for signs of muscle entrapment versus direct nerve injury 1
3. Assess for Urgent Surgical Indications
Critical warning signs requiring immediate surgical consultation include: 1
- Evidence of muscle or periorbital tissue entrapment on CT 1
- Progressive diplopia with positive forced ductions 1
- Globe subluxation (rare but demands immediate repair) 1
- Large floor fractures with hypoglobus 1
- Progressive infraorbital hypoesthesia 1
Timing Considerations for Surgical Repair
Repair Within 2 Weeks (Most Likely Scenario)
Given the two-week timeframe since injury, this patient is approaching the critical window:
- Symptomatic diplopia with entrapment on CT requires repair within approximately 2 weeks 1
- Significant fat or periorbital tissue entrapment can result in permanent strabismus even without muscle entrapment 1
- Early enophthalmos or hypoglobus causing facial asymmetry will not resolve and are best addressed within about 2 weeks 1
Delayed Repair or Observation
If imaging shows minimal findings:
- Waiting 4-6 months after orbital trauma is advised in the absence of muscle entrapment, as strabismus may resolve spontaneously 1
- A short burst of oral steroids can hasten recovery and uncover persistent strabismus after orbital edema resolves 1
Common Pitfalls to Avoid
- Do not assume the palpable mass is simply residual swelling - it may represent entrapped tissue, hematoma, or developing mucocele requiring intervention 1
- Do not delay imaging beyond 2 weeks - the window for optimal surgical repair is closing, and permanent functional deficits may result 1
- Do not attribute facial weakness to temporary nerve neuropraxia without imaging - structural entrapment or significant nerve injury must be excluded 1
- Plain radiographs are inadequate - they have only 53-82% diagnostic accuracy for facial fractures and do not alter management 1
Specialist Referral
Immediate referral to facial trauma surgery or oculoplastic surgery is warranted given the combination of persistent facial weakness and palpable mass at two weeks post-injury. 1, 3
The goals of surgical intervention should be clearly discussed: eliminating diplopia in primary position and downgaze, enlarging the field of binocular single vision, and restoring facial symmetry. More than one operation may be required. 1