What is the recommended imaging protocol for patients presenting with facial trauma, specifically for suspected fractures or serious injuries, using Computed Tomography (CT) scans?

CT Imaging Protocol for Facial Trauma

Multidetector CT (MDCT) of the maxillofacial region without intravenous contrast is the first-line imaging modality for patients presenting with suspected facial fractures or serious facial trauma. 1

Primary Imaging Recommendation

• CT maxillofacial without IV contrast should be obtained as the initial study, providing superior delineation of osseous and soft-tissue structures with high-resolution thin-section acquisitions that detect even subtle nondisplaced fractures 1
• Multiplanar reconstructions (coronal, sagittal) and 3D volume rendering should be routinely performed, as surgeons find these critical for preoperative planning and characterization of complex fractures 1
• CT allows faster acquisition time than radiography or MRI and is less reliant on patient positioning, making it ideal for trauma settings 1
• IV contrast does not aid in detection of osseous facial injury and should not be used 1

Complementary Head CT

A contemporaneous CT head without contrast should be obtained in patients with facial trauma, particularly those with frontal sinus, orbital wall, or midface fractures. 1

• 68% of patients with facial fractures have associated head injury, making head CT essential for complete evaluation 1
• More than one-third of patients with frontal sinus fractures have concomitant intracranial injury, with 8-10% requiring surgical intervention for subdural or epidural hematoma 1, 2
• 9% of patients with orbital wall fractures have concomitant intracranial injury 1
• Important caveat: While head CT alone detects 95% of facial fractures, it often only partially images midface fractures, so a dedicated maxillofacial CT remains necessary 1

Cervical Spine Imaging Considerations

CT cervical spine should be obtained when there is high-velocity trauma or clinical suspicion of cervical spine injury. 1

• 6-19% of patients with significant maxillofacial trauma have associated cervical spine injuries 1, 2
• 7% of all facial fracture patients have concomitant cervical spine injury 1
• The likelihood of cervical spine injury increases with severity of maxillofacial injury 1
• Frontal bone fractures result from high-energy forces that drive the cervical spine into extension, making concomitant cervical injury common 1

Technical Specifications

• Thin-section acquisitions are essential for detecting subtle nondisplaced fractures 1
• Multiplanar reconstructions (MPR) in coronal and sagittal planes improve detection of orbital tissue herniations, particularly in inferior orbital wall fractures 3
• 3D volume rendering provides critical information for surgical planning and is superior to 2D imaging for characterizing complex fracture patterns 1
• Cinematic rendering is an emerging technique that shows promise for illustrating maxillofacial fractures 1

When MRI May Be Indicated (Not Initial Imaging)

MRI is not useful for initial evaluation but may supplement CT in specific scenarios:

• Cranial nerve deficits not explained by CT (e.g., infraorbital nerve injury in Le Fort II or zygomaticomaxillary complex fractures) 1
• Suspected CSF leak from skull base fractures, where heavily T2-weighted sequences can be helpful 1
• Detection of small asphalt foreign bodies, where MRI is superior to CT 1
• MRI is rarely necessary for acute diagnostic workup 1

Common Pitfalls to Avoid

• Do not rely on plain radiographs - CT provides superior fracture detection and characterization compared to conventional radiography 1, 4
• Do not use IV contrast for routine facial trauma imaging, as it does not aid in fracture detection 1
• Do not skip head CT in patients with frontal sinus, orbital, or severe midface injuries due to high rates of intracranial injury 1, 2
• Do not assume head CT alone is sufficient - dedicated maxillofacial CT is necessary as head CT often incompletely images midface fractures 1
• Be vigilant for posterior table frontal sinus fractures, which indicate potential dural disruption and communication with the anterior cranial fossa 1, 2

Clinical Indicators for Imaging

Obtain facial CT when any of the following are present:

• Visible or palpable nasal deformity 4
• Periorbital contusion or subconjunctival hemorrhage 5
• Lip, intraoral, or nasal lacerations (remember the acronym LIPS-N: Lip laceration, Intraoral laceration, Periorbital contusion, Subconjunctival hemorrhage, Nasal laceration) 5
• Suspected complex injuries or associated facial fractures 4
• Malocclusion, facial asymmetry, or enophthalmos 1