Imaging for Non-Orbital Facial Pain or Swelling After Trauma
CT maxillofacial (facial CT) with IV contrast is the recommended first-line imaging study for evaluating non-orbital facial pain or swelling following trauma. 1
Primary Imaging Recommendation
CT maxillofacial with IV contrast should be obtained as the initial imaging modality for the following reasons:
Superior detection of facial fractures: CT provides excellent delineation of both osseous and soft-tissue structures with high resolution, allowing detection of subtle nondisplaced fractures that may be missed on plain radiography 1
Multiplanar reconstruction capability: CT offers multiplanar and 3-D image reconstructions that are critical for characterizing complex fractures and surgical planning 1
Rapid acquisition: CT allows for quicker acquisition time compared to other modalities and is less reliant on patient positioning than radiography 1
Comprehensive soft tissue evaluation: CT with IV contrast can identify associated soft-tissue injuries, hematomas, and inflammatory changes that may be contributing to pain or swelling 2
When to Add or Consider MRI
MRI orbits, face, and neck without and with IV contrast should be added in specific circumstances:
Suspected intracranial complications: If there is concern for epidural abscess, subdural empyema, cerebritis, brain abscess, or meningitis, MRI has superior diagnostic accuracy (97%) compared to CT (87%) 3
Suspected orbital complications: MRI with contrast provides better characterization of intraorbital soft-tissue complications than CT alone 3
Persistent or atypical pain: When facial pain persists despite negative or inconclusive CT findings, MRI can identify intracranial lesions or other pathology not visible on CT 4
Salivary gland pathology: If swelling is thought to be related to salivary gland disease rather than trauma, MRI is highly effective and can replace invasive sialography 5
Imaging NOT Recommended
Plain radiography should be avoided as the initial imaging study because:
- Limited evaluation of soft-tissue structures 3
- Inferior sensitivity for detecting facial fractures compared to CT 1
- No added value when CT is available 5
Other modalities with no supporting evidence for initial evaluation of traumatic facial pain/swelling include: CTA, MRA, PET/CT, SPECT, and ultrasound 3
Clinical Pearls
Contrast administration: IV contrast is essential for CT maxillofacial when evaluating soft-tissue injury and complications; noncontrast CT is limited to bony evaluation only 3
Field of view considerations: CT maxillofacial typically includes adjacent orbital and intracranial structures, but if intracranial complications are strongly suspected, consider adding CT head with contrast for extended coverage 3
Tooth aspiration: If a tooth is missing after facial trauma, chest radiography may be warranted to exclude aspiration 1