Diagnostic Imaging and Management of Facial Trauma

Clinical Presentation and Diagnosis

The American College of Radiology recommends CT maxillofacial imaging to evaluate for zygomaticomaxillary complex fracture with possible soft tissue entrapment or hematoma, and to characterize facial nerve injury in patients with facial weakness and palpable mass near the nasal and cheek area two weeks post-trauma 1, 2
A palpable mass near the nasal and cheek area two weeks post-trauma is highly concerning for zygomaticomaxillary complex fracture, possible entrapped orbital fat or soft tissue, facial nerve injury, and potential hematoma or developing mucocele, according to the American College of Radiology and Ophthalmology guidelines 3, 4, 5

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, as recommended by the American College of Radiology 1, 2, 3
CT offers superb detection of subtle nondisplaced fractures and characterizes complex fracture patterns, with 3-D reformations critical for preoperative planning in complex facial injuries 1
IV contrast does not aid in detection of facial injury and should not be used, according to the American College of Radiology 1, 6

Critical warning signs requiring immediate surgical consultation include evidence of muscle or periorbital tissue entrapment on CT, progressive diplopia with positive forced ductions, globe subluxation, large floor fractures with hypoglobus, and progressive infraorbital hypoesthesia, as indicated by Ophthalmology guidelines 4
Symptomatic diplopia with entrapment on CT requires repair within approximately 2 weeks, and significant fat or periorbital tissue entrapment can result in permanent strabismus even without muscle entrapment, according to Ophthalmology guidelines 4
Early enophthalmos or hypoglobus causing facial asymmetry will not resolve and are best addressed within about 2 weeks, as recommended by Ophthalmology 4

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, as recommended by the American College of Radiology and Praxis Medical Insights 2, 7
The goals of surgical intervention should be clearly discussed, including eliminating diplopia in primary position and downgaze, enlarging the field of binocular single vision, and restoring facial symmetry, according to Ophthalmology guidelines 4