Other Radiological Investigations

When would a spiral facial CT scan be appropriate?

Although it is widely recognised [10] that a spiral facial CT scan is far more accurate at identifying ZMC and zygomatic arch fractures, its use in the ED is restricted to either a second line investigation, usually initiated by the maxillofacial team, or when other injuries (e.g. cervical spine injury) prevent routine facial x-rays being performed.

The facial CT shows an opacified right maxillary sinus.

What methods of investigation could be used to diagnose an orbital blow-out fracture?

The diagnosis of an orbital blow-out fracture may be made on routine facial x-rays (e.g. a ‘teardrop’ sign) but CT scan remains the gold standard if this injury is suspected or identified. Relatively recently, focused ocular ultrasound (FOUS) has been evaluated in the ED [11,12] and found to be highly accurate in both diagnosing and excluding both orbital and ocular trauma.

The x-ray shows a teardrop sign on the left (arrow) indicating an orbital blow-out fracture.

Are x-rays of the nasal bones necessary?

It is now universally recognised that x-rays of the nasal bones are unnecessary as they do not alter management of the injury. EM doctors attempt to justify them [13] and they are still being performed [14], but they are not warranted for either clinical or medico-legal reasons due to a poor sensitivity and specificity.

Learning bite

There can be no justification for ordering x-rays of the nasal bones for a patient with a suspected nasal fracture.