Clinical Assessment of the Diagnostic Value of Facial Radiography in Facial Trauma Patients at the Emergency Department

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1 Chin J Radiol 2005; 30: Clinical Assessment of the Diagnostic Value of Facial Radiography in Facial Trauma Patients at the Emergency Department PI-YUN CHIU 1 JEN-DAR CHEN 1,2 PING-YI KO 1 CHENG-YEN CHANG 1,2 Department of Radiology 1, Taipei Veterans General Hospital School of Medicine 2, National Yang-Ming University Facial injury is a common reason for patients admission at Emergency Department. Water s view of skull is usually used as the screening modality for facial bone fracture. We evaluated 100 patients, who received both Water s view and facial CT due to trauma during a 18-month period. There were 68 males and 32 females with the age ranging from 15 to 88 years (mean 41.4 years). The causes of trauma included traffic accident in 40 cases, falls in 12, assault in 9, stab injury in 1, and non-specified causes in 38. Both the images of Water s view and CT were evaluated and compared. Of the 81 patients with CT-proven facial fractures, it could be identified by Water s view in 73. Of 19 cases without facial fracture on CT, one was misdiagnosed with facial fracture on Water s view. The result showed sensitivity of 90%, specificity of 94.7%, positive predictive value (ppv) of 98.6%, negative predictive value (npv) of 69%, and accuracy of 91%. As to paranasal sinus fluid, subcutaneous gas, soft tissues welling, or foreign body in the face or paranasal sinus, all had low sensitivity for diagnosis of facial fractures. Furthermore, intracranial hemorrhage was also associated in 16% of facial fractures found by CT. Water s view is indeed valuable as a screening examination in the diagnosis of facial fractures for trauma patients at Emergency Department. Reprint requests to: Dr. Jen-Dar Chen Department of Radiology, Taipei Veterans General Hospital. No. 201, Sec. 2, Shih Pai Road, Taipei 112, Taiwan, R.O.C. Key words: Computed tomography; Face, fracture; Radiography The aim of this study is to evaluate the clinical value of facial radiography in the diagnosis of facial trauma. This procedure is widely used in the Emergency Departments (EDs) in demonstrating facial fracture in trauma patients. And it is also used to determine whether a single Water s view of the skull is sufficient to locate a facial fracture [1]. Facial radiographic findings can influence the decisions of surgeons in the Emergency Department. They need to decide whether computed tomography (CT) of face is required to confirm the facial fracture, the site, the severity and presence of intracranial hemorrhage. This study aims to evaluate the reliability of facial radiography and its clinical value in the diagnosis of facial fractures. MATERIALS AND METHODS From September 2003 to March 2005, 100 patients with facial trauma were enrolled, including 68 males and 32 females, with the mean age of 41.4 years (15 88 years). All patients underwent facial radiography and/or facial CT. The largest group of facial trauma cases (40 cases) was caused by motor vehicle accidents. There were 12 cases with falls and stumbles, 9 cases with assault, 1 case with stabbing injury, and 38 cases with other causes. When patients with facial trauma were brought to the ED, the trauma doctors at the ED ordered facial radiographs, which were taken in the radiography room at the ED. Water s view might be taken upright if the patients condition allowed. Most patients in this study without major trauma, or C-spine injury, and with clear consciousness underwent upright Water s view radiographs. Before taking the radiograph, the patient s head was positioned so that the

2 328 Value of facial radiography mentomeatal line (MML) was perpendicular to the plane of the image receptor and the orbitomeatal line (OML) was at a 37 angle with the table. The central ray was aligned perpendicular to the image receptor so that it exited at the acanthion. The radiographer then returned to the control table and pressed the exposure button to complete the facial radiography. It was essential that cervical spine injury was excluded before attempting any manipulation of the patient s head or neck. For the severe or poor conscious patients or those patients with suspected C-spine injury, reverse Water s view in recumbent position was performed. Reverse Water s view (AP acanthioparietal) was achieved by angling the central ray cephalad as needed to parallel the MML at the angle of 37 between central ray and OML without movement of patient s head and neck or removal of cervical collar or backboard. The radiographic machines used in this study were Fuji Film FCR 5502D, FCR5501D, and Toshiba DST-100A. Trauma doctors in the ED then reviewed the patient s clinical condition and the results of the facial radiography. If further evaluation was required, facial CT was arranged for the patient. For facial CT, patients lay supine with their head entering the gantry first to obtain a lateral scout view of the head. Landmarks are set at 100 mm superior (S) and 100 mm inferior (I) to the head from the OM line (S=0, I=0). The scan was carried out in the cranial-tocaudal direction, using the axial scan mode. The slice thickness was 5 mm and the gap is 5 mm. The patient was scanned from the top of the head to the level of the jaw. All trauma patients also received a cranial CT. If the patients were able to lie prone or tilt their head backwards, then coronal view slices could be added (slide thickness 5 mm, gap 5 mm). If the patient was unable to cooperate, a spiral CT was performed with slice thickness of 3 mm and gap of 3 mm. The CT used in this study was a GE Hispeed Advantage (GE Medical Systems, Milwaukee, WI, USA). The radiographs on Water s view and facial CT of these patients were reviewed by the first and second authors in this study to assess the presence of fractures, fluid in the paranasal sinuses, subcutaneous emphysema, swelling of facial soft tissues, and foreign bodies in the face or paranasal sinuses by consensus. The findings of fracture on the CT were used as the basis for comparison with the results of facial radiograph. RESULTS Of the 100 cases of facial trauma with midface fractures, zygomatic arch fractures or orbital fractures included in this study, 81 patients showed evidence of facial fracture on CT, but 19 patients didn t. On facial radiographs, fracture was detected in only 74 cases. Of the 81 cases with fracture shown on CT, 73 (90%) showed fracture on facial radiographs (Fig. 1). However, of the 19 cases without any fracture on CT, Table 1. Comparison of fractures shown on Water s view facial radiography and on facial CT. Water s view Fracture Total No fracture Fracture No fracture Tota l Table 2. Findings of fluid in paranasal sinuses on Water s view facial radiography compared with facial fractures as shown by CT. Fluid in sinus No fluid Table 3. Findings of subcutaneous emphysema on Water s view facial radiography compared with facial fractures as shown by CT. Subcutaneous emphysema No subcutaneous emphysema

3 Value of facial radiography 329 1a 1b Figure 1. a. Facial radiograph of a 23-year-old male with traumatic head injury clearly showed fractures of the right malar and maxillary bones (short solid arrows); as well as presence of fluid in maxillary sinuses (long solid arrow). b. CT of this patient s bone window showed fracture of the right maxillary bone (long solid arrow), large amount of fluid in the maxillary sinus (asterisk), swelling in the adjacent soft tissues (short solid arrow), and subcutaneous emphysema (arrow head). 2a 2b Figure 2. a. Facial radiograph of a 49-year-old female patient involved in motor vehicle accident showed fracture of the left maxillary sinus and fluid in the sinus (long solid arrow), and the presence of a tooth inside the left maxillary sinus (short solid arrow). b. in bone window of the same patient showed fracture of the left maxillary sinus (long solid arrow) and considerable amount of fluid accumulated inside the sinus (asterisk), as well as the presence of a tooth inside the left maxillary sinus (short solid arrow). only one case showed fracture on facial radiograph (Table 1). Therefore, the facial radiograph in detecting fracture showed the sensitivity of 90%, the specificity of 94.7%, the positive predictive value of 98.6%, the negative predictive value of 69%, and the accuracy of 91%. Of the 81 cases with fracture shown on CT, 60 (74%) had fluid in their paranasal sinuses on facial radiographs (Fig. 1). Of the 19 cases without any fracture on CT, only 6 cases (31.58%) had fluid in their paranasal sinuses on facial radiographs (Table 2). Therefore, with regard to the diagnosis of facial fracture, fluid in paranasal sinuses seen on facial radiographs has the sensitivity of 74%, the specificity of 68%, the positive predictive value of 90.9%, the negative predictive value of 38%, and the accuracy of 73%. Of the 81 cases of facial fracture diagnosed based on CT findings, 8 cases (9.88%) had subcutaneous emphysema on facial radiographs (Fig. 1). Of the 19 cases without any fracture on CT, only 1 (5.26%) had subcutaneous emphysema on facial radiographs (Table 3). Therefore, with regard to the diagnosis of facial fractures, subcutaneous emphysema seen on facial radiographs had the sensitivity of 9.88%, the specificity of 94.7%, positive predictive value of 88.9%, the negative predictive value of 19.8%, and the accuracy of 26%. Of the 81 cases of facial fracture detected on CT, 48 cases (59%) had soft tissue swelling on facial radiographs. Of the 19 cases showing no fractures on CT, 11 (57.89%) had facial soft tissue swellings on facial radiographs (Table 4). Therefore, with regard to the diagnosis of facial fracture, facial soft tissue swelling seen on facial radiographs has the sensitivity of 59%, the specificity of 42%, the positive predictive value of 81%, the negative predictive value of 19.5%, and the accuracy of 56%. Of the 81 facial fracture cases detected on CT, 2 cases (2.47%) had foreign bodies in the face or in paranasal sinuses (Fig. 2 ). Of the 19 cases showing no facial fracture on CT, none had foreign bodies in the face or in paranasal sinuses on facial radiographs

4 330 Value of facial radiography (Table 5). Therefore, with regard to the diagnosis of facial fracture, the presence of foreign body in the face or paranasal sinuses seen on facial radiographs has the sensitivity of 2.47%, the specificity of 100%, the positive predictive value of 100%, the negative predictive value of 19%, and the accuracy of 21%. Of the 74 cases with fracture shown on facial radiographs, 12 cases (16%) had intracranial hemorrhage on CT (Fig. 3), but none had intracranial complications in 26 cases without visible fractures on radiographs (Table 6). Table 4. Findings of facial soft tissue swellings on Water s view facial radiography compared with facial fractures as shown by CT. Facial soft tissue swellings No facial soft tissue swellings Table 5. Findings of foreign body in the face or paranasal sinuses on Water s view facial radiography compared with facial fractures as shown by CT. Foreign body in the face or paranasal sinuses No foreign body in the face or paranasal sinuses Table 6. Comparison of Water s view facial radiography with intracranial hemorrhage on CT. Water s view Intracranial hemorrhage No intracranial hemorrhage Total Fracture No fracture Total a 3b 3b Figure 3. a. Facial radiograph of 22-year-old male patient involved in motor vehicle accident showed multiple fractures at the medial aspects of both left and right orbits, lateral aspect of the right orbit, nasal bone, and left maxillary sinus (short solid arrow). It also shows considerable accumulation of fluid inside the maxillary sinus bilaterally, ethmoid sinus, and right frontal sinus. b. in bone window of the same patient showed fracture of the maxillary sinus bilaterally and fluid in the sinuses bilaterally (asterisk). c. Head CT of the same patient showed a small amount of cerebral hemorrhage (short solid arrow) and epidural hemorrhage (long solid arrow) at the posterior frontal region on the left.

5 Value of facial radiography 331 DISCUSSION The results of this study showed that facial radiography had high sensitivity and specificity in diagnosing facial fractures in patients sustaining facial trauma. Although about 16% of our patients presented poor consciousness, the facial radiography was obtained successfully either by traditional upright Water s view or supine reverse Water s view depending on the patient s condition. Therefore, the results of our study may apply to either major or nonmajor trauma patients. As shown in Table 1, of the 74 fractures detected by facial radiography, only one was not detected on CT; fracture was confirmed in the other 73 cases by facial CT. Therefore, facial radiography has a very high positive predictive value of 98.6%. Of the 26 cases without visible fractures on facial radiographs, CT confirmed the absence of fractures in 18 cases, giving a negative predictive value of 69%. On the basis of these findings, facial radiography is a reliable way of diagnosing facial fractures, as shown by the high positive predictive value of 98.6%. On the other hand, lack of evidence of fracture on facial radiography does not always mean that there are no fractures, as indicated by the moderate negative predictive value. This study found that the facial radiograph for detection of fracture has the sensitivity of 90%, the specificity of 94.7%, and the accuracy of 91%. Therefore facial radiography still has high diagnostic value with regard to the assessment of facial fractures. The facial radiographs of patients with facial trauma also often showed fluid in the paranasal sinuses, subcutaneous emphysema, soft tissue swellings in the face, and a foreign body in the face or paranasal sinuses. Comparison of these four findings on facial radiographs with findings of facial fractures on CT revealed that none of the four conditions was associated with high sensitivity in the diagnosis of facial fractures. However, findings of subcutaneous emphysema and a foreign body in the face or paranasal sinuses correlated with high specificity for facial fractures (94.7% and 100% respectively). The Water s view of skull was used to detect fractures in all 100 facial trauma patients in this study. We found that its use alone could provide a lot of information to help us detect and determine the extent of facial fracture [1, 3]. Therefore, Water s view radiography is very useful for diagnosing fractures and evaluating their severity in patients with facial trauma. The site of facial fracture can be shown clearly no matter which angle the radiographs are taken [2, 4, 5]. Although facial radiography is associated with a high diagnostic rate, its ability to show complex facial fractures such as fractures at the nasal bone, maxillary sinus, mandible bones and the orbital rim is still limited [6, 7, 8]. Because of this limitation, CT is performed to help us to determine whether complex facial fractures exist and to pinpoint the fracture sites. Overall, the result of facial CT is superior to that of facial radiographs [9]. Nevertheless, a facial fracture shown on radiography alone indicates careful treatment is required. According to our results, of the 74 cases of facial fracture shown on radiographs, 12 (16%) had intracranial hemorrhage shown on CT. It suggests that a significant percentage of patients with positive radiography findings may have concurrent intracranial hemorrhage, thus requiring close observation and careful management. In the ED, facial radiography can also provide important information about facial trauma-induced intracranial hemorrhage, allowing proper diagnosis and management. Nevertheless, some extrinsic factors may influence doctor s interpretation of radiographs. For example, of the 81 facial fractures diagnosed from CT, 8 were not identified on radiographs. A possible explanation for this was that the 3-dimensional shape of the head and ambiguities stemming from tissue superimposition made it difficult to determine whether the image was normal. Other explanations included the suboptimal radiographic exposure conditions, the excessive or inadequate kilovoltage (KV) or milliampere seconds (MAS), and the poor positioning of the patient either because of the radiologist negligence or patient s inability to cooperate (comatose, agitated, or having poor consciousness). In this study, CT excluded fracture in one case mistakenly diagnosed as a fracture on facial radiography. This could be due to a false image on the radiograph, a scratch mark on the image plate, or other sites of injury on the scalp superimposed on the facial bones. All of the above factors could result in imaging features similar to those of facial fractures and thus affect the reading and interpretation of the radiograph by the clinical doctor or the reporting radiologist. CONCLUSION Traditional facial radiography has an important role in the emergency department. It is a valuable imaging tool for the diagnosis of facial fractures. In addition, up to 16% of the patients with facial fractures shown on facial radiograph will have combined intracranial hemorrhage, which requires further assessment by facial CT.

6 332 Value of facial radiography REFERENCE 1. Goh SH, Low BY. Radiologic screening for midfacial fractures: A single 30-degree occipitomental view is enough. J Trauma 2002; 52: McGhee A, Guse J. Radiography for midfacial trauma: is a single OM 15 degrees radiograph as sensitive as OM 15 degrees and OM 30 degrees combined?. Brit J Radiol 2000; 73: Pogrel MA, Podlesb SW, Goldman KE. Efficacy of a single occipitomental radiograph to screen for midfacial fractures. J Oral Maxillofac Surg 2000; 58: Sidebottom AJ, Sissons G. Radiographic screening for midfacial fracture in A&E Brit J Radiol 1999; 72: Sidebottom AJ, Cornelius P, Allen PE, Cobby M, Rogers SN. Routine post-traumatic radiographic screening of midfacial injuries: is one view sufficient? Injury 1996; 27: Kassel EE. Traumatic Injuries of the Paranasal Sinus. Otolaryngol Clin North Am 1988; 21: Noyek AM, Kassel EE, Wortzman G, Jazraey H, Greyson ND, Zizmor J. Contemporary radiologic evaluation in maxillofacial trauma: Symposium on trauma to the head and neck. Otolaryngol Clin North Am 1983 ;16: DelBalso AM, Hall RE. Advances in maxillofacial imaging. Curr Probl Diagn Radiol 1993; 22: Tanrikulu R. Erol B. Comparison of computed tomography with conventional radiography for midfacial fractures (abstract). DentoMaxilloFac Rad 2001; 30:

7 Value of facial radiography 333 顏邥 X 光攝影對顏邥外傷的評估價值 1 邱碧雲 1,2 陳振德 1 葛平夷 1,2 張政彥 1 台北榮民總醫院放射線部 2 國立陽明大學醫學院 X Water s View of skull X X Water s View of skull 19 X 1 X 90% 94.7% 98.6% 69% 91% X 16% X X X X

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