A Simple Set of Clinical Criteria to Guide Utilization of Maxillofacial CT in Trauma Patients
Thomas J. Sitzman, M.D., Summer E. Hanson, M.D., Nila H. Alsheik, M.D., Lindell R. Gentry, M.D., John F. Doyle, D.D.S, Karol A. Gutowski, M.D..
University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
PURPOSE: Physicians rely heavily on maxillofacial CT imaging to identify facial fractures in the over 160,000 patients who present annually with maxillofacial trauma. These physicians attempt to balance the dangers of missed injury against the cost of imaging and the risks of radiation exposure. Decision instruments are available to ensure appropriate screening of high-risk patients and reduce unnecessary imaging in low-risk patients for many types of injuries. For example, the NEXUS Criteria are routinely used to identify trauma patients at high risk of cervical spine fracture and the Ottawa Ankle Rule identifies patients at high risk for ankle fracture. Despite the high incidence of maxillofacial trauma and the substantial effect facial fractures have on patient care, no sensitive criteria exist to screen for facial fractures.
METHODS: To identify screening criteria for maxillofacial CT, we conducted a retrospective chart and radiographic imaging review of patients evaluated for head and neck trauma at our Level I Trauma Center over a three-year period. We included all patients who underwent a maxillofacial exam and maxillofacial CT. A single senior neuroradiologist evaluated each maxillofacial CT and systematically cataloged all facial fractures.
RESULTS: A total of 525 patients underwent maxillofacial exam and CT imaging during the study period. Injury to the maxillofacial skeleton, excluding isolated nasal fractures, occurred in 332 patients (63.2%). The presence of any of the following four physical exam criteria identified patients at high risk for facial fracture: bony step-off or instability, malocclusion, peri-orbital contusion, or Glasgow Coma Scale (GCS) ≤13. These criteria identified all but 8 of the 332 patients with a facial fracture (sensitivity 97.6%). The negative predictive value was 84.6%. Only one patient classified as unlikely to have a facial fracture by these criteria required surgical treatment. Excluding non-operative fractures, the negative predictive value exceeded 98.0%. If these criteria had been applied to the study population, radiographic imaging could have been avoided in 9.9% of patients.
CONCLUSION: The criteria of bony step-off or instability, malocclusion, peri-orbital contusion, or GCS ≤13 are highly sensitive for maxillofacial skeletal injury. Physicians caring for patients with maxillofacial trauma can apply these criteria in their own institutions to improve screening for maxillofacial trauma and reduce the use of maxillofacial imaging.