…and thoughts on whether or not we need them

I wanted to share this great post I recently read on Don’t Forget the Bubbles. It reviewed facial X-Rays and included some great diagrams. Check it out here.

I don’t personally order a lot of facial X-Rays (Note: mandible films are a separate entity). Facial CT is far more specific for fractures. Here are two examples of how I approach facial imaging;

I’m willing to (radiographically) miss a non displaced orbital fracture in lieu of the radiation exposure commensurate with the Facial CT experience. A child with a swollen traumatic eyelid that has full extraocular motion, normal vision, a normal eye exam and no palpable displaced fractures along the superior and inferior orbital rims won’t need an ophthalmologist immediately to “fix” an entrapped muscle or other problem secondary to a fracture. If the swelling goes down and there is a fracture then get the CT. However, the above set of exam findings is sensitive enough to avoid the CT in the ED.

For the child struck in the nose without severe epistaxis, who can breathe through their nose and whose nasal bridge and adjacent facial structures are stable on exam I also eschew facial imaging in the ED. I advise parents to wait 5 to 7 days for the selling to go down. At that time if the nose is asymmetric then see ENT or Plastic Surgery. The surgeon will have to see a nose that isn’t swollen in order to get it straight in the OR during rhinoplasty – which is decidedly less delicate than it sounds.