British Journal of Oral and Maxillofacial Surgery (2000) 38, 525–529 © 2000 The British Association of Oral and Maxillofacial

Surgeons doi: 10.1054/bjom.2000.0501

BRITISH JOURNAL OF ORAL

& M A X I L L O FA C I A L S U R G E RY

Assessment of zygomatico-orbital complex fractures using ultrasonography
P. J. McCann,* L. M. Brocklebank,† A. F. Ayoub‡ *Final Year Dental Student, University of Glasgow Dental School; †Senior Lecturer/Honorary Consultant, Oral Radiology, University of Glasgow Dental School; ‡Senior Lecturer/Honorary Consultant in Oral & Maxillofacial Surgery, University of Glasgow Dental School and Canniesburn Hospital, Glasgow, UK SUMMARY. Twenty-two patients were referred to the maxillofacial surgical unit for assessment and management of suspected fractures of the zygomatico-orbital complex. In each case, both routine plain radiographic and ultrasound examinations were made. The aim of the study was to investigate the sensitivity and reliability of ultrasound to detect such fractures. Imaging with ultrasound was carried out at five areas: the infraorbital margin; lateral wall of the maxillary sinus; zygomatic arch; frontozygomatic process; and orbital floor. Both radiographic and ultrasound findings were correlated with the findings at operation. An overall agreement of 85% between radiographs and ultrasound scans was found. Ultrasound imaging was most reliable at the lateral wall of the maxillary sinus, where the sensitivity was 94% and specificity 100%. The positive predictive value at this area was 100% compared with radiographic findings. We conclude that ultrasound is a useful tool in imaging facial trauma as an initial investigation, and can help to reduce the total number of radiographs required for the diagnosis of fractures of the zygomatico-orbital complex. © 2000 The British Association of Oral and Maxillofacial Surgeons

INTRODUCTION Traditional assessment of injured patients involves a structured clinical examination including history, inspection, palpation, percussion, and auscultation. When the signs and symptoms indicate the presence of a fracture of the facial skeleton, the clinician must select from a number of imaging methods to confirm the diagnosis. The complexity of the facial skeleton has led to the development of many specialized views to visualize the entire facial skeleton adequately. Standard facial views, including occipitomental and submentovertex radiographs, are routinely used to diagnose zygomatic bone fractures.1 Computed tomography (CT), both coronal and axial cuts, are required in complex cases to assess blow-out fractures and disruption of the orbital walls.2,3 The main disadvantages of CT are the patient’s exposure to a high dose of radiation and the potential risk of development of a cataract. Delay in extricating the patient from the machine in an emergency is widely recognized and may prove fatal.3 Magnetic resonance imaging (MRI) provides substantially more information about the soft tissue structures but it does not provide enough information about the underlying bone fractures. Both CT and MRI machines are expensive to buy and operate, and they are not available in many district general hospitals. Ultrasound has been used extensively in orbital and ocular diagnosis,4 but the use of ultrasound to assess facial trauma is limited. Forrest et al.5 compared ultrasonograph findings with CT in 18 patients who had injuries of zygomatico-orbital complex, and ultrasound showed 94% correlation. Ultrasound had satisfactory sensitivity (92%), specificity (100%), and positive predictive value (100%) compared with CT.6
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The use of ultrasound in diagnosis and management of facial trauma has been reported previously. Akizuki et al.6 reported three cases of ultrasoundassisted reduction of fractures of the zygomatic arch and concluded that ultrasound was helpful in achieving satisfactory reduction. Ultrasound was used in the assessment of five patients with facial trauma.7 A 10-MHz probe frequency was adequate in recording the fractures but a frequency in excess of 15-MHz enhanced the details of smaller structures. The use of a high-resolution scanner allowed identification of 0.1 mm disruptions in the bony surface, which were often missed on plain film radiographs.7 We decided, therefore, to assess the usefulness and accuracy of ultrasonic imaging in diagnosing fractures of the zygomatico-orbital complex as a result of acute trauma.

PATIENTS AND METHODS We studied 22 patients, 9 women and 13 men, with suspected fractures of the zygomatico-orbital complex. All patients had been examined in regional accident and emergency departments where routine plain radiographs were taken, and they were then referred to our oral and maxillofacial unit for treatment. Ultrasound examination was carried out on each patient by the same operator who was not aware of the radiological findings. A Toshiba ‘Capasee’ ultrasound machine was used, generating B-mode with a 7.5-MHz convex probe. The reproducibility of positioning the ultrasound’s cursor was ensured by practising on a calibration device and an accuracy of 0.1 mm was achieved. A systematic routine of facial

and eight patients had open reduction and internal fixation using microplates (Table 3).6 Hirai et al. One patient found the procedure uncomfortable and the rest tolerated it well. In the assessment of the orbital floor (Fig. In 12 of the 22 patients. and the soft tissues of the neck. Ultrasound was accurate in assessing the lateral wall of the maxillary sinus (Fig. specificity of 95%. and Table 2 shows the wide range of the ultrasound diagnostic accuracy at different sites. Figure 3 is a radiograph showing a fracture and of the left zygomatico-orbital complex. In maxillofacial trauma. The zygomatic arch and frontozygomatic suture were scanned to detect any discontinuity. . a fall in 7 cases. The cause of injury was assault in 13 cases. The operative findings (Table 3) were in agreement with the radiographic and ultrasonography diagnosis.8–11 Gateno et al. there was agreement between ultrasound and radiographic findings with regard to the fractures. The usual ultrasound scan took about 10 minutes. and road traffic accidents in 2 cases. Figures 1 and 2 are the radiograph and ultrasound scan of one of the patients with a blow-out fracture of the orbital floor. ultrasound scanning has also been used to aid in the closed reduction of fractures of the zygomatic arch. The data obtained from the radiographic assessment and the ultrasound investigation were correlated and compared with the operative findings of those patients who were operated on. 7) because of late diagnosis of the fracture. and were not detected on either plain radiography or ultrasound. Its role in maxillofacial surgery is less widely recognized. Eleven patients were treated conservatively. three of these were orbital floor defects. specificity of 100% and positive predictive value. Fig. one patient had an osteotomy (patient no. infra-orbital margin and foramen. The 10 in whom there was disagreement are shown in Table 1. 2). and in the others there was no clear indication for operation. Attempting to measure the infraorbital foramen on the fractured side proved to be difficult because the fracture line passed through the foramen in most of the patients. Figures 4 A–D are the ultrasound images of the same patient showing the fractures at different anatomical sites. 3 – Radiographic appearance of left side zygomatico-orbital complex fracture. 4B) with a sensitivity of 94%. We accept radiographs as the gold standard. in five cases minute fractures lines were observed at operation. with sensitivity of 100%.526 British Journal of Oral and Maxillofacial Surgery RESULTS The patients’ ages ranged from 11 to 60 years (mean 31). 1 – Radiograph showing blow-out fracture of the right orbital floor. and positive predictive value of 75% (Table 2). 2 – Ultrasonograph of blow-out fracture of the orbital floor showing circular tear drop of tissue prolapsed in the right maxillary sinus Fig. DISCUSSION Ultrasound has traditionally been used to image irregularities of soft tissue and is used extensively for examination of the abdomen and pelvis. as well as the lateral wall of the maxillary sinus. but.7 reported five scanning was developed.12 investigated the use of ultrasound pre-operatively to aid in adjusting the mandibular condyle in relation to the glenoid fossa during osteotomy of the mandibular ramus. medial and lateral walls. The mean number of radiographs taken was 5 (range 2–17). ultrasound scanning detected 1 false positive and no false negatives. one patient refused treatment (case 22). Fig. two had closed reduction and fixation with K wire. Surgical treatment was not carried out in half of the patients. which included vertical and horizontal images of the orbit to visualize the orbital floor.

21. patients in whom ultrasound was used preoperatively and postoperatively. Table 1 – Agreement between radiograph findings and ultrasound findings Ten patients in whom there was disagreement between radiographic (XR) and ultrasonographic (US) findings. 11. 13. 10. 22) had no disagreement. 14. 4.8 They reported that ultrasound is useful in assessing the reduction of facial fractures. a high . No fracture = N Case number Site of fracture or separation Infraorbital margin XR US Lateral wall maxillary sinus XR US Zygomatic arch XR US Fronto-zygomatic process XR US Blow-out fracture of orbital floor XR US 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Y Y N Y N Y Y Y Y N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y N Y N Y Y Y Y Y Y Y N N N N N N N Y N Y N N N Y N Y Y Y Y Y N N N N N N N N Y Y Y Y N N Y Y Y Y Y Y Y Y N Y N N Y Y Y N N N Y Y N N N N Y Y N N Y Y Y Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N Y N N N Y N Y Y Y Y Y Y Y Y Y Y Y N N N N Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N Y N Y N N N N N N N N N N N N N N N N N Y N N N N N N N N Y Y N N Y N 12 cases (2. 16. 7. (C) no substantial opening at the fronto-zygomatic suture. and (D) the zygomatic arch. 12. to assess fractures in the facial region. (B) the lateral wall of the maxillary sinus. Fracture = Y. 18.Assessment of zygomatico-orbital complex fractures using ultrasonography 527 Fig. 4 – Ultrasound scans of the same patient showing different fracture sites: (A) the inferior orbital margin.

lateral wall of maxillary sinus. zygomatic arch and fronto-zygomatic arch Displaced fractures at infraorbital margin and lateral wall of maxillary sinus 4 7 10 11 13 ORIF and plating at infraorbital margin and lateral wall of maxillary sinus ORIF and plating at infraorbital margin. Nevertheless. lateral wall of maxillary sinus. zygomatic arch and fronto-zygomatic suture ORIF and plating at infraorbital margin. zygomatic arch and fronto-zygomatic suture Displaced fracture of the inferior orbital margin and lateral wall of the maxillary sinus Displaced fractures at infra-orbital margin. 2 Treatment ORIF and plating at infraorbital margin and lateral wall of maxillary sinus Reconstruction of orbital floors with bone graft Reduction of fracture by Gillies temporal approach and reconstruction of orbital floor with silastic sheet Osteotomy and plating at infraorbital margin. lateral wall of the maxillary sinus. lateral wall of maxillary sinus. undisplaced fracture inferior orbital margin Displaced fractures at infraorbital margin. zygomatic arch. lateral wall of maxillary sinus. Jenkins and Thaw reported that ultrasound had an accuracy of 86% and sensitivity of 85% in detecting orbital floor fractures. the clinical relevance of such minute disruptions is doubtful.528 British Journal of Oral and Maxillofacial Surgery Table 2 – Comparison of radiographic and ultrasound findings at different sites of the zygomatic orbital complex (n=22) Inferior orbital margin Radiographic finding: Fracture No fracture Ultrasound finding: Fracture No fracture Using radiographs as standard: False positive False negative Sensitivity (%) Specificity (%) Positive predictive value Lateral wall of maxillary sinus Zygomatic arch Separation of frontozygomatic suture Orbital floor ‘blow out’ fracture 18 4 19 3 1 0 100 75 95 18 4 17 5 0 1 94 100 100 19 3 15 7 2 0 100 78 87 11 11 9 13 0 2 82 100 100 3 19 4 18 1 0 100 95 75 Table 3 – Treatment and surgical findings in the nine patients who had open reduction and internal fixation (ORIF) Case no.7 Regarding the usefulness of ultrasound in diagnosing facial fractures. the specificity. and frontozygomatic suture ORIF plating at infraorbital margin Findings Displaced fracture at infraorbital margin and lateral wall of maxillary sinus 1 cm defect in orbital floor. zygomatic arch and fronto-zygomatic suture ORIF and plating at lateral wall of maxillary sinus 14 19 21 resolution probe can detect disruptions of the bone of as little as 0. but the sensitivity. and separation of frontozygomatic suture Displaced fractures at the infraorbital margin and comminution of lateral wall of maxillary sinus Displaced fracture at infraorbital margin and comminution of lateral wall of maxillary sinus Displaced fracture of the inferior orbital margin. and the positive predictive value are different at different sites. We reviewed the extent of swelling and difficulty in doing the scan in the cases that had scored less than 80% agreement of ultrasound with radiographic findings. zygomatic arch.1 mm. Air in the tissues gives a ‘ring down’ effect with multiple echo areas extending .13 Our study showed that ultrasound can be used with 85% accuracy to diagnose fractures of the zygomatico-orbital complex. there was gross swelling as a result of surgical emphysema. which made the scanning of the bony outlines difficult. In these cases. and lateral wall of maxillary sinus ORIF and plating at lateral wall of maxillary sinus.

This may suggest the necessity of CT scanning in all cases with injuries to the zygomatico-orbital complex to detect fractures of the orbital floor or the medial wall. Lindqvist C. J. Clin Radiol 1997. Shoshani Y. Reliability of ocular and orbital diagnosis with B-Scan ultrasound.ac.9 This. inexpensive. Int J Oral Maxillofac Surg 1993. Manor WF. J Oral Maxillofac Surg 1996. Ultrasound may be considered as an alternative to repeating plain films to answer any doubts about configuration or displacement of fractures. Am J Ophthalmol 1972. It could be argued that the use of plain radiographs as a reference to assess the accuracy of ultrasound is not optimal. J CranioMaxillofac Surg 1989. neither plain radiographs nor ultrasound are useful in diagnosing medial fractures of the orbital wall. Turski PA. Moos JJ. 12. 15: 306–311. 17. The Authors P. eds. plain radiographs missed a number of fractures. Marcuzzin DW. Michi K. 10. Brocklebank DDRRCR. although it was not accurate enough to replace plain radiography as the principal mode of imaging. 52: 708–711. The other possible roles of ultrasound may include peroperative assistance in closed reduction of the malar complex. CONCLUSIONS Ultrasound offers a safe. 151: 1081–1086. MSc Senior Lecturer/Honorary Consultant Oral Radiology University of Glasgow Dental School Glasgow. AJR 1984. Yoshida H. Smith DJ. Akizuki H. Osseous and soft tissue complications. Tel: +44(0) 141 211 9650 or +44(0)141 211 5758. 15: 297–305. High resolution CT analysis of facial struts in trauma. 16: 363–367. Miloro M. B-scan sonography in maxillo-facial surgery. Taicher S. J Cranio Maxillofac Surg 1987. Buddemyer EU. Coleman DJ. Ayoub PhD. Ayoub Oral & Maxillofacial Surgery. Duncan JG. Kaffe I. MDS Senior Lecturer/Honorary Consultant in Oral & Maxillofacial Surgery University of Glasgow Dental School and Canniesburn Hospital Glasgow. Ultrasound imaging in assessment of fracture of the orbital floor. Ord RA. The use of ultrasound to determine the position of the mandibular condyle. Paraesthesia of the infraorbital nerve following fracture of the zygomatic complex. Michi K. Gateno J. and loss of detail beyond the air pockets. 1986: 233. Ultrasonic observation of facial bone factures.gla.Assessment of zygomatico-orbital complex fractures using ultrasonography 529 into the tissue. Lata AC. Plast Reconstr Surg 1993. Recovery of the infraorbital nerve after zygomatic complex fracture: A preliminary study of different treatment methods. Mares MD. However. this is difficult to resolve because not all patients were operated on or had CT scans. Intraoral ultrasonic scanning as a diagnostic aid. Glasgow G2 3JZ. Computed tomography and B-mode scan ultrasonography in the diagnosis of fractures of the medial orbital wall. Clark KC. Schilli W. Forrest CR. 22: 339–341. Int J Oral Maxillofacial Surg 1987. Yoshida H. 74: 704–710.5. Report of cases. on either the orbital floor or the medial wall. Naylor E. RCS. Strother CM. 9.ayoub@dental. is likely to be responsible for the poor correlation in these cases. Jenkins CN. 15. Moos KF. UK Correspondence and requests for offprints to: Dr Ashraf F. University of Glasgow Dental School.17 References 1. Ardekian L. J Oral Maxillofac Surg 1993. Hendler BH. Gentry LR. Radiol Clin North Am 1975. 118: 263–266. Our study showed 85% accuracy in diagnosing fractures of the zygomatico-orbital complex. we think that CT scanning is essential when there are clinical signs or symptoms of a fracture of the orbital wall. FRCSI Final Year Dental Student L. Akizuki H. which were detected only during operation. 6. AJR 1983. The role of orbital ultrasound in the diagnosis of orbital fractures. 14. Baily MH. 92: 28–34. CT would not provide information on the size of the residual defect in the orbital floor that would arise after reduction of the fracture. together with tissue oedema. M. McCann MB BCh. Clark’s positioning in radiology. Hell B. Fax: +44(0) 141 211 9834. 4. Thuau M. BDS. Harrow M. Saggers GC. FDSRCPS.f. J CranioMaxillofac Surg 1990. UK. Plast Reconstr Surg 1981. 16. These defects were detected neither radiographically nor by ultrasound. Ultrasound can be also used to assess the remodelling around the infraorbital foramen. UK A. Nagamoto K. E-mail: a. Franco JM. 8. this requires further investigation. London: Heinemann Medical Books. 54: 776–779. 2. Nevertheless. Samet N. Le May M. 7. 17: 39–45. Reychler H. Swallow RA. The technique may also be useful when there is a coexisting injury to the cervical spine or in the assessment of uncooperative patients when CT is impracticable. 142: 1041–1045. F. small bony defects that required grafting were seen during operation. 11th edn. In three cases. Oral Maxillofac Surg Clin North Am 1990. J Cranio-Maxillofac Surg 1987. 5. 67: 281–288.15 In our study. FRACDS. On the other hand. Manders EK. FDS. Mobile: 041 041 3133. Hirai T. BAO.uk Paper received 9 July 1999 Accepted 13 April 2000 . The physics of diagnostic ultrasound. Lenoir JL. The diagnostic limitations of ultrasonography in maxillo-facial surgery. Kreipke DL. 2: 155–169.16. Piette E. Ultrasonographic evaluation during reduction of zygomatic arch fractures. 13: 391–395. which may be used as a prognostic tool to predict infraorbital nerve recovery. Computed tomography and sectional tomography in facial trauma. 11. accurate adjunct to conventional radiography of the facial bones and is well tolerated by recently injured patients. 13. 3. 378 Sauchiehall Street. 140: 533–541. Treatment of zygoma fractures. Jungell P.

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