Imaging of Facial Trauma Following Primary Survey

Variant: 1 Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.

Procedure	Appropriateness Category	Relative Radiation Level
CT maxillofacial without IV contrast	Usually Appropriate	☢☢
CT head without IV contrast	Usually Appropriate	☢☢☢
Radiography skull	Usually Not Appropriate	☢
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢
MRA head and neck with IV contrast	Usually Not Appropriate	O
MRA head and neck without and with IV contrast	Usually Not Appropriate	O
MRA head and neck without IV contrast	Usually Not Appropriate	O
MRI cervical spine with IV contrast	Usually Not Appropriate	O
MRI cervical spine without and with IV contrast	Usually Not Appropriate	O
MRI cervical spine without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
MRI maxillofacial with IV contrast	Usually Not Appropriate	O
MRI maxillofacial without and with IV contrast	Usually Not Appropriate	O
MRI maxillofacial without IV contrast	Usually Not Appropriate	O
CT maxillofacial with IV contrast	Usually Not Appropriate	☢☢
CT cervical spine with IV contrast	Usually Not Appropriate	☢☢☢
CT cervical spine without and with IV contrast	Usually Not Appropriate	☢☢☢
CT cervical spine without IV contrast	Usually Not Appropriate	☢☢☢
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT maxillofacial without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 2 Pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia. Suspect midface injury. Initial imaging following primary survey.

Procedure	Appropriateness Category	Relative Radiation Level
CT maxillofacial without IV contrast	Usually Appropriate	☢☢
Radiography chest	Usually Not Appropriate	☢
Radiography paranasal sinuses	Usually Not Appropriate	☢
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢
MRA head and neck with IV contrast	Usually Not Appropriate	O
MRA head and neck without and with IV contrast	Usually Not Appropriate	O
MRA head and neck without IV contrast	Usually Not Appropriate	O
MRI cervical spine with IV contrast	Usually Not Appropriate	O
MRI cervical spine without and with IV contrast	Usually Not Appropriate	O
MRI cervical spine without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
MRI maxillofacial with IV contrast	Usually Not Appropriate	O
MRI maxillofacial without and with IV contrast	Usually Not Appropriate	O
MRI maxillofacial without IV contrast	Usually Not Appropriate	O
CT maxillofacial with IV contrast	Usually Not Appropriate	☢☢
CT cervical spine with IV contrast	Usually Not Appropriate	☢☢☢
CT cervical spine without and with IV contrast	Usually Not Appropriate	☢☢☢
CT cervical spine without IV contrast	Usually Not Appropriate	☢☢☢
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT maxillofacial without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 3 Visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis. Suspect nasal injury. Initial imaging following primary survey.

Procedure	Appropriateness Category	Relative Radiation Level
CT maxillofacial without IV contrast	Usually Appropriate	☢☢
US maxillofacial	May Be Appropriate	O
Radiography paranasal sinuses	May Be Appropriate	☢
MRI maxillofacial with IV contrast	Usually Not Appropriate	O
MRI maxillofacial without and with IV contrast	Usually Not Appropriate	O
MRI maxillofacial without IV contrast	Usually Not Appropriate	O
CT maxillofacial with IV contrast	Usually Not Appropriate	☢☢
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT maxillofacial without and with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 4 Trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth. Suspect mandibular injury. Initial imaging following primary survey.

Procedure	Appropriateness Category	Relative Radiation Level
CT maxillofacial without IV contrast	Usually Appropriate	☢☢
Radiography mandible	May Be Appropriate	☢☢
Radiography chest	Usually Not Appropriate	☢
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢
MRA head and neck with IV contrast	Usually Not Appropriate	O
MRA head and neck without and with IV contrast	Usually Not Appropriate	O
MRA head and neck without IV contrast	Usually Not Appropriate	O
MRI cervical spine with IV contrast	Usually Not Appropriate	O
MRI cervical spine without and with IV contrast	Usually Not Appropriate	O
MRI cervical spine without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
MRI maxillofacial with IV contrast	Usually Not Appropriate	O
MRI maxillofacial without and with IV contrast	Usually Not Appropriate	O
MRI maxillofacial without IV contrast	Usually Not Appropriate	O
CT maxillofacial with IV contrast	Usually Not Appropriate	☢☢
CT cervical spine with IV contrast	Usually Not Appropriate	☢☢☢
CT cervical spine without and with IV contrast	Usually Not Appropriate	☢☢☢
CT cervical spine without IV contrast	Usually Not Appropriate	☢☢☢
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT maxillofacial without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢

Panel Members

Matthew S. Parsons, MD^a; Bruno Policeni, MD, MBA^b; Amy F. Juliano, MD^c; Mohit Agarwal, MD^d; Elizabeth R. Benjamin, MD, PhD^e; Judah Burns, MD^f; Timothy Doerr, MD^g; Prachi Dubey, MBBS, MPH^h; Elliott R. Friedman, MDⁱ; Maria K. Gule-Monroe, MD^j; Karol A. Gutowski, MD^k; Mari Hagiwara, MD^l; Vikas Jain, MD^m; Tanya J. Rath, MDⁿ; Brian Shian, MD^o; Devaki Shilpa Surasi, MD^p; M. Reza Taheri, MD, PhD^q; David Zander, MD^r; Amanda S. Corey, MD^s.

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
A. Arteriography cervicocerebral

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
B. CT cervical spine

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
C. CT head

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
D. CT maxillofacial

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
E. CTA head and neck

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
F. MRA head and neck

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
G. MRI cervical spine

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
H. MRI head

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
I. MRI maxillofacial

Variant 1: Tenderness to palpation or contusion or edema over frontal bone. Suspect frontal bone injury. Initial imaging following primary survey.
J. Radiography skull

Variant 2: Pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia. Suspect midface injury. Initial imaging following primary survey.

Variant 3: Visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis. Suspect nasal injury. Initial imaging following primary survey.

Variant 3: Visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis. Suspect nasal injury. Initial imaging following primary survey.
A. CT head

Variant 3: Visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis. Suspect nasal injury. Initial imaging following primary survey.
B. CT maxillofacial

Variant 4: Trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth. Suspect mandibular injury. Initial imaging following primary survey.

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.