ORIGINAL ARTICLE

Validation of Clinical Criteria for Obtaining Maxillofacial Computed Tomography in Patients With Trauma Thomas J. Sitzman, MD, Nyama M. Sillah, MD,y Summer E. Hanson, MD, PhD,§ Lindell R. Gentry, MD,z John F. Doyle, DDS,y and Karol A. Gutowski, MDjj

Background: More than 180 000 patients present annually with facial trauma to emergency rooms in the United States. Maxillofacial computed tomography is the gold standard in identifying facial fractures. Providers must evaluate patients quickly; therefore, they use decision instruments to determine which patients need imaging. We previously developed a decision instrument that identified patients with trauma at low risk for facial fracture who could avoid imaging. The present study aims to perform an internal validation of that tool. Methods: The decision instrument used 5 criteria: bony step-off or instability, periorbital swelling or contusion, Glasgow Coma Scale 1 year. Inclusion criteria were maxillofacial physical examination, head and maxillofacial computed tomography at presentation. Physical examination findings were collected and imaging reviewed to determine whether the decision tool could accurately detect the presence of a facial fracture in a different patient population from which it was derived. Results: One hundred seventy-nine patients met enrollment criteria. Facial fractures occurred in 81% of patients (n ¼ 145). The decision instrument was 97.4% sensitive (95% confidence interval, 93.8–99.3) for the presence of facial fracture. The negative predictive value was 81.3% (95% confidence interval, 55.0–95.0). Application of the instrument resulted in a missed injury rate of 2.6% (n ¼ 3). All of the missed fractures were nondisplaced and managed nonoperatively. Conclusions: The proposed decision tool identifies patients with trauma at low risk for facial fracture who can avoid maxillofacial imaging. Validation in a prospective study is warranted.

From the Division of Plastic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; yDivision of Plastic and Reconstructive Surgery; zDepartment of Radiology, University of Wisconsin Hospital & Clinics, Madison, WI; §Department of Plastic Surgery, University of Texas M.D. Anderson Cancer Center, Houston, TX; and jjPrivate Practice, Northbrook, IL. Received June 9, 2014. Accepted for publication September 2, 2014. Address correspondence and reprint requests to Thomas J. Sitzman, MD, Division of Plastic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2020, Cincinnati, OH 45229. E-mail: [email protected] There are no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001712

The Journal of Craniofacial Surgery



Key Words: Facial, trauma, maxillofacial, computed tomography, tool (J Craniofac Surg 2015;26: 1199–1202)

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wenty-four percent of multisystem patients with trauma will present with some form of facial injury.1 Although the severity of these injuries will vary, evaluating physicians must maintain a high index of suspicion for facial fracture. The gold standard for evaluation of facial fracture is maxillofacial computed tomography (CT).2–6 Maxillofacial CT comprehensively evaluates the entire facial skeleton in a single study. Panorex and facial roentgenogram, by comparison, are less accurate, more difficult to interpret, and limited to specific areas of the facial skeleton.3,5,6 With the availability of CT imaging in the emergency setting, physicians should use maxillofacial CT as the primary radiographic method for evaluation of suspected facial trauma. At present, no validated criteria exist to guide maxillofacial CT use in patients with trauma. More than 180 000 patients present with facial trauma annually to emergency departments in the United States.1 Estimates from retrospective and prospective studies indicate between 12% and 40% of facial patients with trauma possess a fracture.7–9 Indiscriminate use of maxillofacial CT exposes patients to unnecessary radiation, can potentially delay further care, and may represent a significant cost in the assessment of patients with trauma. Therefore, physicians need a decision support instrument, also called a clinical decision rule, to guide proper screening of at-risk patients and avoid indiscriminate or inappropriate use of maxillofacial CT.10 Surgeons specializing in craniofacial and maxillofacial surgery have an extensive experience with facial trauma and their broad clinical training place them in the ideal position to develop this instrument. We previously developed a decision instrument for the use of maxillofacial CT in multisystem patients with trauma.11 This instrument includes 5 clinical findings: bony step-off or instability, periorbital swelling or contusion, Glasgow Coma Scale

Validation of Clinical Criteria for Obtaining Maxillofacial Computed Tomography in Patients With Trauma.

More than 180,000 patients present annually with facial trauma to emergency rooms in the United States. Maxillofacial computed tomography is the gold ...
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