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Neuroradiology Case of the Week

Case 412

May 2009

Gurshawn Singh, MS2, Rajiv Mangla, MD, Ashwani K. Sharma, MD,
and P-L Westesson, MD, PhD, DDS

Clinical Presentation: Patient is a 45-year-old male with multiple trauma to the face.

Imaging Findings: On CT images there are multiple fractures in the face region involving the superior and inferior nasal apertures extending into the inferior and lateral walls of orbits, maxillary sinuses, bilateral zygomas, and zygomatic arches with involvement of bilateral pterygoid plates. There is extensive opacification of the nasal cavity, almost all of the paranasal sinuses, due to hemorrhage. Also there is asymmetry of the face with fractures noted in both halves of the mandible. Endotracheal tube is seen passing through the oral cavity.

Diagnosis: LeFort III fracture

Discussion: A midfacial fracture where the entire facial skeleton is separated from the skull base, with a fracture line going through the root of the nose, bilaterally across the lacrimal bones and medial orbital walls to the floor of each orbit is classified as a LeFort III fracture. The zygomatic arches are fractured, along with fracture lines extending upward across the lateral orbital walls creating complete separation of the skull base and facial skeleton. 70% of the cases involve the infraorbital nerves. LeFort III fractures are usually classified as transverse craniofacial disjunctions and occur usually as a result of severe facial trauma. The location of the fracture is associated with a high occurrence of CSF rhinorrhea along with hemorrhage and presents with a dish-face deformity. The distinguishing factor between LeFort II and LeFort III fracture is that LeFort III will include fracture to zygomas and lateral orbital walls.
     These fractures occur most commonly in high force trauma. Motor vehicle accidents are the predominate cause and are also associated with assaults and falls.
     Coronal CT can be helpful in viewing bilateral fractures to many facial structures such as the nasal apertures and associated opacification due to hemorrhage, along with orbital wall fractures. A fractured zygomatic arch can also be viewed on coronal CT.

References:

1. Som PM, Curtin HD. Head and Neck Imaging. 4th ed., Mosby, 2003:382-385.
2. Larheim TA, Westesson PL. Maxillofacial Imaging. Springer, 2006:219.