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Three Part Question

In [adult patients presenting to the ED with orbital trauma] can [emergency physician performed ultrasound imaging compared with CT] [identify the nature and extent of orbital trauma]?

Clinical Scenario

A 17-year-old male presents to the Emergency Department with a unilateral loss of vision and orbital swelling a day after an altercation outside a community college with weapons-carrying students. The patient is not forthcoming with details. The pupils are equal and reactive to light. You want to establish the extent of orbital/ocular damage. There is a wait for a CT scan so you wonder if using the bedside ultrasound scanner (USS) for a focused ocular ultrasound would provide useful imaging for either safely reviewing the patient later or making an informed prioritisation for CT.

Search Strategy

Ovid MEDLINE 1946—April 2011
EMBASE 1980—July 2011
Cochrane Central Register of Controlled Trials.
Medline: ((exp Orbit/) OR (orbit.mp) OR (orbit$.mp) OR (ocular.mp) OR (exp Eye/) OR (eye.mp) OR (exp Eye Injuries/)) AND ((ultrasound.mp) OR (exp Ultrasonography/) OR (ultrasonography.mp) OR (ultraso$.mp) OR (USS.mp)) AND ((injury.mp) OR (exp “Wounds and Injuries”/) OR (trauma.mp) OR (fracture.mp)) search limited to English language, adults and humans only.

Three hundred and nineteen papers were identified, of which five were relevant and only one directly answered the BET by assessing Emergency Physician performance.

Embase:((exp eye injury/)) AND ((exp ultrasound/) OR (exp ultrasound scanner/) OR (exp high intensity focused ultrasound/)) limits to humans, English language and adults.

Thirty-three papers found but none relevant to the question.

Cochrane: none relevant

Search Outcome

5 relevancies

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Blaivas M et al, 2002, USA	136 patients presenting with ocular trauma or visual change (61 included) to a high-volume suburban emergency department	Convenience sample, single-blinded, prospective observational	Emergency physician's FOUS-aided diagnosis (from a 10 MHz linear-array transducer probe, closed eye technique) in agreement with either or both CT and ophthalmologist opinion	Sensitivity 100% (95% CI; 94% - 100%) Specificity 97.2% (95% CI; 89% - 99%) PPV 96.2% (95% CI; 88% - 99%) NPV 100% (95% CI; 94% - 100%)	Small numbers This study looks at trauma to the globe and surrounding soft tissue but not the skeletal orbit
Jenkins CNJ and Thuau H, 1997, UK	20 patients presenting to maxillofacial surgery with orbital trauma history and clinical evidence of trauma to orbital floor. Injury to globe/palpebral laceration excluded	Blinded, prospective observational	Blinded radiologist USS-aided diagnosis confirmed by CT or surgical exploration.	Sensitivity 85% Specificity 88%br> PPV 92% PPV 78%	No confidence intervals provided The FOUS was performed by a radiologist (not an emergency physician) Injury to globe/palpebral laceration excluded
Jank S et al, 2004, Austria	60 patients included based on clinically suspected orbital injury	Convenience sample, single-blinded, prospective observational	Blinded oral & maxillofacial surgeon USS investigation of infraorbital rim, findings confirmed by CT.	Sensitivity 94% Specificity 92% PPV 91% NPV 92%.	Orbital soft tissue injuries were excluded No confidence intervals provided The FOUS was performed by a maxillofacial surgeon (not an emergency physician)
			USS investigation of orbital floor by blinded oral & maxillofacial surgeon, findings confirmed by CT.	Sensitivity 95% Specificity 100% PPV 100% NPV 77%
Forrest et al, 1993, Canada	18 patients with facial trauma with clinically suspected orbital injuries.	Prospective observational study	USS investigation of both orbits Findings confirmed by CT scan blinded to USS results	Sensitivity 92% Specificity 100% PPV 100%	FOUS performed by plastic surgeons Small sample size with no sample size estimates performed Open globe injuries, alteration of visual acuity conditions excluded

Comment(s)

Blaivas et al (2002) demonstrated that emergency physicians with variable training in FOUS can reach the same diagnosis as that made available from a reported CT or ophthalmological opinion. No other studies have looked at Emergency Department scenarios exclusively. Studies from maxillofacial units where non-radiologists performed the FOUS (Jenkins 1997; Jank et al 2004 and 2006) also show comparable outcomes to Blaivas et al (2002) as well as demonstrating the ability to identify fractures. An additional number of case reports advocate the use of FOUS in the emergency department for a range of traumas and more recently Eze et al (2009) reviewed their local experience of FOUS findings in trauma patients, but did not confirm their findings by CT. The generalisability of these findings is somewhat limited by the fact that the nature of trauma being looked for varies across studies and so does the practitioner's clinical background.

Editor Comment

FOUS, focused ocular ultrasound.

Clinical Bottom Line

CT remains the ‘gold standard’ in imaging trauma to the orbit and its contents. FOUS does however facilitate highly specific and sensitive assessment of the nature and extent of orbital trauma. Ultrasound scanning is often more rapidly available than CT, or more suitable when the spine is compromised. USS is a sensible and available adjunct to informed patient management and may replace the need for a CT in some instances.

References

1. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department Acad Emerg Med 2002;9(8):791-799.
2. Jenkins CNJ, Thuau H. Ultrasound imaging in assessment of fractures of the orbital floor Clinical Radiology 1997;52:708-711.
3. Jank S, Emshoff R, Etzelsdorfer M, et al. The diagnostic value of ultrasonography in the detection of orbital floor fractures with a curved array transducer Int J Oral Maxillofac Surg. 2004;33:13-18.
4. Jank S, Emshoff R, Strobl H et al. Effectiveness of ultrasonography in determining medial and lateral orbital wall fractures with a curved-array scanner J Oral Maxillofac Surg. 2004;62:451-455.
5. Forrest CR, Lata AC, Marcuzzi DW, et al. The role of orbital ultrasound in the diagnosis of orbital fractures. Plastic and Reconstructive Surgery 1993;92:28–34.
6. Eze KC, Enock ME, Eluehike SU. Ultrasonic evaluation of orbito-ocular trauma in Benin-City, Nigeria. Niger Postgrad Med J 2009;16:198–202.
7. Jank S, Deibl M, Strobl H, et al. Intrarater reliability in the ultrasound diagnosis of medial and lateral wall fractures with a curved array transducer. Int J Oral Maxillofac Surg 2006;64:68–73.