Normal CT Facial Bones Report Template (Maxillofacial Trauma)

EXAMINATION: CT of the maxillofacial bones without contrast.

CLINICAL HISTORY: [indication, e.g. “Facial trauma after assault,
left periorbital swelling” / “Motor vehicle collision, evaluate for
facial fractures”]

COMPARISON: [None available. / Head CT of the same date.]

TECHNIQUE: Helical non-contrast CT of the facial bones from the
frontal sinuses through the mandible, with thin-section axial images
reconstructed in bone and soft tissue algorithms and coronal and
sagittal reformats. [3D volume-rendered images were generated.]
Dose reduction techniques were used.

FINDINGS:
Orbits: The orbital walls, including the floors, medial walls (lamina
papyracea), roofs and lateral walls, are intact. Normal globes and
optic nerves. No intraorbital hematoma, emphysema or herniation of
orbital fat or extraocular muscle. The extraocular muscles are
normal in size and position.
Zygomaticomaxillary complex: The zygomatic arches, zygomaticofrontal
sutures, inferior orbital rims and anterior and posterolateral
maxillary sinus walls are intact bilaterally. No tripod (ZMC)
fracture.
Nasal bones and septum: The nasal bones and frontal processes of the
maxilla are intact. The nasal septum is midline [with mild
deviation to the x]. No naso-orbito-ethmoid injury.
Maxilla and pterygoid plates: The maxillary alveolus, palate and
pterygoid plates are intact. No Le Fort pattern of injury.
Frontal bone: The anterior and posterior tables of the frontal
sinuses are intact.
Mandible and TMJs: The mandibular symphysis, body, angles, rami,
coronoid and condylar processes are intact. The condyles are
normally seated in the glenoid fossae bilaterally. No dental
fracture or avulsion on this examination. [Dental restorations are
present.]
Paranasal sinuses: The sinuses are clear. No air-fluid level or
hemosinus. No fracture of the sinus walls.
Soft tissues: [Mild] soft tissue swelling over the [left periorbital
region] without underlying fracture. No foreign body. No
subcutaneous emphysema.
Visualized intracranial contents: No intracranial hemorrhage on the
included images; see the dedicated head CT [if performed].
Skull base and cervical spine (included portions): Intact.

IMPRESSION:
1. No facial bone fracture.
2. [Left periorbital soft tissue swelling without underlying
fracture.]

MyRadAgent turns a scratch dictation into this report — structured, guideline-checked, in your own section headers and phrasing. It learns your style from every correction. Free trial: 100 reports over 14 days, no card, no IT ticket.