There is extensive edema overlying the lateral orbit and soft tissues, both deep and superficial of scalp on the right side. There is a lesser degree of soft tissue swelling on the left likely due to contra coup injury.

There is gas in the soft tissues, which appears to come from the area of the lateral orbital wall, likely from fractures that involve the orbit and maxillary sinus. There is no evidence of a foreign body.

There is punctate hemorrhage in the right frontal lobe with some possible surrounding edema and also possible punctate hemorrhage in the region of the anterior limb of the internal capsule and thalamus, although the latter are less definite. There is an area of the old encephalomalacia in the left frontal region.

There is minimal subarachnoid bleeding high in the convexity region likely of the central sulcus on the left side.

There is no subperiosteal, epidural or subdural hematoma and/or pneumocephalus along the boney walls of the anterior or middle cranial fossa or elsewhere.

The preseptal soft tissues including the lacrimal gland and sac show swelling more on the right than the left. There is no evidence of a foreign body at the fracture site, to suggest penetrating injury. There are blood products in in both maxillary sinuses, as well as within the nasal cavity.

There are extensive subperiosteal hematomas involving both orbits mainly along the roof and lateral wall on the right side and along the roof and medial wall and, to a lesser extent, the floor on the left side.

The extraconal and intraconal orbital fat is edematous bilaterally, more on the right than the left. There is no evidence of significantly herniated intra-orbital fat.

The superior, lateral and inferior rectus muscles are swollen on the right side and the lateral rectus markedly displaced. Superior rectus muscle on the left side is displaced by the subperiosteal hematoma.

The soft tissues of the orbital apex and the superior and inferior orbital fissures may be abnormal on the right side.

The orbital veins appear normal although somewhat more prominent on the right.
 

There is a minimally displaced fracture of the right zygoma and a displaced fracture of the lateral orbital wall on the right side. The floor of the orbit on the right appears to be somewhat inferiorly displaced but is not obviously fractured. The roof of the orbit is fractured posteriorly on the right but the optic strut and optic canal are intact. No obvious orbital fractures are seen on the left side.

The zygomatic arch has a nondisplaced fracture on the right.

The greater wing of the sphenoid bone on the right is fractured but that fracture does not clearly extend into the lesser wing or more central skull base.

There is no entrapment of the muscles of mastication by the fracture of the zygomatic arch.

There is a fracture of the greater wing of the sphenoid bone that does not extend into the basisphenoid.

Moderately severe proptosis is present. The optic nerve is  stretched in appearance on both sides, and the posterior aspect of the globe is tented in appearance on the right. Signs of tension orbit are clearly present on the right side and the left side shows early tension orbit. These findings most likely related to the subperiosteal hematomas.

There is no evidence of injuries to the eyes.

The naso-orbito-ethmoid complex is not fractured.

There is no bony injury of the midface or mandible.

The visualized portions of the cervical spine are normal for the patient’s age.