Nasal Bone Fracture Reduction Under Local Anaesthesia: A Holistic Approach to Nasal Blocks and a Comparison with General Anaesthesia

Abstract

To compare the pain scores in closed reduction of nasal bone fractures under local anaesthesia (LA) and general anaesthesia (GA), and to outline the blocks that should be used for the same based on their nerve supply. A prospective study was conducted with 40 patients with Class 1 and 2 nasal bone and septal fracture. 20 patients underwent the procedure under LA and 20 under GA. The local blocks that should be used based on the complete nerve supply of the nose has been tabulated. Pain scores were recorded immediately after the procedure and 6 h later. Additionally, all the patients undergoing reduction under LA were asked, if given the choice again, if they would prefer to undergo the procedure under LA or GA. The overall difference in the pain scores calculated by T-test showed a p-value of 0.08807 (the result was not significant at p < .05) in the immediate post operative period. At the 6 h post operative period, overall difference in the pain scores showed a p-value of 0.384972 (not significant at p < .05). Of the patients who underwent the procedure under LA, 18 of 20 (90%) said that if given a choice again, they would undergo the procedure under LA, while 2 said they would prefer GA. Based on the pain score in the La vs. GA groups, there is no significant difference in the pain scores whether closed reduction is done under local or general anaesthesia. If all the blocks are given keeping the nerve supplies in mind, and both externally, and with pledgets, the entire nerve supply of the nose can be blocked.

Introduction

Nasal bone is the 3rd most fractured bone of the human body, and the most common type of facial fracture [1].

Since a lot of the nasal fractures can be seen in the emergency department, closed reduction of the fracture under local anaesthesia (LA) is a commonly done procedure. But there are no clear distinctive set of regional blocks mentioned, and every text has their own set of blocks. Here we have attempted to outline the entire nerve supply of the nose, and a full list appropriate blocks to be given to anaesthetise the entire nose, to provide as painless an experience as possible under LA and compare the subsequent results to general anaesthesia (GA).

Methods

A prospective study was conducted between January 2022 to December 2022. 40 patients between the ages of 18–60 years of age with Class 1 and Class 2 nasal bone and nasal septal fracture, with nasal deviation less than half the width of the nasal bridge were included. Only patients presenting within 10 days of injury were considered for the study, in whom close reduction could be attempted. 20 patients underwent closed reduction under LA, with 20 undergoing under GA. Patients with underlying ischemic heart disease were ruled out.

For LA, 2% lignocaine with 1:200000 adrenaline preformed mixture was used which is commercially available. The maximum dose of LA with adrenaline is 7 mg/kg and concentration of lignocaine in 2% is 20 mg/mL. Hence the maximum volume which can be safely used, is 0.35 mL/kg. In an average 60 kg adult, the maximum volume of LA which can be used is 21 mL (0.35 mL/kg × 60 kg) [2]. In the injections administered by us, the dose of LA given is around 7ml.

The blocks that we used, and should ideally be used are all outlined in the table below. The reasoning for the blocks is provided based on the nerve supply of the nose, along with the references for the same. Cotton pledgets soaked in 0.05% oxymetazoline combined with 4% topical lignocaine were also placed in the nasal cavity at the floor, middle meatus (up to the posterior end of the middle turbinate) and superior meatus to anaesthetize the Internal Nasal nerve, Nasopalatine nerve and intranasal branches of the Sphenopalatine ganglion.

Manipulation (without any external or internal osteotomy) was done with the help of Asch and Walsham Forceps, and pre operative and post operative picture were taken of the patient for visual comparison of reduction (Fig. 1). External and internal nasal splints were applied, with the internal splint being kept in position for 5 days, and the external splint in position for 3 weeks. Pre operative and post operative CT scans of the face were also taken to confirm the resetting of the bones, the post operative scans being taken after removal of the external splint (Fig. 2).

Fig. 1.

Shows various cases of nasal bone fracture reduction which was done by manipulation under LA. The pictures on the left are the pre operative pictures, while the ones on the right are the respective post operative pictures

Fig. 2.

Shows one of the CT images of a patient who underwent reduction under LA. The picture on top is the pre operative scan, and the one below is the post operative scan

Pain was measured by the Wong Baker Faces Pain Rating Scale, which is a self-assessment tool that consists of a face chart with a pain rating below each face, that helps record pain scores from zero (no pain) to ten (severe pain). For patients undergoing the reduction under LA, pain was recorded immediately during the procedure and 6 h later, the same being recorded for patients who underwent reduction under GA. Additionally, all the patients undergoing reduction under LA were asked, if given the choice again, if they would prefer to undergo the procedure under LA or GA. Patients in both groups were given Tablet Diclofenac (50 mg) twice a day for 5 days after the procedure.

Results

Of the people undergoing the procedure under LA, 12 had a pain score of 2 and 8 had a score of 4 in the immediate post operative period (mean 2.8), while in the GA group, 16 had a score of 2 and 4 had a score of 4 (mean 2.4). The overall difference in the pain scores calculated by T-test for 2 independent means, with a significance level of 0.05, showed a p-value of 0.08807 (the result was not significant at p < .05) and a t value of 1.37841. At the 6 h post operative period, in the LA group 2 patients had a score of 0, 16 had a score of 2 and 2 had a score of 4 (mean 2), while in the GA group 4 had score of 0, 13 had a score of 2 and 3 had a score of 4 (mean 1.9). The overall difference in the pain scores calculated by T-test for 2 independent means, with a significance level of 0.05, showed a p-value of 0.384972 (the result was not significant at p < .05) and a t value of 0.29455.

Fig. 3.

shows the pain scores of patients in the LA and GA group both in the immediate post operative period, and after 6 h

Of the patients who underwent the procedure under LA, 18 of 20 (90%) said that if given a choice again, they would undergo the procedure under LA, while 2 said they would prefer GA.

Discussion

The main sensory innervation of the nose is as follows:

1. Anterior Ethmoidal nerve: Continuation of the Nasociliary nerve, itself a division of the Ophthalmic branch of Trigeminal nerve (V1). It runs along the anterior ethmoidal foramen and canal, and then along the cribriform plate before entering the nasal cavity. Its main terminal branches are the Internal and External Nasal branches. The Internal Nasal nerve supplies the anterior and upper part of the septum through its medial branch, and the anterior part of the lateral wall of the nasal cavity through its lateral branch. The External Nasal nerve supplies the skin over the nasal tip and external lateral nose.

2. Infraorbital nerve: It is the largest terminal branch of the Maxillary division of the Trigeminal nerve (V2). After passing through the floor of the orbit along the infraorbital canal, exiting at the infraorbital foramen, running inferiorly lateral to the nose, and supplying its tip.

3. Anterior Superior Alveolar nerve: This is a branch of the infraorbital nerve, given off in the infraorbital canal. It communicates with the middle superior alveolar nerve to supply the inferior meatus and nasal cavity floor via a nasal branch in the lateral wall of the inferior meatus.

4. Infratrochlear nerve: Also a branch of the Nasociliary nerve, it courses forward along the medial rectus muscle to supply the skin of the root of the nose.

5. Sphenopalatine ganglion: This ganglion resides in the pterygopalatine fossa and gives off 5 major branches: the orbital branches, palatine branches, nasal branches, pharyngeal branch and lacrimal branch. Of these, the Greater Palatine nerve (from the palatine branch) descends through the greater palatine foramen to supply sensation to the mucosa over the inferior nasal concha and the inferior and middle meatuses via the Posterior Inferior Lateral Nasal Branches. The Nasal branches of the ganglion enter the nose via the sphenopalatine foramen to supply the superior, middle nasal conchae and nasal septum via the Lateral Posterior Superior branches and Medial Posterior Superior branches. The largest of the Medial Posterior Superior branches is the Nasopalatine nerve which supplies the septum by running along a groove on the vomer before exiting via the incisive canal [8, 9].

Nasal bone fractures can be classified on the basis of nature of the injury, extent of deformity or on the pattern of fracture. One of the most common and accepted classifications of the pattern of nasal bone fracture, which not only considers the mode of trauma and parts involved, but also sheds a little light on the appropriate management to be followed, divides the fractures into 3 classes. Class 1 are low to moderate degree trauma fractures that involve the nasal bone with or without septal involvement, and minimal displacement. Class 2 fractures involve the nasal bones, the frontal process of the maxilla and septum (which presents as a “C” shaped fracture). Class 3 fractures are naso-orbito-ethmoid fractures and are often associated with maxillary fractures [10].

Nasal bone and nasal septal fractures have multiple modes of management, ranging from closed reduction to open septorhinoplasty depending the pathology and time from fracture.

Isolated nasal bone fractures or nasal bone and nasal septal fractures are generally considered for closed nasal bone fracture reductions, unless complicated by other features such as a hematoma that may need to be drained or an external injury or gross functional disruption of the septum requiring septoplasty. All Class 1 and most Class 2 fractures can be dealt with by closed reduction. Usually, the indications for closed reduction in adults include unilateral or bilateral nasal bone fracture or naso-septal complex fracture with nasal deviation less than half the width of the nasal bridge. If the patients present within 3–6 h of the injury, immediate assessment and reduction should be done, failing which, edema may set it and the patient may have to reassessed after a few days once the edema subsides. Overall, in case close reduction without any osteotomies is to be done, it should be done within 10–12 days of the injury or else on table manipulation of the bones become difficult and open approaches may be required [10, 11].

Closed reduction can give satisfactory results in 90% cases, especially when patients present in the acute phase, and even if it fails, open reduction can be attempted later. But since closed reduction is the least invasive method, it is prudent to attempt it first [12].

Patients with nasal bones deviated more than half the nasal bridge width tend to have a concomitant, C-shaped fracture of the bony and cartilaginous septum. Hence such patients require an open approach with submucous resection of the septum to aid in improved long-term cosmetic and functional outcome. This is because of the alleviation of overlapped, interlocking fragments of the septum which would otherwise result in long term nasal deformity.

Fig. 4.

This flow chart represents an algorithm for treatment of nasal bone fracture, taken from a paper by Rohrich et al. [13].

Within the purview of a closed reduction, especially in the emergency setting, another significant debate is the usage of local vs. general anaesthesia. Ridder et al. opine that local anaesthesia is sufficient for adults, with there being no difference in outcome between the 2 groups [12]. Rohrich et al. also similarly state that in most cases local anaesthesia is clinically as effective, and less expensive than general anaesthesia for closed reduction [13]. Khawaja et al. similarly in a trial also showed that local anaesthesia was just as effective as general anaesthesia in the first line management of nasal bone fracture reduction, their primary outcome being calculated based on pain scores [14]. Similarly, our results showed that on providing local blocks in a holistic manner, there is no significant difference in the pain scores whether performed under GA or LA.

Many current textbooks have outlined different local blocks for nasal bone fracture reduction, but there does not seem to be any consensus on the types of blocks given, the places where they are given and the regions anaesthetised.

For example, the 8th edition of Scott Brown’s Otorhinolaryngology Head and Neck Surgery textbook advocates a combination of external infiltration along with internal application of topical preparations such as EMLA or AMETOP. The external infiltrations are along the nasomaxillary groove, infraorbital foramen and around the Infratrochlear nerve [10].

Rob and Smith’s Textbook of Operative Surgery suggests that the nose be sprayed and packed preoperatively with ribbon gauze, along with 2% lignocaine infiltration given intranasally at the columella for branches of the greater palatine nerve, superiorly along the dorsum for the external nasal nerve and at the root for the Infratrochlear nerve, and laterally near the roof of the maxillary sinus for the infra orbital nerve. All these infiltrations are given intranasally, and not externally on the skin [15].

Eugene Myers’ Operative otolaryngology Head and Neck Surgery, on the other hand, clearly mentions that external injections are better tolerated. They advise to place pledgets with 4% lignocaine along with a vasoconstrictive agent such as oxymetazoline for 10–15 min on the undersurface of the nasal bones, lateral nasal wall in the region of the sphenopalatine foramen, floor of nose and mid septum. 1% lignocaine with 1:100,000 epinephrine is then injected in the region of the dorsum from the rhinion to the supratip, for the Nasociliary nerve distribution, around the infraorbital foramen and base of the columella for the Nasopalatine nerve [16].

Cummings Otolaryngology Head and Neck Surgery also suggests a combination of topical and injected anaesthesia. Cotton pledgets soaked in 0.05% oxymetazoline combined with 4% topical lidocaine are used to anaesthetize the branches of the anterior and posterior ethmoid, sphenopalatine, and nasopalatine nerves in the nasal cavity, while 1% lidocaine with 1: 100,000 epinephrine is also injected on the septum, lateral wall and floor of the nasal cavity. The external nasal branch, the infraorbital nerve and branches from the nasopalatine nerve are blocked with external injections [7].

A paper by Ahilasamy et al. has recently outlined all the nerve blocks that can be used in endoscopic sinus surgery [17]. We similarly wanted to compare the pain scores in patients undergoing nasal bone fracture reduction under local anaesthesia and general anaesthesia and comprehensively outline all the blocks that should be used in the same for as painless an experience for the patient as possible. Hence based on the nerve supply, we have given multiple blocks, which is a combination of various standard textbooks and published articles, as detailed in Table 1, to provide a comprehensive outline of the set of blocks to be used in closed reduction under LA.

Table 1.

shows a comprehensive list of all the blocks that were given by us to completely anaesthetise the nose [3–7].

Nerve Block	Anatomical Landmark	Area anaesthetised
External Nasal nerve	Inter-cartilaginous injection into the dorsum of the nose from the rhinion to the tip (1ml)	Skin over the nasal tip and external lateral nose.
Internal Nasal nerve	Injection on the upper anterior part of nasal septum and at the axilla of middle turbinate, along with cotton pledgets soaked in 0.05% oxymetazoline combined with 4% topical lignocaine in the nasal cavity (0.5ml at each site for a total of 2ml bilaterally)	Anterior and upper part of the septum and anterior part of the lateral wall of the nasal cavity.
Infraorbital nerve	Gingivobuccal border at the base of the maxillary canine, directed upwards about 10 mm till reaching the infraorbital foramen (which was palpated externally also) (0.5ml at each side)	Sides of the nose and the cheek
Anterior Superior Alveolar nerve	Same as the block for Infraorbital nerve	Inferior meatus and nasal cavity floor
Infratrochlear nerve	Internal angle of the orbit just above the internal canthus (0.5ml at each side)	Skin of the root of the nose
Greater Palatine nerve	Antero- medial to the third maxillary tooth (0.5ml at each side)	Mucosa over the inferior nasal concha and the inferior and middle meatuses
Lateral Posterior Superior branches of Nasal Branch	Cotton pledgets soaked in 0.05% oxymetazoline combined with 4% topical lignocaine in the nasal cavity as described above	Superior, middle nasal conchae and nasal septum
Medial Posterior Superior branches of Nasal Branch	Cotton pledgets soaked in 0.05% oxymetazoline combined with 4% topical lignocaine in the nasal cavity as described above	Superior, middle nasal conchae and nasal septum
Nasopalatine nerve	Terminal branches from the nasopalatine nerve that are not anaesthetized by the pledgets are Blocked with an injection at the base of the columella and nasal tip. (1ml)	Septum along its lower part

Conclusion

Based on the pain score in the La vs. GA groups, there is no significant difference in the pain scores whether closed reduction is done under local or general anaesthesia. If all the blocks are given keeping the nerve supplies in mind, and both externally, and with pledgets, the entire nerve supply of the nose can be blocked. The 80% people who said that they would be willing to undergo the procedure under LA if given the chance again show that they have had a satisfactory painless outcome which is aesthetically pleasing. This again has been confirmed by our CT scans done pre and post procedure.

Funding

All the authors declare they have not received any funding.

Declarations

Ethics approval and consent to participate

All procedures performed in the study were in accordance with the ethical standards of the institute.

Informed Consent

Written informed consent was obtained from all the individual participants in the study.

Conflict of Interest

All the authors declare they have no conflicts of interest.