Abstract
Purpose:
The aim of this study was to compare the diagnostic performance (accuracy, sensitivity, specificity, positive predictive value, and negative predictive value) of plain film (PF), ultrasonography (USG), and computed tomography (CT) in diagnosing nasal bone fractures (NBFs).
Methods:
In a search of PubMed and Scopus, “nasal bone fracture” AND “X-ray OR CT OR USG OR MRI” were searched. Among the 369 titles from PubMed and 379 titles from Scopus, 257 duplicate titles were excluded and 491 titles were reviewed. Among them, 36 full articles were reviewed. From these, 21 were excluded and 1 mined article was added; thus, 16 articles were reviewed.
Results:
The accuracy of CT (94.4% ± 2.3%) was significantly higher (P < .001) than that of USG (85.0% ± 3.6%). The accuracy of USG was significantly higher (P < .001) than that of PF (67.7% ± 4.7%). Computed tomography (89.3% ± 3.1%) and USG (87.2% ± 3.3%) were significantly more sensitive than PF (P < .001 and P < .001, respectively). The specificity of CT (94.2% ± 2.3%) was significantly higher (P = .001) than that of USG (87.4% ± 3.3%). The specificity of USG was significantly higher (P < .001) than that of PF (67.8% ± 4.7%). Among the PF techniques, combining a lateral view and the Water’s view (71.8% ± 4.5%) had significantly higher accuracy than a lateral view alone (62.4% ± 4.8%) or the Water’s view alone (61.0% ± 4.9%). In USG, there was no significant difference (P = .300) in accuracy among lateral and dorsal views (95.8% ± 2.0%), a lateral view alone (84.2% ± 3.7%), and a dorsal view alone (84.2% ± 3.6%).
Conclusion:
The results of this review might be helpful in choosing the most appropriate diagnostic tool in patients suspected having NBF.
Keywords: nasal bone, fractures, bone, diagnosis, tomography, X-ray computed, ultrasonography, X-ray film, sensitivity and specificity
Abstract
Objectif :
La présente étude visait à comparer le rendement diagnostique (précision, sensibilité, spécificité, valeur prédictive positive et valeur prédictive négative) du film radiographique (FR), de l’échographie (ÉG) et de la tomodensitométrie (TDM) pour diagnostiquer les fractures de l’os nasal (FON).
Méthodologie :
Les auteurs ont cherché les termes nasal bone fracture ET X-ray OU CT OU USG OU MRI dans PubMed et Scopus. Parmi les 369 articles tirés de PubMed et les 379 articles tirés de Scopus, ils ont exclu 257 articles dédoublés et examiné 491 articles. De ce nombre, ils ont revu 36 articles intégraux. Ils en ont exclu 21, ont ajouté un article extrait des précédents et ont analysé 16 articles.
Résultats :
La TDM (94,4 % ± 2,3 %) était considérablement plus précise (P < 0,001) que l’ÉG (85,0 % ± 3,6 %). L’ÉG était considérablement plus précise (P < 0,001) que le FR (67,7 % ± 4,7 %). La TDM (89,3 % ± 3,1 %) et l’ÉG (87,2 % ± 3,3 %) étaient considérablement plus sensibles que le FR (P < 0,01 et P < 0,001, respectivement). La TDM (94,2 % ± 2,3 %) était considérablement plus spécifique (P = 0,001) que l’ÉG (87,4 % ± 3,3 %). L’ÉG était considérablement plus spécifique (P < 0,001) que le FR (67,8 % ± 4,7 %). Parmi les techniques de FR, la combinaison de la vue latérale et de la vue de Water (71,8 % ± 4,5 %) était considérablement plus précise que la vue latérale seule (62,4 % ± 4,8 %) ou que la vue de Water seule (61,0 % ± 4,9 %). La précision des vues latérale et dorsale (95.8 % ± 2.0 %), de la vue latérale seule (84,2 % ± 3,7 %) et de la vue dorsale seule (84,2 % ± 3,6 %) de l’ÉG n’était pas statistiquement significative (P = 0,300).
Conclusion :
Les résultats de la présente analyse peuvent être utiles pour choisir l’outil diagnostique le mieux adapté aux patients susceptibles d’avoir une FON.
Introduction
The nose is the most prominent central part of the face, and fracture of the nasal bone is the most common type of facial fracture.1 Many articles have provided information on the efficiency of several radiological tools for diagnosing nasal bone fractures (NBFs); however, few studies have presented a systematic review. Becker reported that plain film (PF) radiographs revealed definite fractures in 53% of the cases included in that study.2 The reliability of PF radiographs for diagnosing NBFs was found to be 82% in our previous study.1
The aim of this study was to compare the diagnostic performance (accuracy, sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of PF, ultrasonography (USG), and computed tomography (CT) in diagnosing NBFs.
Materials and Methods
In a search of PubMed and Scopus, the search terms “nasal bone fracture” AND “X-ray OR CT OR USG OR MRI” were used. Studies that did not discuss the radiological diagnosis of NBFs were excluded. No restrictions on language or publication form were imposed. All articles were read by 2 independent reviewers who extracted the data.
The data were summarized. A statistical analysis was performed using SPSS 19.0 (IBM Corp, Armonk, New York).
Among the 748 titles (369 titles from PubMed and 379 titles from Scopus), 257 duplicate titles were excluded and 491 titles were reviewed. Among the 491 remaining titles, 434 were excluded, resulting in 57 abstracts that met our inclusion criteria (“nasal bone fracture” and “radiological diagnosis” appeared in the title). Studies that did not allow an evaluation of NBFs and the diagnosis thereof were excluded. Based on these exclusion criteria, 21 abstracts were excluded and 36 full articles providing data on NBF, and diagnosis rates were reviewed. In addition to these 36 articles, 1 externally identified article was added, resulting in 37 articles. Of those 37 articles, 21 were excluded because they did not have quantitative values (11 studies), were not relevant (5 studies), or were not original articles (5 studies). Thus, 16 articles were reviewed (Figure 1).3-18 We followed “Preferred Reporting Items for Systematic Reviews and Meta-Analyses ” guidelines in this study.19
Figure 1.
Selection process of the articles included in this study.
Results
A total of 4628 cases of NBFs from 16 articles were analyzed.3-18 For the diagnosis of NBFs, PF (n = 2020, 43.6%), USG (n = 1480, 40.0%), and CT (n = 1128, 14.4%) were used (Table 1).
Table 1.
Diagnostic Performance of Each Method for Nasal Bone Fracture.
| Diagnostic performances | PF | USG | CT | Total |
|---|---|---|---|---|
| Number (%) | 2020 (43.6) | 1480 (32.0) | 1128 (24.4) | 4628 (100.0) |
| Accuracy (%) | 1188/1755 (67.7 ± 4.7) | 1019/1199 (85.0 ± 3.6) | 980/1038 (94.4 ± 2.3) | 3187/3992 (79.8±4.0) |
| Sensitivity (%) | 911/1403 (64.9 ± 4.8) | 994/1140 (87.2 ± 3.3) | 800/896 (89.3 ± 3.1) | 2705/3439 (78.7 ± 4.1) |
| Specificity (%) | 660/973 (67.8 ± 4.7) | 799/914 (87.4 ± 3.3) | 652/692 (94.2 ± 2.3) | 2111/2579 (81.9 ± 3.9) |
| PPV (%) | 967/1178 (82.1 ± 3.8) | 922/1002 (92.0 ± 2.7) | 268/300 (89.3 ± 3.1) | 2157/2480 (87.0 ± 3.4) |
| NPV (%) | 507/981 (51.7 ± 5.0) | 717/850 (84.4 ± 3.6) | 922/1002 (92.0 ± 2.7) | 2146/2833 (75.8 ± 4.3) |
Abbreviations: CT, computed tomography; NPV, negative predictive value; PF, plain film; PPV, positive predictive value; USG, ultrasonography.
Accuracy
The accuracy of CT (94.4% ± 2.3%) was the highest among the 3 methods, followed by USG (85.0% ± 3.6%) and PF (67.7% ±4.7%). Computed tomography had significantly higher accuracy than USG (P < .001 [analysis of variance [ANOVA], Scheffe method]). Ultrasonography had significantly higher accuracy than PF (P < .001 [ANOVA, Scheffe method], Tables 2 -4, Figure 2).
Table 2.
Diagnostic Performance of Plain Film for Nasal Bone Fracture.
| Author | Year | Location | N | Accuracy | Sensitivity | Specificity | PPV | NPV |
|---|---|---|---|---|---|---|---|---|
| Thiede4 | (2005) | Lateral | 126 | 94/126 | 61/74 | 33/52 | 61/68 | 33/38 |
| Occipitomental | 126 | 62/126 | 43/82 | 19/44 | 43/55 | 19/35 | ||
| Pyramid | 126 | 83/126 | 67/84 | 16/42 | 67/84 | 16/25 | ||
| Subtotal | 378 | 239/378 | 171/240 | 68/138 | 171/207 | 68/98 | ||
| Atiggechi15 | (2014) | Lateral | 118 | 65/118 | 59/118 | 85/118 | 99/118 | 38/118 |
| Water’s | 118 | 66/118 | 63/118 | 77/118 | 97/118 | 76/118 | ||
| Lateral + Water’s | 118 | 73/118 | 68/118 | 68/118 | 97/118 | 40/118 | ||
| Subtotal | 354 | 204/354 | 190/354 | 230/354 | 293/354 | 154/354 | ||
| Masoomi17 | (2015) | Lateral + Dorsum | 124 | 84/124 | 57/89 | 27/35 | 57/65 | 27/59 |
| Water’s + Wall | 124 | 84/124 | 29/54 | 55/70 | 29/44 | 55/80 | ||
| Subtotal | 248 | 168/248 | 86/143 | 82/105 | 86/109 | 82/139 | ||
| Gürkov5 | (2008) | Dorsum | 80 | 72/80 | 52/59 | 20/21 | 52/53 | 20/27 |
| Lateral | 80 | 33/80 | 18/64 | 15/16 | 18/19 | 15/61 | ||
| Subtotal | 160 | 105/160 | 70/123 | 35/37 | 70/72 | 35/88 | ||
| Lee18 | (2016) | Lateral | 59 | – | 34/59 | 34/59 | 21/59 | 46/59 |
| Midline | 31 | – | 19/31 | 18/31 | 18/31 | 26/31 | ||
| Subtotal | 90 | – | 53/90 | 52/90 | 39/90 | 72/90 | ||
| Lou12 | (2012) | Lateral | 23 | 18/23 | 20/23 | 6/23 | 20/23 | 8/23 |
| Skull AP + Lat | 17 | 10/17 | 8/17 | 17/17 | 17/17 | 5/17 | ||
| Water’s | 12 | 5/12 | 2/12 | 12/12 | 12/12 | 4/12 | ||
| Subtotal | 52 | 33/52 | 30/52 | 35/52 | 49/52 | 17/52 | ||
| Zhong16 | (2014) | – | 202 | 161/202 | – | – | – | – |
| Lee6 | (2009) | Lateral + Water’s | 140 | 110/140 | 108/138 | 2/2 | 108/108 | 2/32 |
| Baek13 | (2013) | Coronal + Lateral | 108 | 71/108 | 67/88 | 4/20 | 67/83 | 4/25 |
| Mohammadi7 | (2009) | Lateral + Water’s | 103 | – | 79/103 | 84/103 | 84/103 | 73/103 |
| Mohammadi10 | (2011) | Lateral + Water’s | 72 | – | 57/72 | 68/72 | – | – |
| Kunitskiĭ11 | (2013) | – | 60 | 48/60 | – | – | – | – |
| Çil14 | (2013) | – | 45 | 41/45 | – | – | – | – |
| Dorobisz3 | (1983) | Lateral + Water’s | 8 | 8/8 | – | – | – | – |
| Total | 2020 | 1188/1755 (67.7) | 911/1403 (64.9) | 660/973 (67.8) | 967/1178 (82.1) | 507/981 (51.2) |
Abbreviations: N, number of patient; NPV, negative predictive value; PPV, positive predictive value.
Table 3.
Diagnostic Performance of Ultrasonography for Nasal Bone Fracture.
| Author | Year | Location | N | Accuracy | Sensitivity | Specificity | PPV | NPV |
|---|---|---|---|---|---|---|---|---|
| Thiede4 | (2005) | Dorsum | 126 | 72/126 | 34/74 | 36/52 | 35/40 | 36/56 |
| Lateral | 126 | 88/126 | 57/82 | 31/44 | 57/64 | 31/47 | ||
| Nasal pyramid | 126 | 83/126 | 65/84 | 25/42 | 65/75 | 25/38 | ||
| Subtotal | 378 | 243/378 | 158/240 | 92/138 | 158/179 | 92/141 | ||
| Masoomi17 | (2015) | Dorsum | 124 | 119/124 | 85/89 | 34/35 | 85/86 | 34/38 |
| Lateral | 124 | 117/124 | 48/54 | 69/70 | 48/49 | 69/75 | ||
| Subtotal | 248 | 236/248 | 133/143 | 103/105 | 133/135 | 103/113 | ||
| Gürkov5 | (2008) | Dorsum | 80 | 78/80 | 58/59 | 20/21 | 58/59 | 20/21 |
| Lateral | 80 | 75/80 | 63/64 | 12/16 | 63/67 | 12/13 | ||
| Subtotal | 160 | 153/160 | 121/123 | 325/37 | 121/126 | 32/34 | ||
| Lee18 | (2015) | Lateral | 59 | – | 44/59 | 45/59 | 31/59 | 50/59 |
| Midline | 31 | – | 25/31 | 28/31 | 23/31 | 29/31 | ||
| Subtotal | 90 | – | 69/90 | 73/90 | 54/90 | 79/90 | ||
| Lee12 | (2009) | – | 140 | 140/140 | 140/140 | 140/140 | 140/140 | 140/140 |
| Atiggechi15 | (2014) | Lateral | 118 | 97/118 | 99/118 | 89/118 | 107/118 | 72/118 |
| Mohammadi7 | (2009) | – | 103 | – | 93/103 | 101/103 | 101/103 | 90/103 |
| Mohammadi10 | (2011) | – | 72 | – | 72/72 | 66/72 | – | – |
| Lou12 | (2012) | Dorsum | 71 | 69/71 | 71/71 | 63/71 | 68/71 | 71/71 |
| Kunitskiĭ11 | (2013) | – | 60 | 58/60 | – | – | – | – |
| Javadrashid9 | (2011) | Dorsum + Lateral | 40 | 23/24 | 38/40 | 40/40 | 40/40 | 38/40 |
| Total | 1480 | 1019/1199 (85.0) | 994/1140 (87.2) | 799/914 (87.4) | 922/1002 (92.0) | 717/850 (84.4) |
Abbreviations: N, number of patient; NPV, negative predictive value; PPV, positive predictive value.
Table 4.
Diagnostic Performance of Computed Tomography for Nasal Bone Fracture.
| Author | Year | Location | N | Accuracy | Sensitivity | Specificity | PPV | NPV |
|---|---|---|---|---|---|---|---|---|
| Kim8 | (2010) | Axial-ob1 | 145 | 133/145 | 129/145 | 135/145 | – | – |
| Axial-ob2 | 145 | 131/145 | 116/145 | 138/145 | – | – | ||
| Sagittal-ob1 | 145 | 143/145 | 141/145 | 144/145 | – | – | ||
| Sagittal-ob2 | 145 | 137/145 | 128/145 | 140/145 | – | – | ||
| Subtotal | 580 | 544/580 | 514/580 | 557/580 | – | – | ||
| Lee18 | (2015) | Midline | 31 | – | 25/31 | 26/31 | 21/31 | 29/31 |
| Lateral | 59 | – | 54/59 | 50/59 | 40/59 | 57/59 | ||
| Subtotal | 90 | – | 79/90 | 76/90 | 61/90 | 86/90 | ||
| Zhong16 | (2014) | – | 202 | 202/202 | – | – | – | – |
| Lee12 | (2009) | – | 140 | 129/140 | 128/138 | 1/2 | 128/129 | 1/11 |
| Baek13 | (2013) | – | 108 | 97/108 | 79/88 | 18/20 | 79/81 | 18/27 |
| Dorobisz3 | (1983) | – | 8 | 8/8 | – | – | – | – |
| Total | 1128 | 980/1038 (94.4) | 800/896 (89.3) | 652/692 (94.2) | 268/300 (89.3) | 105/128 (82.0) |
Abbreviations: N, number of patient; NPV, negative predictive value; PPV, positive predictive value.
Figure 2.
Diagnostic performance of each method. CT indicates computed tomography; NPV, negative predictive value; PF, plain film; PPV, positive predictive value; USG, ultrasonography. *P < .05.
In PF, a lateral view with the Water’s view (71.8% ± 4.5%) had the highest accuracy, followed by the lateral view alone (62.4% ± 4.8%) and the Water’s view alone (61.0% ± 4.9%). A lateral view with the Water’s view had significantly higher accuracy than a lateral view alone (P = .038 [ANOVA, Scheffe method]) or the Water’s view alone (P = .037, [ANOVA, Scheffe method]). However, there was no significant difference between a lateral view and the Water’s view (P = .932 [ANOVA, Scheffe method], Table 5, Figure 3).
Table 5.
Diagnostic Performance of Each Method of Plain Film for Nasal Bone Fracture.
| Method | Author | Year | N | Accuracy | Sensitivity | Specificity | PPV | NPV |
|---|---|---|---|---|---|---|---|---|
| Lateral | Thiede4 | (2005) | 126 | 94/126 | 61/74 | 33/52 | 61/68 | 33/38 |
| Masoomi17 | (2015) | 124 | 84/124 | 57/89 | 27/35 | 57/65 | 27/59 | |
| Atiggechi15 | (2014) | 118 | 65/118 | 59/118 | 85/118 | 99/118 | 38/118 | |
| Gürkov5 | (2008) | 80 | 33/80 | 18/64 | 15/16 | 18/19 | 15/61 | |
| Lee18 | (2015) | 59 | – | 34/59 | 34/59 | 21/59 | 46/59 | |
| Lou12 | (2012) | 23 | 18/23 | 20/23 | 6/23 | 20/23 | 8/23 | |
| Subtotal | 530 | 294/471 | 249/427 | 200/303 | 276/352 | 167/358 | ||
| Water’s | Masoomi17 | (2015) | 124 | 84/124 | 29/54 | 55/70 | 29/44 | 55/80 |
| Atiggechi15 | (2014) | 118 | 66/118 | 63/118 | 77/118 | 97/118 | 76/118 | |
| Lou12 | (2012) | 12 | 5/12 | 2/12 | 12/12 | 12/12 | 4/12 | |
| subtotal | 254 | 155/254 | 94/184 | 144/200 | 138/174 | 135/210 | ||
| Lateral + Water’s | Lee12 | (2009) | 140 | 110/140 | 108/138 | 2/2 | 108/108 | 2/32 |
| Atiggechi15 | (2014) | 118 | 73/118 | 68/118 | 68/118 | 97/118 | 40/118 | |
| Mohammadi7 | (2009) | 103 | – | 79/103 | 84/103 | 84/103 | 73/103 | |
| Mohammadi10 | (2011) | 72 | – | 57/72 | 68/72 | – | – | |
| Dorobisz3 | (1983) | 8 | 8/8 | – | – | – | – | |
| Subtotal | 441 | 191/266 | 312/431 | 222/295 | 289/329 | 115/253 | ||
| Total | 1225 | 640/991 (64.6) | 655/1042 (62.9) | 566/798 (70.9) | 703/855 (82.2) | 417/821(50.8) |
Abbreviations: N, number of patient; NPV: negative predictive value; PPV, positive predictive value.
Figure 3.
Diagnostic performance of plain film. NPV indicates negative predictive value; PPV, positive predictive value. *P < .05.
In USG, lateral and dorsal views (LD) had the highest accuracy (95.8% ± 2.0%), followed by a lateral view alone (L, 84.2% ± 3.7%) and a dorsal view alone (D, 84.2% ± 3.6%). However, there was no significant difference among them (P = .300 [ANOVA, Scheffe method]; Table 6, Figure 4).
Table 6.
Diagnostic Performance of Each Method of Ultrasonography for Nasal Bone Fracture.
| Method | Author | Year | N | Accuracy | Sensitivity | Specificity | PPV | NPV |
|---|---|---|---|---|---|---|---|---|
| Lateral | Thiede4 | (2005) | 126 | 88/126 | 57/82 | 31/44 | 57/64 | 31/47 |
| Masoomi17 | (2015) | 124 | 117/124 | 48/54 | 69/70 | 48/49 | 69/75 | |
| Atiggechi15 | (2014) | 118 | 97/118 | 99/118 | 89/118 | 107/118 | 72/118 | |
| Gürkov5 | (2008) | 80 | 75/80 | 63/64 | 12/16 | 63/67 | 12/13 | |
| Lee18 | (2015) | 59 | – | 44/59 | 45/59 | 31/59 | 50/59 | |
| subtotal | 507 | 377/448 | 311/377 | 246/307 | 306/357 | 234/312 | ||
| Dorsum | Thiede4 | (2005) | 126 | 72/126 | 34/74 | 36/52 | 35/40 | 36/56 |
| Masoomi17 | (2015) | 124 | 119/124 | 85/89 | 34/35 | 85/86 | 34/38 | |
| Gürkov5 | (2008) | 80 | 78/80 | 58/59 | 20/21 | 58/59 | 20/21 | |
| Lou12 | (2012) | 71 | 69/71 | 71/71 | 63/71 | 68/71 | 71/71 | |
| subtotal | 401 | 338/401 | 248/293 | 153/179 | 246/256 | 161/186 | ||
| Lateral + Dorsum | Javadrashid9 | (2011) | 40 | 23/24 | 38/40 | 40/40 | 40/40 | 38/40 |
| Total | 948 | 738/873 (84.5) | 597/710 (84.1) | 439/526 (83.5) | 592/653 (90.7) | 433/538 (80.5) |
Abbreviations: N, number of patient, NPV, negative predictive value; PPV, positive predictive value.
Figure 4.
Diagnostic performance of ultrasonography. NPV indicates negative predictive value; PPV, positive predictive value. *P < .05.
Sensitivity
The sensitivity of CT (89.3% ± 3.1%) was the highest among the 3 methods, followed by USG (87.2% ± 3.3%) and PF (64.9% ±4.8%). Computed tomography and USG had higher sensitivity than PF (P < .001 and P < .001, respectively [ANOVA, Scheffe method]). However, there was no significant difference between USG and CT (P = .492 [ANOVA, Scheffe method]; Tables 2 -4, Figure 2).
In PF, a lateral view with the Water’s view (72.4% ± 4.5%) had the highest sensitivity, followed by a lateral view alone (58.3% ± 4.9%) and the Water’s view alone (51.0% ± 5.0%). A lateral view with the Water’s view had significantly higher sensitivity than a lateral view alone (P < .001 [ANOVA, Scheffe method]). A lateral view had significantly higher sensitivity than the Water’s view (P < .001 [ANOVA, Scheffe method]; Table 5, Figure 3).
In USG, LD had the highest sensitivity (95.0% ± 2.2%), followed by D (84.6% ± 3.6%) and L (82.5% ± 3.8%). However, there was no significant difference among them (P = .114 [ANOVA, Scheffe method]; Table 6, Figure 4).
Specificity
The specificity of CT (94.2% ± 2.3%) was highest among the 3 methods, followed by USG (87.4% ± 3.3%) and PF (67.8% ± 4.7%). Computed tomography had significantly higher specificity than USG (P = .001 [ANOVA, Scheffe method]). Ultrasonography had significantly higher specificity than PF (P < .001 [ANOVA, Scheffe method]; Tables 2 -4, Figure 2).
In PF, a lateral view with the Water’s view (75.3% ± 4.3%) had significantly higher specificity than a lateral view alone (66.0% ± 4.7%; P = .045 [ANOVA, Scheffe method]). However, there was no significant difference between a lateral view with the Water’s view and the Water’s view alone (72.0% ± 4.5%; P = .735 [ANOVA, Scheffe method]) or between the Water’s view alone and the lateral view alone (P = .349 [ANOVA, Scheffe method]; Table 5, Figure 3).
In USG, LD (100.0%) had significantly higher specificity than L (80.1% ± 4.0%; P = .006 [ANOVA, Scheffe method]). However, there was no significant difference between LD and D (85.5% ± 3.5%; P = .080 [ANOVA, Scheffe method]) or between D and L (P = .306 [ANOVA, Scheffe method]; Table 6, Figure 4).
Positive Predictive Value
The PPVs of USG (92.0% ± 2.7%) and CT (89.3% ± 3.1%) were higher than the PPV of PF (82.1% ± 3.8%; P < .001 and P = .004, respectively [ANOVA, Scheffe method]). However, there was no significant difference between USG and CT (P = .4724 [ANOVA, Scheffe method], Tables 2 -4, Figure 2).
In PF, a lateral view with the Water’s view (87.8% ± 3.3%) had a higher PPV than a lateral view alone (78.4% ± 4.1%; P = .006 [ANOVA, Scheffe method]). However, there was no significant difference between a lateral view with the Water’s view and the Water’s view alone (79.3% ± 4.1%; P = .058 [ANOVA, Scheffe method]), or between the Water’s view alone and a lateral view alone (P = .968 [ANOVA, Scheffe method]; Table 5, Figure 3).
In USG, LD (100.0%) and D (96.1% ± 1.9%) had higher PPVs than L (85.7% ± 3.5%; P = .012 and P < .001, respectively [ANOVA, Scheffe method]). However, there was no significant difference between LD and D (P = .725 [ANOVA, Scheffe method]; Table 6, Figure 4).
Negative Predictive Value
The NPVs of USG (84.4% ± 3.6%) and CT (82.0% ± 3.9%) were higher than the NPV of PF (51.7% ± 5.0%; P < .001 and P < .001, respectively [ANOVA, Scheffe method]). However, there was no significant difference between USG and CT (P = .856 [ANOVA, Scheffe method]; Tables 2 -4, Figure 2).
In PF, the Water’s view (64.3% ± 4.8%) had a higher NPV than a lateral view (46.6% ± 5.0%), and a lateral view with the Water’s view (45.5% ± 58.0%; P < .001 and P < .001, respectively [ANOVA, Scheffe method]). However, there was no significant difference between a lateral view alone and a lateral view with the Water’s view (P = .958 [ANOVA, Scheffe method]; Table 5, Figure 3).
In USG, LD (95.0% ± 2.2%) and D (86.6% ± 3.4%) had higher NPVs than L (75.0% ± 4.3%; P = .010 and P < .007, respectively [ANOVA, Scheffe method]). However, there was no significant difference between LD and D (P = .466 [ANOVA, Scheffe method]; Table 6, Figure 4).
Discussion
The accuracy of CT (94.4% ± 2.3%) was significantly higher (P < .001) than that of USG (85.0% ± 3.6%). The accuracy of USG was significantly higher (P < .001) than that of PF (67.7% ± 4.7%; Tables 2 -4, Figure 2). Computed tomography (89.3% ± 3.1%) and USG (87.2% ± 3.3%) had significantly higher sensitivity than PF (P < .001 and P < .001, respectively). However, there was no significant difference between USG and CT (P = .492; Tables 2 -4, Figure 2). The specificity of CT (94.2% ± 2.3%) was significantly higher (P = .001) than that of USG (87.4% ± 3.3%). The specificity of USG was significantly higher (P < .001) than that of PF (67.8% ± 4.7%; Tables 2 -4, Figure 2).
It is thought PF should be the first diagnostic tool for detecting an NBF. Ultrasonography or CT can confirm the diagnosis. In performing the reduction of the NBF, CT can serve as a precise map for the surgeons.
For PF, combining a lateral view and the Water’s view (71.8% ± 4.5%) had significantly higher accuracy than a lateral view alone (62.4% ± 4.8%) or the Water’s view alone (61.0% ± 4.9%; Table 5, Figure 3). The combination of a lateral view and the Water’s view (72.4% ± 4.5%) likewise had significantly higher sensitivity than a lateral view alone (58.3% ± 4.9%) or the Water’s view alone (51.1% ± 5.0%; Table 5, Figure 3). Thus, a combination of a lateral view and the Water’s view is recommended in patients in whom an NBF is suspected.
In USG, there was no significant difference (P = .300) in the accuracy among LD (95.8% ± 2.0%), L (84.2% ± 3.7%), and D (84.2% ± 3.6%; Table 6, Figure 4). There was also no significant difference (P = .300) in sensitivity among LD (95.0% ± 2.2%), L (82.5% ± 3.8%), and D (84.6% ± 3.6%; Table 6, Figure 4). It is thought that any view will do well when using USG for detecting an NBF.
We compared the diagnostic performance (accuracy, sensitivity, specificity, PPV, and NPV) of each method (PF, USG, and CT) for NBFs. The results of this review may be helpful in choosing the most appropriate diagnostic tool in patients suspected to have an NBF.
Footnotes
Level of Evidence: Level 3, Diagnostic
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from National Research Foundation of Korea (NRF-2017R1A2B4005787).
ORCID iD: Kun Hwang 
http://orcid.org/0000-0002-1994-2538
References
- 1. Hwang K, You SH, Kim SG, Lee SI. Analysis of nasal bone fractures; a six-year study of 503 patients. J Craniofac Surg. 2006;17(2):261–264. [DOI] [PubMed] [Google Scholar]
- 2. Becker OJ. Nasal fractures. Arch Otolaryngol. 1948;48(3):344–361. [PubMed] [Google Scholar]
- 3. Dorobisz H, Voegeli E, Hardt N. Conventional radiology and computed tomography in facial fractures. Rontgenblatter. 1983;36(12):428–433. [PubMed] [Google Scholar]
- 4. Thiede O, Krömer JH, Rudack C, Stoll W, Osada N, Schmäl F. Comparison of ultrasonography and conventional radiography in the diagnosis of nasal fractures. Arch Otolaryngol Head Neck Surg. 2005;131(5):434–439. [DOI] [PubMed] [Google Scholar]
- 5. Gürkov R, Krause E, Clevert D. Sonography versus plain X rays in diagnosis of nasal fractures. Am J Rhinol. 2008;22(6):613–616. [DOI] [PubMed] [Google Scholar]
- 6. Lee MH, Cha JG, Hong HS, et al. Comparison of high-resolution ultrasonography and computed tomography in the diagnosis of nasal fractures. J Ultrasound Med. 2009;28(6):717–723. [DOI] [PubMed] [Google Scholar]
- 7. Mohammadi A, Javadrashid R, Pedram A, Masudi S. Comparison of ultrasonography and conventional radiography in the diagnosis of nasal bone fractures. Iran J Radiol. 2009;6(1):7–11. [Google Scholar]
- 8. Kim BH, Seo HS, Kim AY, et al. The diagnostic value of the sagittal multiplanar reconstruction CT images for nasal bone fractures. Clin Radiol. 2010;65(4):308–314. [DOI] [PubMed] [Google Scholar]
- 9. Javadrashid R, Khatoonabad M, Shams N, Esmaeili F, Khamnei HJ. Comparison of ultrasonography with computed tomography in the diagnosis of nasal bone fractures. Dermatomaxillofac Radiol. 2011;40(8):486–491. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Mohammadi A, Ghasemi-Rad M. Nasal bone fracture-ultrasonography or computed tomography? Med Ultrason. 2011;13(4):292–295. [PubMed] [Google Scholar]
- 11. Kunitskiĭ VS, Semenov SA. Diagnostics of nasal bone fractures with the use of ultrasound study techniques. Vestn Otorinolaringol. 2013;(1):72–76. [PubMed] [Google Scholar]
- 12. Lou YT, Li HL, Lee SS, et al. Conductor-assisted nasal sonography: an innovative technique for rapid and accurate detection of nasal bone fracture. J Trauma Acute Care Surg. 2012;72(1):306–311. [DOI] [PubMed] [Google Scholar]
- 13. Baek HJ, Kim DW, Ryu JH, Lee YJ. Identification of nasal bone fractures on conventional radiography and facial CT: comparison of the diagnostic accuracy in different imaging modalities and analysis of interobserver reliability. Iran J Radiol. 2013;10(3):140–147. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Çil Y, Kahraman E. An analysis of 45 patients with pure nasal fractures. Ulus Travma Acil Cerrahi Derg. 2013;19(2):152–156. [DOI] [PubMed] [Google Scholar]
- 15. Atiggechi S, Baradaranfar MH, Karimi G, et al. Diagnostic value of ultrasonography in the diagnosis of nasal fractures. J Craniofac Surg. 2014;25(1):e51–e53. [DOI] [PubMed] [Google Scholar]
- 16. Zhong Z, Fan X, Lian Z, Cheng Z, Zhuang Y. Clinical analysis of 202 nasal bone fractures cases. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2014;28(23):1842–1844. [PubMed] [Google Scholar]
- 17. Masoomi A, Gharibvand MM, Rekabi H, Zakaeifar M, Khorami E, Saki N. Comparison of ultrasonography and conventional radiography in the diagnosis of new nasal bone fractures in adults. Biomed Pharmacol J. 2015;12:1–6. [Google Scholar]
- 18. Lee IS, Lee JH, Woo CK, et al. Ultrasonography in the diagnosis of nasal bone fractures: a comparison with conventional radiography and computed tomography. Eur Arch Otorhinolaryngol. 2016;273(2):413–418. [DOI] [PubMed] [Google Scholar]
- 19. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analysis: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. [DOI] [PMC free article] [PubMed] [Google Scholar]