Nasal fractures: a dedicated clinic providing reduction under local anaesthesia improves time to manipulation

Abstract

Introduction

Guidelines for nasal injury state that assessment should be at 7–10 days post-injury and manipulation within 14 days. We performed a plan, do, study, act improvement cycle to assess whether a dedicated nasal fracture service led to better outcomes.

Materials and methods

A retrospective study was carried out of all patients undergoing manipulation under anaesthesia for nasal trauma between February 2013 and December 2016 in a district general hospital. A dedicated nasal fracture clinic providing manipulation under local anaesthesia was implemented followed by a prospective study of all patients presenting to the clinic between February and November 2017. Main outcome measures included time from injury to otolaryngology assessment, time from injury to manipulation and incidence of secondary septorhinoplasty.

Results

The retrospective series involved 525 patients including 381 males (72.6%) and 144 females (27.4%). Mean time from injury to assessment was 10 days. Mean time from injury to surgery was 14.5 days. Mean time from assessment to surgery was five days. The incidence of septorhinoplasty was 2.3%. The prospective series involved 119 patients including 78 males (65.5%) and 41 females (34.5%). Following implementation of a nasal fracture clinic, mean time from injury to assessment and manipulation was 6.1 days and 5.4% of patients underwent septorhinoplasty for secondary deformity.

Discussion

Implementation of a nasal fracture clinic providing reduction under local anaesthesia reduced the time to assessment and manipulation. The incidence of septorhinoplasty is low following reduction under general or local anaesthesia. Assessment earlier than seven days is feasible and advice for referral can be changed accordingly.

Introduction

Nasal fractures are the most common facial fractures.¹ Diagnosis is via a thorough history and physical examination without need for plain radiographs.² However, physical examination at the time of injury may be complicated by traumatic oedema.³ Johnston and Jones for ENT UK state that an otolaryngologist should examine the patient 7–10 days post-injury once the swelling has subsided to facilitate accurate assessment. If a deformity is present then manipulation under anaesthetic (MUA) should be performed within 14 days.⁴ The incidence of secondary deformities requiring septorhinoplasty varies widely in the literature but can be up to 50%.⁵

We investigated the effect of a dedicated nasal fracture clinic providing manipulation under local anaesthesia on time to manipulation and on the incidence of septorhinoplasty. Our aims were to assess whether patients with nasal fractures in our unit are assessed between 7–10 days and manipulated within 14 days of the injury as per ENT UK guidelines; to assess the incidence of septorhinoplasty following MUA, and to assess the effect of a dedicated nasal fracture clinic providing manipulation under local anaesthesia on time to manipulation and the incidence of septorhinoplasty.

Materials and methods

Ethical considerations

This study was undertaken according to our trust’s audit department protocol. All patient data were encrypted and kept anonymous throughout the data collection process.

Study design

This was a combined retrospective and prospective cohort study. Data were collected retrospectively on all patients undergoing MUA in our unit over a three-year period. A dedicated nasal fracture clinic providing manipulation under local anaesthesia was implemented at the start of 2017. Patient data from this clinic were collected prospectively over nine months. Data were analysed to determine the effect of our nasal fracture clinic on patient outcomes.

Patients and setting

All patients included in this study had been assessed and treated at Pennine Acute Hospitals NHS Trust, which consists of three district general hospitals providing an acute ear, nose and throat (ENT) service. All patients undergoing MUA for nasal fracture between February 2013 and November 2016 were included in the retrospective series, while all patients presenting with nasal trauma between February and November 2017 were included in the prospective series. Patients who underwent MUA were identified from theatre records and data were extracted from their hospital records for the retrospective study. Patient data were collected directly from the nasal fracture clinic for the prospective study. Follow-up data were identified from clinic letters for the retrospective study and patients were followed-up if deemed necessary after the initial consultation for the prospective study. No potential sources of bias were identified.

Outcome measures

Outcome measures were time between injury to ENT assessment, time between ENT assessment and manipulation, time between injury and manipulation and incidence of septorhinoplasty.

Data analysis

Data analysis was carried out using Microsoft Excel. Time from injury to assessment, assessment to manipulation and injury to manipulation were calculated by calculating the number of days between dates of events. The mean, range and standard deviation were calculated using standard Excel functions. The incidence of septorhinoplasty was calculated by evaluating the number of patients who were offered, declined and underwent septorhinoplasty. Where data were unavailable, these patients were omitted from the analysis for that specific outcome measure.

Results

First cycle

All 525 patients undergoing MUA for nasal fracture between February 2013 and December 2016 were included in the retrospective study. The mean age was 26.3 years. There was a marked male preponderance (381/525; 72.6%). Mean time from injury to ENT assessment was 10 days (standard deviation, SD, 5 days; range 0–78 days). Mean time from injury to surgery was 14.5 days (SD 7.7 days; range 3–81 days). Mean time from ENT assessment to manipulation was five days (SD 3.5 days; range 0–28 days). Five patients (1%) underwent manipulation under local anaesthesia. The incidence of septorhinoplasty, including those completed, planned and declined by the patient, was 2.3% (12/525). The mean duration of follow-up for patients requiring septorhinoplasty was eight months.

Second cycle

All 119 patients referred to our dedicated nasal fracture clinic with nasal injuries between February and November 2017 were included in the prospective study. The mean age was 31.9 years. There were more males than females (78/119; 68.4%). Some 59 patients (49.6%) had an isolated bony injury and 15 (12.5%) had combined bony and septal injury. A total of 37 patients (62.7%) with bony injury underwent MUA, with 29 (78.4%) having an immediately successful outcome. Mean time from injury to assessment by otolaryngology was 6.1 days (SD 3.6 days, range 1–15 days). A total of 5.4% (2/37) of patients who underwent MUA required secondary septorhinoplasty.

Discussion

Synopsis of key findings

The main findings from this study indicate that our unit adheres to ENT UK guidelines, our nasal fracture clinic reduces time to manipulation, reduction under local anaesthetic is successful in most cases and septorhinoplasty following nasal trauma is rarely required (Table 1).

Table 1.

Summary of key results

	Retrospective cohort	Prospective cohort
Patients (n)	525	119
Age (mean years)	26.3	31.9
Male : female (%)	381 : 144 (72.6 : 27.4)	78:41 (68.4:31.6)
Time between injury and ENT assessment (days)	10	6.1
Time between ENT assessment and manipulation (days)	5	0
Time between injury and manipulation (days)	14.4	6.1
Requiring secondary septorhinoplasty (%)	12 (2.3)	2 (5.4)

Strengths and limitations of the study

This was a large study based on national guidelines, which included consecutive patients treated over four years for a common ENT problem. There were two study cycles involving both retrospective and prospective data collection to clearly demonstrate the effect of implementing a dedicated nasal fracture clinic in our unit.

The majority of the data collected for this study were retrospective and taken from computer-based hospital records, which led to some missing data. The success of the manipulation at the time of operation was inconsistently documented and we were therefore unable to compare the success rate before and after implementing the nasal fracture clinic. Our prospective cohort size was much smaller than our retrospective cohort and we were not able to fairly compare the number of patients requiring septorhinoplasty before and after implementation of the clinic.

The two cohorts were identified differently as the retrospective group included all patients undergoing MUA for nasal fracture whereas the prospective group included all patients attending the clinic with nasal trauma who may or may not have undergone MUA. Therefore, these groups were not directly comparable.

Patients are not routinely followed up following MUA and it is possible that patients who may benefit from septorhinoplasty are not re-referred. Some patients sustained multiple nasal fractures on separate occasions during the study period, which limited their duration of follow-up and complicated their management. Some patients had sustained fractures in the past, which may have influenced their need for septorhinoplasty. The duration of follow-up in the prospective cohort is limited and we can therefore not accurately comment on the need for septorhinoplasty in this group. A proportion of the patients in the prospective cohort had isolated septal injuries, which did not require septorhinoplasty. A small number of patients in the retrospective cohort had procedures under local anaesthesia and so the comparison between the retrospective series (mainly under general anaesthesia) and the prospective series (all under local anaesthesia) is not entirely accurate.

Comparison with other studies

The use of local anaesthesia for nasal fracture manipulation has been investigated in several studies. Courtney et al found that the rate of revision surgery following reduction under local anaesthesia (17.2%) to be much higher compared with general anaesthetic (3.2%) in a large study including 324 patients.⁶ Similarly to our study, Wild et al set up a nasal fracture clinic where 37 patients underwent reduction under local anaesthesia, demonstrating that 94% of patients over the age of 14 preferred local compared with general anaesthesia and that 80% of patients were satisfied with the procedure at three months.⁷ However, this study is limited by the short duration of follow-up and small sample size. Waldron et al published similar findings, in addition to demonstrating a similar reoperation rate between general and local anaesthetic reduction.⁸ Airway patency and cosmesis at four hours and eight weeks were no different in patients in a randomised trial published by Cook et al, which emphasised the cost effectiveness and convenience of reduction under local anaesthesia.⁹ A systematic review by Chadha et al provides further evidence in support of local anaesthesia for nasal reduction.¹⁰

The incidence of septorhinoplasty in our unit seemed to increase from 2.3% to 5.4% following implementation of the nasal fracture clinic. This may be explained by the difference in sample size between both groups or because reduction under local anaesthesia actually does increase the incidence of septorhinoplasty, as shown by Courtney et al.⁶ Studies investigating the need for secondary septorhinoplasty are limited. Fattahi et al undertook a retrospective study involving 50 patients over a three-year period and demonstrated that 20% of patients with nasal fracture required septorhinoplasty.¹¹ This may be in part due to 12% of Fattahi’s patients not undergoing primary reduction due to multisystem injury or comorbidities, of which we had none. Similarly, Waldron et al identified a 15% incidence of septorhinoplasty in a prospective study of 100 patients undergoing closed reduction.⁸ Follow-up in this study was limited to three months only. Cook et al published a randomised prospective series involving 45 patients, which showed a 17% incidence of post-reduction deformity requiring surgery.⁹ Watson et al reported a 29–50% incidence of secondary deformity following closed reduction in 29 patients undergoing manipulation under both general and local anaesthesia.¹² However, this study is limited by a small sample size. Our incidence of septorhinoplasty is low in comparison with the data published in these studies (Fig 1).

Figure 1.

Comparison of rates of secondary septorhinoplasty in different studies

Clinical applicability of the study

Nasal trauma is the most common facial fracture and one of the most common ENT emergencies.¹ This study demonstrates that nasal fractures can be manipulated successfully under local anaesthesia before seven days with good results. This will spare the patient of the risks of general anaesthesia, speed up the time to definitive management and improve the use of hospital resources. By providing a ‘one stop shop’ we have reduced the number of days between ENT assessment and manipulation from five to zero days. This eliminates the need for patients to be seen by ENT on separate occasions for assessment and manipulation. This study also demonstrates that the need for septorhinoplasty following MUA for nasal fracture is rare and therefore supports the use of MUA for treatment of nasal fractures. The creation of a nasal fracture clinic also opens up many educational opportunities for ENT trainees by increasing their exposure to reduction under local anaesthesia. Furthermore, obtaining funding through the Care Commissioning Group for septorhinoplasty can be a long and difficult journey for the NHS patient. Therefore, minimising the need for septorhinoplasty is essential and we believe that our clinic is a step forward to achieving this.

Conclusion

A dedicated nasal fracture clinic providing reduction under local anaesthesia reduces time to manipulation without significant effect on the incidence of septorhinoplasty. Nasal trauma can be treated before seven days post-injury with good outcomes. Advice to referring clinicians should be amended in light of these findings.