Local anaesthesia for manipulation of nasal fractures: systematic review

Comparison of outcomes for general and local anesthesia in the management of nasal bone fractures: a meta-analysis

BACKGROUND

This meta-analysis aimed to perform a head-to-head comparison of the role of general anesthesia (GA) and local anesthesia (LA) in the management of patients with nasal bone fractures (NBFs).

METHODS

PubMed, Embase, and Web of Science were comprehensively searched. Studies investigating the clinical outcomes of GA and LA in the management of NBFs were included. Pooled odds ratios (OR) with the respective 95% confidence intervals (CIs) were calculated. Heterogeneity between the included studies was evaluated. The risk of bias in the included studies was assessed.

RESULTS

Eight studies were included in this meta-analysis. The pooled ORs for cosmetic results, residual septal deformity, the need for further surgery, patients' satisfaction with the anesthesia procedure, and patients' satisfaction with the surgery results were 0.70 (95% CI 0.18, 2.64; z = - 0.53, p = 0.5957), 1.11 (95% CI 0.37, 3.30; z = 0.18, p = 0.8558), 1.19 (95% CI 0.65, 2.20; z = 0.56, p = 0.5760), 1.57 (95% CI 0.92, 2.69; z = 1.65, p = 0.0982), and 1.00 (95% CI 0.55, 1.80; z = - 0.00, p = 0.9974).

CONCLUSIONS

Insignificant difference on clinical outcomes was observed between GA and LA in the manipulation of patients with NBFs, and the choice of anesthetic approach should be based on the tolerability of the methods and the severity of nasal fractures.

Manipulation under anaesthesia of fractured nasal bones - a 10-year retrospective study

BACKGROUND

Nasal bone fractures are treated by manipulation under general or local anaesthesia procedures. Data on long-term benefits of manipulation under local anaesthesia are limited. This study aimed to quantify the proportion of patients requiring septoplasty or septorhinoplasty after manipulation under general and local anaesthesia procedures.

METHODS

Anonymised data were collected from electronic records of all patients who underwent manipulation under anaesthesia at our centre over a 10-year period, including demographics, manipulation under anaesthesia timing and further surgery requirements.

RESULTS

The study identified 625 manipulation under general anaesthesia and 52 manipulation under local anaesthesia procedures. Manipulation under local anaesthesia procedures were performed earlier (local anaesthesia = 9 days, general anaesthesia = 15 days; p < 0.05) and were more likely to achieve manipulation (local anaesthesia = 83 per cent, general anaesthesia = 76 per cent; p < 0.05). There was no difference between techniques in the percentage of patients requiring further surgery.

CONCLUSION

This paper describes a large cohort of patients who underwent manipulation under anaesthesia over a 10-year period. Manipulation under local anaesthesia procedures have increased since the coronavirus disease 2019 pandemic, and the results are comparable to manipulation under general anaesthesia, with reduced delays between injury and manipulation.

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

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.

Endonasal Infiltrative Anesthesia for Nasal Fracture Reduction

This study investigated the use of endonasal infiltrative anesthesia for the management of pain associated with nasal bone fracture reduction. Fifty-two patients with nasal bone fractures were distributed in 2 groups. In the first group, topical endonasal anesthesia and external transcutaneous infiltrative anesthesia were employed. In the second group, endonasal infiltrative anesthesia was also added. Visual analog scale pain scores related to the different steps of the procedure were registered. The addition of endonasal infiltrative anesthesia was associated with a significant decrease (p < .05) in pain during reduction maneuvers (6.71 vs. 4.83) and nasal packing (5.18 vs. 3.46). Addition of endonasal infiltrative anesthesia is an effective method of pain reduction during nasal bone fracture treatment.

Functional and Psychological Impact of Nasal Bone Fractures Sustained during Sports Activities: A Survey of 87 Patients

Nasal bone fractures that require reduction are a common sequela of sports injuries. We conducted a survey to ascertain the outcomes of patients who had experienced a nasal bone fracture and who subsequently underwent manipulation under anesthesia. We reviewed data on 217 nasal bone fractures that had been seen at our institution over a 3-year period. Of these, 133 (61.3%) had occurred as a result of a sports activity. Thirty of the 133 patients (22.6%) had been managed conservatively, while the other 103 (77.4%) had undergone manipulation under anesthesia. We were able to contact 87 of the 103 patients (84.5%) by telephone, who served as the study population. The most common sports associated with these 87 injuries were hurling (n = 26; 29.9%), rugby (n = 22; 25.3%), Gaelic football (n =20; 23.0%), and soccer (n = 13; 14.9%). Patients who had undergone treatment within 2 weeks were significantly more satisfied with their outcome than were those who had been treated later (p < 0.01). Twenty-six patients (29.9%) reported that their injury had had a detrimental impact on their subsequent performance in their sport; 12 (13.8%) described a fear of reinjury when they returned to play, 7 (8.0%) experienced functional problems, 3 (3.4%) complained of diminished performance, and 4 others (4.6%) quit playing contact sports altogether. To the best of our knowledge, our study is the first to demonstrate that a fracture of the nasal bones may have a notable psychological impact on an athlete and that it can lead to diminished performance or a complete withdrawal from contact sports.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Evidence-Based Facial Fracture Management

With demands for an evidence-based approach to patient care, the management of facial fractures will come under increasing scrutiny because there is an overall deficiency in higher level clinical evidence. This article reviews the management of facial fractures, focusing on an evidence-based approach. It focuses on select areas of facial trauma in which there is controversy and presents randomized studies and meta-analysis to help define best practice. The article notes the many areas where the evidenced-based literature is weak and looks at the future of evidence-based facial trauma care.

Local versus general anesthesia for the management of nasal bone fractures: a systematic review and meta-analysis

PURPOSE

The aim of this study was to answer the following question: in patients with nasal bone fractures (NBFs), does closed reduction under local anesthesia (LA) produce comparable outcomes as closed reduction under general anesthesia (GA)?

MATERIALS AND METHODS

A systematic review with meta-analysis and a comprehensive electronic search without date and language restrictions was performed in August 2014. The inclusion criteria were studies in humans, including randomized or quasi-randomized controlled trials (RCTs), controlled clinical trials (CCTs), and retrospective studies whose aim was comparing clinical outcomes between LA and GA for closed reduction of NBFs.

RESULTS

Eight publications were included: 3 RCTs, 2 CCTs, and 3 retrospective studies. Three studies showed a low risk of bias, and 5 studies showed a moderate risk of bias. There was no statistical difference between LA and GA for closed reduction of NBFs with regard to patient satisfaction with anesthesia, patient satisfaction with function of the nose, need for subsequent retreatment (septoplasty, septorhinoplasty, or rhinoplasty with refracture), and a patient's chosen treatment for a refracture of the nose. There was a statistical difference between LA and GA for closed reduction of NBFs with regard to patient satisfaction with the appearance of the nose.

CONCLUSION

Regardless of the cost and risks associated with GA, the results of the meta-analysis showed that GA provides better patient satisfaction with anesthesia, appearance and function of the nose, and preference of treatment for a refracture of the nose. In addition, the meta-analysis showed that GA decreased the number of subsequent corrective surgeries (septoplasty, septorhinoplasty, and rhinoplasty) required.

Applicability and Effectiveness of Closed Reduction of Nasal Fractures under Local Anesthesia

Introduction A significant portion of patients treated in emergency departments have nasal fracture. It is important that the otolaryngologist know how to treat such damage.

Objectives To evaluate the effectiveness of nasal fracture reduction under local anesthesia and tolerance to the procedure.

Methods Twenty-four patients treated in the emergency department with closed reduction under local anesthesia were prospectively followed. Epidemiologic information and data regarding pain and complications during the management were noted. The degree of satisfaction was researched by visual analog scale.

Results The majority of patients were male (75%), and the most common cause of injury was motor vehicle accident. We found a significant association between time to reduction and referred pain during the procedure. In patients in whom the procedure was delayed (over 3 days), there was less pain, and those who bled during the procedure had a shorter average time to reduction than the group of patients who did not bleed. Most patients were very satisfied, with more than 95% of these willing to undergo the same process again, if necessary.

Conclusions The closed approach in the clinic under local anesthesia was effective and safe in restoration of the nose.

Decreased postoperative pain after reduction of fractured nasal bones using a nerve block of the anterior ethmoidal nerve

There is consensus that all patients should experience minimal pain following reduction of a fractured nasal bone. The issue requiring further study is what technique will provide patients with the greatest pain relief following the reduction of nasal fractures. This study investigated the use of an anterior ethmoidal nerve block as preemptive analgesia for the management of postoperative pain associated with reduction of nasal bone fractures. The medical documents of 85 patients were reviewed for a retrospective case-controlled comparative study. Patients in the nerve block group (n=45) were injected with 2% lidocaine containing epinephrine into the anterior ethmoidal nerve and dorsal periosteum, and those in the control group (n=40) were not. The rate of patients requiring postoperative injectable analgesics was compared between the two groups. The rate of patients who received a postoperative analgesic injection was significantly lower in the nerve block group than in the control group (P=0.034). The use of an anterior ethmoidal nerve block and dorsal periosteal injection of anaesthetic solution during reduction of fractured nasal bones under general anaesthesia resulted in the effective reduction of postoperative pain. Thus, this is regarded as a good method for enhancing patient quality of care and compliance in the reduction of fractured nasal bones.

Manipulation of nasal fractures with local anaesthetic: a 'how to do it' with online video tutorial

Nasal fractures are the most common facial fractures and displaced fractures may cause considerable cosmetic concern. Traditionally, displaced nasal fractures have been manipulated under general anaesthesia (GA) performed within 2 weeks of the injury. Despite evidence for the benefit of local anaesthesia (LA), nasal fractures are still most commonly reduced under GA. We have presented a method of reduction of simple nasal fractures under LA in an outpatient setting. This has the advantage of being painless, simple to attempt and cost-effective. If reduction is inadequate then a general anaesthetic reduction is still possible. A recent comprehensive systematic review of all the available evidence did not show any significant difference (in terms of cosmesis, pain or nasal obstruction) between using LA and GA methods and highlighted the evidence base to support LA. We describe our method of assessment and treatment of displaced nasal fractures and provide an online tutorial (http://sciencestage.com/v/22194/local-anaesthetic-nasal-fracture-reduction.html). It is important to keep in mind that any concerns should be referred to an otolaryngology specialist for further management and that practitioners attempting this technique should first receive training from an otolaryngologist.

New delivery systems for local anaesthetics-part 2

Part 2 of this paper deals with the techniques for drug delivery of topical and injectable local anaesthetics. The various routes of local anaesthetic delivery (epidural, peripheral, wound catheters, intra-nasal, intra-vesical, intra-articular, intra-osseous) are explored. To enhance transdermal local anaesthetic permeation, additional methods to the use of an eutectic mixture of local anaesthetics and the use of controlled heat can be used. These methods include iontophoresis, electroporation, sonophoresis, and magnetophoresis. The potential clinical uses of topical local anaesthetics are elucidated. Iontophoresis, the active transportation of a drug into the skin using a constant low-voltage direct current is discussed. It is desirable to prolong local anaesthetic blockade by extending its sensory component only. The optimal release and safety of the encapsulated local anaesthetic agents still need to be determined. The use of different delivery systems should provide the clinician with both an extended range and choice in the degree of prolongation of action of each agent.