The radiology of nasal injuries: problems of interpretation and clinical relevance

Comparison of the Outcomes of Closed Reduction Nasal Bone Fractures With a Surgical Navigation System

BACKGROUND

The most prevalent form of facial bone fractures is nasal fractures. The surgical procedures used for these fractures are relatively simple, but complete correction is not easy because the nasal bone is small and identifying the fracture site by palpation is difficult. This study aimed to investigate the efficacy of intraoperative surgical navigation systems in nasal bone fracture surgery through a prospective analysis.

METHODS

Between February 2019 and July 2019, 25 navigation-assisted closed reductions of nasal fractures were performed. Preoperative computed tomography images were obtained at 1-mm intervals before surgery and the navigation was set by a simulation to have an error rate of less than 1. Then, the navigation system was used to identify the fracture site. Closed reduction was performed with Asch forceps and a Langenbeck elevator based on the previous markings made using the navigation system.

RESULTS

The degree of reduction was evaluated by plain X-rays and computed tomography scans, which were performed 1 month after surgery. In the navigation group, the average distance between the fragment and normal bony alignment was decreased from 2.38 to 0.49 mm and the modified Motomura score was an average of 2.40 points. The decrease in the mean distance was significantly different (P = 0.038) compared with the conventional group.

CONCLUSIONS

Surgical navigation systems could be a useful tool for localizing fracture sites and guiding closed reductions. In particular, the system could be recommended for nasal bone fracture reductions in the tip or pyriform regions, which are difficult to correct.

LEVEL OF EVIDENCE

II.

Nasal bone fractures and the use of radiographic imaging: An otolaryngologist perspective

OBJECTIVE

To determine radiologic preferences of practicing otolaryngologists regarding isolated nasal bone fractures.

STUDY DESIGN

An 8-question survey on isolated nasal bone fractures was designed.

SETTING

Surveys were sent to all otolaryngology residency program directors for distribution among residents and faculty. Additional surveys were distributed to private practice otolaryngology groups.

RESULTS

140 physicians responded to the survey. 57% of the respondents were practicing otolaryngologists (75% with 10+ years of experience), while 43% of respondents were residents-in-training. 56% of respondents treated 1-5 nasal bone fractures per month. 80% of all respondents reported imaging being performed prior to consultation. If imaging was obtained before consultation, plain films and computed tomography (CT) maxillofacial/sinus scans were the most frequent modalities. 33% of residents and 70% of practicing otolaryngologists report imaging as 'rarely' or 'never' helpful in guiding management. 42% of residents and 20% of practicing otolaryngologists report asking for imaging when it wasn't already obtained. Decreased use of radiography was associated with greater years in practice and higher frequency of fractures treated.

CONCLUSIONS AND RELEVANCE

Otolaryngologists seldom request imaging to evaluate and treat isolated nasal bone fractures. When ordered, imaging is utilized more often among residents-in-training and non-otolaryngology consulting physicians. This study highlights an opportunity to educate primary care and emergency room providers as well as otolaryngology residents on the value of comprehensive physical exam over radiographic imaging in the work-up of isolated nasal fractures. In addition, widespread adoption of a "no x-ray policy" in this setting may result in better resource utilization.

A Five-Year Retrospective Cohort Study Analyzing Factors Influencing Complications after Nasal Trauma

The purpose of this study was to assess the outcomes of patients with nasal trauma during a long period of time and determine factors predisposing to complications after nasal trauma treatment. A retrospective cohort study was conducted that included all patients who were attended for a nasal trauma between January and December 2010. In 2015, the charts were retrospectively reviewed and the patients were prospectively followed up looking for outcomes after treatment of nasal trauma. A univariate analysis between complications and risk factors was performed and a logistic regression model was used to explore the prognostic role of the variables considered to have clinical relevance and to estimate the odds ratio for the occurrence of postoperative complications. A total of 220 consecutive patients with nasal trauma were included in the study. The mean follow-up was 44.3 ± 10.3 months (3-67) with 10% of lost patients. The most important factors determining complications after nasal trauma treatment were male gender, acute septal injury, chronic septal deviation, displaced or comminuted fractures in the radiologic study, and late nasal reduction surgery. A decision-making algorithm is proposed based on the fact that nasal bone fracture is not a minor problem and that closed nasal bone reduction is not the treatment of choice for all patients with nasal trauma.

Postoperative Changes After Closed Reduction of Nasal Fracture

Nasal bone fracture is the most common facial fracture; however, surgery does not guarantee reduction and complications, such as undercorrection, overcorrection, and deviation, may occur. By analyzing findings of computed tomography (CT) immediately and at 3 months postoperatively, we evaluated the accuracy of reduction and long-term changes to the nasal bone.Patients with pure nasal bone fracture were evaluated from January 1, 2010 to December 31, 2011. First, we categorized fracture types according to the Stranc-Robertson classification system, using preoperative CT findings (ie, F1, F2, L1, and L2). We categorized each result of reduction by immediate postoperative CT scan findings as "Excellent," "Good," "Fair," and "Poor," with "Excellent" and "Good" ratings being considered a "Success." We evaluated changes to the nasal bone at 3 months after reduction, using the same grade.A total of 128 patients were analyzed. The results of patients in the F1 group were better than those of other patients immediately postoperatively, whereas those of the L2 group were worse. The overall success rate was 49.2% (58/118). At 3 months postoperatively, 33 cases exhibited an improvement to a higher grade, whereas 25 cases improved from an unacceptable outcome to a successful outcome, with the overall success rate being 70.3% (83/118).Immediately postoperative CT scans can be helpful for surgeons in determining whether a secondary adjustment is necessary. Incompletely reduced nasal bone showed spontaneous improvement in bony arrangement according to our study, so simple observation could be a choice.

Correction of Nasal Fractures

Nasal fractures are the most frequently fractured facial bone from blunt facial trauma resulting in a significant number of patients seeking treatment. Proper evaluation and treatment in the acute setting can minimize secondary surgeries, lower overall health care costs, and increase patient satisfaction. Nasal fracture management, however, varies widely between surgeons. The open treatment of isolated nasal fractures is a particularly controversial subject. This review seeks to describe the existing literature in isolated nasal fracture management.

Acute nasal fracture management: A prospective study and literature review

OBJECTIVES/HYPOTHESIS

Functional and cosmetic deformities are common after nasal injuries and at times necessitate advanced surgery to reverse the effects of trauma. This study was designed to study the factors related to nasal injury and patient parameters in influencing the acute management of nasal injuries and its outcome.

STUDY DESIGN

Prospective study.

METHODS

Nasal injuries from County Waterford in Southeast Ireland were referred to a new Cost-Neutral Nasal Fracture Clinic. The first 400 patients from this prospective audit, referred to Waterford Regional Hospital from August 2009 through December 2010, were included in this study. Twenty-one variables, including satisfaction scores using Visual Analog Scale (VAS), were studied. Data was obtained at each stage of management, from initial assessment in ears, nose, and throat (ENT) casualty to being seen and further reviewed in consultant-based specialty clinic.

RESULTS

Men outnumbered women 72: 28, and the mean age was 26.89 (0.4 years-87 years). Patients presenting time to the ENT casualty after the injury ranged between 1 and 90 days (mean 10.5 days). The interval between injury and intervention was on an average 6.1 days. Accident (41%) and soccer (46%), among the sports group, were predominantly related to nasal injury. The overall satisfaction rate was 77.5% for breathing and 85.6% for cosmesis. One hundred twenty-seven (31.8%) patients were referred to and managed from the septorhinoplasty clinic. Overall, 11% required septorhinoplasty. Patient satisfaction was seen in manipulation performed up to 5 weeks postinjury.

CONCLUSION

Our databank is the largest prospectively studied series of nasal-fracture management from Ireland. The incidence of nasal fracture in the southeast of Ireland is 0.37%. Age, gender, mode of injury, and type of sport influenced the satisfaction rates in this study. This type of service may not be practical in all ENT departments, but a regional center may be an idea worth considering.

Ultrasonography in the diagnosis of nasal bone fractures: a comparison with conventional radiography and computed tomography

The purpose of this study was to evaluate and compare the diagnostic efficacy of ultrasonography (US) with radiography and multi-detector computed tomography (CT) for the detection of nasal bone fractures. Forty-one patients with a nasal bone fracture who underwent prospective US examinations were included. Plain radiographs and CT images were obtained on the day of trauma. For US examinations, radiologist used a linear array transducer (L17-5 MHz) in 24 patients and hockey-stick probe (L15-7 MHz) in 17. The bony component of the nose was divided into three parts (right and left lateral nasal walls, and midline of nasal bone). Fracture detection by three modalities was subjected to analysis. Furthermore, findings made by each modality were compared with intraoperative findings. Nasal bone fractures were located in the right lateral wall (n = 28), midline of nasal bone (n = 31), or left lateral wall (n = 31). For right and left lateral nasal walls, CT had greater sensitivity and specificity than US or radiography, and better agreed with intraoperative findings. However, for midline fractures of nasal bone, US had higher specificity, positive predictive value, and negative predictive value than CT. Although two US evaluations showed good agreements at all three sites, US findings obtained by the hockey-stick probe showed closer agreement with intraoperative findings for both lateral nasal wall and midline of nasal bone. Although CT showed higher sensitivity and specificity than US or radiography, US found to be helpful for evaluating the midline of nasal bone. Furthermore, for US examinations of the nasal bone, a smaller probe and higher frequency may be required.

Refinement treatment of nasal bone fracture: A 6-year study of 329 patients

BACKGROUND

The reliability of X-ray radiography for diagnosing nasal bone fractures (NBFs) remains controversial. Recent studies show that, for determining the orientation and location of the displaced/depressed fracture, nasal sonography is as accurate as facial computed tomography. This retrospective study compared conductor-assisted nasal sonography (CANS) to conventional diagnostic tools and reported subjective patient satisfaction and discomfort after closed reduction combined with tube technique.

METHODS

This retrospective study reports the results of 329 refinement treatments for nasal bone fracture (including 199 men and 130 women) performed from 2005 to 2011. All patients were assessed with CANS and completed a survey immediately prior to removing the packing. Questionnaires were adapted from the nasal obstruction symptom evaluation (NOSE) scale.

RESULTS

The study found that CANS has a 97.2% rate of accuracy in diagnosing NBF. The visual analog scale scores of nasal obstruction, nasal congestion, sleep disturbance, trouble breathing, and inability to move air through the nose were analyzed. The experimental group scores were significantly different from the control group for all scores (p < 0.001).

CONCLUSION

Compared to conventional methods, CANS is more accurate for detecting NBF. We recommend its use as an alternative tool for diagnosing a nasal fracture. Because the tube technique balances pressure between the nasopharynx and middle ear during swallowing, patient comfort is enhanced. Application of these modifications can improve accuracy in diagnosing NBF and can improve the quality of NBF treatment.

Ultrasonography findings in nasal bone fracture; 6-month follow-up: can we estimate time of trauma?

Differentiation of a recent nasal bone fracture from an old one may become of utmost importance, especially in medico-legal issues. The aim of this study was to demonstrate the value of high-resolution ultrasonography (HRUS) in determining the time of nasal bone fracture. A longitudinal, descriptive-analytic study was done on 45 patients with a clinical manifestation of acute unilateral nasal bone fracture. After a thorough rhinologic physical examination, HRUS was performed by an expert consultant who was blinded to the clinical data of the patients. All patients were followed-up for 6 months: in the first 5 days, 3rd, 6th, 12th and 24th weeks after the trauma. In each session, the ultrasonographic findings were recorded. Thirty-six cases (mean age, 27 years) completed the study course successfully. On HRUS, subperiosteal hematoma, with a mean thickness of 1.14 mm (0.79-1.31 mm) was highly sensitive (100 %) for the diagnosis of nasal bone fracture during the first few days after the trauma, but it was present in 13 cases in the 6th week, with a mean thickness of 0.71 mm (0.62-0.80 mm), and disappeared in all patients in the 24th week, with a mean thickness of 0.47 mm (almost equal to the non-traumatic side). According to the changes of subperiosteal reaction on the traumatic side and by means of generalized linear model and generalized estimating equations, we proposed an equation to estimate the time of nasal bone trauma. In conclusion, HRUS is a reliable diagnostic tool for estimating the time of nasal bone fracture.

Utility of computed tomography scans in predicting need for surgery in nasal injuries

In many centers, computed tomography (CT) scan is preferred over plain film radiographs in the setting of acute nasal injury because CT scan is thought to be more sensitive in predicting nasal bone fracture. However, the usefulness of CT scans in predicting the need for surgery in acute nasal injury has not been well-studied. We conducted a retrospective review of 232 patients with known nasal bone fracture and found very similar rates of surgery in patients with a diagnosis of nasal fracture by CT scan as by nasal radiographs (41 and 37%, respectively). This suggests that experienced clinical examination remains the gold standard for determining the need for surgery in isolated nasal trauma, regardless of CT findings.

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

Background

There has been no study to compare the diagnostic accuracy of an experienced radiologist with a trainee in nasal bone fracture.

Objectives

To compare the diagnostic accuracy between conventional radiography and computed tomography (CT) for the identification of nasal bone fractures and to evaluate the interobserver reliability between a staff radiologist and a trainee.

Patients and Methods

A total of 108 patients who underwent conventional radiography and CT after acute nasal trauma were included in this retrospective study. Two readers, a staff radiologist and a second-year resident, independently assessed the results of the imaging studies.

Results

Of the 108 patients, the presence of a nasal bone fracture was confirmed in 88 (81.5%) patients. The number of non-depressed fractures was higher than the number of depressed fractures. In nine (10.2%) patients, nasal bone fractures were only identified on conventional radiography, including three depressed and six non-depressed fractures. CT was more accurate as compared to conventional radiography for the identification of nasal bone fractures as determined by both readers (P <0.05), all diagnostic indices of an experienced radiologist were similar to or higher than those of a trainee, and κ statistics showed moderate agreement between the two diagnostic tools for both readers. There was no statistical difference in the assessment of interobserver reliability for both imaging modalities in the identification of nasal bone fractures.

Conclusion

For the identification of nasal bone fractures, CT was significantly superior to conventional radiography. Although a staff radiologist showed better values in the identification of nasal bone fracture and differentiation between depressed and non-depressed fractures than a trainee, there was no statistically significant difference in the interpretation of conventional radiography and CT between a radiologist and a trainee.

Clinical utility of three-dimensional facial computed tomography in the treatment of nasal bone fractures: a new modality involving an air-bone view with a volume rendering technique

To evaluate the utility of three-dimensional (3D) reconstruction when planning the surgical treatment of nasal bone fractures. The axial scan of high-resolution facial bone CT was reconstructed in 3D using the program V-works 4.0 (CyberMed, Seoul, Korea) with a volume and surface rendering technique. For detailed stereoscopic examination of the nasal valve area, an air-bone view with the volume rendering technique was obtained using thresholds for air, cartilage, and bone. In most nasal bone fractures, 2D and 3D CT had similar detection rates. However, to determine the fracture angle and dimpled area, and identify multiple fractures, surgeons can get better information to help with the reduction of the fractured bone from 3D reconstruction images. Additionally, with a septal deformity, this view helps in deciding on the need for septal surgery during nasal reduction. The air view of the nasal passage provides clues to obstruction of the nasal cavity. We could identify the contour and location of the fracture site accurately from 3D CT images. The detection rate of fractures was similar to that of 2D CT. However, 3D CT enabled the accurate determination of the distance and direction of the fractured bony fragment from normal bone structure. Additionally, a stereoscopic image of the fracture site facilitated an understanding of the location and range of reduction. The air-bone view gave more information about the pathological obstruction of the nasal air passage.

The diagnostic value of the sagittal multiplanar reconstruction CT images for nasal bone fractures

AIM

To compare the diagnostic performance of sagittal multiplanar reconstruction (MPR) images and axial images for the detection of a nasal bone fracture.

MATERIALS AND METHODS

This prospective study included 533 consecutive patients who underwent three-dimensional images with 64-section multidetector-row CT for the evaluation of a facial bone fracture between June 2007 and May 2008 (366 males; 167 females; mean age +/- standard deviation 31.1+/-21.2 years; age range 1-92 years). Two observers independently scored the possibility of a nasal bone fracture on axial and sagittal images. Receiver operating characteristic (ROC) curve analysis was performed.

RESULTS

The Az values of the sagittal images were higher than those of the axial images for both observers (p=0.002 and 0.010, respectively) with higher accuracy (p<0.001 and 0.016, respectively). The sensitivities of sagittal images were superior to those of axial images, especially for type 1simple nasal bone fractures with no or minimal displacement (observer 1, 98.6 versus 72.8%; observer 2, 84.9 versus 71%).

CONCLUSION

Sagittal MPR facial bone CT images provided superior diagnostic performance, and their addition to axial images is useful for the evaluation of nasal bone fractures.

Comparison of high-resolution ultrasonography and computed tomography in the diagnosis of nasal fractures

OBJECTIVE

The purpose of this study was to compare the value of high-resolution ultrasonography (HRUS) and computed tomography (CT) in the diagnosis of nasal fractures.

METHODS

Facial CT and HRUS examinations performed on 140 consecutive patients (103 male and 37 female; age range, 2-74 years; mean, 26 years) with nasal trauma between October 2004 and April 2007 were retrospectively evaluated. Sonograms were obtained with a hockey stick probe (15-7 MHz linear array transducer). All patients also underwent facial CT and conventional radiography. The nasal fracture detection rates for HRUS, CT, and conventional radiography were compared with the clinical and surgical diagnosis. Nasal fractures were classified into high- and low-grade groups according to severity. They were also compared with the CT findings of all 280 lateral nasal bones and with HRUS findings as the reference standard.

RESULTS

The accuracy rates for HRUS, CT, and conventional radiography in detecting nasal fractures were 100%, 92.1%, and 78.6%, respectively. Compared with HRUS, CT revealed only 196 of 233 lateral nasal bone fractures; its accuracy was 80%. In high-grade fractures, the accuracy of CT was 87%, but it decreased to 68% in low-grade fractures.

CONCLUSIONS

Compared with HRUS, CT had lower accuracy, especially in low-grade nasal fractures. Thus, HRUS is a reliable diagnostic tool for the evaluation of nasal fractures.

Sonography versus plain x rays in diagnosis of nasal fractures

BACKGROUND

The standard imaging procedure for suspected nasal fractures has been radiography (XR). However, its usefulness for clinical decision making is highly controversial. High-resolution ultrasonography now offers a promising new diagnostic imaging option. In this study we compared the diagnostic value of high-resolution ultrasonography and conventional XR in the evaluation of suspected nasal fractures.

METHODS

A prospective single-blinded study was performed. Ultrasound (US) and XR findings in 80 patients with suspected nasal fractures were compared with the definite clinical diagnosis with respect to sensitivity, specificity, and accuracy.

RESULTS

For detection of fractures of the nasal dorsum, both modalities had high sensitivity (98 and 88% for US and XR, respectively) and specificity (95% for both US and XR). In lateral nasal wall fractures, specificity was higher for XR (75% versus 94%). Sensitivity was significantly higher for the US examination (98% versus 28%). In summary, the accuracy was higher for US.

CONCLUSION

When available, US should be the first-line imaging procedure in the evaluation of nasal fractures.

[Conventional radiological examination of the nasal bone--helpful or superfluous? Case histories and literature survey]

Fractures of the nasal pyramid are among the most common injuries to the skull. Numerous studies have shown that conventional radiological examination of simple fractures of the nose give no information that is helpful either in reaching a diagnosis or in deciding on the therapeutic management. Nevertheless, physicians still frequently refer patients for such examinations to check for fractures. It is now increasingly important to reduce the costs, and particularly to avoid unhelpful investigations and unnecessary radiation exposure.

High-resolution sonography for nasal fracture in children

OBJECTIVE

We describe the sonographic findings of nasal fracture in children, and we evaluate the diagnostic value of sonography as compared with conventional radiography and clinical findings to determine whether sonography can be a primary technique for evaluating nasal fracture in children.

MATERIALS AND METHODS

Conventional radiographs and sonographic scans were obtained in 26 consecutive children with nasal trauma who were seen at our hospital from March 2003 to March 2005. There were five girls and 21 boys, and their ages ranged from 1 year 9 months to 15 years 11 months (mean age, 9.9 years). The following sonographic scans (HDI-5000 unit with a 7-15-MHz linear array transducer) were used to evaluate the nasal bone at different levels: a midline longitudinal image; axial scans of the nasal bones at the upper, middle, and lower levels; images of the nasal septum; and transverse and longitudinal scans of both lateral walls. Ten children also underwent CT.

RESULTS

Conventional radiographs depicted 14 (54%) of 26 fractures. Sonographic scans were able to show all the fracture lines. One case was diagnosed as an old nasal fracture on the basis of a physical examination, even though a visible fracture line was seen on sonography. The sonographic findings of nasal fracture were disruption of the bone continuity with or without separation of the fractured segment (7/26), displacement of the bone segment as being depressed or overriding (20/26), associated septal deviation (7/26), and separation of the pyriform aperture of the maxilla and nasal bone (2/26). The associated findings were soft-tissue edema and hypoechoic hematoma near the fracture lines in 25 cases. The fractures involved both sides of the nasal bones in 11 of 26 cases, the midline part of the bones in six of 26 cases, and the unilateral paramedian or lateral part of the bones in 12 of 26 cases. Among the 10 CT scans, one CT scan did not depict the fracture, showing only soft-tissue swelling, and one scan showed fractures of the orbital floor and maxilla.

CONCLUSION

Sonography can be a primary diagnostic technique for evaluating nasal fracture in children. It inflicts no radiation, provides various imaging planes without positional change, and can be used to evaluate the cartilaginous septum. Potential pitfalls are the nasofrontal suture, the junction between the nasal bone and the pyriform aperture of the maxilla, the vascular groove, and the presence of an old fracture. CT can be used in addition to sonography in cases of suspected complex facial bone trauma.

Pre- and postoperative x-ray and computed tomography evaluation in acute nasal fracture

Between January 1997 and July 2003, 156 acute nasal fractures were treated by closed reduction in Ishikiri-Seiki Hospital. For all patients, x-ray and computed tomography (CT) taken pre- and postoperatively were used to classify fractures and evaluate postoperative conditions. Acute nasal fractures requiring surgery were classified into the following 5 types. Unilateral type (U), bilateral type (B), frontal type (F), laterofrontal type (L), and comminuted type (C). Postoperative conditions were classified as good, fair, or poor. On statistical analysis, it was found that reduction is easier in the U, F, B, L, and C types in order. Furthermore, it was found that in the U, B, and F types, reduction can be performed after swelling has subsided, but in the L and L+C types, reduction should be performed earlier. On follow-up x-ray and CT, there was no significant difference between the postoperative evaluation and follow-up evaluation. A few overreduced cases improved, but correct reduction was preferable to overreduction. Accurate preoperative understanding of the fracture type and postoperative evaluation by x-ray and CT are necessary to obtain good results and to decrease secondary deformity caused by poor primary reduction.

Management of nasal trauma--widespread misuse of radiographs

OBJECTIVE

To assess the reasons behind the widespread use of X-ray in the management of nasal trauma despite the fact that it has no useful purpose, comparing the responses of doctors in Accident and Emergency (A&E) departments between the District General Hospitals (DGH) and the Teaching Hospitals.

METHOD

A multiple-choice questionnaire was sent to all doctors in Accidents and Emergency departments in the North-West Region of England.

RESULT

212 questionnaires were sent out and 159 were returned. Amongst the 92 (57.9 per cent) doctors who use nasal radiographs, the overall most common reason is medico-legal in 48 (52.1 per cent). A high proportion of DGH doctors use radiographs for diagnostic purposes and 35 (28.9 per cent) will refer patients based on X-ray demonstration of nasal bone fracture. Other stated reasons included detection of unsuspected facial fracture, diagnosis of compound nasal fracture and foreign body detection.

CONCLUSION

Doctors need to be better informed that nasal radiography has no useful value. A clear clinical guideline should be set up nationwide to protect patients from unnecessary exposure to radiation. This will also save the time of the doctors, radiographers and patients. It will prevent inappropriate referrals. Money and other resources will therefore be better utilized.

The utility of nasal bone radiographs in nasal trauma

A prospective study was performed to assess the value of nasal bone radiographs taken in the accident and emergency department. The study population consisted of 100 consecutive patients who had nasal bone radiographs in our accident and emergency (A&E) department following trauma. We looked at the casualty officers', radiologists' and ENT surgeons' assessment of the cases. Thirty months later we reviewed the patients' notes to identify the number who sought medico-legal reports on their injury in that interval. We found sporting injuries to be the commonest mechanism of injury, followed closely by accidental falls. The remaining third was made up predominantly of cases of personal assault and road traffic accidents. Only two patients had a naso-pharyngeal history recorded on their visit to A&E. Thirty-five patients were referred to ENT out-patients, only 24 kept their appointment. Thirty-one of the 35 ENT referrals were felt to have a fracture demonstrated on their radiographs. However, 19 of those discharged were also thought to have an X-ray-proven fracture. Thirty months later only two patients had requested a medico-legal report. We demonstrate that the decisions regarding treatment of nasal trauma are based on clinical findings and that nasal bone radiography has no place in the decision making process and should therefore be abandoned.

Can more efficient use be made of x ray examinations in the accident and emergency department?

Increasing workloads in our radiology department prompted a study of casualty officers' use of x ray examinations, of which there were 5463 in the period. While casualty officers were in post referrals for x ray examination did not become more selective, but skills in interpreting films improved. Overall, 4.9% of trauma radiographs were misinterpreted, but this fell from 7.1% to 2.9% during tenure of post. One in four errors was clinically important. Clinical guidelines for selective radiography produced a significant and sustained reduction in the number of x ray examinations requested by the department. Analysis of one common injury indicated that the quality of patient care was not adversely affected. The number of x ray examinations carried out in the accident and emergency department can be reduced by using guidelines, and this does not compromise the quality of patient care. Appreciable savings may be made in patients' waiting times and radiodiagnostic expenditure.

Rationalising abdominal radiography in the accident and emergency department

A retrospective analysis is presented of 100 consecutive patients attending an accident department and referred for abdominal radiography. In general the reasons for requesting supine films appeared sound. Five per cent of referrals were for haematemesis which is not a valid reason for plain radiography. An erect abdominal film as a routine request is indicated only in suspected intestinal obstruction (4% in this series), but 83% of patients were referred for both erect and supine films. If haematemesis were excluded as a reason for X-ray referral, and if erect films were limited to suspected intestinal obstruction, 95% of the patients would still have been referred for radiography, but almost half the abdominal films would not have been required. This would have reduced film wastage, workload and more important, gonadal irradiation.

An assessment of the clinical effects of reporting accident and emergency radiographs

A prospective study of the accuracy of interpretation of radiographs by casualty officers and radiologists is presented. The casualty officers readings were correct in 83% of cases, and the radiologists' in 95%. There was agreement of interpretation in 83% of the examinations. This study indicates that there are clinical and economic benefits when the radiologist's report is available before the patient leaves the hospital. Delayed reporting of films is considered to be less satisfactory but is still of value as it increases the detection of clinically significant abnormalities and also clarifies most of the 10% of studies about which the casualty officer is uncertain. Where a delayed reporting system is practised, a25% reduction in radiologist's workload would be achieved by reporting only those films considered by the casualty officer to be "normal" or "uncertain". Attempts to reduce workload still further by not reporting any films will increase the number of patients poorly managed in casualty.