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Should Nasal Fractures be manipulated under local anaesthesia?

Three Part Question

In [adults with displaced nasal fractures] does [digital manipulation under local anaesthesia vs manipulation under GA] produce [cosmetic appearance and airway patency comparable to manipulation under general anaesthesia, at acceptable pain levels for the patient].

Clinical Scenario

In [adults with displaced nasal fractures] does [ digital manipulation under local anaesthesia] produce [cosmetic appearance and airway patency comparable to manipulation under general anaesthesia, at acceptable pain levels for the patient

Search Strategy

medline/pubmed online search
cochrane database online search
NCBI/PUBMED search for relevant articles using the terms
"nasal fracture local anaesthesia manipulation"
Cochrane database search for relevant articles using the terms
"Nasal fracture"

Search Outcome

NCBI/PUBMED search found 18 articles of which 11 were relevant.
Cochrane search found 10 articles of which 4 were relevant.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Cook et al,
50 Adult patients with radiologically confirmed nasal fractures referred to ENT clinic by ED and GP, randomly assigned to LA or GA for nasal fracture manipulation (25 patients in each group)Randomised trial (closed envelope system) comparing LA with GA in terms of post-procedure airway patency, cosmesis and pain levelsNo significant difference in terms of airway patency, cosmesis and pain levels between the two groupsLA is a preferable mode of anaesthesia to GA for manipulation of nasal fractures in terms of avoiding complications of GASmall numbers. Pain score used was a linear 1–5 score (not as well validated as the VAS)
Watson et al,
40 Patients with recent nasal fracturesA prospective blind randomised trial, subjects were randomly assigned to LA or GA using random number tables. Nasal deviation and nasal airway was assessed before procedure and then 4 weeks post-procedure with the assessor blinded. Also patient questionnaire of acceptability of procedure was collectedThere was no significant difference in the cosmetic results between the groups, no significant difference in nasal median airway resistance between the groups; of the 17 patients in the LA group only one would not have LA againLA is comparable to GA in terms of nasal deviation and nasal airway improvement and in terms of patient acceptibility of procedureSmall numbers (40 subjects). Two of 40 patients did not have surgery and nine of 40 patients were lost to follow-up
Kwaja et al,
176 Adults requiring nasal fracture manipulationMulticentre, randomised, prospective trial comparing LA and GA techniques in nasal fracture manipulation in terms of pain scores, cosmetic appearance and requirement for septorhinoplasty post initial manipulationNo significant difference between groups in terms of pain scores, no difference in post-manipulation cosmetic appearance, no difference in septorhinoplasty rates (secondary procedure)No significant difference between the two groups thus LA is recommended as first line for nasal fracture manipulation because of inate risk of GAPain scores used are linear analogue scale as opposed to the more validated VAS. Discrepancy between surgical and patients’ own assessment of cosmetic improvement. 37 Patients lost to follow-up
Waldron et al,
104 Patients with nasal fracturesProspective study of 50 consecutive nasal fracture reductions under GA versus 54 consecutive LA reductions in terms of cosmetic and functional improvement, time from injury to manipulation and patient toleranceNo significant difference between the reduction results in each group, time to manipulation 8 days for LA, 10 days for GA, patient tolerance of LA procedure 92%No significant difference in reduction results between LA and GAPatients were not randomly assigned. Assessment of cosmetic and functional result did not use validated parameters
51 Adult patients with nasal fracture reduced under LAA case series of pre and post-manipulation nasal shape and their pain score using linear analogue scales. Patient satisfaction and surgeons’ reduction assessment was recorded73% of patients reported a pain score between 1 and 3 out of 10. 95% stated they would undergo the procedure again. Reduction results were poor, 1/3 of patients were listed for a second procedureNasal fracture reduction under LA is an acceptable procedure for the majority of patientsSmall numbers
Adult patients with nasal bone fractures attending otolaryngology outpatients over a 5-month periodA case series of 30 of these patients received manipulation under LA. Patients’ reduction result (complete or incomplete) was recorded, the observed reaction to each stage of manipulation and the patients’ assessment of pain using a 4-point score (no discomfort, mild, moderate, severe), and comparison relative to a dental filling (more comfortable, as comfortable, mild moderate or severely more uncomfortable)71% had complete reduction of their fracture, 8% of patients had a vocal reaction to their manipulation. 63% found the pain to be no more than a tooth being filled. 96% would have it done againNasal fracture manipulation under LA is a well tolerated procedureSmall numbers
Walshe et al,
10 Patients with nasal fracturesCase series of 10 patients undergoing manipulation of nasal fractures under LA. Reduction results were recorded and pain levelsSatisfactory reduction and pain levelsReduction and pain levels satisfactory under LASmall numbers. No objective reduction or validated pain parameters used
Courtney et al,
New Zealand
555 Patients who had nasal fractures manipulated over a 6-year periodA telephone survey to analyse LA versus GA retrospectively with respect to reoperation rates, ie, those who required a secondary procedurePatients in the LA group had a significantly higher reoperation rate than the GA group (17.2% vs 3.2%)Manipulation under LA has a higher reoperation rate than manipulation under GA324 of 555 patients available for analysis. Similar but smaller study by same investigators at same institution showed no significant difference between LA/GA groups. The two institutions involved used different reduction methods (digital and instrumental)
Rajapakse et al,
New Zealand
197 Patients (adult) with nasal fractures over a 2-year periodA telephone survey retrospectively analysing reoperation rates of LA versus GA techniques used in primary manipulation of nasal fracturesNo significant difference in reoperation rates or patient satisfaction with either procedureNo significant difference in outcome between LA or GA in fractured nose reductionsSmall numbers. A larger trial carried out by the same investigators over a 6-year period in the same institutions showed a significantly higher reoperation rate for LA reductions
Hung et al,
Hong Kong
62 Patients who underwent closed reduction of fractured nasal bonesTelephone interview retrospective analysis of patients’ satisfaction with closed reduction in terms of nasal deformity, cosmetic deformity, nasal obstruction and willingness to undergo revision surgery13% dissatisfied with their nasal deformity, 11% with their cosmetic appearance, 21% with their airway patency, 29% willing to undergo revision surgeryOverall significant 29% dissatisfaction with outcome of closed reductionSmall numbers. no objective clinical assessment of patient by clinicians (telephone survey)
Wild et al,
43 Adult patients with nasal fractureProspective audit of patient satisfaction in terms of pain and cosmetic result with LA reduction25 Patients made long-term (3-month) follow-up of which 20 (80%) were satisfied with their reduction80% Patient satisfaction rate at long-term follow-upSmall numbers. 25 of 37 recieved were available for long-term follow-up


A large prospective randomized trial is needed to assess the reduction outcome of manipulation of the fractured nose under Local Anaesthesia as compared to General Anaesthesia.

Clinical Bottom Line

The evidence available points towards Manipulation under Local Anaesthesia as being a procedure which is acceptable to the patient in terms of pain, cosmetic and functional outcome. A large prospective randomised multicentre trial is required to conclude.


  1. Cook JA, Duncan R, McRae R. A randomised comparison of manipulation of the fractured nose under local and general anaesthesia. Clin Otolaryngol 1990;15:343–6.
  2. Watson DJ, Parker AJ, Slack RWT, et al. Griffiths local versus general anaesthetic in the management of the fractured nose. Clin Otolaryngol 1988;13:491–4.
  3. Kwaja S, Pahade AV, Luff D, et al. Green nasal fracture reduction, local versus general anaesthesia. Rhinology 2007;45:83–8.
  4. Waldron J, Mitchell DB, Ford G. Reduction of fractured nasal bones; local versus general anaesthesia. Clin Otolaryngol 1988;14:357–9.
  5. Green KMJ. Reduction of nasal fractures under local anaesthetic. Rhinology 2001;39::43–6.
  6. Owen GO. Fractured-nose reduction under local anaesthesia. Is it acceptable to the patient? Rhinology 1992;30:89–96.
  7. Walshe P, Harney M, McConn Walsh R, et al. Manipulation of nasal bone fractures under local anaesthetic. Irish Med J 2003;96:50–1.
  8. Courtney MJ, Rajapakse Y, Duncan G, et al. Nasal fracture manipulation: a comparative study of general and local anaesthesia techniques. Clin Otolaryngol Allied Sci 2003;28:472–5.
  9. Rajapakse Y, Courtney M, Bialostocki A, et al. A study comparing local and general anaesthesia techniques. Aust NZ J Surg 2003;73:396–9.
  10. Hung T, Chang W, Vlantis AC, et al. Patient satisfaction after closed reduction of nasal fractures. Arch Fac Plast Surg 2007;9:40–3
  11. Wild DC, El Alami MA, Conboy PJ. Reduction of nasal fractures under local anaesthesia: an acceptable practice? Surgeon 2003;1:45–7.