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Three Part Question

In [patients with suspected nasal bone fracture], is [ultrasound is better than radiography] for [diagnosis of nasal fracture] ?

Clinical Scenario

As a new attending in a regional hospital, you constantly search for new indications to use your brand new ultrasound machine. You see a 23 years old man with facial trauma after a ski accident and suspect a nasal bone fracture. You ask yourself if an ultrasound would be as sensitive or even more than your standard CR to confirm a clinical diagnosis of nasal bone fracture in adults.

Search Strategy

1.No BestBets answering the clinical question was found

2.The website clinicaltrials.gov was searched for an ongoing trial on the topic: 1 completed observational cohort study was found, with completion of data collection in 2009 which was also found in MEDLINE

-MEDLINE (PUBMED) :
1: Ultrasound [all fields] OR ultrasonography [all fields] OR echography [all fields] OR ultrasound [all fields] : 464434
2: Nasal bone [all fields] OR nose [all fields] AND fracture [all fields]: 3190
3: Evaluation [all fields] OR diagnosis [all fields] OR accuracy [all fields]: 9715746

-1+2+3: 39 papers
-After abstract/title review = 16 relevant papers including one systematic review
-7 exluded (written in other language than English)
-3 already included in a systematic review
-6 relevant papers
-4 included (two excluded because of smallest cohort and similar results)

3.EMBASE : 'ultrasound'/exp OR ultrasound AND nasal AND ('bone'/exp OR bone) AND ('fracture'/exp OR fracture) :24 results
-After abstract review = 6 relevant papers (including preceding relevant papers)
-All six either already excluded for foreign langage or part of preceding relevant papers

4.Cochrane : There were no Cochrane review on the subject

Search Outcome

Relevant papers included = 5

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
W. L. Adeyemo, O. A. Akadiri 2011 Nigeria	Not specified in systematic review -1 article had pediatric population (n = 26) (2) - 2 studies with 171 and 138 consecutive patients -patients excluded if >2 weeks after trauma, fracture manipulation in one study (3)	Systematic review Ultrasound in comparison to conventional CR and occasionally CT, cross-sectionnal not controlled	Sensibility	90-100%	Gold standard= clinical evaluation One study MSK radiologist = external validity problem (other not specified) 2 out of 4 studies no comparison to CT (which could be a objective gold standard) Not a meta-analysis Different techniques (probes) 2 out of 4 studies had small cohorts (5 and 26 pt)
			Specificity	98-100%
			Sensibility and specificity of CT and conventional X-ray not specified in systematic review
S. Atighechi, M. H. Baradaranfar and al. 2014 Iran	128 sequential patients who consent, with clinical signs of nasal fracture Exclusion: pregnany, non consent (92.2%) had a definite diagnosis of fracture	Prospective cross-sectionnal study Ultrasound and CR compared to clinical diagnostic	US Sensibility	84%	Clinical examination by ENT specialist Ultrasound examination by radiologist (external validity problem) Blinded to physical examination but risk of bias due to bedside evaluation (radiologist sees the patient’s nose)
			US Specificity	75%
			Lat-Waters view CR Sensibility	64%
			Lat-Waters view CR Specificity	58%
Mohammadi A1, Ghasemi-Rad M. 2011 Iran	Retrospective study 87 consecutive patients who had 3 diagnostic modalities Exclusion: open fracture, fracture manipulation, more than 1 week after trauma Physical examination was positive in 72 and negative in 15 patients	Ultrasound, CR and CT compared to clinical diagnostic (positive physical examination)	US Sensibility	97%	Ultrasound examination by radiologist (external validity problem) Blinded to physical examination but risk of bias due to bedside evaluation Selection bias of patients because of retrospective selection of patients who underwent all diagnostic modalities
			US Specificity	100%
			CR Sensibility	72%
			CR Specificity	73%
			CT Sensibility	86%
			CT Specificity	87%
Yun-Ting Lou, MD, Hsing-Lin Lin, MD 2011 Taiwan	Retrospective study 71 consecutive patients who had both ultrasound and CT	Ultrasound compared to positive CT scan report CR in patients whom had one was also compared to CT	US Sensibility	100%	Ultrasound examination by experience physician (no more specification about training/experience) = emergency physician or trauma surgeon Not blinded sonographer Single institution
			US specificity	89%
			CR Sensibility	89%
			CR Specificity	25%
Thiede O, Krömer JH, Rudack C, Stoll W, Osada N, Schmäl F. 2005 Germany	Prospective study 63 consecutive patients who had both ultrasound and CT	Ultrasound and CR Compared to clinical and surgical diagnosis Blind interpretation of results (3 US images or 2 CR images) Clinical examination by 2 clinicians	US Dorsum sens/spec	49%/69%	Diagnosis by ultrasound is a dynamic process with multiple images. Since US accuracy was calculated with the interpretation of only 3 images by blind readers, US accuracy could be underestimated.
			US Lateral wall sens/spec	70%/70%
			US pyramid sens/spec	75%/57%
			CR Dorsum sens/spec	82%/69%
			CR Lateral wall sens/spec	52%/49%
			CR pyramid sens/spec	80%/38%

Comment(s)

We found one systematic review (which included 4 relevant papers for nasal fracture) and 6 others studies that could answer our clinical question, of which 4 were included in this analysis. It appears in every studies that High Resolution Ultrasound is more sensitive and specific than CR and CT, when compared to a clinical diagnostic of nasal bone fracture as a gold standard. In most of the studies, ultrasound was performed by radiologists, which limits external validity and probably increase sensibility and specificity compared to emergency medicine physicians. One study compared Ultrasound to CR with a CT diagnostic of nasal bone fracture as a gold standard and showed better accuracy for ultrasound ratter than CR. This study was performed by bedside non-radiologist physicians. It is probably the most relevant paper to our clinical scenario, and favors ultrasound over CR.

Clinical Bottom Line

Even though clinical utility is not clear, ultrasound is an alternative to CR and CT scan when performed by radiologists. However, further studies need to be made about accuracy of ultrasound for diagnostic of nasal bone fracture in comparison to gold standard (clinical diagnosis) when performed by non-radiologists in order to determine if US is better than CT.

References

1. W. L. Adeyemo, O. A. Akadiri A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures Int. J. Oral Maxillofac. Surg. 2011; 40: 655–661
2. S. Atighechi, M. H. Baradaranfar and al. Diagnostic Value of Ultrasonography in the Diagnosis of Nasal Fractures The Journal of Craniofacial Surgery January 2014, Volume 25, Number 1
3. Mohammadi A1, Ghasemi-Rad M. Nasal bone fracture--ultrasonography or computed tomography? Medical ultrasonography 2011 Dec;13(4):292-5
4. Yun-Ting Lou, MD, Hsing-Lin Lin, MD Conductor-assisted nasal sonography: an innovative technique for rapid and accurate detection of nasal bone fracture Journal of Trauma 2011, vol 72, no 1
5. 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 May;131(5):434-9.