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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, 1990, UK	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 levels	No significant difference in terms of airway patency, cosmesis and pain levels between the two groups	LA is a preferable mode of anaesthesia to GA for manipulation of nasal fractures in terms of avoiding complications of GA	Small numbers. Pain score used was a linear 1–5 score (not as well validated as the VAS)
Watson et al, 1988, UK	40 Patients with recent nasal fractures	A 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 collected	There 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 again	LA is comparable to GA in terms of nasal deviation and nasal airway improvement and in terms of patient acceptibility of procedure	Small numbers (40 subjects). Two of 40 patients did not have surgery and nine of 40 patients were lost to follow-up
Kwaja et al, 2007, UK	176 Adults requiring nasal fracture manipulation	Multicentre, 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 manipulation	No 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 GA	Pain 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, 1988, UK	104 Patients with nasal fractures	Prospective 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 tolerance	No 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 GA	Patients were not randomly assigned. Assessment of cosmetic and functional result did not use validated parameters
Green, 2001, UK	51 Adult patients with nasal fracture reduced under LA	A case series of pre and post-manipulation nasal shape and their pain score using linear analogue scales. Patient satisfaction and surgeons’ reduction assessment was recorded	73% 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 procedure	Nasal fracture reduction under LA is an acceptable procedure for the majority of patients	Small numbers
Owen, 1992, UK	Adult patients with nasal bone fractures attending otolaryngology outpatients over a 5-month period	A 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 again	Nasal fracture manipulation under LA is a well tolerated procedure	Small numbers
Walshe et al, 2003, Eire	10 Patients with nasal fractures	Case series of 10 patients undergoing manipulation of nasal fractures under LA. Reduction results were recorded and pain levels	Satisfactory reduction and pain levels	Reduction and pain levels satisfactory under LA	Small numbers. No objective reduction or validated pain parameters used
Courtney et al, 2003, New Zealand	555 Patients who had nasal fractures manipulated over a 6-year period	A telephone survey to analyse LA versus GA retrospectively with respect to reoperation rates, ie, those who required a secondary procedure	Patients 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 GA	324 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, 2003, New Zealand	197 Patients (adult) with nasal fractures over a 2-year period	A telephone survey retrospectively analysing reoperation rates of LA versus GA techniques used in primary manipulation of nasal fractures	No significant difference in reoperation rates or patient satisfaction with either procedure	No significant difference in outcome between LA or GA in fractured nose reductions	Small 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, 2007, Hong Kong	62 Patients who underwent closed reduction of fractured nasal bones	Telephone interview retrospective analysis of patients’ satisfaction with closed reduction in terms of nasal deformity, cosmetic deformity, nasal obstruction and willingness to undergo revision surgery	13% dissatisfied with their nasal deformity, 11% with their cosmetic appearance, 21% with their airway patency, 29% willing to undergo revision surgery	Overall significant 29% dissatisfaction with outcome of closed reduction	Small numbers. no objective clinical assessment of patient by clinicians (telephone survey)
Wild et al, 2003, UK	43 Adult patients with nasal fracture	Prospective audit of patient satisfaction in terms of pain and cosmetic result with LA reduction	25 Patients made long-term (3-month) follow-up of which 20 (80%) were satisfied with their reduction	80% Patient satisfaction rate at long-term follow-up	Small numbers. 25 of 37 recieved were available for long-term follow-up

Comment(s)

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.

References

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.