Audit Article

Reduction of nasal fractures under local anaesthesia: an acceptable practice?

D.C. Wild
M.A. El Alami 
P.J. Conboy
Department of Otorhinolaryngology, Leicester Royal Infirmary, Leicester, UK

Correspondence to: Mr D.C. Wild, Clinical Research Fellow, Department of Otorhinolaryngology, Leicester Royal Infirmary, Leicester LE1 5WW

Introduction Methods Results

Discussion Conclusion References

Keywords: Nasal fracture, reduction, local anaesthesia
Surg J R Coll Surg Edinb Irel., 1 February 2003, 45-47

Nasal fractures are among the most common bony injuries and are among the most frequent reasons for referral to Otorhinolaryngology departments resulting in significant pressure on clinical resources. We present our experience of a Nasal Fracture Clinic dedicated to the assessment of nasal injuries. A prospective study has been undertaken using questionnaires regarding patient satisfaction and acceptability of manipulation under a local anaesthetic (LA). During our three-month study period 91 new patients with nasal injuries were seen; 43 patients were diagnosed to have a displaced nasal fracture requiring reduction. Reduction of the nasal fracture under LA was performed in 37 patients. We found that manipulation under LA was preferred by 94% of patients over the age of 14 years. We achieved a high patient satisfaction rate (80 % after three months). The discomfort associated with reduction under LA did not exceed that of a minor dental procedure. No significant complications were encountered during the study period. We conclude that reduction of nasal fractures under LA is a safe and attractive alternative to reduction under a general anaesthetic (GA) and frees-up valuable clinical resources

INTRODUCTION
Reduction of displaced nasal fractures has been reported since Ancient Egypt in 3000 BC: "One having a break to the column of his nose: an ailment I shall treat".¹ The inception of anaesthetic agents and the relative safety of a GA have enabled fracture reduction of displaced fractures under a LA or a GA. Reduction of nasal fractures under a GA has become the preferred method in many departments.² This practice, however, has lead to pressure on operating lists and hospital beds.

In our institution, all nasal injuries are directly referred from the Accident and Emergency Department or from general practitioners to a specialised “Nasal Fracture Clinic”. This outpatient clinic is run on a weekly basis within the department of Otorhinolaryngology.

Reduction of a displaced nasal fracture under LA is the preferred method in our department and for most patients is usually performed at the initial visit.

In a prospective study we have assessed our results, together with patient satisfaction and acceptance of the procedure. We discuss the possible advantages to the patient and of managing the workload of our department. We describe our experience and the impact it has on surgical resources.

METHODS
In this prospective audit all patients referred to the Nasal Fracture Clinic were assessed, recording type of injury and the indication for manipulation. The results of fracture reduction under a LA were analysed using questionnaires filled in by the surgeon and the patient.

Indication for manipulation, type of anaesthetic employed and surgical results were recorded. Patient discomfort associated with the application of nasal spray, injection, manipulation and post-procedure pain was recorded using visual analogue scoring. The patients were also asked to compare the discomfort with that of other minor procedures (e.g. blood test, dental procedure). Patient acceptance and satisfaction were also recorded. All procedures were performed using the same anaesthetic and surgical technique. A haematoma block infiltrating the fracture site with 2ml of 2% lignocaine with adrenaline (1:80000) was used. Additionally, 4% Cophenylcaine^® was applied topically to the nasal mucosal for vasoconstriction and anaesthesia.

RESULTS
A preliminary retrospective review of the notes showed that a total of 494 new and 22 follow-up patients were seen in the Nasal Fracture Clinic in a one-year period. During this period 146 manipulations of displaced nasal fractures under LA were performed. Indications for admission for reduction under a GA were injuries in children, severely depressed fractures and patient's individual preference.

A prospective study of all new patients presenting to the Nasal Fracture Clinic was undertaken over a two-month period. From July to September 2001 a total of 91 new patients were seen. Follow-up appointments were necessary in 12 patients. The majority (76) of patients were referred from accident and emergency departments, the remainder (12) from general practitioners and other medical specialities (3).

Thirty-two female and 59 male patients were seen. The sex and age distribution of patients attending the Nasal Fracture Clinic are presented in Table 1. This shows the predominance of male patients between the age of 11 to 30 in the total number of attendees. The average time between injury and appointment was not statistically different for referrals from general practitioners (11 days) or accident and emergency departments (10 days). In three cases, patients with displaced nasal fractures attended later than three weeks after the injury and, therefore, were not considered as candidates for manipulation. Alleged assaults were named as the cause of the nasal injury by 45 patients, falls by 29 patients; 17 patients stated other causes (mainly sport-related injuries).

Forty-three patients (47% of cases) required manipulation of their nasal fracture; 37 MUAs were performed under LA, eight under GA (including two patients in which the LA reduction was unsuccessful). Reasons for admission for GA were patients age below 14 (four patients), patient preference (two patients) and failed procedures (two patients).

Of the 37 patients undergoing manipulation under LA, 30 patients (81%) completed the questionnaires. Reasons for patients undergoing manipulation of their displaced nasal fracture were the altered shape of their nose in 20, nasal obstruction in 3 and both in 7 patients. Table 1 shows reasons for patients preferring reduction under a LA as opposed to a GA.

Pain scores, as assessed by visual analogue score, were recorded for the application of the LA and the procedure itself. The average pain score for the application of the topical anaesthetic was 1.17, for the injection of the LA it was 2.4. The manipulation itself was associated with a pain score of 3.1. Table 2 illustrates how the discomfort of the manipulation under LA compared with other common medical procedures. For the majority of patients the discomfort encountered did not exceed that of a minor dental procedure.

Twenty-four of the 30 patients were immediately satisfied with the cosmetic result achieved with the reduction under LA. Four patients were unsure initially, but were satisfied with the outcome when assessed again at a follow-up appointment one week later. Only two patients were dissatisfied with the result and underwent a successful reduction under GA subsequently.

We were able to follow-up 25 patients three months after their manipulation under a LA. In this group, 20 (80%) were satisfied with the functional and cosmetic result. Five patients required further assessment for cosmetic problems or/and nasal obstruction.

DISCUSSION
Fracture reduction under a LA appears to be an attractive alternative to a GA. Previous studies comparing the results of fracture reduction under GA and LA have found no difference in surgical outcome.^3,4  The advantage of direct patient feedback is valuable for the patient and the surgeon. All of our trainees have found this to be a valuable experience in this designated clinic, as patient satisfaction remains the most important outcome measure.

Figure 1: Age and sex distribution of patients attending the fractured nose clinic at Leicester Royal Infirmary from July to September 2001

Complex or severely depressed fractures may require surgery under GA, as elevation or open reduction may be necessary. Adequate assessment and patient selection, therefore, is of paramount importance.

Patients valued the safety and rapid recovery associated with a LA procedure. Not having to spend an extra day in hospital was the most frequently stated reason to opt for the immediate reduction under a LA.

Our 80% long-term satisfaction rate compares favourably with a previous study with a similar sample size and composition of patients which had a success rate of 71%.5 The object of our study was to compare our results achieved in standard clinical practice with those of other units and to show the validity of our approach.

Thirty-two per cent of all patients referred to our clinic had their nasal fracture manipulated under a LA (146/ 494), saving nearly the same number of admissions for reduction under a GA. Assuming an average turnover time of 15 minutes in theatre this translates into 36 hours of surgical time or 12 whole operating lists every year.

CONCLUSION
Reduction of nasal fractures under LA is a safe, acceptable and efficient mode of dealing with these injuries. Results are comparable to those achieved under a GA, but the added risks associated with general anaesthesia are avoided. Manipulations under LA are also quicker to perform and will not require hospitalisation resulting in freeing-up of resources and theatre time.

ACKNOWLEDGEMENTS 
We would like to thank the nursing staff of the outpatient department at Leicester Royal Infirmary for their support in the Nasal Fracture Clinic.

REFERENCES
1. Classic reprint. Treatment of fractured noses in Ancient Egypt. From: Breasted JH. Edwin Smith surgical papyrus. Commentary by McDowell. Plastic and Reconstructive Surgery 1969; 43: 31-36
2. Maran AG, Murray JA. Fractures of the nose. Lancet 1988; 19: 649
3. Owen GO, Parker AJ, Watson DJ. Fractured-nose reduction under local anaesthesia. Is it acceptable to the patient? Rhinology 1992; 30: 89-96
4. Waldron J, Mitchell DB, Ford G. Reduction of fractured nasal bones; local versus general anaesthetic. Clin Otolaryngol 1989; 14: 357-59
5. Watson DJ, Parker AJ, Slack RW, Griffiths MV. Local versus general anaesthetic in the management of the fractured nose. Clin Otolaryngol 1988; 13: 491-94

Copyright: 25 November 2002