Accuracy of ultrasound for diagnosis of nasal fracture
Date First Published:
May 3, 2015
Last Updated:
May 3, 2015
Report by:
Eric Brassard, Emergency medicine PGY3 (Universite Laval)
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
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
Outcome:
Relevant papers included = 5
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures 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 | |||||
| Diagnostic Value of Ultrasonography in the Diagnosis of Nasal Fractures 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% | ||||
| Nasal bone fracture--ultrasonography or computed tomography? 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% | ||||
| Conductor-assisted nasal sonography: an innovative technique for rapid and accurate detection of nasal bone fracture 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% | ||||
| Comparison of ultrasonography and conventional radiography in the diagnosis of nasal fractures 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% |
Author Commentary:
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.
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:
- W. L. Adeyemo, O. A. Akadiri. A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures
- S. Atighechi, M. H. Baradaranfar and al. . Diagnostic Value of Ultrasonography in the Diagnosis of Nasal Fractures
- Mohammadi A1, Ghasemi-Rad M.. Nasal bone fracture--ultrasonography or computed tomography?
- Yun-Ting Lou, MD, Hsing-Lin Lin, MD. Conductor-assisted nasal sonography: an innovative technique for rapid and accurate detection of nasal bone fracture
- Thiede O, Krömer JH, Rudack C, Stoll W, Osada N, Schmäl F. . Comparison of ultrasonography and conventional radiography in the diagnosis of nasal fractures