Should Nasal Fractures be manipulated under local anaesthesia?

Date First Published:
November 28, 2007
Last Updated:
August 13, 2008
Report by:
Oisin Powell, Spr Emergency Medicine (Cork University Hospital, Ireland.)
Search checked by:
Deepak Doshi, Cork University Hospital, Ireland.
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
Search Details:
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"
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):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
A randomised comparison of manipulation of the fractured nose under local and general anaesthesia. Cook JA, Duncan R, McRae R. 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)
Griffiths local versus general anaesthetic in the management of the fractured nose. Watson DJ, Parker AJ, Slack RWT, 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
Green nasal fracture reduction, local versus general anaesthesia. Kwaja S, Pahade AV, Luff D, 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
Reduction of fractured nasal bones; local versus general anaesthesia. Waldron J, Mitchell DB, Ford G. 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
Reduction of nasal fractures under local anaesthetic. Green KMJ. 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
Fractured-nose reduction under local anaesthesia. Is it acceptable to the patient? Owen GO. 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
Manipulation of nasal bone fractures under local anaesthetic. Walshe P, Harney M, McConn Walsh R, 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
Nasal fracture manipulation: a comparative study of general and local anaesthesia techniques. Courtney MJ, Rajapakse Y, Duncan G, 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)
A study comparing local and general anaesthesia techniques. Rajapakse Y, Courtney M, Bialostocki A, 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
Patient satisfaction after closed reduction of nasal fractures. Hung T, Chang W, Vlantis AC, 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)
Reduction of nasal fractures under local anaesthesia: an acceptable practice? Wild DC, El Alami MA, Conboy PJ. 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
Author Commentary:
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.
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.
  2. Watson DJ, Parker AJ, Slack RWT, et al. . Griffiths local versus general anaesthetic in the management of the fractured nose.
  3. Kwaja S, Pahade AV, Luff D, et al.. Green nasal fracture reduction, local versus general anaesthesia.
  4. Waldron J, Mitchell DB, Ford G. . Reduction of fractured nasal bones; local versus general anaesthesia.
  5. Green KMJ.. Reduction of nasal fractures under local anaesthetic.
  6. Owen GO. . Fractured-nose reduction under local anaesthesia. Is it acceptable to the patient?
  7. Walshe P, Harney M, McConn Walsh R, et al.. Manipulation of nasal bone fractures under local anaesthetic.
  8. Courtney MJ, Rajapakse Y, Duncan G, et al.. Nasal fracture manipulation: a comparative study of general and local anaesthesia techniques.
  9. Rajapakse Y, Courtney M, Bialostocki A, et al. . A study comparing local and general anaesthesia techniques.
  10. Hung T, Chang W, Vlantis AC, et al. . Patient satisfaction after closed reduction of nasal fractures.
  11. Wild DC, El Alami MA, Conboy PJ. . Reduction of nasal fractures under local anaesthesia: an acceptable practice?