Nasal fracture is the most common type of facial fractures (Hwang, You, Kim, & Lee, 2006). Despite being a very frequent injury, there is no consensus treatment protocol or anesthetic method (Al-Moraissi & Ellis, 2015). Current evidence indicates that closed reduction under local anesthesia is an acceptable procedure and is not significantly inferior to general anesthesia in terms of pain and functional and aesthetic results (Chadha, Repanos, & Carswell, 2009; Cook, McRae, & Irving, 1990; Powell & Doshi, 2008).
There is considerable variability for local anesthesia techniques regarding the type of anesthetics and methods. However, there are few studies that have compared them (Atighechi, Hossein Baradaranfar, & Allaf Akbari, 2009; Jones & Nandapalan, 1999). The method most that is often described in the literature consists of a combination of topical intranasal anesthesia and external infiltration of the nasal dorsum in the fracture focus.
The aim of this study was to assess the effectiveness of endonasal infiltrative anesthesia in the management of nasal bone reduction.
Between January and July 2016, consecutive patients who presented in the emergency department with mild nasal bone fractures were randomly assigned to two groups. All patients provided written informed consent to participate. The study was carried out in accordance with ethical standards of our institution. Exclusion criteria were as follows: age less than 16 years or more than 80 years, fracture Type III or IV of the Murray–Maran scale (Table 1; Murray & Maran, 1980), allergies to local anesthesia, impaired consciousness (due to dementia or alcohol, toxin, or drug ingestion), psychiatric disorders, associated facial fractures, open nasal fractures, and significant associated facial injuries. Demographic data including age, sex, and type of fractures were recorded.
The conventional anesthetic technique was employed on Group A. For Group B, the alternative technique was performed by adding endonasal infiltrative anesthesia. All patients received 2 ml of 10% topical lidocaine (Xilonibsa Aerosol) applied in each nostril through gauze plugs wetted with anesthesia solution, which were kept in place for 10 min. Subsequently, all patients were administered 4 ml of 2% mepivacaine with adrenaline (1 in 100,000) through a percutaneous injection in the fracture focus. For the patients assigned to Group B, after completing the previous steps, 4 ml of 2% mepivacaine with adrenaline was injected endonasally through each nostril with the help of a rhinoscope to block mucous sensitivity in the area of the nasal bones and septum.
Nasal fracture treatment was accomplished through closed manipulation until a satisfactory reduction was achieved. Afterward, bilateral anterior nasal tamponade with gauze and antibiotic ointment was performed.
After completing the procedure, the pain was assessed through the visual analog scale (VAS), which comprised a horizontal line of 10 cm anchored at one end with the words “no pain at all” and at the other end with the words “worst pain imaginable.” Patients were first asked about a known pain (the pain of a paper cut) to compare the sensitivity with the previous pain in both groups. Then they were questioned about the following steps of the procedure: (1) pain during the endonasal anesthesia process; (2) pain with percutaneous infiltration anesthesia at the focus of the fracture; (3) pain with the fracture reduction maneuvers; and (4) pain during the nasal packing. Finally, the patients were inquired if, in the case of nasal bone reduction again in the future, they would opt for the same method of anesthesia.
The a priori calculation of sample size indicated that to detect 10-point changes in the VAS (with a standard deviation of 20 points and α and β levels of .05 and .2, respectively), each group needed to include 17 cases.
Fifty-two patients were included in the study; 46 were men (88.46%) and 6 were women (11.54%). Thirty of these fractures were classified as Grade I, and 22 were classified as Grade II on the Murray–Maran scale. After the randomization process, 28 patients were assigned to Group A and 24 to Group B.
There were no significant differences between groups in terms of age, sex, and type of fractures. Both groups were also homogeneous in terms of prior sensitivity to pain. There was significant pain reduction with the reduction maneuvers and during the nasal packing in the group that included the endonasal infiltrative anesthesia. There were also significant differences when comparing pain with the topical endonasal anesthesia and the topical plus infiltrative anesthesia (Table 2). As to whether the patient would choose the same anesthetic method, there were no significant differences between the two groups (p = .575).
For most nasal fractures, which tend to be mild, general anesthesia provides no significant advantage and represents greater human and financial resources (Al-Moraissi & Ellis, 2015; Cook et al., 1990; Powell & Doshi, 2008). Although these injuries can be manipulated under local anesthesia in many cases, the considerable variety of methods described in the literature shows that reduction under local anesthesia is still far from being a completely painless and satisfactory procedure (Atighechi et al., 2009; Chadha et al., 2009; Jones & Nandapalan, 1999).
Endonasal infiltrative anesthesia is commonly used when rhinoplasty is performed under local anesthesia (Metzinger, Bailey, Boyce, & Lyons, 1992), but its use is not well established in nasal fractures. Kim, Lee, and Jeong (2013) reported that endonasal block of the anterior ethmoidal nerve is helpful for the control of postoperative pain. In our study, endonasal infiltrative anesthesia was effective for reducing pain during the reduction maneuvers. This technique also reduced the pain associated with nasal tamponade.
Endonasal infiltration was obviously more painful than topical anesthesia. However, the pain value with endonasal infiltration anesthesia was low: VAS pain less than 4 is considered low (Ahlers, van der Veen, van Dijk, Tibboel, & Knibbe, 2010), and some authors define no pain as VAS score less than 3 (Chanques, Jaber, & Barbotte, 2006) because of the prior application of topical anesthesia.
The study's limitations include the fact that the patients were treated by various surgeons. Although the anesthesia technique is easily reproducible and can be applied in a similar way regardless of the person who administers it, it is not so much the reduction maneuvers, in which each surgeon uses a different force and more or less abrupt movements, so that there may be a bias according to the person executing the intervention. Moreover, because of the nature of the operation, it was not possible to employ blind or double-blind masking techniques.
IMPLICATION FOR PRACTICE
The results of our study suggest that addition of endonasal infiltrative anesthesia can decrease pain related to nasal fracture manipulation. Besides, this can be achieved with a very simple, safe, and inexpensive maneuver that is well tolerated by the patients and can be executed in the emergency department or in the plastic surgeon's office. For these reasons, we think that this method of anesthesia should be considered as the technique of choice for management of mild nasal fractures.
Ahlers S. J., van der Veen A. M., van Dijk M., Tibboel D., Knibbe C. A. (2010). The use of the Behavioral Pain Scale to assess pain in conscious sedated patients. Anesthesia & Analgesia, 110(1), 127–133.
Al-Moraissi E. A., Ellis E. 3rd. (2015). Local versus general anesthesia for the management of nasal bone fractures: A systematic review and meta-analysis. Journal of Oral and Maxillofacial Surgery, 73(4), 606–615.
Atighechi S., Baradaranfar M. H., Akbari S. A. (2009). Reduction of nasal bone fractures: A comparative study of general, local, and topical anesthesia techniques. Journal of Craniofacial Surgery, 20(2), 382–384.
Chadha N. K., Repanos C., Carswell A. J. (2009). Local anaesthesia for manipulation of nasal fractures: Systematic review. The Journal of Laryngology & Otology, 123(8), 830–836.
Chanques G., Jaber S., Barbotte E., Violet S., Sebbane M., Perrigault P. F., et al (2006). Impact of systematic evaluation of pain and agitation in an intensive care unit. Critical Care Medicine, 34(6), 1691–1699.
Cook J. A., McRae R. D., Irving R. M., Dowie L. N. (1990). A randomized comparison of manipulation of the fractured nose under local and general anaesthesia. Clinical Otolaryngology and Allied Sciences, 15(4), 343–346.
Hwang K., You S. H., Kim S. G., Lee S. I. (2006). Analysis of nasal bone fractures; A six-year study of 503 patients. Journal of Craniofacial Surgery, 17(2), 261–264.
Jones T. M., Nandapalan V. (1999). Manipulation of the fractured nose: A comparison of local infiltration anaesthesia and topical local anaesthesia. Clinical Otolaryngology and Allied Sciences, 24(5), 443–446.
Kim H. S., Lee H. K., Jeong H. S., Shin H. W. (2013). Decreased postoperative pain after reduction of fractured nasal bones using a nerve block of the anterior ethmoidal nerve. International Journal of Oral and Maxillofacial Surgery, 42(6), 727–731.
Murray J. A., Maran A. G. (1980). The treatment of nasal injuries by manipulation. The Journal of Laryngology & Otology, 94(12), 1405–1410.
Metzinger S. E., Bailey D. J., Boyce R. G., Lyons G. D. (1992). Local anesthesia in rhinoplasty: A new twist?Ear, Nose & Throat Journal, 71(9), 405–406.
Powell O., Doshi D. (2008). Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 4: Should nasal fractures be manipulated under local anaesthesia?Emergency Medicine Journal (EMJ), 25(8), 525–527.