ANESTHESIA/FACIAL PAIN Local Versus General Anesthesia for the Management of Nasal Bone Fractures: A Systematic Review and Meta-Analysis Essam Ahmed Al-Moraissi, BDS, MSc, PhD, * and Edward Ellis III, DDS, MSy Purpose: The aim of this study was to answer the following question: in patients with nasal bone frac- tures (NBFs), does closed reduction under local anesthesia (LA) produce comparable outcomes as closed reduction under general anesthesia (GA)? Materials and Methods: A systematic review with meta-analysis and a comprehensive electronic search without date and language restrictions was performed in August 2014. The inclusion criteria were studies in humans, including randomized or quasi-randomized controlled trials (RCTs), controlled clinical trials (CCTs), and retrospective studies whose aim was comparing clinical outcomes between LA and GA for closed reduction of NBFs. Results: Eight publications were included: 3 RCTs, 2 CCTs, and 3 retrospective studies. Three studies showed a low risk of bias, and 5 studies showed a moderate risk of bias. There was no statistical difference between LA and GA for closed reduction of NBFs with regard to patient satisfaction with anesthesia, patient satisfaction with function of the nose, need for subsequent retreatment (septoplasty, septorhino- plasty, or rhinoplasty with refracture), and a patient’s chosen treatment for a refracture of the nose. There was a statistical difference between LA and GA for closed reduction of NBFs with regard to patient satis- faction with the appearance of the nose. Conclusion: Regardless of the cost and risks associated with GA, the results of the meta-analysis showed that GA provides better patient satisfaction with anesthesia, appearance and function of the nose, and pref- erence of treatment for a refracture of the nose. In addition, the meta-analysis showed that GA decreased the number of subsequent corrective surgeries (septoplasty, septorhinoplasty, and rhinoplasty) required. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:606-615, 2015 The central position of the nose and its anterior pro- jection on the face make it susceptible to injury, so it should not be surprising that fractures of the nasal bones are the most common facial fractures (39 to 45% of all facial fractures) and the third most com- mon fracture in the human skeleton. 1,2 Like other facial fractures, the male-to-female ratio for nasal fractures is greater than 2:1. 2 The incidence peaks bi-modally in patients 15 to 30 years old and in the elderly, in whom a small increase is related to falls. 2 Most nasal fractures in young adults are due to assaults, sports, and, less commonly, motor vehicle accidents. 2-6 The incidence and association with alcohol vary according to the study location. 2-6 Fracture of the nasal bones is suggested by external nasal deformity, crepitus, or palpably mobile bony segments. 5 Epistaxis and pain are common symptoms, and these can be accompanied by ecchymosis of the periorbital soft tissues (black eyes) and nasal obstruction, especially if the septum Received from Department of Oral and Maxillofacial Surgery, Faculty of Oral and Dental Medicine, Cairo University, Egypt. *Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Thamar, Yemen. yProfessor and Chair, Department of Oral and Maxillofacial Surgery, University of Texas Health Science Center, San Antonio, TX. Conflict of Interest Disclosures: None of the authors reported any disclosures. Address correspondence and reprint requests to Dr Al-Moraissi: Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Redaa Street, Thamar, Yemen; e-mail: [email protected]Received September 9 2014 Accepted October 13 2014 Ó 2015 American Association of Oral and Maxillofacial Surgeons 0278-2391/14/01612-7 http://dx.doi.org/10.1016/j.joms.2014.10.013 606
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Local Versus General Anesthesia for the Management of Nasal Bone Fracture
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ANESTHESIA/FACIAL PAIN
Rec
of O
Sur
Sur
dis
De
Local Versus General Anesthesia for theManagement of Nasal Bone Fractures:A Systematic Review and Meta-Analysis
eived f
ral an
*Assista
gery, Fa
yProfesgery, U
Conflic
closure
Addres
partme
Essam Ahmed Al-Moraissi, BDS, MSc, PhD,* and Edward Ellis III, DDS, MSy
Purpose: The aim of this study was to answer the following question: in patients with nasal bone frac-
tures (NBFs), does closed reduction under local anesthesia (LA) produce comparable outcomes as closed
reduction under general anesthesia (GA)?
Materials and Methods: A systematic review with meta-analysis and a comprehensive electronic
search without date and language restrictions was performed in August 2014. The inclusion criteria
were studies in humans, including randomized or quasi-randomized controlled trials (RCTs), controlled
clinical trials (CCTs), and retrospective studies whose aim was comparing clinical outcomes between
LA and GA for closed reduction of NBFs.
Results: Eight publications were included: 3 RCTs, 2 CCTs, and 3 retrospective studies. Three studies
showed a low risk of bias, and 5 studies showed a moderate risk of bias. There was no statistical difference
between LA and GA for closed reduction of NBFs with regard to patient satisfaction with anesthesia,patient satisfaction with function of the nose, need for subsequent retreatment (septoplasty, septorhino-
plasty, or rhinoplasty with refracture), and a patient’s chosen treatment for a refracture of the nose. There
was a statistical difference between LA and GA for closed reduction of NBFs with regard to patient satis-
faction with the appearance of the nose.
Conclusion: Regardless of the cost and risks associated with GA, the results of the meta-analysis showed
that GA provides better patient satisfactionwith anesthesia, appearance and function of the nose, and pref-
erence of treatment for a refracture of the nose. In addition, the meta-analysis showed that GA decreased
the number of subsequent corrective surgeries (septoplasty, septorhinoplasty, and rhinoplasty) required.
� 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 73:606-615, 2015
The central position of the nose and its anterior pro-jection on the face make it susceptible to injury, so
it should not be surprising that fractures of the nasal
bones are the most common facial fractures (39 to
45% of all facial fractures) and the third most com-
mon fracture in the human skeleton.1,2 Like other
facial fractures, the male-to-female ratio for nasal
fractures is greater than 2:1.2 The incidence peaks
bi-modally in patients 15 to 30 years old and inthe elderly, in whom a small increase is related to
romDepartment of Oral and Maxillofacial Surgery, Faculty
d Dental Medicine, Cairo University, Egypt.
nt Professor, Department of Oral and Maxillofacial
culty of Dentistry, Thamar University, Thamar, Yemen.
sor and Chair, Department of Oral and Maxillofacial
niversity of Texas Health Science Center, San Antonio, TX.
t of Interest Disclosures: None of the authors reported any
s.
s correspondence and reprint requests to Dr Al-Moraissi:
nt of Oral and Maxillofacial Surgery, Faculty of Dentistry,
606
falls.2 Most nasal fractures in young adults are dueto assaults, sports, and, less commonly, motor
vehicle accidents.2-6 The incidence and association
with alcohol vary according to the study
location.2-6 Fracture of the nasal bones is suggested
by external nasal deformity, crepitus, or palpably
mobile bony segments.5 Epistaxis and pain are
common symptoms, and these can be accompanied
by ecchymosis of the periorbital soft tissues (blackeyes) and nasal obstruction, especially if the septum
managed in different ways and not all are equally effec-tive. For NBFs, there are 3 major aspects to consider to
ensure the best treatment: the timing of treatment, the
choice of anesthetic (local or general), and surgical
technique (open or closed reduction).11 There are
different opinions about the most appropriate timing
of treatment and a surgeon’s preference often has
much to do with the decision about when to inter-
vene.11 Some injuries might require immediate atten-tion, whereas others might be better treated after a
delay.11 Often, the swelling is so severe that closed
treatment in the acute setting is not performed
because it would be difficult to determine whether
the nasal bones were properly reduced. Another com-
mon reason for delaying surgery is the surgeon’s
to patient satisfaction with anesthesia. CI, confidence interval; GA,
Maxillofac Surg 2015.
FIGURE 3. Forest plot of LA versus GA for nasal bone fractures according to patient satisfaction with function of the nose. CI, confidenceinterval; GA, general anesthesia; LA, local anesthesia; M-H, Mantel-Haenszel.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
612 LA VERSUS GA IN THE MANIPULATION OF NBFS
philosophy. One has the choice of reducing the nasal
bones back into the pre-trauma position or performing
a rhinoplasty to obtain a result that might be better
than what the patient had before the injury. Many pa-tients have pre-existing nasal and septal deformities.
To merely reduce the bones back into the malposition
they were in before injury does not provide improve-
ment for the patient. It only restores what the patient
had before injury. Therefore, if a surgeon’s philosophy
is to improve the patient’s appearance and nasal
airway, the surgeonmight choose to delay surgery, lett-
ing the bones heal in a malunited position, so thebones can be refractured or repositioned using formal
septorhinoplasty or rhinoplasty techniques that can
address the internal and external components of
the nose.
One of the major variables in the treatment of nasal
fractures is in the choice of anesthetic. Most rhinoplas-
tic surgeons use GA when performing a formal rhino-
plasty. However, the patient who presents to theemergency room with a displaced NBF often will be
treated under LA (possibly with the addition of seda-
tion) to facilitate treatment. However, this takes a
very cooperative patient to merely withstand the
pain of instillation of LA in and around the nose. If a pa-
tient is not cooperative, a general anesthetic will
become necessary. However, if a patient needs to be
treated acutely and requires a general anesthetic, get-ting a patient to the operating room for a general anes-
thetic requires paperwork and takes away 1 of the
variables under the surgeon’s control—the timing of
treatment. If the surgeon can manage the patient in
the emergency room using LA, the patient can be
readily treated and discharged. If instead a general
anesthetic is preferred or required, one has the
FIGURE 4. Forest plot of LA versus GA for nasal bone fractures accordinginterval; GA, general anesthesia; LA, local anesthesia; M-H, Mantel-Haen
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral
additional variables of availability of anesthetic, oper-
ating room personnel, and operating room time. This
might not be expeditious. Conceivably, the surgery
might not be possible for hours and this can greatly up-set the surgeon’s schedule. This also could be a reason
why patients who do not require acute care are dis-
charged and treated on a secondary basis, weeks to
months later. It puts the timing of treatment back un-
der the surgeon’s control.
Is there a difference in the outcomes of primary
treatment of nasal fractures based on the type of anes-
thetic used during treatment? The results of this studyshowed that although there was a trend toward better
outcomes with GA, there was no a statistically mean-
ingful difference between LA and GA for closed reduc-
tion of NBFs with regard to patient satisfaction with
anesthesia, function of the nose, subsequent treat-
ments (septoplasty, septorhinoplasty, rhinoplasty and
refracture), or preference of anesthesia if the nose
were to refracture. This is in accord with the previousliterature.7,10,20-25
All previous studies have shown that LA techniques
are safe, effective, and comparable to GA in the manip-
ulation of NBFs, but there was no evidence to support
or refute the superiority of one technique over
another. To the best of the authors’ knowledge this
is the first meta-analyses comparing LA with GA in
closed reduction of NBFs. In addition to providingcomparable efficacy to GA, LA offers greater safety,
lower cost, use of fewer hospital resources, and less
time in the hospital.
Therefore, LA is appropriate for cooperative adults
with simple nasal fractures that do not require open
reduction of the septum. Certainly, GA also can be
used in such cases, but most resort to using GA for
to patient satisfaction with appearance of the nose. CI, confidenceszel.
Maxillofac Surg 2015.
FIGURE 5. Forest plot of LA versus GA for nasal bone fractures according to subsequent corrective surgeries. CI, confidence interval;GA, general anesthesia; LA, local anesthesia; M-H, Mantel-Haenszel.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
FIGURE 6. Forest plot of LA versus GA for nasal bone fractures according to patient preference for treatment if the nose were to refracture.CI, confidence interval; GA, general anesthesia; LA, local anesthesia; M-H, Mantel-Haenszel.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
AL-MORAISSI AND ELLIS 613
FIGURE 7. Funnel plot of publication bias according to the reported incidence of subsequent corrective surgeries, showing a symmetric dis-tribution.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
614 LA VERSUS GA IN THE MANIPULATION OF NBFS
uncooperative or young patients, those with severely
displaced fractures, and those who require extensive
septal work.
Although treatment of NBFs under GA is more
costly, it is welcomed by many patients who ‘‘don’t
want to be awake’’ during the surgery. Three studies
in the present analysis assessed postoperative pain us-ing pain scores,20,22,26 but they did not report the
standard deviation needed to performed meta-
analysis for the outcome of pain. Not surprisingly, pa-
tients treated under GA obtained better outcomes
than under LA and this might be due to patients expe-
riencing less pain. Nasal instrumentation can be
considered barbaric to patients and their families and
the request for GA is not uncommon.25 Although GAhas some potential risks, such as adverse effects of
anesthetic drugs, for healthy patients, the risk is minor.
In conclusion, regardless of the cost and risks associ-
ated with GA, the results of the meta-analysis showed
that GA provides a trend toward better outcomes with
GA for satisfaction with anesthesia, function of the
plasty, rhinoplasty and refracture), and patients’ prefer-ence of anesthesia if they were to refracture their nose.
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