Printer Friendly

ACCORDANCE BETWEEN CLINICAL AND RADIOLOGIC FINDINGS OF NASAL BONE FRACTURE/NAZAL KEMIK KIRIGININ KLINIK VE RADYOLOJIK BULGULARI ARASINDAKI UYUMU.

ABSTRACT

Objective: The goal of our study was to compare physical examination with plain X-ray findings in patients with a suspected nasal bone fracture (NBF).

Methods: The study included 403 patients who received a suspected NBF between 2014 and 2016; the files of these patients were retrospectively reviewed. In our tertiary hospital, patients with nasal bone trauma are principally admitted to the trauma and emergency department. Patients are first examined by a general surgeon for suspected NBF. Afterwards, lateral nasal radiography and otorhinolaryngology (ORL) consultations are requested. Presence of crepitation, radiologic findings, swelling, deviation of nasal axis, septal hematoma/fracture, and cause of trauma are all documented.

Results: The 403 patients who presented to the trauma and emergency department for suspected NBF included 274 males and 129 females, the median age was 25[+ or -]18.7 years (range, 2-106 years). When the correlation between positive clinical and radiologic findings was analyzed, crepitation was correlated with radiologic data in 155/156 (99.3%) cases, deviation of nasal axis in 135/142 (95%), septal hematoma 4/5 (80%), swelling in 103/134 (76.8%), laceration in 60/93 (64.5%), and epistaxis in 7/14 (50%). The correlation of crepitation, deviation of nasal axis, and swelling with radiologic evaluation were found statistically significant.

Conclusion: Crepitation of nasal bone, deviation of nasal axis and swelling of the nasal dorsum were significantly correlated with plain X-ray imaging that had a positive finding of fracture. We believe that these results might have practical potential for diagnostic management and save time especially in crowded emergency departments.

Keywords: Crepitation; epistaxis; nasal; nasal bone fracture; plain X-ray; septal hematoma; trauma.

OZET

Amac: Calismamizin amaci nazal kemik kirigi (NKK) olan hastalarda fizik muayene ile duz grafi bulgularini karsilastirmakti.

Yontem: Calismada, 2014-2016 yillari arasinda supheli nazal kemik frakturu tanisi alan 403 hastanin dosyalari retrospektif olarak incelendi. Ucuncu basamak hastanemizde, burun kemigi travmasi olan hastalar Travmatoloji ve Acil Cerrahi basvurusunun ardindan, NKK suphesiyle lateral burun radyografisi ile Kulak Burun Bogaz Servisi'ne konsulte edilmektedir. Hastalarin bulgulari krepitasyon, sislik, aks devisyonu ve septal hematom/kirik varligina; radyolojik bulgulara ve travmanin nedenine gore kategorize edildi.

Bulgular: Nazal kemik kirigi suphesi nedeniyle degerlendirilen 403 hastanin 274 u erkek ve 129 u kadin olup; medyan yas 25 [+ or -] 18.7 idi. (aralik; 2-106 yas) Pozitif klinik ve radyolojik bulgular arasindaki korelasyonu analiz ettigimizde radyolojik verilerde; krepitasyon 155/156 (% 99.3), aks deviasyonu 135/142 (%95), septal hematom 4/5 (% 80), sislik 103/134 (% 76.8), laserasyon 60/93 (%64.5) ve burun kanamasi 7/14(% 50) oraninda tespit edildi. Krepitasyon, aks deviasyonu ve sislik ile radyolojik degerlendirme arasindaki korelasyon istatistiksel olarak anlamli bulundu.

Sonuc: Fizik muayene ile burun kemiginin krepitasyonu, aks deviasyonu ve burun dorsumunun sismesi ile kirik bulgusu pozitif olan duz X-ray goruntuleme arasinda anlamli korelasyon gostermistir. Bu sonuclarin, ozellikle kalabalik acil servislerde tani yontemleri icin pratik bir potansiyele sahip olabilecegine ve zaman kazandiracagina inaniyoruz.

Anahtar kelimeler: Burun; krepitasyon; epistaksis; nazal; nazal kemik kirigi; direk grafi; septal hematom; travma.

INTRODUCTION

Nasal bone fracture (NBF) is the most common type of facial fracture, and the third most common fracture of the human skeleton (1, 2). Interpersonal violence and motor vehicle crashes are the main causes, and alcohol consumption is often another factor (3).

Identifying NBFs is dependent on a thorough history and physical examination (4). Patients usually present with some combination of epistaxis, edema, laceration, instability, crepitation, ecchymosis, and deformity; however, these physical findings may not always be present and are often fading (5). Although radiographic assessment (plain X-ray) is highly controversial for the clinical decision of nasal fracture in the emergency department, it is a common procedure for imaging of suspected cases. Plain X-ray has high sensitivity (88%) and specificity (95%) for NBF; however, both sensitivity and specificity is lower for fractures of the lateral nasal wall than for those of nasal bones, although the specificity is higher (75%) than the sensitivity (28%) (6). On the other hand, nasal bones are not totally ossified and fused in the pediatric population in whom X-ray has even less value (7).

Newer computed tomography (CT) scans have greater sensitivity and specificity for NBF. However, radiation exposure, high price, and lack of impact on management do not justify their use in diagnosing isolated NBFs, however, CT scans can be a valuable tool if the patient has extensive maxillofacial trauma (8).

Untreated NBFs, delayed time to treatment, traumatic edema, and occult septal injury may cause functional and cosmetic defects. Therefore, timely accurate diagnosis and appropriate intervention are important steps for the management of NBFs (4).

The goal of this study was to compare physical examinations with plain X-ray findings in patients with a suspected NBF, and also to demonstrate descriptive results in the emergency department.

MATERIALS AND METHODS

The study is a retrospective review of 403 patients who received suspected NBF between 2014 and 2016.

In our tertiary hospital, patients with nasal bone trauma are principally admitted to the trauma and emergency department. Patients are first examined by a general surgeon for suspected NBF. Afterwards, plain X-ray for lateral nasal radiography and otorhinolaryngology (ORL) consultations are requested.

Clinical and radiologic evaluation of the patient is performed by an ORL subspecialist and expert radiologist. The final diagnosis is immediately reported in case of any similarity between radiologic findings and physical examination. If there is no physical and historical clue of NBF, doubtful radiologic findings are concluded as negative.

Clinical assessment of patient by ORL subspecialists start with an inspection of the face, paying attention to the presence of any swelling and/or deviation of the nasal axis (Fig. 1). Then nasal cavity is examined with anterior rhino-endoscopy for septal hematoma and/or fracture, and presence and/or location of epistaxis. Moreover, the nasal dorsum is palpated in order to detect any sign of crepitation. Presence of crepitation, radiologic findings, swelling, deviation of the nasal axis, septal hematoma/fracture, and causes of trauma are all documented.

RESULTS

The 403 patients who presented to the trauma and emergency department for suspected NBF included 274 males and 129 females, the median age was 25[+ or -]18.7 years (range, 2-106 years). No statistically significant differences were observed in terms of sex. Moreover, NBF was found more common in patients in their second and third decades.

The causes of trauma were associated with accidents in 12 (3%) cases, falls in 134 (33.3%), violence in 75 (18.6%), and bump in 182 (45.2%) (Table 1).

Radiologic findings were positively correlated with nasal bone fracture in 240 cases. CT scans were obtained for only one case because of suspicious findings in plain X-ray.

Clinical findings included crepitation of the nasal bone in 166 patients, nasal axis deviation in 142, swelling of the nasal dorsum in 134, laceration of nasal skin in 93, epistaxis in 14, and septal hematoma in 5 patients.

When we analyzed the correlation between positive clinical and radiologic findings, we found that crepitation was correlated with radiologic data in 155/156 (99.3%) cases, deviation of nasal axis in 135/142 (95%), septal hematoma 4/5 (80%), swelling in 103/134 (76.8%), laceration in 60/93 (64.5%), and epistaxis in 7/14 (50%). The correlation of crepitation, deviation of nasal axis, and swelling with radiologic evaluation was found statistically significant (Table 2) (p<0.05).

DISCUSSION

Diagnosis of NBF is primarily clinical. Patients with acute nasal trauma may report epistaxis, nasal deformity, subconjuctival hemorrhage, pain, edema, ecchymosis or nasal obstruction. Highly suspicious signs of nasal fracture are crepitation, mucosal lacerations, septal fracture and/or dislocation, obvious concavity, and depressions of the nasal bone (8).

Radiographic assessment (plain X-ray) of nasal fracture is highly controversial for clinical decisions in the emergency department. Besides, the anatomy of the nose with cartilaginous and boney structures can cause confusion for the management of this injury (Fig. 2). For instance, plain X-Ray is usually not useful for diagnosis of NBF in the pediatric population whose nasal bones are not ossified (7). There are some more limitations of X-ray imaging. It is not capable of detecting cartilaginous fracture and there are several situations with false positive results such as soft tissue swelling, previous fracture, the presence of suture lines, developmental defects, and vascular marking. (9) Nevertheless, some studies suggest that radiography of the nose should be obtained for showing fractures and for medicolegal purposes (10, 11).

CT scans have greater sensitivity and specificity for NBF and should be obtained if there is a concern of multiple facial fractures (8, 12). CT scans are very important for detecting NBF, though in some depressed nasal fractures, lateral plain X-ray may be more useful than CT (13). Radiation exposure, higher cost, and the time-consuming nature of CT are counted among its disadvantages, thus plain X-Ray imaging for diagnostic study should be preferred (8, 14. 15). In our clinic, we order plain X-ray imaging for all patients with sole suspicion of NBF both for diagnostic workup and medicolegal purposes, and high resolution maxillofacial CT for patients with extensive trauma.

In acute trauma, a complete physical examination is mandatory. Higuera et al. classified patients with nasal trauma clinically rather than by pathologic pattern of injury. Type I trauma can be defined as soft tissue injury without any concomitant injury of nasal structures. Type II-a trauma defines a simple unilateral nondisplaced nasal bone fracture, whereas type II-b involves simple bilateral nondisplaced fracture. Type III defines simple displaced fracture, and type IV injuries are determined as closed comminuted fractures. An open comminuted fracture or any of the above types with concomitant septal hematoma, cerebrospinal fluid rhinorrhea, airway obstruction, crush injury, severe displacement or associated naso-orbito-ethmoid midface fractures are defined as type V fractures (16). Some studies suggested that the most certain sign of fracture was a tender palpable or visible deformity. Radiographs are of no real use in this assessment (8, 16). We found crepitation of the nasal bone as the most significant sign for NBF, followed by deviation of the nasal axis and swelling, respectively.

Among the external facial bones, nasal bones are the most fragile structures with the least amount of resistance to impact force (17). We found that cause of trauma was significantly related to NBF incidence and interpersonal violence was the most frequent reason. This result can be explained as impact force is directly targeted to the nasal bones. Some studies have shown that the resultant nasal fracture is associated with lateral forces (18, 19). It has been shown that the amount of force needed to create fracture in the nasal bone was approximately 24-50 kilopascals. In this type of trauma, the nasal axis may appear deviated, the sign that has better prognosis for cosmetic and functional restoration than depressed-type fracture (20). On the other hand, some studies mentioned mission of the nasal septum during nasal trauma. When damage occurs, depending on the degree of force, the septum may dislocate, flex or fracture (8, 21). However, we found that septal hematoma, which can be an indicator for septal injury, was not significantly associated with NBF. There was a paucity of cases (n=5) with septal hematoma in our cohort and new case series are needed.

We found the peak incidence of NBF in patients in their second and third decades. In this age group, resultant fractures were frequently associated with bumping and violence, respectively. This result is in agreement with studies in the literature (11, 12).

The major limitation of this study is the lack of detailed information with regard to fracture. Hence, it is difficult to comment on the exact extent of injury and classify cohorts.

CONCLUSION

Our study revealed that clinical findings such as crepitation of nasal bone, deviation of the nasal axis, and swelling of the nasal dorsum were significantly correlated with plain X-ray imaging that had a positive finding of fracture. We believe that these results might have practical potential for diagnostic management and save time, especially in crowded emergency departments.

Acknowledgment

We would like to thank David Chapman for English Editing. We would also like to thank Ozge Papakci Aydin for illustration.

Conflict of interest The authors declare that they have no conflict of interest.

REFERENCES

(1.) Rhee SC, Kim YK, Cha JH, Kang SR, Park HS. Septal fracture in simple nasal bone fracture. Plast Reconstr Surg 2004; 113:45-52.

(2.) Murray JA, Maran AG, Mackenzie IJ, Raab G. Open v closed reduction of the fractured nose. Arch Otolaryngol 1984; 110:797-802.

(3.) Carvalho TB, Cancian LR, Marques CG, Piatto VB, Maniglia JV, Molina FD. Six years of facial trauma care: an epidemiological analysis of 355 cases. Braz J Otorhinolaryngol 2010; 76:565-74.

(4.) Rohrich RJ, Adams WP, Jr. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg 2000; 106:266-73.

(5.) Schultz RC, Tremolet deVillers Y. Nasal Fractures. J Trauma Acute Care Surg 1975;15:319-27.

(6.) Gurkov R, Clevert D, Krause E. Sonography versus plain x rays in diagnosis of nasal fractures. Am J Rhinol 2008; 22:613-6.

(7.) Holt GR. Immediate open reduction of nasal septal injuries. Ear Nose Throat J 1978;57:343-54.

(8.) Perkins SW, Dayan SH. Management of nasal trauma. Aesthetic Plast Surg 2002; 26(1):3.

(9.) Basheeth N, Donnelly M, David S, Munish S. Acute nasal fracture management: A prospective study and literature review. Laryngoscope 2015;125:2677-84.

(10.) Oluwasanmi AF, Pinto AL. Management of nasal trauma--widespread misuse of radiographs. Clin Perform Qual Health Care 2000;8:83-5.

(11.) Cil Y, Kahraman E. An analysis of 45 patients with pure nasal fractures. Ulus Travma Acil cerrahi Derg 2013; 19:152-6.

(12.) Remmler D, Denny A, Gosain A, Subichin S. Role of three-dimensional computed tomography in the assessment of nasoorbitoethmoidal fractures. Ann Plast Surg 2000; 44:553-62; discussion 562-53.

(13.) Yabe T, Ozawa T, Sakamoto M, Ishii M. Pre- and postoperative x-ray and computed tomography evaluation in acute nasal fracture. Ann Plast Surg 2004; 53:547-53.

(14.) Liu C, Legocki AT, Mader NS, Scott AR. Nasal fractures in children and adolescents: Mechanisms of injury and efficacy of closed reduction. Int J Pediatr Otorhinolaryngol 2015; 79:2238-42.

(15.) Gharehdaghi J, Samadi Rad B, Ghatreh Samani V, Kolahi F, Khatami Zonoozian A, Marashian SM. Comparison of physical examination and conventional radiography in diagnosis of nasal fracture. Indian J Otolaryngol Head Neck Surg 2013; 65:304-7.

(16.) Higuera S, Lee EI, Cole P, Hollier LH, Jr., Stal S. Nasal trauma and the deviated nose. Plast Reconstr Surg 2007;120:64-75.

(17.) Hampson D. Facial injury: a review of biomechanical studies and test procedures for facial injury assessment. J Biomech 1995; 28:1-7.

(18.) Dingman R, Converse J. The clinical management of facial injuries and fractures of the facial bones. Reconstructive plastic surgery, WB Saunders, Philadelphia 1977:599-747.

(19.) Owen G, Parker A, Watson D. Fractured-nose reduction under local anaesthesia. Is it acceptable to the patient? Rhinology 1992; 30:89-96.

(20.) Stranc MF, Robertson GA. A classification of injuries of the nasal skeleton. Annals of plastic surgery 1979; 2:468-74.

(21.) Fomon S. The Surgery of Injury and Plastic Repair. Ann Surg 1940; 111:511.

(22.) Hwang K, You SH, Kim SG, Lee SI. Analysis of nasal bone fractures; a six-year study of 503 patients. J Craniofac Surg 2006; 17:261-4.

Mehmet CELIK (*), Said SONMEZ (*), Mehmet Melih CICEK (*), Levent AYDEMIR (*), Mehmet Serkan ALPASLAN (*), Senol COMOGLU (*)

(*) Istanbul University, Istanbul Faculty of Medicine, Department of Otorhinolaryngology-Head and Neck Surgery, Istanbul, TURKEY

(Corresponding author/Iletisim kurulacak yazar: mehmetcelik@istanbul.edu.tr)

Date received/Dergiye geldigi tarih: 28.03.2017 -- Date accepted/Dergiye kabul edildigi tarih: 03.04.2017
Table 1: This table demonstrates the descriptive results of the patients

Median Age (years)             25 [+ or -] 18.7
Male, n (%)                   274 (68%)
Female, n (%)                 129 (32%)
Cause of Trauma, n (%)
            * Accident         12 (3%)
            * Violence         75 (18.6%)
            * Fall            134 (33.3%)
            * Bump            182 (45.2%)

Table 2. Correlation between clinical and radiologic findings of nasal
bone fracture

Clinical Findings, n (%)      Plain X-Ray Findings    p-Value: test for

                            Negative    Positive      significant
                            n: 163      n: 240        relationship
                                                      between clinical
                                                      and radiologic
                                                      findings

Crepitation of Nasal Bone    1          155 (99.3%)   p<0.05
Swelling of Nasal Dorsum    31          103 (76.8%)   p<0.05
Nasal Septal Hematoma        1            4 (80%)     p<0.05
Laceration of Nasal Skin    33           60 (64.5%)   p<0.05
Epistaxis                    7            7 (50%)     p<0.05
Deviation of Nasal Axis      7          135 (95%)     p<0.05
Cause of Trauma, n (%)
            * Accident       4 (33.3%)    8 (66.7%)
            * Violence       9 (12%)     66 (88%)     p<0.05
            * Fall          58 (43.3%)   76 (56.7%)
            * Bump          92 (56.4%)   90 (37.6%)
COPYRIGHT 2017 AVES
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2017 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:KLINIK ARASTIRMA/ CLINICAL RESEARCH
Author:Celik, Mehmet; Sonmez, Said; Cicek, Mehmet Melih; Aydemir, Levent; Alpaslan, Mehmet Serkan; Comoglu,
Publication:Journal of Istanbul Faculty of Medicine
Article Type:Report
Date:Mar 1, 2017
Words:2756
Previous Article:BENIGN BONE AND SOFT-TISSUE TUMORS OF THE EXTREMITIES CAUSING COMPRESSION OF NERVES/SINIR BASISI YAPAN BENIGN KEMIK VE YUMUSAK DOKU TUMORLERI:...
Next Article:INFLAMATUAR BARSAK HASTALIGI OLAN HASTALARDA BLASTOCYSTIS SPP.'NIN FARKLI TANI YONTEMLERI ILE ARASTIRILMASI VE GENOTIPLENDIRILMESI/EVALUATION OF...
Topics:

Terms of use | Privacy policy | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters