Accepted Manuscript Comparison of ultrasonography-assisted closed reduction with conventional closed reduction for the treatment of acute nasal fractures Tetsuji Yabe , M.D., Ph.D. Tomoyuki Tsuda , M.D. Shunsuke Hirose , M.D. Toshiyuki Ozawa , M.D., Ph.D. Katsuya Kawai , M.D., Ph.D. PII:
S1748-6815(14)00285-X
DOI:
10.1016/j.bjps.2014.05.043
Reference:
PRAS 4227
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 20 January 2014 Revised Date:
16 May 2014
Accepted Date: 20 May 2014
Please cite this article as: Yabe T, Tsuda T, Hirose S, Ozawa T, Kawai K, Comparison of ultrasonography-assisted closed reduction with conventional closed reduction for the treatment of acute nasal fractures, British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.05.043. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Comparison
of
ultrasonography-assisted
closed
reduction
with
conventional closed reduction for the treatment of acute nasal fractures
Tetsuji Yabe, M.D., Ph.D.*; Tomoyuki Tsuda, M.D.*;
RI PT
Brief title: Intraoperative ultrasonography in acute nasal fractures
SC
Shunsuke Hirose, M.D.*; Toshiyuki Ozawa, M.D., Ph.D. *;
M AN U
Katsuya Kawai, M.D., Ph.D.†
*Department of Plastic and Reconstructive Surgery, Ishikiri-Seiki Hospital, 18-28, Yayoi-cho, Higashi-Osaka City, Osaka 579-8026, Japan †Department of Plastic and Reconstructive Surgery, Graduate School of
606-8507, Japan
TE D
Medicine, Kyoto University, 54, Kawahara-cho Shogoin, Sakyo-ku, Kyoto
EP
Address correspondence to: Tetsuji Yabe M.D., Department of Plastic
AC C
Surgery, Ishikiri-Seiki Hospital, 18-28, Yayoi-cho, Higashi-Osaka City, Osaka 579-8026, Japan
Phone number: (81) 0729-88-3121, Fax number: (81) 0729-86-3860 E-mail address: [email protected]
1
ACCEPTED MANUSCRIPT
Summary Ultrasonography has often been reported to be a useful tool in cases of nasal fracture, not only for diagnosing such fractures, but also for
RI PT
intraoperatively assessing surgical outcomes. In this study, we examined the utility of ultrasonography for intraoperatively assessing the results of surgery for acute nasal fractures. In the conventional group, the outcome of
SC
each fracture reduction procedure was intraoperatively confirmed by visual inspection and palpation. In the ultrasound group, intraoperative
M AN U
ultrasonography was used to assess the condition of the fracture before and after closed reduction. The outcomes of the reduction procedures and the reoperation rate were compared between the two groups. According to computed tomography-based evaluations, there were no significant
TE D
differences in the outcomes of the reduction procedures between the two groups (p >0.05). As for the reoperation rate, 2 patients (2.8%) in the conventional group underwent reoperations, but no patients (0%) required
EP
reoperations in the ultrasound group. However, the difference in the reoperation rate between the two groups was not significant (p >0.05).
AC C
These results indicate that visual inspection and palpation are as reliable as ultrasonography for intraoperatively assessing the outcomes of surgery for acute nasal fractures. Surgeons should not depend on ultrasonography alone, but rather should use it in addition to visual inspection and palpation.
Keywords:
nasal
fracture,
ultrasonography,
intraoperative utility, reoperation 2
closed
reduction,
ACCEPTED MANUSCRIPT
Introduction Recently, ultrasonography has often been reported to be useful in cases of facial fracture
1 - 8)
. In most of these reports, ultrasonography was used for
RI PT
fracture diagnosis, but it can also be used to aid surgical operations. During an operation, it is very useful to be able to assess the outcome of a fracture reduction procedure with ultrasonography, especially in cases involving
SC
nasal fractures, which are almost always repaired using closed reduction. At our institution, ultrasonography has been used to assess the condition of
M AN U
acute nasal fractures before and after closed reduction since April 2010. In this study, we compared ultrasonography-assisted closed reduction with conventional closed reduction as treatments for acute nasal fractures.
TE D
Materials and Methods
Between January 2008 and December 2009, 81 consecutive patients with acute nasal fractures underwent closed reduction without ultrasonography
consecutive
EP
(conventional group), and between January 2011 and December 2012 94 patients
with
acute
nasal
fractures
underwent
AC C
ultrasonography-assisted closed reduction (ultrasound group). The patients treated in 2010 were excluded because there was a period of trial and error during which the surgeons were figuring out how ultrasonography should be used to facilitate surgery for acute nasal fractures. In addition, the ultrasound apparatus was changed during that period. The outcomes of the reduction procedures and the reoperation rate were compared between the two groups. Statistical comparisons were performed using the Chi-squared
3
ACCEPTED MANUSCRIPT
test, Student's t-test, Fisher’s exact test, or Mann-Whitney test.
Surgical Procedure
RI PT
Ketamine-induced (1 mg/kg) intravenous anesthesia was usually employed, but general anesthesia was induced in small children and adults who requested it. Before the reduction procedure, intranasal packing
SC
soaked in 1% lidocaine and 0.01% adrenalin was installed for a few minutes. The closed reduction was performed with Walsham forceps and a
M AN U
Langenbeck elevator. In the ultrasound group, we used ultrasonography (SonoSite S-Nerve™, FUJIFIIM SonoSite, Inc., Tokyo, Japan) to intraoperatively assess the condition of each fracture before and after the closed reduction procedure. A transducer cover filled with physiological
TE D
saline solution was used as the coupling agent (Fig. 1). After the reduction procedure, intranasal packing was inserted, and an external splint was applied to support the bone fragment. The gauze used for the intranasal
EP
packing was left in place for 4 or 5 days, and the external splint was
AC C
applied for 2 weeks.
Classification of Acute Nasal Fractures Using a previously reported classification system 9), the nasal fractures were categorized into the following 5 types based on computed tomography (CT) images and lateral view x-rays: Unilateral type (U type): Unilateral nasal bone displacement but no posterior displacement (Fig. 2). 4
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Bilateral type (B type): Bilateral nasal bone displacement but no posterior displacement (Fig. 3). Frontal type (F type): Posterior nasal bone displacement but no lateral
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displacement (Fig. 4).
Laterofrontal type (L type): Both bilateral nasal bone displacement and posterior displacement (Fig. 5).
SC
Comminuted type (C type): The nasal bone had been broken into several
M AN U
pieces, and its shape had been markedly distorted (Fig. 6).
Evaluation of the Outcomes of the Reduction Procedures The outcomes of the reduction procedures were evaluated using postoperative CT scans and lateral view x-rays and were classified as
TE D
follows:
Good: No displacement or only slight irregularities were observed on CT scans or lateral view x-rays, and a good arch shape had been restored (Fig.
EP
2).
Fair: Slight displacement was observed on CT scans or lateral view x-rays,
AC C
but the shape of the arch had almost been restored (Fig. 5). Poor: There was no improvement or the shape of the arch had not been restored. Obvious displacement was observed on both CT scans and lateral view x-rays (Fig. 6).
Results In the conventional group, there were 71 males and 10 females (age range: 5
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from 7 to 76 years, mean age: 25.5 years), whereas in the ultrasound group there were 73 males and 21 females (age range: from 7 to 84 years, mean age: 27.1 years). There were no significant differences between the two
RI PT
groups in terms of sex (Chi-squared test) or age (Student's t-test) distribution (p >0.05).
In the conventional group, the fractures were preoperatively classified as
SC
follows (Table 1): U type, 20 patients (24.7%); B type, 36 patients (44.4%); F type, 15 patients (18.5%); L type, 9 patients (11.1%); and C type, 1
M AN U
patient (1.2%). In the ultrasound group, the fractures were preoperatively classified as follows: U type, 23 patients (24.5%); B type, 36 patients (38.3%); F type, 26 patients (27.7%); L type, 6 patients (6.4%); and C type, 3 patients (3.2%). There were no significant differences between the two
TE D
groups according to the Chi-squared test (p >0.05).
As for the outcomes of the reduction procedures, in the conventional group the fractures of 58 (71.6%), 18 (22.2%), and 5 patients (6.2%) were
EP
assessed as being in good, fair, and poor condition, respectively, whereas in the ultrasound group the fractures of 62 (65.9%), 26 (27.7%), and 6
AC C
patients (6.4%) were assessed as being in good, fair, and poor condition, respectively (Table 2). There were no significant differences between the two groups according to the Mann-Whitney test (p > 0.05). Regarding the reoperation rate after the postoperative CT evaluation, 2 patients (2.8%) in the conventional group had to undergo reoperations, but none of the patients in the ultrasound group underwent reoperations (Table 3). There were no significant differences between the two groups according 6
ACCEPTED MANUSCRIPT
to Fisher’s exact test (p >0.05).
Discussion
RI PT
Nasal fractures are the most common type of facial fracture and are usually diagnosed using x-ray radiographs and CT scans. Most nasal fractures are treated with closed reduction, and the outcomes of reduction
SC
procedures are judged by visual inspection and palpation during the operation. However, severe swelling and the small size of children’s noses
M AN U
can make such assessments difficult. Recently, ultrasonography has been reported to be useful in cases of nasal fracture, not only for diagnosis 4 – 8), but also for performing intraoperative assessments of surgical outcomes 10). In this study, we examined the utility of ultrasonography for
TE D
intraoperatively assessing the outcome of surgery for acute nasal fractures by comparing ultrasonography-assisted reduction with conventional closed reduction. The outcomes of the reduction procedures were evaluated using
EP
postoperative lateral view x-rays and CT scans. At the beginning of the study, we expected that the results of the ultrasound group would be better
AC C
than those of the conventional group. However, there were no significant differences in the outcomes of the reduction procedures or the reoperation rate between the two groups, indicating that intraoperative visual inspection and palpation are as reliable as ultrasonography. One of the disadvantages of using ultrasonography to assess nasal fractures is that some types of fracture can produce shadowing on ultrasound images. Namely, when fractured bone fragments overlap, the lower fragment can not be seen. As 7
ACCEPTED MANUSCRIPT
the nasal bone is shaped like an arch, overlapping bone fragments are often encountered, and slight overlapping after closed reduction is very difficult to detect using ultrasonography. Thus, we rely on postoperative CT more
RI PT
than intraoperative ultrasonography for assessments of the outcomes (Fig. 3). Consequently, we consider that intraoperative ultrasonography should be used to supplement visual inspection and palpation rather than replace
SC
them. Interestingly, we also found that the application of a little jelly to the fingertips or fractured region makes it is easier to determine the condition
intraoperative ultrasonography.
M AN U
of a fracture during palpation. We discovered this after we had started using
Magnetic resonance imaging (MRI) is alternative imaging tool, but it is difficult to detect nasal fractures using MRI because nasal bone is thin and
TE D
does not contain bone marrow; therefore, it is always depicted as a narrow low density region on MRI (Fig. 4).
As for pediatric nasal fractures, they are too small to be judged by
nasal
EP
palpation, but they can be easily assessed by ultrasonography because the prominence
is
AC C
ultrasonography-assisted
not
high
closed
in
children.
reduction
might
In
this
regard,
be
superior
to
conventional reduction, but there were too few pediatric patients in our study population to allow us to perform a meaningful comparison in this study. Abu-Samra M et al.
10)
reported that intraoperative ultrasound-guided
reduction is useful for treating nasal bone fractures. Although their ultrasonic reduction procedure produced better outcomes than simple 8
ACCEPTED MANUSCRIPT
closed reduction, they evaluated the outcomes of the procedures using visual inspection alone; therefore, their assessment method was less objective than ours.
RI PT
In the present study, 2 of the patients in the conventional group had to undergo reoperations due to their postoperative CT findings. On the other hand, none of the patients in the ultrasound group required reoperations.
SC
Although the indications for reoperation vary between physicians, no reoperations were required in any of the cases in which ultrasonography
M AN U
was employed, even in the cases in which the outcome of the reduction procedure was not categorized as good.
In some cases in which the reduction outcome was assessed as fair or poor, we considered that this was not caused by a lack of skill on the part of the
TE D
physician, but rather the condition of the fracture, e.g., it was comminuted or involved dislocated bony fragments or soft tissue invagination. In such cases, it would have been difficult to obtain further improvement by
EP
performing the closed reduction procedure again. Thus, ultrasonography allows the limitations of reduction procedures to be determined
AC C
intraoperatively; i.e., before postoperative CT examinations. In this regard, ultrasonography is considered to be useful; however, the present study did not produce any statistical evidence to confirm this.
Conclusion In this study, there were no significant differences in the outcomes of the reduction procedures or the reoperation rate between the ultrasound group 9
ACCEPTED MANUSCRIPT
and the conventional group. Therefore, it was demonstrated that visual inspection and palpation are as reliable as ultrasonography for intraoperatively assessing the outcomes of reduction procedures for acute
RI PT
nasal fractures. Surgeons should not depend on ultrasonography alone, but rather should use it to supplement visual inspection and palpation.
SC
Conflicts of interest statement
Funding: None.
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EP
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Ethical Approval: Not required.
M AN U
None of the authors have any conflicts of interest to declare.
10
ACCEPTED MANUSCRIPT
References 1.
McCann
PJ,
Brocklebank
LM,
Ayoub
AF.
Assessment
of
zygomatico-orbital complex fractures using ultrasonography. Br J Oral
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Maxillofac Surg. 2000; 38; 525-9.
2. Adeyemo WL, Akadiri OA. A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures. Int J Oral Maxillofac Surg.
SC
2011; 40; 655-61
3. Mohammadi A. Systematic review of the diagnostic role of
M AN U
ultrasonography in maxillofacial fracture. Int J Oral Maxillofac Surg. 2012 ;41:276.
4. Hong HS, Cha JG, Paik SH, et al. High-resolution sonography for nasal fracture in children. AJR Am J Roentgenol. 2007;188:W86-92.
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5. Gürkov R, Clevert D, Krause E. Sonography versus plain x rays in diagnosis of nasal fractures. Am J Rhinol. 2008; 22; 613-6. 6. Lee MH, Cha JG, Hong HS, et al. Comparison of high-resolution
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ultrasonography and computed tomography in the diagnosis of nasal fractures. J Ultrasound Med. 2009; 28; 717-23.
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7. Mohammadi A, Ghasemi-Rad M. Nasal bone fracture -- ultrasonography or computed tomography? Med Ultrason. 2011; 13; 292-5. 8. Lou YT, Lin HL, Lee SS, et al. Conductor-assisted nasal sonography: an innovative technique for rapid and accurate detection of nasal bone fracture. J Trauma Acute Care Surg. 2012; 72: 306-11. 9. Yabe T, Ozawa T, Sakamoto M, Ishii M. Pre- and postoperative x-ray and computed tomography evaluation in acute nasal fracture. Ann Plast 11
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Surg. 2004; 53; 547-53. 10. Abu-Samra M, Selmi G, Mansy H, Agha M. Role of intra-operative ultrasound-guided reduction of nasal bone fracture in patient satisfaction
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and patient nasal profile (a randomized clinical trial). Eur Arch Otorhinolaryngol. 2011; 268; 541-46.
SC
Figure legends
Fig. 1 Intraoperative evaluation with ultrasonography.
M AN U
A transducer cover filled with physiological saline solution was used as the coupling agent.
Fig. 2 (Left) A fracture that was preoperatively classified as belonging to the unilateral type.
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(Right) Postoperatively, the outcome of the reduction procedure was evaluated as good. No residual displacement was observed. Fig. 3 (Left) A fracture that was preoperatively classified as belonging to
EP
the bilateral type.
(Center) After closed reduction, slight overlapping remained, but it was
AC C
difficult to detect using ultrasonography. (Right) Postoperatively, CT clearly shows the overlapping bone fragments. Fig. 4 (Left) A fracture that was preoperatively classified as belonging to the frontal type. (Right) Nasal bone is depicted as a low density region on MRI images; thus, it is difficult to evaluate fractures using MRI. Fig. 5 (Left) A fracture that was preoperatively classified as belonging to 12
ACCEPTED MANUSCRIPT
the laterofrontal type. (Right) Postoperatively, the outcome of the reduction procedure was evaluated as fair.
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Fig. 6 (Left) A fracture that was preoperatively classified as belonging to the comminuted type.
(Right) Postoperatively, the outcome of the reduction procedure was
SC
evaluated as poor.
M AN U
Table 1
Preoperative assessment of fracture type Table 2
Postoperative assessment of the outcomes of the reduction procedures
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EP
Reoperation rate
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Table 3
13
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Table 1 B type 20
Ultrasound group, n
23
L-F type
C type
36
15
9
1
36
26
6
3
M AN U
Conventional group, n
F type
SC
U type
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EP
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There were no significant differences between the two groups according to the Chi-squared test (p > 0.05).
1
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Table 2 Fair 58
Ultrasound group, n
62
18
5
26
6
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Conventional group, n
Poor
SC
Good
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EP
TE D
There were no significant differences between the two groups according to the Mann-Whitney test (p > 0.05).
1
Table 3
Conventional group, n
79
Ultrasound group, n
94
SC
Reoperation (+)
M AN U
Reoperation (-)
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2 0
AC C
EP
according to Fisher’s exact test (p > 0.05).
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There were no significant differences between the two groups
1
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EP
TE D
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SC
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EP
TE D
M AN U
SC
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EP
TE D
M AN U
SC
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EP
TE D
M AN U
SC
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EP
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SC
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EP
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SC
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S1748-6815(14)00285-X
DOI:
10.1016/j.bjps.2014.05.043
Reference:
PRAS 4227
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 20 January 2014 Revised Date:
16 May 2014
Accepted Date: 20 May 2014
Please cite this article as: Yabe T, Tsuda T, Hirose S, Ozawa T, Kawai K, Comparison of ultrasonography-assisted closed reduction with conventional closed reduction for the treatment of acute nasal fractures, British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.05.043. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Comparison
of
ultrasonography-assisted
closed
reduction
with
conventional closed reduction for the treatment of acute nasal fractures
Tetsuji Yabe, M.D., Ph.D.*; Tomoyuki Tsuda, M.D.*;
RI PT
Brief title: Intraoperative ultrasonography in acute nasal fractures
SC
Shunsuke Hirose, M.D.*; Toshiyuki Ozawa, M.D., Ph.D. *;
M AN U
Katsuya Kawai, M.D., Ph.D.†
*Department of Plastic and Reconstructive Surgery, Ishikiri-Seiki Hospital, 18-28, Yayoi-cho, Higashi-Osaka City, Osaka 579-8026, Japan †Department of Plastic and Reconstructive Surgery, Graduate School of
606-8507, Japan
TE D
Medicine, Kyoto University, 54, Kawahara-cho Shogoin, Sakyo-ku, Kyoto
EP
Address correspondence to: Tetsuji Yabe M.D., Department of Plastic
AC C
Surgery, Ishikiri-Seiki Hospital, 18-28, Yayoi-cho, Higashi-Osaka City, Osaka 579-8026, Japan
Phone number: (81) 0729-88-3121, Fax number: (81) 0729-86-3860 E-mail address: [email protected]
1
ACCEPTED MANUSCRIPT
Summary Ultrasonography has often been reported to be a useful tool in cases of nasal fracture, not only for diagnosing such fractures, but also for
RI PT
intraoperatively assessing surgical outcomes. In this study, we examined the utility of ultrasonography for intraoperatively assessing the results of surgery for acute nasal fractures. In the conventional group, the outcome of
SC
each fracture reduction procedure was intraoperatively confirmed by visual inspection and palpation. In the ultrasound group, intraoperative
M AN U
ultrasonography was used to assess the condition of the fracture before and after closed reduction. The outcomes of the reduction procedures and the reoperation rate were compared between the two groups. According to computed tomography-based evaluations, there were no significant
TE D
differences in the outcomes of the reduction procedures between the two groups (p >0.05). As for the reoperation rate, 2 patients (2.8%) in the conventional group underwent reoperations, but no patients (0%) required
EP
reoperations in the ultrasound group. However, the difference in the reoperation rate between the two groups was not significant (p >0.05).
AC C
These results indicate that visual inspection and palpation are as reliable as ultrasonography for intraoperatively assessing the outcomes of surgery for acute nasal fractures. Surgeons should not depend on ultrasonography alone, but rather should use it in addition to visual inspection and palpation.
Keywords:
nasal
fracture,
ultrasonography,
intraoperative utility, reoperation 2
closed
reduction,
ACCEPTED MANUSCRIPT
Introduction Recently, ultrasonography has often been reported to be useful in cases of facial fracture
1 - 8)
. In most of these reports, ultrasonography was used for
RI PT
fracture diagnosis, but it can also be used to aid surgical operations. During an operation, it is very useful to be able to assess the outcome of a fracture reduction procedure with ultrasonography, especially in cases involving
SC
nasal fractures, which are almost always repaired using closed reduction. At our institution, ultrasonography has been used to assess the condition of
M AN U
acute nasal fractures before and after closed reduction since April 2010. In this study, we compared ultrasonography-assisted closed reduction with conventional closed reduction as treatments for acute nasal fractures.
TE D
Materials and Methods
Between January 2008 and December 2009, 81 consecutive patients with acute nasal fractures underwent closed reduction without ultrasonography
consecutive
EP
(conventional group), and between January 2011 and December 2012 94 patients
with
acute
nasal
fractures
underwent
AC C
ultrasonography-assisted closed reduction (ultrasound group). The patients treated in 2010 were excluded because there was a period of trial and error during which the surgeons were figuring out how ultrasonography should be used to facilitate surgery for acute nasal fractures. In addition, the ultrasound apparatus was changed during that period. The outcomes of the reduction procedures and the reoperation rate were compared between the two groups. Statistical comparisons were performed using the Chi-squared
3
ACCEPTED MANUSCRIPT
test, Student's t-test, Fisher’s exact test, or Mann-Whitney test.
Surgical Procedure
RI PT
Ketamine-induced (1 mg/kg) intravenous anesthesia was usually employed, but general anesthesia was induced in small children and adults who requested it. Before the reduction procedure, intranasal packing
SC
soaked in 1% lidocaine and 0.01% adrenalin was installed for a few minutes. The closed reduction was performed with Walsham forceps and a
M AN U
Langenbeck elevator. In the ultrasound group, we used ultrasonography (SonoSite S-Nerve™, FUJIFIIM SonoSite, Inc., Tokyo, Japan) to intraoperatively assess the condition of each fracture before and after the closed reduction procedure. A transducer cover filled with physiological
TE D
saline solution was used as the coupling agent (Fig. 1). After the reduction procedure, intranasal packing was inserted, and an external splint was applied to support the bone fragment. The gauze used for the intranasal
EP
packing was left in place for 4 or 5 days, and the external splint was
AC C
applied for 2 weeks.
Classification of Acute Nasal Fractures Using a previously reported classification system 9), the nasal fractures were categorized into the following 5 types based on computed tomography (CT) images and lateral view x-rays: Unilateral type (U type): Unilateral nasal bone displacement but no posterior displacement (Fig. 2). 4
ACCEPTED MANUSCRIPT
Bilateral type (B type): Bilateral nasal bone displacement but no posterior displacement (Fig. 3). Frontal type (F type): Posterior nasal bone displacement but no lateral
RI PT
displacement (Fig. 4).
Laterofrontal type (L type): Both bilateral nasal bone displacement and posterior displacement (Fig. 5).
SC
Comminuted type (C type): The nasal bone had been broken into several
M AN U
pieces, and its shape had been markedly distorted (Fig. 6).
Evaluation of the Outcomes of the Reduction Procedures The outcomes of the reduction procedures were evaluated using postoperative CT scans and lateral view x-rays and were classified as
TE D
follows:
Good: No displacement or only slight irregularities were observed on CT scans or lateral view x-rays, and a good arch shape had been restored (Fig.
EP
2).
Fair: Slight displacement was observed on CT scans or lateral view x-rays,
AC C
but the shape of the arch had almost been restored (Fig. 5). Poor: There was no improvement or the shape of the arch had not been restored. Obvious displacement was observed on both CT scans and lateral view x-rays (Fig. 6).
Results In the conventional group, there were 71 males and 10 females (age range: 5
ACCEPTED MANUSCRIPT
from 7 to 76 years, mean age: 25.5 years), whereas in the ultrasound group there were 73 males and 21 females (age range: from 7 to 84 years, mean age: 27.1 years). There were no significant differences between the two
RI PT
groups in terms of sex (Chi-squared test) or age (Student's t-test) distribution (p >0.05).
In the conventional group, the fractures were preoperatively classified as
SC
follows (Table 1): U type, 20 patients (24.7%); B type, 36 patients (44.4%); F type, 15 patients (18.5%); L type, 9 patients (11.1%); and C type, 1
M AN U
patient (1.2%). In the ultrasound group, the fractures were preoperatively classified as follows: U type, 23 patients (24.5%); B type, 36 patients (38.3%); F type, 26 patients (27.7%); L type, 6 patients (6.4%); and C type, 3 patients (3.2%). There were no significant differences between the two
TE D
groups according to the Chi-squared test (p >0.05).
As for the outcomes of the reduction procedures, in the conventional group the fractures of 58 (71.6%), 18 (22.2%), and 5 patients (6.2%) were
EP
assessed as being in good, fair, and poor condition, respectively, whereas in the ultrasound group the fractures of 62 (65.9%), 26 (27.7%), and 6
AC C
patients (6.4%) were assessed as being in good, fair, and poor condition, respectively (Table 2). There were no significant differences between the two groups according to the Mann-Whitney test (p > 0.05). Regarding the reoperation rate after the postoperative CT evaluation, 2 patients (2.8%) in the conventional group had to undergo reoperations, but none of the patients in the ultrasound group underwent reoperations (Table 3). There were no significant differences between the two groups according 6
ACCEPTED MANUSCRIPT
to Fisher’s exact test (p >0.05).
Discussion
RI PT
Nasal fractures are the most common type of facial fracture and are usually diagnosed using x-ray radiographs and CT scans. Most nasal fractures are treated with closed reduction, and the outcomes of reduction
SC
procedures are judged by visual inspection and palpation during the operation. However, severe swelling and the small size of children’s noses
M AN U
can make such assessments difficult. Recently, ultrasonography has been reported to be useful in cases of nasal fracture, not only for diagnosis 4 – 8), but also for performing intraoperative assessments of surgical outcomes 10). In this study, we examined the utility of ultrasonography for
TE D
intraoperatively assessing the outcome of surgery for acute nasal fractures by comparing ultrasonography-assisted reduction with conventional closed reduction. The outcomes of the reduction procedures were evaluated using
EP
postoperative lateral view x-rays and CT scans. At the beginning of the study, we expected that the results of the ultrasound group would be better
AC C
than those of the conventional group. However, there were no significant differences in the outcomes of the reduction procedures or the reoperation rate between the two groups, indicating that intraoperative visual inspection and palpation are as reliable as ultrasonography. One of the disadvantages of using ultrasonography to assess nasal fractures is that some types of fracture can produce shadowing on ultrasound images. Namely, when fractured bone fragments overlap, the lower fragment can not be seen. As 7
ACCEPTED MANUSCRIPT
the nasal bone is shaped like an arch, overlapping bone fragments are often encountered, and slight overlapping after closed reduction is very difficult to detect using ultrasonography. Thus, we rely on postoperative CT more
RI PT
than intraoperative ultrasonography for assessments of the outcomes (Fig. 3). Consequently, we consider that intraoperative ultrasonography should be used to supplement visual inspection and palpation rather than replace
SC
them. Interestingly, we also found that the application of a little jelly to the fingertips or fractured region makes it is easier to determine the condition
intraoperative ultrasonography.
M AN U
of a fracture during palpation. We discovered this after we had started using
Magnetic resonance imaging (MRI) is alternative imaging tool, but it is difficult to detect nasal fractures using MRI because nasal bone is thin and
TE D
does not contain bone marrow; therefore, it is always depicted as a narrow low density region on MRI (Fig. 4).
As for pediatric nasal fractures, they are too small to be judged by
nasal
EP
palpation, but they can be easily assessed by ultrasonography because the prominence
is
AC C
ultrasonography-assisted
not
high
closed
in
children.
reduction
might
In
this
regard,
be
superior
to
conventional reduction, but there were too few pediatric patients in our study population to allow us to perform a meaningful comparison in this study. Abu-Samra M et al.
10)
reported that intraoperative ultrasound-guided
reduction is useful for treating nasal bone fractures. Although their ultrasonic reduction procedure produced better outcomes than simple 8
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closed reduction, they evaluated the outcomes of the procedures using visual inspection alone; therefore, their assessment method was less objective than ours.
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In the present study, 2 of the patients in the conventional group had to undergo reoperations due to their postoperative CT findings. On the other hand, none of the patients in the ultrasound group required reoperations.
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Although the indications for reoperation vary between physicians, no reoperations were required in any of the cases in which ultrasonography
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was employed, even in the cases in which the outcome of the reduction procedure was not categorized as good.
In some cases in which the reduction outcome was assessed as fair or poor, we considered that this was not caused by a lack of skill on the part of the
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physician, but rather the condition of the fracture, e.g., it was comminuted or involved dislocated bony fragments or soft tissue invagination. In such cases, it would have been difficult to obtain further improvement by
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performing the closed reduction procedure again. Thus, ultrasonography allows the limitations of reduction procedures to be determined
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intraoperatively; i.e., before postoperative CT examinations. In this regard, ultrasonography is considered to be useful; however, the present study did not produce any statistical evidence to confirm this.
Conclusion In this study, there were no significant differences in the outcomes of the reduction procedures or the reoperation rate between the ultrasound group 9
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and the conventional group. Therefore, it was demonstrated that visual inspection and palpation are as reliable as ultrasonography for intraoperatively assessing the outcomes of reduction procedures for acute
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nasal fractures. Surgeons should not depend on ultrasonography alone, but rather should use it to supplement visual inspection and palpation.
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Conflicts of interest statement
Funding: None.
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Ethical Approval: Not required.
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None of the authors have any conflicts of interest to declare.
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References 1.
McCann
PJ,
Brocklebank
LM,
Ayoub
AF.
Assessment
of
zygomatico-orbital complex fractures using ultrasonography. Br J Oral
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Maxillofac Surg. 2000; 38; 525-9.
2. Adeyemo WL, Akadiri OA. A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures. Int J Oral Maxillofac Surg.
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2011; 40; 655-61
3. Mohammadi A. Systematic review of the diagnostic role of
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ultrasonography in maxillofacial fracture. Int J Oral Maxillofac Surg. 2012 ;41:276.
4. Hong HS, Cha JG, Paik SH, et al. High-resolution sonography for nasal fracture in children. AJR Am J Roentgenol. 2007;188:W86-92.
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5. Gürkov R, Clevert D, Krause E. Sonography versus plain x rays in diagnosis of nasal fractures. Am J Rhinol. 2008; 22; 613-6. 6. Lee MH, Cha JG, Hong HS, et al. Comparison of high-resolution
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ultrasonography and computed tomography in the diagnosis of nasal fractures. J Ultrasound Med. 2009; 28; 717-23.
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7. Mohammadi A, Ghasemi-Rad M. Nasal bone fracture -- ultrasonography or computed tomography? Med Ultrason. 2011; 13; 292-5. 8. Lou YT, Lin HL, Lee SS, et al. Conductor-assisted nasal sonography: an innovative technique for rapid and accurate detection of nasal bone fracture. J Trauma Acute Care Surg. 2012; 72: 306-11. 9. Yabe T, Ozawa T, Sakamoto M, Ishii M. Pre- and postoperative x-ray and computed tomography evaluation in acute nasal fracture. Ann Plast 11
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Surg. 2004; 53; 547-53. 10. Abu-Samra M, Selmi G, Mansy H, Agha M. Role of intra-operative ultrasound-guided reduction of nasal bone fracture in patient satisfaction
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and patient nasal profile (a randomized clinical trial). Eur Arch Otorhinolaryngol. 2011; 268; 541-46.
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Figure legends
Fig. 1 Intraoperative evaluation with ultrasonography.
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A transducer cover filled with physiological saline solution was used as the coupling agent.
Fig. 2 (Left) A fracture that was preoperatively classified as belonging to the unilateral type.
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(Right) Postoperatively, the outcome of the reduction procedure was evaluated as good. No residual displacement was observed. Fig. 3 (Left) A fracture that was preoperatively classified as belonging to
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the bilateral type.
(Center) After closed reduction, slight overlapping remained, but it was
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difficult to detect using ultrasonography. (Right) Postoperatively, CT clearly shows the overlapping bone fragments. Fig. 4 (Left) A fracture that was preoperatively classified as belonging to the frontal type. (Right) Nasal bone is depicted as a low density region on MRI images; thus, it is difficult to evaluate fractures using MRI. Fig. 5 (Left) A fracture that was preoperatively classified as belonging to 12
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the laterofrontal type. (Right) Postoperatively, the outcome of the reduction procedure was evaluated as fair.
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Fig. 6 (Left) A fracture that was preoperatively classified as belonging to the comminuted type.
(Right) Postoperatively, the outcome of the reduction procedure was
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evaluated as poor.
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Table 1
Preoperative assessment of fracture type Table 2
Postoperative assessment of the outcomes of the reduction procedures
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Reoperation rate
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Table 3
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Table 1 B type 20
Ultrasound group, n
23
L-F type
C type
36
15
9
1
36
26
6
3
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Conventional group, n
F type
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U type
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There were no significant differences between the two groups according to the Chi-squared test (p > 0.05).
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Table 2 Fair 58
Ultrasound group, n
62
18
5
26
6
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Conventional group, n
Poor
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Good
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There were no significant differences between the two groups according to the Mann-Whitney test (p > 0.05).
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Table 3
Conventional group, n
79
Ultrasound group, n
94
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Reoperation (+)
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Reoperation (-)
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2 0
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according to Fisher’s exact test (p > 0.05).
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