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Comparison of Ultrasonography and Conventional Radiography in the Diagnosis of Nasal Fractures

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Comparison of Ultrasonography and Conventional Radiography in the Diagnosis of Nasal Fractures ORIGINAL ARTICLE Comparison of Ultrasonography and Conventional Radiography in the Diagnosis of Nasal Fractures Oliver Thiede, MD; Jan-Hendrik Krömer, MD; Claudia Rudack, MD; Wolfgang Stoll, MD; Nani Osada, MD; Frank Schmäl, MD Objective: To compare the diagnostic findings of ul- The results were analyzed by various statistical testing trasonography and radiography in nasal fractures. methods (for sensitivity, specificity, positive and nega- tive predictive value, and accuracy). Design and Main Outcome Measures: In this pro- spective study, 63 patients (23 female and 40 male; mean Results: Assessment of the lateral nasal walls revealed age, 26.8 years) with clinical signs of a nasal bone frac- that ultrasonography was statistically superior (P=.04) ture were investigated. All patients underwent radiogra- to radiography. In contrast, assessment of the nasal dor- phy (lateral view of the nose plus occipitomental view) sum showed radiography to be statistically superior and ultrasonography (10-MHz ultrasound scanner) of the (P=.01) to ultrasonography. Assessment of the nasal pyra- nasal dorsum and the lateral nasal walls and a clinical mid revealed no statistical difference between radiogra- examination by 2 consultants. Thirty-six patients under- phy and ultrasonography (P=.91). went nasal fracture reduction. Two radiographs and 3 ul- trasound images of each patient were analyzed by 2 Conclusion: In assessment of the nasal pyramid, ultra- experienced readers at different times. After assessing the sonography can be considered an alternative to radiog- nasal dorsum and lateral nasal walls in radiographs and raphy, with equivalent diagnostic performance. ultrasound images, they decided whether the nose was fractured or not or whether the results were uncertain. Arch Otolaryngol Head Neck Surg. 2005;131:434-439 ASAL FRACTURES ARE THE In addition to the clinical examina- most commonly ob- tion (crepitation, deviation from the mid- served fractures in the line, and dislocated fracture), the nasal trauma setting.1 A uni- bone fracture is often diagnosed by radi- form classification of these ography. The radiographs usually com- fractures has not been established, but there prise a lateral image of the nasal bone fo- N 2 have been some attempts to classify them. cused on the nasal dorsum and an The nasal pyramid is a complex structure occipitomental radiograph from which the consisting of the 2 nasal bones and the 2 lateral nasal walls can be assessed. The frontal processus of the maxillary bone. A need for radiography has been ques- nasal fracture can involve any part of the na- tioned by some authors,4 who find it an sal pyramid. The lateral nasal walls (cau- inappropriate means of assessing a nasal dal part of the nasal bones and parts of the fracture. However, adequate imaging of a frontal processus) and the nasal dorsum nasal fracture is often required because of (cranial part of the nasal bones), as well as legal consequences resulting from nasal the nasal septum, generally require the most fracture etiology. attention when assessing a fracture of the An alternative to radiography is ultra- nasal pyramid. sonography, a common and easy method Author Affiliations: If there are no further injuries, such as involving no additional radiation expo- Department of hematomas or expanded fractures of the na- sure. The value of ultrasonography as a di- Otorhinolaryngology, Head and sal septum, within 7 days after trauma the agnostic tool for the detection of “bone” Neck Surgery, University patient undergoes reduction of the nasal fractures (eg, in congenital hip disloca- Hospital (Drs Thiede, Krömer, fracture under local anesthesia or, in cases tion, fractures of the radial or clavicular Rudack, Stoll, and Schmäl), and of noncompliance, under general anes- bone, or fractures of the ribs or skull) has Department of Medical thesia.3 Afterward, the nose is fixed with been proven in various studies.5-8 Informatics and 9-12 Biomathematics, University a plaster cast. Some authors recommend To our knowledge, only 4 studies of Münster (Dr Osada), nasal packs to stabilize the bone frag- have dealt with the diagnosis of nasal frac- Münster, Germany. ments, especially in the case of a de- tures by ultrasound imaging. Danter et al10 Financial Disclosure: None. pressed fracture.3 used a special 20-MHz ultrasound head of (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 131, MAY 2005 WWW.ARCHOTO.COM 434 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 A B C Figure 1. Defined positions of the ultrasound head. A, Right lateral wall. B, Left lateral wall. C, Nasal dorsum. an ultrasound device to investigate nasal fractures in 18 DIAGNOSIS AND TREATMENT patients. The ultrasonographic results were compared with the clinical diagnosis (sensitivity, 83%; and specificity, Following clinical examination, a first-line imaging set of con- 50%) and with radiography findings (sensitivity, 94%; ventional radiographs (lateral view and occipitomental [or and specificity, 83%). The authors did not distinguish be- Waters] view of the nasal bones) was taken in every subject. tween the nasal dorsum and the lateral nasal walls. Fur- The radiologic management of patients was performed accord- ing to the guidelines of the German Society of Otorhinolaryn- thermore, a comparison of the radiographic findings with 11 gology, Head and Neck Surgery. The lateral view of the nose the clinical diagnosis was not performed. Kwon et al delineates fractures of the nasal dorsum, where the 2 nasal performed ultrasonography on 45 patients who were sus- bones are connected. The Waters view is used to detect frac- pected to have a nasal fracture. Ten of those patients also tures of the lateral nasal walls. Furthermore, an ultrasound underwent a computed tomographic scan. The authors examination in defined positions (Figure 1) was performed found that the ultrasound diagnosis showed a positive by 2 experienced otorhinolaryngologists (O.T. and J.-H.K.) correlation with the findings on computed tomographic using a 10-MHz ultrasound head (EUP-L34T, 3ϫ1.4 cm; scanning. Beck et al9 examined 21 patients using 5-MHz Hitachi Medical Corp, Tokyo, Japan) of a commonly used and 7.5-MHz ultrasound heads. These authors demon- ultrasound device (EUB-525RS, Hitachi Medical Corp). On strated that all fractures diagnosed by radiography also the basis of these diagnostic findings (clinical examination, radiography, and ultrasonography), a decision was made on could be detected by ultrasonography. However, they did whether there was a nasal fracture, and the treatment was not compare the ultrasonographic and radiographic re- then determined. sults with the clinical diagnosis. In 36 patients, repositioning of the fractured nasal bone was The aim of the present single-blinded study (2 inde- performed under local or general anesthesia. In most cases, na- pendent readers [F.S. and C.R.]) was to analyze the cor- sal reduction was performed by digital pressure and an eleva- relation of ultrasonography and radiography results with tor. The surgeons were asked to document all details about the the clinical and the intraoperative findings in a repre- nasal repositioning, especially the fracture location, occur- sentative number of patients. Furthermore, we ana- rence of crepitation, and type of stabilization (plaster cast or lyzed whether the 2 diagnostic methods showed differ- other). Furthermore, they were to document whether the frac- ent results based on different fracture locations. ture had been stably repositioned. After data collection for all 63 patients, 2 otorhinolaryn- gologists (F.S. and C.R.) who had more than 10 years’ clinical METHODS experience analyzed the radiographs (lateral view and occipi- tomental view of the nasal bones) and ultrasound images (right and left lateral nasal walls and nasal dorsum) at different times STUDY POPULATION without being aware of the patients’ history (single-blinded study). The sequence in which the diagnostic methods (ultra- Sixty-three patients (23 female and 40 male; mean age, 26.8 sonography and radiography) were analyzed was randomized. years) with clinical signs of a nasal fracture were enrolled in For each diagnostic method and for each fracture location (na- this prospective study. The study was carried out between Janu- sal dorsum and lateral nasal walls), the reader noted whether ary 2003 and November 2003 in accord with ethical standards there was a fracture, no fracture, or an uncertain result. The established in an appropriate version of the 1964 Declaration reader then stated whether the nasal pyramid was or was not of Helsinki. broken or whether the result was uncertain. (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 131, MAY 2005 WWW.ARCHOTO.COM 435 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 A B Figure 2. Lateral view of the nose (A) and ultrasound image (B) in a patient with a fractured nasal dorsum. Arrow indicates fracture. The ultrasonographic and radiographic results were com- be improved by reduction. Reduction of the nasal frac- pared with the diagnosis made in the outpatient clinic. The di- tures was performed under local anesthesia in 26 pa- agnosis was based on results from the clinical examination, ra- tients. In 4 patients, the nose deviated so much or these diographs, ultrasound images, and, in cases in which reduction 4 patients were so noncompliant that reduction was pos- of the nasal bone was performed, intraoperative findings. The findings were rated as “correct” if the radiography or the ul- sible only under general anesthesia. Because of a frac- trasonography result matched the clinical diagnosis. If they failed ture of the nasal septum in 5 patients, the nasal septum to match, they were rated as “incorrect.” When assessment of and the nasal fracture also had to be reconstructed. One the nose by radiography or ultrasonography was uncertain, the of these patients also had a septum hematoma. Reduc- cases were rated as “uncertain,” irrespective of whether the nose tion of the lateral nasal walls was possible in all but 1 pa- was broken.
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