Clin[ Otolaryn`ol[ 0887\ 23, 058Ð060

Efficacy of external fixation following nasal manipulation

under local anaesthesia
D[J[HOUGHTON\ Z[HANAFI\ K[PAPAKOSTAS\ M[PARTON + A[S[JONES
Department of Otolaryn`olo`y:Head and Neck Sur`ery\ Royal Liverpool University Hospital\ Liverpool\ UK

Accepted for publication 07 November 0886

HOUGHTON D[J[\ HANA Z[\ PAPAKOSTAS K[\ PARTON M[ + JONES A[S[

"0887# Clin[ Otolaryn`ol[ 23, 058Ð060

Efficacy of external fixation following nasal manipulation under local anaesthesia

Nasal fractures are one of the commonest reasons for patients being referred to ENT departments\ but
few studies have been published about the management of this condition[ In particular\ the e.cacy of
external splintage following manipulation has not been assessed[ This was a prospective randomized study\
which examined the results of manipulation under local anaesthetic and the bene_t to be gained from
external _xation with Plaster of Paris "POP# following this procedure[ Accurate measurements of the
degree of deviation of the nose pre! and post!manipulation were obtained using a camera mounted on a
specially designed frame[ Thirty!three out of 130 consecutive patients seen at a research clinic over the
course of 01 months were included in the study[ The mean deviation of the nasal bridge at presentation
was 3[01 mm[ Manipulation under local anaesthetic signi_cantly improved the degree of deviation "mean
1[36 mm\ P  9[9900\ 89) CI\ 0Ð1 mm#[ Randomization of the patients\ following manipulation\ into
POP:none!POP groups showed that external splintage of the nose appeared to be of little practical bene_t[
Keywords nose injury randomized controlled trials

Nasal manipulation following fracture can be performed
under local or general anaesthesia[ There are con~icting opi!
nions as to the most e}ective way of managing this common
condition\ ranging from open reduction under general anaes!
thesia to closed reduction under local anaesthesia[0Ð2 Evidence
in support of external _xation following the manipulation of
nasal fractures is anecdotal and at present there is no clear
consensus amongst ENT surgeons[ Problems with obtaining
reliable measurements before and after manipulation have
made it di.cult to assess the e.cacy of treatment and this
may in part account for the lack of studies[ However\ the
design of a camera frame which keeps patient|s head steady
and in a consistent position\ has recently been published[3 By
using a copy of this frame it has been possible to obtain
reliable measurements before and after manipulation[
This is a randomized controlled study\ which aims to test
the null hypothesis that there is no bene_t to be gained from
the use of Plaster of Paris "POP# as an external splint following
nasal manipulation[ The group of patients was also examined
pre! and post!manipulation in order to measure the change in
Correspondence] Mr D[J[ Houghton\ Department of Otolaryngology:
Head and Neck Surgery\ University Clinical Department\ The
Duncan Building\ Daulby Street\ Liverpool L58 2GA\ UK[
the degree of deviation brought about by manipulation of the
fracture under local anaesthesia[
Methods
Two hundred and forty!one patients were seen consecutively
at a weekly research clinic at Royal Liverpool Hospital over
01 months from July 0885[ All the patients were referred from
the hospital|s Accident and Emergency Department and were
seen at the research clinic within 0 week of presentation[ For
the _rst 4 months one ENT surgeon ran the clinic and for the
latter 6 months a second ENT surgeon ran the clinic[ The
patients were assessed by these clinicians and a decision made
as to the need for manipulation[ The inclusion criteria for the
study were that the patient had to have a clinical nasal fracture
less then 1 weeks old with deviation of the nose as determined
by the doctor and patient[ The patient had to be willing to
have the manipulation under local anaesthetic and be photo!
graphed[ Manipulation was performed under local anaes!
thesia^ the nasal bridge having been injected externally with
1) xylocaine and 0 in 79 999 adrenaline[
The measurement of outcome was the degree of lateral
deviation of the nasal bridge post!manipulation compared
with pre!manipulation[ The way in which this was measured is

Þ 0887 Blackwell Science Ltd 058

069 D[J[Hou`hton et al[

as follows[ Photographs were taken with the patient|s consent distributed and therefore a Mann!Whitney U!test for non!
immediately prior to the manipulation\ before the injection of parametric data was performed[ Ninety!_ve per cent con!
local anaesthetic\ and one week later\ using an Olympus OM _dence intervals were also calculated[ The 89) power analysis
09 camera with a 094 mm macro lens[ A camera frame based for the study was determined and is detailed in the results[
upon Prinsley|s design was used "Figure 0#[ In order to deter!
mine the reliability of the photographs the test:re!test error of
the equipment was determined by photographing 09 vol! Results
unteers on two separate occasions[
The test:re!test error for the photographic frame and the
Sixty!four patients underwent nasal manipulation[ Each of
described method of measurement\ using 09 controls\ was 9[24
these patients was randomized into a POP or none!POP
mm "range 9Ð0[4 mm#[
group[ Occasionally a patient refused the plaster in which case
Data on 22 patients was collected over the course of the
they were not included in the study[ The plaster was made _ve
year^ 14 men and eight women[ Thirteen patients underwent
layers in thickness and applied across the bridge of the nose
manipulation followed by external _xation and 19 patients
extending part!way up the forehead[ It was secured with
had manipulation without _xation[
adhesive plaster\ which the patient was told to re!apply should
The mean deviation of the nasal bridge in all 22 patients
the splint displace\ and left for 0 week[
before manipulation was 3[01 mm "range 0Ð00 mm# and the
There was a very high non!attendance at 0!week follow!up[
mean following manipulation was 1[34 mm "range 9Ð4 mm#
All of these patients were contacted in an attempt to include
"Table 0#[ This improvement in deviation was statistically
them in the study^ however\ this was mostly unsuccessful[ A
signi_cant "Mann!Whitney U!test\ two!tailed Student t!test\
total of 22 patients were included in the study 02 in the POP
P  9[9900^ 84) con_dence interval for di}erences between
group and 19 in the none!POP group[
population means] C[I[  0Ð1 mm#[
The photograph prints were all 5 in×3 in "04 cm×09 cm#
In order to show a 1!mm di}erence between the two groups
in size and were reviewed blindly by a single observer[ One
"pre! and post!manipulation paired data#\ with a power 89)
measurement of the degree of displacement was made in the
and a signi_cance level 4)\ 01 patients are required in each
following way[ Firstly\ an interpupillary line was drawn and
group[
a perpendicular line constructed from the midpoint of this to
Thirteen patients had external _xation of the nasal bridge
the distal extent of the nose[ A point one!third of the length
and 19 had no external _xation[ The mean deviation pre!
of the nose\ from the cephalic end\ was marked[ The lateral
manipulation was 3[2 mm and 3 mm and post!manipulation
deviation of the middle of the nasal bridge from this point
was 1[35 mm and 1[4 mm "POP:none!POP respectively#
was measured[
"Table 1#[ The mean improvement in the two groups was 0[7
mm "POP# and 0[4 mm "none!POP#[ This was not a stat!
STATISTICAL ANALYSIS istically signi_cant di}erence between the two groups "Mann!
Whitney U!test\ two!tailed P  9[74#[ In order to show a
The mean\ median\ variance\ SD and SEM were calculated for
1 mm di}erence between the two groups "POP:none!POP
each group[ A Shapiro!Wilk test was performed for each
unpaired data# with a power of 89) and signi_cance level of
sample analysed[ This showed that the measurements from
4)\ 13 patients are required in each group[ This drops to 00
the pre! and post!manipulation groups were not normally
patients in each group for a 2!mm di}erence "power 89)^
signi_cance level 4)#[

Table 0[ Deviation of the nasal bridge pre! and post!manipulation

in all 22 patients

Pre! Post!
manipulation manipulation

Patient numbers 22 22
Mean 3[01 1[34
Variance 3[59 1[02
SD 1[03 0[32
SEM 9[23 9[14
Median 3[99 1[99

Figure 0[ Olympus OM 09 camera with 094 mm macro lens[  P  9[9900 "two!tailed#^ 84) CI\ 0Ð1[

Þ 0887 Blackwell Science Ltd\ Clinical Otolaryn`olo`y\ 12\ 058Ð060

 External _xation of the nose 060

Table 1[ Comparison between the results of nasal manipulation in manipulation for a power 89) at a signi_cance level 4)[ This
the POP and none!POP groups rises to 86 patients in each group for a 0!mm di}erence[ This
Pre!"POP# Post!"POP# Pre!"none!POP# Post!"none!POP#
study falls just short of the required numbers to demonstrate
no di}erence between the POP:none!POP groups for a 1!mm
Numbers 02 02 19 19 di}erence[
Mean 3[29 1[35 3[99 1[49 The main reason for the reduced numbers\ despite the fact
Variance 6[89 1[33 1[63 1[05 that the research clinic ran for 01 months\ was the high non!
SD 1[70 0[45 0[54 0[36
SEM 9[26 9[22 9[67 9[32 attendance rate\ which is similar to that noted in other studies
Median 3[99 1[99 3[99 1[49 and may be in~uenced by several factors[0 It would be con!
venient to postulate that patient satisfaction with the pro!
 P  9[74 "two!tailed#^ 84) CI\ −0Ð0[ cedure led to their not attending the review appointment but
the opposite may also be the case[ The high non!attendance
is more likely to be related to the characteristics of the patients
treated\ who being for the most part young men may be
Discussion less motivated to attend for follow!up[ This does bring into
The cohort of patients who underwent nasal manipulation question patient compliance when it comes to tolerating a
under local anaesthesia showed a signi_cant improvement in POP for several days[ Whether or not applying a POP made
the degree of deviation following this procedure[ The degree any di}erence to attendance was not analysed[ Certainly\ the
of improvement may appear small "approximate mean of 1 high non!attendance rate does make a study of nasal manipu!
mm# but then so is the degree of original deviation "approxi! lation after fracture di.cult and bearing in mind that the
mate mean of 3 mm#[ This con_rms what all cosmetic nasal study has been unable to show a large e}ect from application
surgeons know\ that a few millimetres can made all the di}er! of external _xation\ some may argue that it is unnecessary[
ence to the external appearance of the nose[ This part of the In conclusion\ this study appears to con_rm that the
study was uncontrolled and so no comment can be made upon manipulation of nasal fractures under local anaesthesia is a
the e.cacy of this form of treatment when compared to other satisfactory method of treatment[ Although the study fell
treatments such as manipulation under general anaesthesia[ short of conclusively showing the POP external _xation of the
However\ these results are in keeping with results of Cook et nose post!manipulation made no di}erence statistically\ if
al[\1\2 which suggest that the results of manipulation under there is a di}erence it was not found to be of practical import!
local anaesthesia are satisfactory and compare favourably ance[
with manipulation under general anaesthesia[ Where this
study di}ers from other work\ however\ is in its measurement Acknowledgement
of outcome\ which is based upon an objective measurement
of the degree of lateral deviation\ whereas other studies rely The authors would like to thank Mr Peter Prinsley\ FRCS[
upon linear scales "0Ð4# recording the patient|s opinion as to
the results of surgery[1\2 References
The null hypothesis stating that there is no di}erence
0 MURRAY J[A[M[ + MARAN A[G[D[ "0879# The treatment of nasal
between the POP and none!POP groups cannot be accepted injuries by manipulation[ J[ Laryn`ol[ Otol[ 83\ 0394Ð0309
with certainty from the results of this study[ Although no 1 COOK J[A[\ MCRAE D[R[\ IRVING R[M[ + DOWIE L[N[ "0889# A
di}erence was identi_ed between the two groups the numbers randomized comparison of manipulation of the fractured nose
are small and there is the chance of making a Type II error[ under local and general anaesthesia[ Clin[ Otolaryn`ol[ 04\ 232Ð235
2 COOK J[A[\ MURRANT N[J[\ EVANS K[L[ + LAVELLE R[J[ "0881#
Analysis of the power of the study from the measurements
Manipulation of the fractured nose under local anaesthesia[ Clin[
made in the 22 patients at presentation\ shows that 13 patients Otolaryn`ol[ 06\ 226Ð239
would be required in each group "POP:none!POP# in order to 3 PRINSLEY P[ "0881# Measurement of nasal displacement by pho!
demonstrate a 1!mm di}erence in the degree of deviation post! tography[ J[ Laryn`ol[ Otol[ 095\ 100Ð102

Þ 0887 Blackwell Science Ltd\ Clinical Otolaryn`olo`y\ 12\ 058Ð060

Copyright of Clinical Otolaryngology & Allied Sciences is the property of Wiley-Blackwell and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.