High-resolution sonography for nasal fracture in children

Diagnostic utility of ultrasound in pediatric nasal bone fractures: a systematic review and meta-analysis

Ultrasonography, a radiation-free and cost-effective modality, stands out as a promising tool for evaluating nasal bone fractures. Despite limited literature on its pediatric application, there is an increasing recognition of its potential to enhance diagnostic precision. To evaluate the diagnostic efficacy of ultrasound in detecting pediatric nasal bone fractures. Employing established guidelines, a systematic review and meta-analysis were conducted through a comprehensive literature search in PubMed, Scopus, Web of Science, and Embase databases until December 5, 2023. Inclusion criteria encompassed studies reporting diagnostic accuracy measures of ultrasound in pediatric patients with nasal bone fractures. Data extraction and analysis were undertaken for the selected studies. Involving four studies with 277 patients, ultrasound demonstrated a pooled sensitivity of 66.1% (95% CI: 35.1-87.5%) and specificity of 86.8% (95% CI: 80.1-91.4%) in diagnosing pediatric nasal fractures. The area under the receiver operating characteristic curve (AUC) was 0.88 (95% CI: 0.72-0.93). After excluding an outlier study, sensitivity and specificity increased to 78.0% (95% CI: 65.6-86.9%) and 87.8 (95% CI: 78.1-93.6%), respectively, with an AUC of 0.79 (95% CI: 0.75-0.94). Pooled positive and negative likelihood ratios were 5.11 (95% CI: 2.12-9.15) and 0.40 (95% CI: 0.14-0.77) before exclusion and 6.75 (95% CI: 3.47-12.30) and 0.26 (95% CI: 0.15-0.40) after exclusion of an outlier study, respectively. This study highlighted ultrasonography's utility in diagnosing pediatric nasal bone fractures with high accuracy and specificity. However, caution is advised in relying solely on ultrasound due to suboptimal overall diagnostic performance, evident in likelihood ratios.

Diagnosis of acute nasal fractures using ultrasound and CT scan

Objective

Nasal fractures need timely and accurate diagnosis for required treatment to prevent future deformities and unnecessary surgery. Radiography does not provide accurate finding in this case. The aim of this study is to evaluated diagnostic efficiency of ultrasound and CT scan for acute nasal fractures.

Methods

In this cross-sectional study included patients with nasal trauma referred to (XXX) from January 2020 to December 2020. Diagnostic ultrasound and CT scan was performed on all the patients and data obtained was stored in patient data collection forms along with their demographics. The data was statistically analyzed using SPSS v20.

Results

Of 32 patients included in our study, 4 (12.5%) were females and 28 (87.5%) were males. The mean age of the patients was 40.28 ± 16.9 years. The specificity and sensitivity of ultrasound was 100% and 83.33%. The accuracy of the test was 93.75%. The specificity, sensitivity and accuracy were 100%, 95% and 96.88%, respectively. Chi square test also showed that there were a significant association between nose fracture and both CT scan and ultrasound, p < 0.001.

Conclusion

Our study showed that both, ultrasound and CT scan are efficient for the diagnosis of nasal fractures in the patients. Further studies with greater sample size are required in this domain.

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Nasal fractures are one of the most common facial fractures due to trauma.

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Nasal fractures need timely and accurate diagnosis for required treatment to prevent future deformities.

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Ultrasound and CT scan are efficient for the diagnosis of nasal fractures in the patients.

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There were a significant association between nose fracture and both CT scan and Sonography.

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Comparative evaluation of ultrasonography and lateral radiography in nasal fractures diagnosis

BACKGROUND

Nasal fractures are the most common type of trauma fracture. Conventional radiography is the primary method of choice. Ultrasonography is used as a new and non-invasive method for this purpose. The aim of this study is to compare the diagnostic values of ultrasonography with nasal X-ray.

METHODS

This was a prospective study which was conducted during 2018-2019 at Bouali hospital, Sari, northern Iran. 130 patients who met our criteria enrolled our study. All patients underwent nasal X-ray and ultrasonography on a day of trauma. The physical examination during the reduction in operation room considered as gold standard for nasal bone fracture. The sensitivity, specificity, precision, positive predictive values, and negative predictive values, along with 95% confidence intervals, were determined by SPSS.

RESULTS

The sensitivity, specificity, positive predictive values, negative predictive values, and precision of nasal X-ray were all reported to be 100% when compared to physical examination (the gold standard). Ultrasonography had a sensitivity of 78.13%, a specificity of 100%, a PPV of 100%, an NPV of 61.82%, and a precision of 83.85% in comparison to physical examination (the gold standard).

CONCLUSION

The findings of this study suggest that ultrasonography can be utilized as a main diagnostic tool in the identification of nasal bone fractures in the vast majority of cases, avoiding the unwanted dangers and problems of X-rays. This is especially critical for expecting mothers and children.

Diagnostic Accuracy of Ultrasonography for the Assessment of Maxillofacial Fractures: A Meta-analysis

Objective

To evaluate the pooled sensitivity and specificity of ultrasonography (USG) in maxillofacial fractures.

Materials and Methods

A systematic search was performed in five databases (PubMed, Scopus, CINAHL, Web of Science, Dentistry and Oral Sciences Source) from inception to September 12, 2020. Studies that reported or from which sensitivity and specificity can be calculated and studies published in the English language were included. Conference proceedings, letter to editors, and case reports were excluded. Screening of studies, data extraction, and risk of bias assessment (QUADAS -2) were done separately by two review authors. A bivariate random-effects model was used to calculate the pooled estimates.

Results

After the removal of duplicates, 1852 studies were included for screening of title and abstracts. Only 22 studies were included in the quantitative synthesis. The sample size ranged from 6 to 87. The majority of the studies assessed orbit and nasal bones fractures. Only two studies included a comprehensive assessment of facial fractures. The overall sensitivity and specificity values were 0.94 and 0.96, respectively.

Conclusion

USG has good diagnostic accuracy for the assessment of fractures of orbit and nasal bones. Clinicians need to consider the advantages and limitations of USG before recommending advanced imaging modalities.

Ability of Bedside Ultrasonography to Detect Pediatric Nasal Bone Fractures

OBJECTIVES/HYPOTHESIS

The aims of this study were to evaluate the diagnostic test features of bedside ultrasonography in pediatric patients with nasal trauma and to investigate whether it is a preferable alternative method to conventional radiography (CR).

STUDY DESIGN

Cross-sectional prospective study.

METHODS

This prospective study was conducted from March 1, 2019, through November 1, 2019. Thirty-one patients under the age of 18 years who had nasal trauma were consecutively included. CR and ultrasonographic imaging tests were investigated in patients with clinical indications for nasal bone fracture. The sensitivity, specificity, and accuracy of ultrasonography and CR were calculated with respect to detecting nasal fractures according to the gold standard method.

RESULTS

Participants were between 3 and 16 years old and the median age was 8 (5-13) years. Nasal bone fracture was clinically detected in 18 patients. While 13 of these fractures were detected with ultrasonography, only 11 were also detected with CR. The sensitivity and specificity of ultrasonography and CR in detecting nasal fractures were 72.2% (95% confidence interval [CI]: 46.5-90.3) and 76.9% (95% CI: 46.2-95.0) for ultrasonography and 61.1% (95% CI: 35.8-82.7) and 69.2% (95% CI: 38.6-90.9) for CR.

CONCLUSIONS

According to the results of this study, ultrasonography may be used with confidence as a first imaging method in the investigation of nasal fractures, particularly with consideration for avoiding the effects of radiation as much as possible. Our findings point to the next step of conducting trials with a greater number of patients in order to define the diagnostic test features of ultrasonography in pediatric patients.

LEVEL OF EVIDENCE

2 Laryngoscope, 131:1398-1403, 2021.

Comparison of the Outcomes of Closed Reduction Nasal Bone Fractures With a Surgical Navigation System

BACKGROUND

The most prevalent form of facial bone fractures is nasal fractures. The surgical procedures used for these fractures are relatively simple, but complete correction is not easy because the nasal bone is small and identifying the fracture site by palpation is difficult. This study aimed to investigate the efficacy of intraoperative surgical navigation systems in nasal bone fracture surgery through a prospective analysis.

METHODS

Between February 2019 and July 2019, 25 navigation-assisted closed reductions of nasal fractures were performed. Preoperative computed tomography images were obtained at 1-mm intervals before surgery and the navigation was set by a simulation to have an error rate of less than 1. Then, the navigation system was used to identify the fracture site. Closed reduction was performed with Asch forceps and a Langenbeck elevator based on the previous markings made using the navigation system.

RESULTS

The degree of reduction was evaluated by plain X-rays and computed tomography scans, which were performed 1 month after surgery. In the navigation group, the average distance between the fragment and normal bony alignment was decreased from 2.38 to 0.49 mm and the modified Motomura score was an average of 2.40 points. The decrease in the mean distance was significantly different (P = 0.038) compared with the conventional group.

CONCLUSIONS

Surgical navigation systems could be a useful tool for localizing fracture sites and guiding closed reductions. In particular, the system could be recommended for nasal bone fracture reductions in the tip or pyriform regions, which are difficult to correct.

LEVEL OF EVIDENCE

II.

The Role of Ultrasound in the Diagnosis of Pediatric Nasal Fractures

BACKGROUND

Nasal fractures are the most commonly encountered facial fracture in children presenting to emergency departments. Though plain radiographs have long been used to aid the diagnosis of fractures, its limited diagnostic accuracy has led to the increasing use of ultrasound. Ultrasound offers a cheap, safe, and readily available imaging modality. Evidence in the adult population has shown ultrasound to be far more accurate in identifying nasal fractures. The efficacy of ultrasound in the pediatric setting though remains uncertain.

METHODS

A systematic review of the Pubmed and EmBase databases was undertaken. The search terms (nose OR nasal) AND (fracture) AND (ultrasound OR ultrasonography OR sonography) and associated MeSH terms were searched. The search was limited to those <18 years of age.

RESULTS

Following review and exclusion, 3 papers met the inclusion criteria. All 3 studies showed ultrasound was able to detect nasal fractures in children. Two studies showed that ultrasound diagnosed fractures with a greater accuracy than plain radiographs. One study used ultrasound alone and reported a sensitivity of 75% and specificity as 92.3%.

CONCLUSION

With the limited evidence to date in the pediatric population, ultrasound appears to offer a more accurate radiological investigation in nasal fractures. It could be considered diagnostically superior to plain radiographs and reduces radiation exposure in children. Further work is required to better determine its true utility and improve its diagnostic accuracy.

Trend analysis of nasal bone fracture

Background

Nasal bone fractures occur frequently because the nasal bone is located at the forefront of the face. The goal of this study was to examine the cause, change in severity, change in incidence, and demographics of nasal bone fracture according to today’s lifestyle.

Methods

A total of 2,092 patients diagnosed as having nasal bone fractures at our department between 2002 and 2017 were included in this study. We retrospectively examined patients’ medical records to extract information regarding age, sex, cause of injury, combined facial bone fractures, and related injuries such as skull base fracture, spinal cord injury, brain hemorrhage, and other bone fractures. Fracture severity was classified by nasal bone fracture type.

Results

No statistically significant difference was found in annual number of patients treated for nasal bone fracture. The proportion of patients who underwent closed reduction was significantly decreased over time for those with nasal bone fractures caused by traffic accidents. However, it was not significantly changed for those with nasal bone fractures due to other causes. The number of patients with combined facial bone fractures increased over time. Incidences of severe nasal bone fracture also increased over time.

Conclusion

The study suggested that there is a decrease in the frequency and increase in the severity of nasal bone fracture due to traffic accident. Many protective devices prevent nasal bone fractures caused by a small amount of external force; however, these devices are not effective against higher amounts of external force. This study highlights the importance of preoperative thorough evaluation to manage patients with nasal bone fractures due to traffic accident.

An Algorithmic Approach Using Ultrasonography in the Diagnosis of Pediatric Nasal Bone Fracture

BACKGROUND

Ultrasonography (US) was recently reported as a reliable modality for diagnosing nasal bone fractures. However, whether US is reliable as a screening tool in the pediatric emergency department (ED) remains unknown. This prospective cohort study had a 2-fold aim: to assess the utility of US in the diagnosis of pediatric nasal bone fracture, and to evaluate the validity of our protocol for managing pediatric nasal bone fractures (Fuchu-Kids algorithm).

PATIENTS AND METHODS

Among the patients who presented at the ED with facial trauma, those with a suspected nasal bone fracture were enrolled in the study. Patients were treated according to Fuchu-Kids algorithm, and the validity of the protocol using US imaging was evaluated.

RESULTS

Among 81 patients who were enrolled during the 1-year study period, 63 patients were able to complete the process described in our protocol for further examination. The diagnostic power of the Fuchu-Kids algorithm had a sensitivity of 91.7%, a specificity of 92.3%, a positive predictive value (PPV) of 88%, and a negative predictive value (NPV) of 94.7%. However, when the performance of US was assessed as a single examination, its sensitivity, specificity, PPV, and NPV were 75%, 92.3%, 85.7%, and 85.7%, respectively.

CONCLUSION

Using our algorithm, the majority of patients with nasal bone fracture were successfully diagnosed and screened out successfully. Repeated US imaging is effective when clinical symptoms persist even if the first US imaging was negative for nasal bone fracture. However, a detailed medical interview and clinical examination are mandatory, regardless of the use of US.

Ultrasonographic Images of Nasal Bone Fractures with Water Used as the Coupling Medium

BACKGROUND

Ultrasonography can show local and superficial fractures of the nasal bone. However, it is difficult to see the whole nasal bone. We used water as the coupling medium for ultrasonography.

METHODS

This method was used in 76 nasal bone fracture cases from July 2011 to March 2013, and we could obtain clear images of the entire nasal bone and surrounding bones. However, in some images, there were artifacts and blurred areas. The patterns of blurring were classified and their causes were analyzed.

RESULTS

The 6 patterns of artifacts and blurred images were (1) Blurred side wall of the nasal bone in 68 cases, (2) air bubbles in the water in 68 cases, (3) unclear deep portions by attenuation in 23 cases, (4) distorted images caused by shaking of the probe in 44 cases, (5) parallel shadows due to multiple reflections in 18 cases, and (6) mysterious shadows caused by side lobes of the ultrasound beams in 55 cases. Almost all of them could be avoided by adding some small changes of techniques.

CONCLUSIONS

Our methods can provide whole clear images of the nasal bone and surrounding bones in 1 field. Almost all the artifacts and blurred images which occurred during the performance of our methods could be avoided by adding some small changes, for example, tilting the probe, pouring the water slowly, and moving the probe closer to the nose.

The accuracy of bedside USG in the diagnosis of nasal fractures

A comparison of the sensitivity and specificity of bedside ultrasonography with conventional radiography for the evaluation of nasal fractures.

INTRODUCTION - PURPOSE

There is increasing use of ultrasonography in the Emergency Dept (ED) and other areas. The purpose of the present study was to evaluate the sensitivity and specificity of bedside ultrasonography with conventional radiographs in the evaluation of nasal fractures in the ED.

METHOD

Patients admitted to ED with maxillofacial trauma were evaluated in this prospective study. Ultrasonography scans of the patients were taken by the emergency physician at the bedside. The images were obtained from both laterals and parallel to the nasal dorsum. The nasal radiography scans were evaluated by an experienced radiologist blinded to the study. The ultrasonography and radiography results were compared statistically.

RESULTS

The study included 103 patients. In showing the presence of nasal fracture, the sensitivity of ultrasonography was determined to be 84.8% (95% CI 71.13%-93.66%), specificity was 93.0% (95% CI 83.00%-98.05%), positive predictive value (PPV) was 90.7% (95% CI 77.86%-97.41%), negative predictive value (NPV) was 88.3% (95% CI 77.43%-95.18%).

CONCLUSION

Ultrasonography can be used in ED as an alternative method to conventional radiography with high rates of sensitivity and specificity in the evaluation of nasal fractures.

Use of radiography and ultrasonography for nasal fracture identification in children under 18 years of age presenting to the ED

PURPOSE

To compare the diagnostic value of ultrasonography (USG), which is rapid, inexpensive, simple, and does not involve radiation, with that of direct radiography for identifying fractures in the nasal bones of pediatric patients presenting in the emergency department with nasal trauma.

EQUIPMENT AND METHODS

Patients under 18years old presenting with nasal trauma at the emergency department included prospectively. The patients' age and sex distribution, trauma type, GCS, physical examination findings, direct radiography, and USG results were recorded. The physical examination made by the emergency medicine specialist on arrival was accepted as the gold standard for diagnosis.

FINDINGS

In total, 133 patients, 34.6% female and 65.4% male, were included in this study. The average patient age was 7.44±5.05years, with the greatest proportion (21.8%, n=29) of patients in the age ranges of 0-2 and 6-8years. The most frequently observed finding on physical examinations was swelling (51.1%, n=68). In total, 50 (37.6%) patients had nasal fractures according to their first physical examination, which was performed by emergency medicine specialists. That is, fractures were detected by direct radiography in only 11 of the 34 cases who were diagnosed with fractures by USG.

CONCLUSIONS

We consider that USG should be preferred over direct radiography for use at the bedside of pediatric patients who present at emergency department with nasal trauma, because of its superior diagnostic ability and the lack of a requirement for radiation.

Usefulness of Ultrasonography-Assisted Closed Reduction for Nasal Fracture under Local Anesthesia

Closed reduction is the treatment of choice for most nasal bone fractures. In this technique, the nasal bone cannot be directly visualized, proper reduction is confirmed by palpation of the bony contour. This confirmation-via-palpation is in most cases too uncomfortable or painful for patients, and this is the reason why most closed reductions of nasal bone fractures are performed under general anesthesia. Recently, ultrasonography has been adopted as a useful diagnostic method and operative adjunct. In this report, we report the use of ultrasonography as a means to provide palpation-less confirmation of proper reduction, which in turn allows for nasal bone reduction under local anesthesia.

Diagnostic value of ultrasonography in the diagnosis of nasal fractures

INTRODUCTION

This study examined the diagnostic value of ultrasound and radiography compared with clinical examinations as the gold standard method to determine whether ultrasound can be used for early diagnosis of nasal fracture.

METHODS

This prospective study was conducted on 128 patients with clinical signs of nasal fracture. Radiography in all patients was performed by 2 different radiologists on Waters and lateral view with a 10-MHz ultrasound probe, and clinical examinations were done by an ENT specialist. Radiography and ultrasound findings were recorded and compared with the final diagnosis which was based on clinical examinations. Results were analyzed with different statistical methods to determine sensitivity, specificity, accuracy, positive predictive value, and negative predictive value.

RESULTS

In the assessment of fracture with ultrasound, sensitivity was 84%, specificity 75%, accuracy 82%, positive predictive value 91%, and negative predictive value 61%. In the assessment of fracture on lateral view radiography, sensitivity was 50%, specificity 72%, accuracy 55%, positive predictive value 84%, and negative predictive value 32%. On Waters view radiography, sensitivity was 53%, specificity 65%, accuracy 56%, positive predictive value 82%, and negative predictive value 31%. On lateral-waters view radiography, sensitivity was 64%, specificity 58%, accuracy 62%, positive predictive value 82%, and negative predictive value 34%. Fracture diagnosis by ultrasound was significantly better as compared with radiography (P = 0.04).

CONCLUSION

The nasal bone ultrasound study is a useful method in determining the nasal fracture and radiography can be replaced with ultrasound in early diagnosis of fracture.

Ultrasonography in the diagnosis of nasal bone fractures: a comparison with conventional radiography and computed tomography

The purpose of this study was to evaluate and compare the diagnostic efficacy of ultrasonography (US) with radiography and multi-detector computed tomography (CT) for the detection of nasal bone fractures. Forty-one patients with a nasal bone fracture who underwent prospective US examinations were included. Plain radiographs and CT images were obtained on the day of trauma. For US examinations, radiologist used a linear array transducer (L17-5 MHz) in 24 patients and hockey-stick probe (L15-7 MHz) in 17. The bony component of the nose was divided into three parts (right and left lateral nasal walls, and midline of nasal bone). Fracture detection by three modalities was subjected to analysis. Furthermore, findings made by each modality were compared with intraoperative findings. Nasal bone fractures were located in the right lateral wall (n = 28), midline of nasal bone (n = 31), or left lateral wall (n = 31). For right and left lateral nasal walls, CT had greater sensitivity and specificity than US or radiography, and better agreed with intraoperative findings. However, for midline fractures of nasal bone, US had higher specificity, positive predictive value, and negative predictive value than CT. Although two US evaluations showed good agreements at all three sites, US findings obtained by the hockey-stick probe showed closer agreement with intraoperative findings for both lateral nasal wall and midline of nasal bone. Although CT showed higher sensitivity and specificity than US or radiography, US found to be helpful for evaluating the midline of nasal bone. Furthermore, for US examinations of the nasal bone, a smaller probe and higher frequency may be required.

Refinement treatment of nasal bone fracture: A 6-year study of 329 patients

BACKGROUND

The reliability of X-ray radiography for diagnosing nasal bone fractures (NBFs) remains controversial. Recent studies show that, for determining the orientation and location of the displaced/depressed fracture, nasal sonography is as accurate as facial computed tomography. This retrospective study compared conductor-assisted nasal sonography (CANS) to conventional diagnostic tools and reported subjective patient satisfaction and discomfort after closed reduction combined with tube technique.

METHODS

This retrospective study reports the results of 329 refinement treatments for nasal bone fracture (including 199 men and 130 women) performed from 2005 to 2011. All patients were assessed with CANS and completed a survey immediately prior to removing the packing. Questionnaires were adapted from the nasal obstruction symptom evaluation (NOSE) scale.

RESULTS

The study found that CANS has a 97.2% rate of accuracy in diagnosing NBF. The visual analog scale scores of nasal obstruction, nasal congestion, sleep disturbance, trouble breathing, and inability to move air through the nose were analyzed. The experimental group scores were significantly different from the control group for all scores (p < 0.001).

CONCLUSION

Compared to conventional methods, CANS is more accurate for detecting NBF. We recommend its use as an alternative tool for diagnosing a nasal fracture. Because the tube technique balances pressure between the nasopharynx and middle ear during swallowing, patient comfort is enhanced. Application of these modifications can improve accuracy in diagnosing NBF and can improve the quality of NBF treatment.

Ultrasonography findings in nasal bone fracture; 6-month follow-up: can we estimate time of trauma?

Differentiation of a recent nasal bone fracture from an old one may become of utmost importance, especially in medico-legal issues. The aim of this study was to demonstrate the value of high-resolution ultrasonography (HRUS) in determining the time of nasal bone fracture. A longitudinal, descriptive-analytic study was done on 45 patients with a clinical manifestation of acute unilateral nasal bone fracture. After a thorough rhinologic physical examination, HRUS was performed by an expert consultant who was blinded to the clinical data of the patients. All patients were followed-up for 6 months: in the first 5 days, 3rd, 6th, 12th and 24th weeks after the trauma. In each session, the ultrasonographic findings were recorded. Thirty-six cases (mean age, 27 years) completed the study course successfully. On HRUS, subperiosteal hematoma, with a mean thickness of 1.14 mm (0.79-1.31 mm) was highly sensitive (100 %) for the diagnosis of nasal bone fracture during the first few days after the trauma, but it was present in 13 cases in the 6th week, with a mean thickness of 0.71 mm (0.62-0.80 mm), and disappeared in all patients in the 24th week, with a mean thickness of 0.47 mm (almost equal to the non-traumatic side). According to the changes of subperiosteal reaction on the traumatic side and by means of generalized linear model and generalized estimating equations, we proposed an equation to estimate the time of nasal bone trauma. In conclusion, HRUS is a reliable diagnostic tool for estimating the time of nasal bone fracture.

Comparison of ultrasonography-assisted closed reduction with conventional closed reduction for the treatment of acute nasal fractures

Ultrasonography has often been reported to be a useful tool in cases of nasal fracture, not only for diagnosing such fractures but also for 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 each fracture reduction procedure was intraoperatively confirmed by visual inspection and palpation. In the ultrasound group, intraoperative 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 differences in the outcomes of the reduction procedures between the two groups (p > 0.05). As for the reoperation rate, two patients (2.8%) in the conventional group underwent reoperations, but no patient (0%) required reoperations in the ultrasound group. However, the difference in the reoperation rate between the two groups was not significant (p > 0.05). 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.

Emergency pediatric ear, nose, and throat imaging

Pediatric ear, nose, and throat emergencies broadly comprise infection, trauma, and airway obstruction secondary to a multitude of etiologies. Imaging occupies center stage in the diagnosis of many of these conditions and their complications, making it imperative for radiologists and other physicians covering the pediatric emergency department to familiarize themselves with the imaging appearances of these entities. Toward this goal, this article describes the imaging features of common pediatric ear, nose, and throat emergencies. Differential considerations, potential fallacies, and complications have been discussed when appropriate. Because a sound knowledge of the most relevant, efficient, time, and cost-effective imaging modality is of undisputable value in the acute setting, the preferred modality for each specific condition has been outlined. Finally, in alignment with our commitment to using radiation judiciously, we have suggested using ultrasonography and magnetic resonance instead of computed tomography, where possible, to optimize cost-benefit ratio for our young patients.

Comparison of ultrasonography with computed tomography in the diagnosis of nasal bone fractures

OBJECTIVES

The aim of this study is to compare ultrasonography with CT in the diagnosis of nasal bone fractures.

METHODS

40 patients (9 female and 31 male) with mid-facial fractures, which were suspected nasal bone fractures, were included. All of the patients had mid-facial CT images. Ultrasonography with a 7.5 MHz transducer (Aloka 3500, Tokyo, Japan) was used to evaluate the nasal bone fractures. All of the sonograms were compared with CT findings for sensitivity, specificity and predictive values. A χ(2) test was applied to the data to assess statistical significance.

RESULTS

CT diagnosed nasal bone fractures in 24 of the 40 patients (9 unilateral fractures and 15 bilateral fractures) while ultrasonography diagnosed the fractured bones in 23 patients (9 unilateral fractures and 14 bilateral fractures). Ultrasonography missed one fractured bone in a bilateral fractured case and a unilateral fracture was also missed (two false-negative results). The sensitivity and specificity of ultrasonography in assessing nasal bone fracture in comparison with CT were 94.9% and 100%, respectively. The positive predictive value (PPV) and the negative predictive value (NPV) of ultrasonographic evaluation of the nasal bone fractures were 100% and 95.3%, respectively. The χ(2) test did not show any significant difference between CT and ultrasonography in diagnosis of nasal bone fractures (P = 0.819).

CONCLUSION

Ultrasonography can be used as a first line of diagnostic imaging for evaluating nasal bone fractures, especially in children and pregnant women.

A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures

This systematic review assessed the diagnostic value of ultrasonography in maxillofacial fractures. A computerized literature search of MEDLINE, PubMed and GoogleMed databases was conducted for publications on diagnostic ultrasound and maxillofacial fractures in English. Search phrases were 'maxillofacial fractures' or 'midfacial fractures' or 'zygomatic complex fractures' or 'nasal bone fractures' or 'orbital fractures' or 'mandibular fractures' combined with 'ultrasound' or 'ultrasonography'. The Boolean operator 'AND' was used to narrow the searches. 17 articles published between 1992 and 2009 were reviewed: two on midfacial fractures, nine on orbital fractures, three on nasal fractures, and two on mandibular fractures. One article described case series of ultrasonographic diagnosis of mandibular and midfacial fractures. The sensitivity and specificity of ultrasound in detecting orbital fractures were 56-100% and 85-100%, respectively, whilst that of nasal fractures were 90-100% and 98-100%, respectively. Sensitivity and specificity of ultrasonography in detecting zygomatic fractures were >90%. For mandibular fractures, the sensitivity and specificity was 66-100% and 52-100%, respectively. Much evidence justifies the use of diagnostic ultrasonography in maxillofacial fractures, especially fractures involving the nasal bone, orbital walls, anterior maxillary wall and zygomatic complex. The sensitivity and specificity of ultrasonography is generally comparable with CT.

Role of intra-operative ultrasound-guided reduction of nasal bone fracture in patient satisfaction and patient nasal profile (a randomized clinical trial)

The objective of this study was to evaluate the benefits of intra-operative ultrasonic guidance in the management of isolated nasal bone fractures. A prospective, randomized, controlled, double blinded study was designed. Sixty-eight patients who had isolated fracture nose were treated by either a simple closed reduction or by ultrasound-guided reduction (34 patients each) with a follow up for an average of 4.5 and 5.5 months, respectively. Post-traumatic and post-reduction nasal profiles were compared (by blinded photographer), and patient's satisfaction was analyzed after reduction in both groups. We used Student's t test for independent groups to compare between the average patient's scores. The average patient's nasal profile score for closed reduction group was 2.31. Thirteen patients (40.6%) had scored 3, 16 (50%) had scored 2, and three (9.4%) patients had scored 1. The average patient's nasal profile score for ultrasonic assisted group was 2.72. Twenty-four patients (75%) had scored 3, 7 (22%) had scored 2, and one (3%) patient had scored 1. The average patient's satisfaction score for closed reduction was 2.62. Twenty-four patients (75%) had scored 3, 4 (12.5%) patients had scored 2, and 4 (12.5%) patients had scored 1. The average patient's satisfaction score for ultrasonic assisted group was 2.78. Twenty-six patients (81%) scored 3, 5 (16%) patients scored 2, and one (3%) patient scored 1. Patients undergoing ultrasonic nasal bone reduction scored significantly better nasal profile scores than patients undergoing simple closed reduction, on the other hand, patient satisfaction scores had no significant difference between both groups. Treating nasal bone fractures with the assistance of intra-operative ultrasound resulted in a significantly better nasal profile appearance, than treating it by simple closed reduction.

Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults

INTRODUCTION

Injury is a major cause of death and disability in children and young adults worldwide. X-rays are routinely performed to evaluate injuries with suspected fractures. However, the World Health Organisation estimates that up to 75% of the world population has no access to any diagnostic imaging services. Use of clinician-performed point-of-care ultrasound to diagnose fractures is not only feasible in traditional healthcare settings, but also in underserved or remote settings. Our objective was to determine the accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults presenting to an acute care setting.

METHODS

We conducted a prospective cohort study of patients aged <25 years that presented to emergency departments with injuries requiring X-rays or CT for suspected fracture. Paediatric emergency physicians with a 1h training session diagnosed fractures by point-of-care ultrasound. X-rays or CT were used as the reference standard to determine test performance characteristics.

RESULTS

Point-of-care ultrasound was performed on 212 children and young adults with 348 suspected fractures. Forty-two percent of all bones imaged were non-long bones. The prevalence rate of fracture was 24%. Overall: sensitivity-73% (95% CI: 62-82%), specificity-92% (95% CI: 88-95%); long bones: sensitivity-73% (58-84%), specificity-92% (86-95%); non-long bones: sensitivity-77% (58-90%); specificity-93% (87-97%); age> or =18 years: sensitivity-60% (39-78%), specificity-92% (87-96%); age<18: sensitivity-78 (65-87%), specificity-93% (87-95)%. Majority of errors in diagnosis (>85%) occurred at the ends-of-bones.

CONCLUSIONS

Clinicians with focused ultrasound training were able to diagnose fractures using point-of-care ultrasound with a high specificity rate. Specificity rates to rule-in fracture were similar for non-long bone and long bone fractures, as well as in skeletally mature young adults and children with open growth plates. Clinician-performed point-of-care ultrasound accuracy was highest at the diaphyses of long bones, while most diagnostic errors were committed at the ends-of-bones or near joints. Point-of-care ultrasound may serve as a rapid alternative means to diagnose midshaft fractures in settings with limited or no access to X-ray.

The diagnostic value of the sagittal multiplanar reconstruction CT images for nasal bone fractures

AIM

To compare the diagnostic performance of sagittal multiplanar reconstruction (MPR) images and axial images for the detection of a nasal bone fracture.

MATERIALS AND METHODS

This prospective study included 533 consecutive patients who underwent three-dimensional images with 64-section multidetector-row CT for the evaluation of a facial bone fracture between June 2007 and May 2008 (366 males; 167 females; mean age +/- standard deviation 31.1+/-21.2 years; age range 1-92 years). Two observers independently scored the possibility of a nasal bone fracture on axial and sagittal images. Receiver operating characteristic (ROC) curve analysis was performed.

RESULTS

The Az values of the sagittal images were higher than those of the axial images for both observers (p=0.002 and 0.010, respectively) with higher accuracy (p<0.001 and 0.016, respectively). The sensitivities of sagittal images were superior to those of axial images, especially for type 1simple nasal bone fractures with no or minimal displacement (observer 1, 98.6 versus 72.8%; observer 2, 84.9 versus 71%).

CONCLUSION

Sagittal MPR facial bone CT images provided superior diagnostic performance, and their addition to axial images is useful for the evaluation of nasal bone fractures.

Usefulness of ultrasonography in the treatment of nasal bone fractures

BACKGROUND

Ultrasonography has recently been used in assessment and diagnosis of maxillofacial trauma because it is easy and quick to perform, inexpensive, portable, and noninvasive. The aim of this study was to estimate ultrasonography as an intraoperative repositioning control of nasal bone fractures.

METHODS

We studied 32 patients with suspected nasal bone fracture. We performed preoperative computed tomography (CT) for evaluation of the type and extent of nasal bone fractures. We also took external photographs for evaluation of external deviation of the nose and nasal deformity. During surgery, we performed real-time ultrasonography-guided closed reduction using a 10 MHz linear transducer. After 1 year, we performed postoperative evaluation with CT and external photography. We classified patients into three groups according to their CT score.

RESULTS

Patients were 23 males and 9 females aged 8-39 years. Clinical symptoms were pain, nasal swelling, nasal bleeding, and localized depression at the trauma site. In almost all patients, postoperative external photographs showed a symmetrical nasal dorsum without external deformity, and postoperative CT showed stabilization of bony fragments and good alignment of the nasal bone. Postoperatively, the CT score was 3 (excellent) in 25 patients, 2 (good) in 5 patients, and 1 (fair) in 2 patients.

CONCLUSION

We suggest that ultrasonography is very useful for evaluating intraoperative repositioning of nasal bone fractures.

Comparison of high-resolution ultrasonography and computed tomography in the diagnosis of nasal fractures

OBJECTIVE

The purpose of this study was to compare the value of high-resolution ultrasonography (HRUS) and computed tomography (CT) in the diagnosis of nasal fractures.

METHODS

Facial CT and HRUS examinations performed on 140 consecutive patients (103 male and 37 female; age range, 2-74 years; mean, 26 years) with nasal trauma between October 2004 and April 2007 were retrospectively evaluated. Sonograms were obtained with a hockey stick probe (15-7 MHz linear array transducer). All patients also underwent facial CT and conventional radiography. The nasal fracture detection rates for HRUS, CT, and conventional radiography were compared with the clinical and surgical diagnosis. Nasal fractures were classified into high- and low-grade groups according to severity. They were also compared with the CT findings of all 280 lateral nasal bones and with HRUS findings as the reference standard.

RESULTS

The accuracy rates for HRUS, CT, and conventional radiography in detecting nasal fractures were 100%, 92.1%, and 78.6%, respectively. Compared with HRUS, CT revealed only 196 of 233 lateral nasal bone fractures; its accuracy was 80%. In high-grade fractures, the accuracy of CT was 87%, but it decreased to 68% in low-grade fractures.

CONCLUSIONS

Compared with HRUS, CT had lower accuracy, especially in low-grade nasal fractures. Thus, HRUS is a reliable diagnostic tool for the evaluation of nasal fractures.

Sonography versus plain x rays in diagnosis of nasal fractures

BACKGROUND

The standard imaging procedure for suspected nasal fractures has been radiography (XR). However, its usefulness for clinical decision making is highly controversial. High-resolution ultrasonography now offers a promising new diagnostic imaging option. In this study we compared the diagnostic value of high-resolution ultrasonography and conventional XR in the evaluation of suspected nasal fractures.

METHODS

A prospective single-blinded study was performed. Ultrasound (US) and XR findings in 80 patients with suspected nasal fractures were compared with the definite clinical diagnosis with respect to sensitivity, specificity, and accuracy.

RESULTS

For detection of fractures of the nasal dorsum, both modalities had high sensitivity (98 and 88% for US and XR, respectively) and specificity (95% for both US and XR). In lateral nasal wall fractures, specificity was higher for XR (75% versus 94%). Sensitivity was significantly higher for the US examination (98% versus 28%). In summary, the accuracy was higher for US.

CONCLUSION

When available, US should be the first-line imaging procedure in the evaluation of nasal fractures.