2017-18 HSC Section 4 Green Book

Evidence-Based Facial Fracture Management

fracture. The review identified 5 RCTs involving 208 subjects. Analysis showed no reduction in meningitis rates, overall mortality, meningitis- related mortality, and the need for surgery from cerebrospinal fluid leak in subjects receiving pro- phylactic antibiotics. No complications from anti- biotic use were seen; however, 1 study did find a change in the microbial flora toward organisms more likely to be resistant to antibiotics. In addi- tion, the review examined 17 nonrandomized studies, which included more than 2100 subjects. The analysis produced results in line with those seen in the randomized data. Most of studies lacked sufficient details on methodology, which limited their quality. The conclusion of this analysis was that there was insufficient evidence for pro- phylactic antibiotic use in patients with skull base fractures with or without a cerebrospinal fluid leak. Until better evidence becomes available, the routine use of antibiotics in these cases should be avoided. No facial injury is more common than the nasal fracture. Despite a frequency of injury that should lend to clinical investigation, there are only a hand- ful of randomized trials examining nasal trauma management. Although closed reduction for a nasal fracture is common practice and, in some lo- cations, the standard of care, the efficacy of this procedure is still debated. Although many sur- geons advocate for closed nasal reduction, others encourage more extensive open techniques to address nasal injuries. Extensive-fracture disloca- tion of the nasal bone and septum, dramatic devi- ation of the nasal pyramid, dislocation or open fractures of the septum, and persistent deformity after an attempt at closed reduction are directing surgeons to an consider an open approach. 10 Some recent publications have even advocated for a more formal rhinoplasty approach with nearly NASAL FRACTURES

studies addressed the antibiotic question, there was wide variability in antibiotics, subjects, and treatment protocols. They suggested there was a trend toward not needing antibiotics beyond 24 hours after fracture repair. They cautioned that this lower degree of evidence with its limited number of level 1 studies did not provide a gold standard for management. To highlight what are clear differences between actual clinical practice and the prevailing literature, the reviewers also presented results from a surgeon survey in which more than 50% of respondents routinely used postoperative antibiotics despite the lack of sup- porting evidence. The literature examining the role of antibiotic prophylaxis in nonmandibular facial fractures is even sparser. In a multi-institutional prospective cohort study, Knepil and Loukota 5 studied prophy- lactic antibiotics in 134 subjects who had surgery for zygoma fractures. They found a postoperative infection rate of only 1.5%, which was seen only after transoral surgical approach. Summarizing the available literature, Morris and Kellman 6 recommend that antibiotics be given for mandible fractures only from injury until comple- tion of the perioperative course but not postoper- atively. There are insufficient data to assess prophylactic antibiotics in nonmandible fractures and isolated condyle fractures but evidence that did exist suggested no benefit to postoperative antibiotics ( Table 1 ). Having highlighted the indications for antibiotics in facial fracture repair, comment on the role of an- tibiotics in skull base trauma is necessary. There is controversy about whether antibiotics should be routinely given to patients with skull base fractures in an effort to prevent infectious complications, including meningitis. Previous publications have both called for and recommended against this practice. 7,8 In 2011, Ratilal and colleagues 9 pub- lished a Cochrane review of RCTs as well as non-RCTS concerning antibiotics and skull base

Table 1 Role for antibiotics in facial fracture treatment

Antibiotics Before Surgery

Perioperative Antibiotics (within 2 h of surgery)

Prophylactic Antibiotics After Surgery No benefit to antibiotics beyond 24–48 h

Mandible fractures (not isolated condyle) Isolated mandibular condyle fractures Midface and frontal sinus fracture

Yes

Yes

No benefit

Yes

No benefit

No benefit

Yes

No benefit

Skull base fractures

No role for prophylactic antibiotics with or without cerebrospinal fluid leak Role for antibiotics with skull base fracture repair not defined

245