2017-18 HSC Section 4 Green Book

Doerr

all of these injuries. 11 Despite the ongoing contro- versy, no prospective RCT has been conducted to directly compare open and closed techniques and help answer this clinical question. In assessing the efficacy of nasal injury treat- ment, a 2002 publication by Staffel 12 deserves comment. He reported on the effectiveness of closed nasal reduction by reviewing several studies in the literature and proposing a treatment algorithm to improve outcomes. He also high- lighted a dichotomy between high patient satisfac- tion with the clinical outcomes (79%) and the low surgeon satisfaction (37%) with those same re- sults. This demonstrates that patient and surgeon expectations can be quite different and suggests that, if patient satisfaction is a primary goal of treatment, closed nasal reduction is likely the appropriate initial approach. There is also no consensus on the best method of anesthesia for reducing a nasal fracture. Previ- ous studies have shown that general anesthesia, sedation, and local anesthesia can all be effective and are well tolerated by subjects undergoing nasal reduction. 13–15 Anesthesia selection is often guided by surgeon preference, operating room availability, and hospital protocol. Advocates for general anesthesia have suggested that reduction can be performed with better outcomes and less pain, 14,15 whereas others showed equivalent out- comes at a lower cost using local anesthesia 13 To address choice of anesthesia for closed nasal reduction Al-Moraissi and Ellis 16 conducted a systematic review of the literature with a meta- analysis. The review identified 8 studies with 846 subjects. Of these studies, 3 were RCTs, 2 were clinical cohort studies, and 3 were retrospective series. The analysis showed subject satisfaction with anesthesia and subject satisfaction with nasal function were both slightly higher, but not statisti- cally higher, under general anesthesia. The subject satisfaction with nasal appearance was statisti- cally higher with general anesthesia ( Table 2 ). These subjects were also less likely to later require a secondary nasal procedure. These results sup- port improved outcomes when nasal reduction is performed under general anesthesia; however,

this must be balanced against other factors, including procedure cost and convenience. Regardless of the anesthesia use in nasal reduc- tion, other clinical factors, including septal and nasal tip deviation, are predictors of a persistent deformity and must be considered in selecting the method of treatment. Mandible fractures are common fractures that encompass a variety of different injuries with an extensive range of treatment options. This diverse group of fractures can be treated with either open or closed reduction, followed by external or inter- nal fixation, or both. Given the variety of fractures and the plethora of treatment options, it is not sur- prising that there is little consensus about which treatment is best for a specific fracture pattern. Advancements in plating systems and a better understanding of the biomechanics of the mandible have led to a gradual evolution in frac- ture management. Closed reduction with mandibular-maxillary fixation (MMF) is increasingly being replaced by open approaches with applica- tion of various fixation hardware. As with most of facial trauma, there is limited high-level evidence to support such a clinical change. Most of the thousands of publications on mandible fracture repair are retrospective studies of suboptimal quality. Only recently have quality randomized tri- als looking at various aspects of mandible fracture repair appeared in the literature. These RCTs have examined many different variables, including the use of single miniplates, locking plates, 3-dimen- sional plates, resorbable plates, and lag screws to treat adult mandible fractures. Patients sustaining mandible trauma usually pre- sent with defined anatomic fracture patterns. Each anatomic fracture pattern offers several op- tions for repair with internal fixation. The presence of third molars and thin cortices of bone make the mandibular angle among the most common sites of fracture. The fractures of the angle have been MANDIBLE FRACTURES Angle Fractures

Table 2 Anesthesia and clinical outcomes in nasal fracture closed reduction

Patient Satisfaction with Anesthesia

Patient Satisfaction with Nasal Function

Patient Satisfaction with Nasal Appearance

General anesthesia Slightly higher Local anesthesia Slightly lower

Slightly higher Slightly lower

Significantly higher Significantly lower

Adapted from Al-Moraissi EA, Ellis E. Local versus general anesthesia for the management of nasal bone fractures: a sys- tematic review and meta-analysis. J Oral Maxillofac Surg 2015;73(4):606–15; with permission.

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