Local Versus General Anesthesia for the Management of Nasal Bone Fracture
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Transcript of Local Versus General Anesthesia for the Management of Nasal Bone Fracture
ANESTHESIA/FACIAL PAIN
Rec
of O
Sur
Sur
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Local Versus General Anesthesia for theManagement of Nasal Bone Fractures:A Systematic Review and Meta-Analysis
eived f
ral an
*Assista
gery, Fa
yProfesgery, U
Conflic
closure
Addres
partme
Essam Ahmed Al-Moraissi, BDS, MSc, PhD,* and Edward Ellis III, DDS, MSy
Purpose: The aim of this study was to answer the following question: in patients with nasal bone frac-tures (NBFs), does closed reduction under local anesthesia (LA) produce comparable outcomes as closed
reduction under general anesthesia (GA)?
Materials and Methods: A systematic review with meta-analysis and a comprehensive electronic
search without date and language restrictions was performed in August 2014. The inclusion criteria
were studies in humans, including randomized or quasi-randomized controlled trials (RCTs), controlled
clinical trials (CCTs), and retrospective studies whose aim was comparing clinical outcomes between
LA and GA for closed reduction of NBFs.
Results: Eight publications were included: 3 RCTs, 2 CCTs, and 3 retrospective studies. Three studies
showed a low risk of bias, and 5 studies showed a moderate risk of bias. There was no statistical difference
between LA and GA for closed reduction of NBFs with regard to patient satisfaction with anesthesia,patient satisfaction with function of the nose, need for subsequent retreatment (septoplasty, septorhino-
plasty, or rhinoplasty with refracture), and a patient’s chosen treatment for a refracture of the nose. There
was a statistical difference between LA and GA for closed reduction of NBFs with regard to patient satis-
faction with the appearance of the nose.
Conclusion: Regardless of the cost and risks associated with GA, the results of the meta-analysis showed
that GA provides better patient satisfactionwith anesthesia, appearance and function of the nose, and pref-
erence of treatment for a refracture of the nose. In addition, the meta-analysis showed that GA decreased
the number of subsequent corrective surgeries (septoplasty, septorhinoplasty, and rhinoplasty) required.
� 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 73:606-615, 2015
The central position of the nose and its anterior pro-jection on the face make it susceptible to injury, so
it should not be surprising that fractures of the nasal
bones are the most common facial fractures (39 to
45% of all facial fractures) and the third most com-
mon fracture in the human skeleton.1,2 Like other
facial fractures, the male-to-female ratio for nasal
fractures is greater than 2:1.2 The incidence peaks
bi-modally in patients 15 to 30 years old and inthe elderly, in whom a small increase is related to
romDepartment of Oral and Maxillofacial Surgery, Faculty
d Dental Medicine, Cairo University, Egypt.
nt Professor, Department of Oral and Maxillofacial
culty of Dentistry, Thamar University, Thamar, Yemen.
sor and Chair, Department of Oral and Maxillofacial
niversity of Texas Health Science Center, San Antonio, TX.
t of Interest Disclosures: None of the authors reported any
s.
s correspondence and reprint requests to Dr Al-Moraissi:
nt of Oral and Maxillofacial Surgery, Faculty of Dentistry,
606
falls.2 Most nasal fractures in young adults are dueto assaults, sports, and, less commonly, motor
vehicle accidents.2-6 The incidence and association
with alcohol vary according to the study
location.2-6 Fracture of the nasal bones is suggested
by external nasal deformity, crepitus, or palpably
mobile bony segments.5 Epistaxis and pain are
common symptoms, and these can be accompanied
by ecchymosis of the periorbital soft tissues (blackeyes) and nasal obstruction, especially if the septum
Thamar University, Redaa Street, Thamar, Yemen; e-mail:
Received September 9 2014
Accepted October 13 2014
� 2015 American Association of Oral and Maxillofacial Surgeons
0278-2391/14/01612-7
http://dx.doi.org/10.1016/j.joms.2014.10.013
AL-MORAISSI AND ELLIS 607
has been displaced.5 Nasal fractures are often unrec-
ognized and inadequately treated at the time of
injury, resulting in chronic functional or esthetic
problems.7,8
Generally speaking, manipulation of the nose (or
closed reduction) involves repositioning of the nasal
bones (with or without instrumentation) without mak-
ing incisions. An open reduction involves a formaloperative procedure with incisions and open manipu-
lation of the nasal bones and septum.9 Despite plenty
of nasal fractures, there is no agreement on themanage-
ment protocol or the anesthetic methods.10 Nasal frac-
tures are managed in different ways, depending on the
surgeon’s preference, hospital protocols, surgical spe-
cialty, and practical reasons.11 Nasal fracture manage-
ment can be performed under local anesthesia (LA)with or without sedation or general anesthesia
(GA).11 Some studies have advocated reducing
fractures under GA because an operation can be
performed with greater accuracy and less pain,7,12
whereas others have stated that LA is just as
satisfactory.13,14 Therefore, the authors implemented
a systematic review with meta-analysis to answer
the following question: inpatientswithnasal bone frac-tures (NBFs), does closed reduction under LA produce
comparable outcomes as closed reduction under GA?
Materials and Methods
SEARCH STRATEGY
A comprehensive systematic review of the literature
was performed in the bibliographic databases PubMed
(National Library of Medicine, National Center for
Biotechnology Information), EMBASE, and the Co-
chrane Central Register of Controlled Trials from
inception to August 2014; the review was performed
in accordance with the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)statement.15
A manual search of oral and maxillofacial surgery-
related journals, including International Journal of
Oral and Maxillofacial Surgery, British Journal of
Oral and Maxillofacial Surgery, Journal of Oral
and Maxillofacial Surgery, Oral Surgery, Oral Medi-
cine, Oral Pathology, Oral Radiology and Endodon-
tology, Journal of Cranio-Maxillo-Facial Surgery,Journal of Craniofacial Surgery, Journal of Maxillo-
facial and Oral Surgery, Clinical Otolaryngology
Journal, Rhinology, and Ear, Nose and Throat Jour-
nal, also was performed.
SEARCH TERMS
A combination of the following search terms was
used: open versus closed treatment in nasal bone
fractures and/or local versus general anesthesia
manipulation in treatment of nasal bone fractures
and/or nasal fracture local anesthesiamanipulation,
nasal fractures, patients satisfaction after closed
reduction in nasal fractures, randomized controlled
trials, and septoplasty, septorhinoplasty or rhino-
plasty after nasal bone fractures.
SELECTION CRITERIA
The following inclusion criteria were adapted using
the PICOS criteria: (P) type of patients: those patients
with NBFs; (I) type of intervention: manipulation un-der GA; (C) type of comparator: manipulation under
LA; (O) type of outcomes: patient satisfaction with
appearance of the nose, patient satisfaction with func-
tion of the nose, patient satisfaction with anesthesia,
subsequent treatment after reduction, subsequent sur-
gery such as septoplasty, septorhinoplasty, and rhino-
plasty and airway patency after NBF reduction; and
(S) type of study: human studies published in English:randomized or quasi-randomized controlled clinical
trials (RCTs), controlled clinical trials (CCTs), and
retrospective studies whose aim was the comparison
between LA and GA for the management of NBFs.
EXCLUSION CRITERIA
The following exclusion criteria were applied:
1) case reports, 2) technical reports, 3) animal or
in vitro studies, 4) review articles, and 5) uncontrolled
clinical studies.
DATA COLLECTION PROCESS
The authors carefully assessed the eligibility of allstudies retrieved from the databases. From the included
studies in the final analysis, the following data were ex-
tracted: study authors, year of publication, study design,
number of patients, gender, mean age in years, follow-
up period, and outcomes. An attempt was made to con-
tact study authors for possible missing data.
RISK FOR BIAS IN INDIVIDUAL STUDIES
A methodologic quality rating was performed by
combining the proposed criteria of the Meta-Analysisof Observational Studies in Epidemiology Statement
(MOSES),16 the Strengthening the Reporting of Obser-
vational Studies in Epidemiology Statement (SRO-
SES),17 and the PRISMA18 to verify the strength of
scientific evidence in clinical decision making. The
classification of risk for bias potential for each study
was based on the following 5 criteria: random selec-
tion in the population, definition of inclusion andexclusion criteria, report of losses to follow-up, vali-
dated measurements, and statistical analysis. A study
that included all these criteria was classified as having
a low risk of bias, and a study that did not include 1 of
these criteria was classified as having a moderate risk
608 LA VERSUS GA IN THE MANIPULATION OF NBFS
of bias. When at least 2 criteriawere missing, the study
was considered to have a high risk of bias.
META-ANALYSIS
Meta-analyses were conducted only if there were
studies of similar comparisons, reporting the same
outcome measurements. For binary outcomes, the
author planned to calculate a standard estimation of
the odds ratio (OR) by the random-effects model if het-erogeneity was detected; otherwise a fixed-effect
model with a 95% confidence interval (CI) was
performed. Weighted mean differences were used
to construct forest plots of continuous data. Data
were analyzed using Review Manager 5.2 (Nordic Co-
chrane Centre, Cochrane Collaboration, Copenhagen,
Denmark).
ASSESSMENT OF HETEROGENEITY
The importance of any discrepancies in the esti-
mates of the treatment effects of the different trials
was assessed by the Cochran test for heterogeneity
and the I2 statistic, which describes the percentage
of the total variation across studies that is due to het-
erogeneity rather than by chance. Heterogeneity was
considered statistically significant at a P value lessthan .1. A rough guide to the interpretation of I2 given
in the Cochrane Handbook for Systematic Reviews of
Interventions19 is as follows: 1) from 0 to 40% the het-
erogeneity might not be important, 2) 30 to 60%might
represent moderate heterogeneity, 3) 50 to 90% might
represent substantial heterogeneity, and 4) 75 to 100%
indicates considerable heterogeneity.
INVESTIGATION OF PUBLICATION BIAS
A funnel plot (plot of effect size vs standard error)
was drawn. Asymmetry of the funnel plot can indicate
publication bias and other biases related to sample
size, although the asymmetry also can represent a
true relation between trial size and effect size.
SENSITIVITY ANALYSIS
If there were sufficient included studies, a sensi-
tivity analysis was performed to assess the robustness
of the review results by repeating the analysis with the
following adjustments: exclusion of studies with a
high risk of bias.
Results
A summary of the study screening process is pre-
sented in Figure 1. The electronic search resulted in367 entries. Of the 367 entries, 108 articles were
excluded because they were in vitro studies. After
the initial screening of the titles and abstracts, 199 ar-
ticles were excluded because they were off topic or
duplicates. The full-text reports of the remaining 60 ar-
ticles led to the exclusion of 52 because they did not
meet the inclusion criteria. Thus, 8 publications
were included in the review.7,10,20-25
CHARACTERISTICS OF INCLUDED STUDIES
Detailed characteristics of the included studies
are listed in Table 1. Three RCTs,7,10,22 2 CCTs,20,21
and 3 retrospective studies23-25 were included in the
meta-analysis and critical appraisal.
A total of 846 patients were enrolled in 8studies7,10,20-25 comparing LA (n = 389) with GA
(n = 404) in the management of NBFs during a
follow-up period from 2 weeks to 2 years.
In patients receiving LA, the anesthesia technique
consisted of topical spray intranasally with a vasocon-
strictor (eg, 5% lidocaine HCl, 0.5% phenylephrine
HCl) followed by application of topical cocaine paste
(10% cocaine with 0.06% adrenalin) and injection of2% lidocaine with dilute epinephrine at the root of the
nose intranasally and bilaterally. The general anesthetic
procedures were carried out in the operating room of
the hospitals after induction of GA. The same technique
of nasal bone reduction was used in the 2 groups.
The reduction techniques in the most laterally dis-
placed fractures were by external digital manipulation
with the occasional use of Walsham or Asch forceps tomanipulate bony fragments and elevators to manipu-
late depressed fragments or digital manipulation.
Depressed fragments were reduced by a gloved finger
or instrument inserted intranasally. Nasal splints or
packing were not used in some studies,21-23 but were
used in others7,10,24 and left in place for 7 days.
RISK OF BIAS WITHIN STUDIES
Concerning the quality assessment of the included
studies, 3 studies7,10,22 showed a low risk of bias and
5 studies20,21,23-25 showed a moderate risk of bias.The scores are listed in Table 2.
RESULTS OF INDIVIDUAL VARIABLES
Patients’ Satisfaction With Anesthesia
Six studies10,20,21,23-25 compared LA (n = 256) with
GA (n = 311) for manipulation of NBFs with regard to
patients’ satisfaction with anesthesia. The cumulative
OR showed an advantage for the GA group (fixed,
OR = 1.32; 95% CI, 0.80-2.17), but this advantage did
not reach statistical significance (P = .27). The test of
heterogeneity (c2 = 7.96; df = 5; P = .16) indicated
homogeneity of the studies (Fig 2).
Patients’ Satisfaction With Function of Nose
Two studies24,25 with 248 patients (118 in LA group
and 130 in GA group) assessed patients’ satisfaction
with function of the nose. There was no significant
FIGURE 1. Study screening process.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
AL-MORAISSI AND ELLIS 609
difference, but the result favored patients treated
under GA (fixed, OR = 1.53; 95% CI, 0.36-6.58; P =
.56). There was no heterogeneity between studies
(c2 = 0.03; df = 1; P = .85; Fig 3).
Patients’ Satisfaction With Appearance of Nose
Three studies20,24,25 investigated patients’
satisfaction with appearance of the nose. A total of
277 patients were included (LA group, n = 135; GA
group, n = 142). There was a significant difference in
favor of patients treated under GA with regard to
improvement in the appearance of the nose
after treatment (fixed, OR = 3.76; 95% CI, 1.46-9.67;P = .006). The test of heterogeneity indicated
an absence of heterogeneity (c2 = 1.08; df = 2;
P = .58; I2 = 0%; Fig 4).
Subsequent Surgeries
Septoplasty. Four studies21,23-25 reported the
incidence of subsequent septoplasty to correct a
deviated nasal septum after closed reduction using
LA or GA. These studies included a total of 437
patients, with 236 patients in the LA group and 201
patients in the GA group. There was a significant
difference in favor of patients treated under GA(fixed, OR = 0.44; 95% CI, 0.20-0.98; P = .04). The
test of heterogeneity indicated an absence of
heterogeneity (c2 = 2.97; df = 2; P = .40; I2 = 0%;
Fig 5).
Septorhinoplasty. Six studies7,20-24 reported the
necessity for septorhinoplasty as subsequent surgery
to correct a deviated nasal septum and external nose
after closed reduction using LA or GA. A total of 605patients were included, with 327 patients in the LA
group and 278 patients in the GA group. There was
an advantage for patients treated under GA (fixed,
OR = 0.86; 95% CI, 0.51-1.74), but this advantage did
not reach the significant level (P = .59). The test of
heterogeneity indicated an absence of heterogeneity
(c2 = 12.41; df = 5; P = .03; I2 = 0%; Fig 5).
Table 1. CHARACTERISTICS OF INCLUDED STUDIES
Study
Year of
Publication
Study
Design
Group:Age
(yr) Group:M/F
Patients,
n
Follow-Up Time Outcomes
How Outcome
Was MeasuredG1 G2
Watson et al20 1988 CCT G1:24, G2:22 G1:16/1, G2:11/1 17 12 4 wk patient satisfaction, cosmetic
outcomes, airway results
rhinomanometry, subjective
assessment by patient
Waldron et al21 1988 CCT G1, G2:16-56 NM 50 50 3 mo subsequent surgery, residual
septal deformity
subjective assessment by
patient
Cook et al22 1990 RCT G1:28.3, G2:31.3 2/1 25 25 8 wk pain, cosmoses, airway patency subjective assessment by
patient
Rider et al23 2002 RS G1, G2:22 G1, G2:140/47 68 21 1-2 yr patient satisfaction subjective assessment by
patient
Rajapakse et al24 2003 RS G1:23, G2:23 4/1 65 59 6 mo patient satisfaction with
function, esthetics,
anesthesia, subsequent
surgery
subjective assessment by
patient
Courteny et al25 2003 RS G1:26.4, G2:26.7 G1:108/26, G2:158/32 134 190 6 mo to 6 yr patient satisfaction with
function, esthetics,
anesthesia, subsequent
surgery
subjective assessment by
patient
Khwaja et al7 2007 RCT G1:28, G2:29 G1:60, G2:49 74 65 2 wk patient satisfaction with
esthetics, subsequent
surgery
subjective assessment by
patient
Atighechi et al10 2009 RCT G1, G2:149/43 G1, G2:27.3 68 72 7, 14, 30 days pain, patient satisfaction, failure subjective assessment by
patient
Abbreviations: CCT, controlled clinical trial; F, female; G1, local anesthesia group; G2, general anesthesia group; M, male; NM, not mentioned; RCT, randomized controlled trial; RS,retrospective study.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
610
LAVERSU
SGAIN
THEMANIPULATIO
NOFNBFS
Table 2. RESULTS OF QUALITY ASSESSMENT (CRITICAL APPRAISAL)
Study
Year of
Publication
Random
Selection in
Population
Defined Inclusion
and Exclusion
Criteria
Loss to
Follow-
Up
Validated
Measurement
Statistical
Analysis
Estimated Potential
Risk of Bias
Watson et al20 1988 no yes yes yes yes moderate
Waldron et al21 1988 no yes yes yes yes moderate
Cook et al22 1990 yes yes yes yes yes low
Rider et al23 2002 no yes yes yes yes moderate
Rajapakse et al24 2003 no yes yes yes yes moderate
Courteny et al25 2003 no yes yes yes yes moderate
Khwaja et al7 2007 yes yes yes yes yes low
Atighechi et al10 2009 yes yes yes yes yes low
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
AL-MORAISSI AND ELLIS 611
Rhinoplasty. Two studies24,25 reported rhinoplasty
as subsequent surgery required to improve the
appearance of the nose after reduction of NBFs usingLA or GA. There was an advantage for patients
treated under GA (fixed, OR = 0.60; 95% CI, 0.10-
3.65), but this advantage did not reach the significant
level (P = .58). The test of heterogeneity indicated
an absence of heterogeneity (c2 = 14; df = 1;
P = .71; I2 = 0%; Fig 5). The cumulative analysis
showed an advantage for the GA group regarding sub-
sequent surgery required to correct a deformed nasalseptum or external nose (fixed, OR = 0.68; 95% CI,
0.46-1.02), but this advantage did not reach statistical
significance (P = .06). The test of heterogeneity indi-
cated homogeneity of studies (c2 = 18.52; df = 12;
P = .11). The OR was 0.68, meaning that the use of
GA in the treatment of NBFs decreased the need to per-
formed subsequent surgeries by 32% compared with
LA (Fig 5).
Patients’ Preference for Treatment If They Were to
Refracture Their Nose
A total of 437 patients enrolled in 4 studies7,22,24,25
(217 in LA group and 220 in GA group) evaluated their
preference for anesthesia if they were to refracture
their nose. There was no significant difference, but
the result favored GA (fixed, OR = 0.88; 95% CI,0.57-1.36; P = .56). There was no significant
FIGURE 2. Forest plot of LA versus GA for nasal bone fractures accordinggeneral anesthesia; LA, local anesthesia; M-H, Mantel-Haenszel.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral
heterogeneity (c2 = 11.85; df = 3; P = .008; I2 = 75%;
Fig 6).
PUBLICATION BIAS
The funnel plot did not show any noticeable asym-
metry, indicating the absence of publication bias
(Fig 7).
Discussion
Despite the commonness of NBFs, the literature on
the best management of simple nasal fractures is
sparse and inconclusive.24 Nasal fractures are
managed in different ways and not all are equally effec-tive. For NBFs, there are 3 major aspects to consider to
ensure the best treatment: the timing of treatment, the
choice of anesthetic (local or general), and surgical
technique (open or closed reduction).11 There are
different opinions about the most appropriate timing
of treatment and a surgeon’s preference often has
much to do with the decision about when to inter-
vene.11 Some injuries might require immediate atten-tion, whereas others might be better treated after a
delay.11 Often, the swelling is so severe that closed
treatment in the acute setting is not performed
because it would be difficult to determine whether
the nasal bones were properly reduced. Another com-
mon reason for delaying surgery is the surgeon’s
to patient satisfaction with anesthesia. CI, confidence interval; GA,
Maxillofac Surg 2015.
FIGURE 3. Forest plot of LA versus GA for nasal bone fractures according to patient satisfaction with function of the nose. CI, confidenceinterval; GA, general anesthesia; LA, local anesthesia; M-H, Mantel-Haenszel.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
612 LA VERSUS GA IN THE MANIPULATION OF NBFS
philosophy. One has the choice of reducing the nasal
bones back into the pre-trauma position or performing
a rhinoplasty to obtain a result that might be better
than what the patient had before the injury. Many pa-tients have pre-existing nasal and septal deformities.
To merely reduce the bones back into the malposition
they were in before injury does not provide improve-
ment for the patient. It only restores what the patient
had before injury. Therefore, if a surgeon’s philosophy
is to improve the patient’s appearance and nasal
airway, the surgeonmight choose to delay surgery, lett-
ing the bones heal in a malunited position, so thebones can be refractured or repositioned using formal
septorhinoplasty or rhinoplasty techniques that can
address the internal and external components of
the nose.
One of the major variables in the treatment of nasal
fractures is in the choice of anesthetic. Most rhinoplas-
tic surgeons use GA when performing a formal rhino-
plasty. However, the patient who presents to theemergency room with a displaced NBF often will be
treated under LA (possibly with the addition of seda-
tion) to facilitate treatment. However, this takes a
very cooperative patient to merely withstand the
pain of instillation of LA in and around the nose. If a pa-
tient is not cooperative, a general anesthetic will
become necessary. However, if a patient needs to be
treated acutely and requires a general anesthetic, get-ting a patient to the operating room for a general anes-
thetic requires paperwork and takes away 1 of the
variables under the surgeon’s control—the timing of
treatment. If the surgeon can manage the patient in
the emergency room using LA, the patient can be
readily treated and discharged. If instead a general
anesthetic is preferred or required, one has the
FIGURE 4. Forest plot of LA versus GA for nasal bone fractures accordinginterval; GA, general anesthesia; LA, local anesthesia; M-H, Mantel-Haen
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral
additional variables of availability of anesthetic, oper-
ating room personnel, and operating room time. This
might not be expeditious. Conceivably, the surgery
might not be possible for hours and this can greatly up-set the surgeon’s schedule. This also could be a reason
why patients who do not require acute care are dis-
charged and treated on a secondary basis, weeks to
months later. It puts the timing of treatment back un-
der the surgeon’s control.
Is there a difference in the outcomes of primary
treatment of nasal fractures based on the type of anes-
thetic used during treatment? The results of this studyshowed that although there was a trend toward better
outcomes with GA, there was no a statistically mean-
ingful difference between LA and GA for closed reduc-
tion of NBFs with regard to patient satisfaction with
anesthesia, function of the nose, subsequent treat-
ments (septoplasty, septorhinoplasty, rhinoplasty and
refracture), or preference of anesthesia if the nose
were to refracture. This is in accord with the previousliterature.7,10,20-25
All previous studies have shown that LA techniques
are safe, effective, and comparable to GA in the manip-
ulation of NBFs, but there was no evidence to support
or refute the superiority of one technique over
another. To the best of the authors’ knowledge this
is the first meta-analyses comparing LA with GA in
closed reduction of NBFs. In addition to providingcomparable efficacy to GA, LA offers greater safety,
lower cost, use of fewer hospital resources, and less
time in the hospital.
Therefore, LA is appropriate for cooperative adults
with simple nasal fractures that do not require open
reduction of the septum. Certainly, GA also can be
used in such cases, but most resort to using GA for
to patient satisfaction with appearance of the nose. CI, confidenceszel.
Maxillofac Surg 2015.
FIGURE 5. Forest plot of LA versus GA for nasal bone fractures according to subsequent corrective surgeries. CI, confidence interval;GA, general anesthesia; LA, local anesthesia; M-H, Mantel-Haenszel.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
FIGURE 6. Forest plot of LA versus GA for nasal bone fractures according to patient preference for treatment if the nose were to refracture.CI, confidence interval; GA, general anesthesia; LA, local anesthesia; M-H, Mantel-Haenszel.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
AL-MORAISSI AND ELLIS 613
FIGURE 7. Funnel plot of publication bias according to the reported incidence of subsequent corrective surgeries, showing a symmetric dis-tribution.
Al-Moraissi and Ellis. LA Versus GA in the Manipulation of NBFs. J Oral Maxillofac Surg 2015.
614 LA VERSUS GA IN THE MANIPULATION OF NBFS
uncooperative or young patients, those with severely
displaced fractures, and those who require extensive
septal work.
Although treatment of NBFs under GA is more
costly, it is welcomed by many patients who ‘‘don’t
want to be awake’’ during the surgery. Three studies
in the present analysis assessed postoperative pain us-ing pain scores,20,22,26 but they did not report the
standard deviation needed to performed meta-
analysis for the outcome of pain. Not surprisingly, pa-
tients treated under GA obtained better outcomes
than under LA and this might be due to patients expe-
riencing less pain. Nasal instrumentation can be
considered barbaric to patients and their families and
the request for GA is not uncommon.25 Although GAhas some potential risks, such as adverse effects of
anesthetic drugs, for healthy patients, the risk is minor.
In conclusion, regardless of the cost and risks associ-
ated with GA, the results of the meta-analysis showed
that GA provides a trend toward better outcomes with
GA for satisfaction with anesthesia, function of the
nose, subsequent treatments (septoplasty, septorhino-
plasty, rhinoplasty and refracture), and patients’ prefer-ence of anesthesia if they were to refracture their nose.
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