Am J Otolaryngol xxx (xxxx) xxxx

Contents lists available at ScienceDirect

Am J Otolaryngol
journal homepage: www.elsevier.com/locate/amjoto

Nasal bone fractures and the use of radiographic imaging: An

otolaryngologist perspective☆,☆☆
Edward Westfall, Benton Nelson, Dominic Vernon, Mohamad Z. Saltagi, Avinash V. Mantravadi,
⁎
Cecelia Schmalbach, Jonathan Y. Ting, Taha Z. Shipchandler
Department of Otolaryngology—Head and Neck Surgery, Indiana University School of Medicine, United States of America

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: To determine radiologic preferences of practicing otolaryngologists regarding isolated nasal bone
Isolated fractures.
Nasal bone fractures Study design: An 8-question survey on isolated nasal bone fractures was designed.
Trauma Setting: Surveys were sent to all otolaryngology residency program directors for distribution among residents
Radiography
and faculty. Additional surveys were distributed to private practice otolaryngology groups.
CT maxillofacial
Survey
Results: 140 physicians responded to the survey. 57% of the respondents were practicing otolaryngologists (75%
with 10+ years of experience), while 43% of respondents were residents-in-training. 56% of respondents treated
1–5 nasal bone fractures per month. 80% of all respondents reported imaging being performed prior to con-
sultation. If imaging was obtained before consultation, plain films and computed tomography (CT) max-
illofacial/sinus scans were the most frequent modalities. 33% of residents and 70% of practicing otolaryngol-
ogists report imaging as ‘rarely’ or ‘never’ helpful in guiding management. 42% of residents and 20% of
practicing otolaryngologists report asking for imaging when it wasn't already obtained. Decreased use of
radiography was associated with greater years in practice and higher frequency of fractures treated.
Conclusions and relevance: Otolaryngologists seldom request imaging to evaluate and treat isolated nasal bone
fractures. When ordered, imaging is utilized more often among residents-in-training and non-otolaryngology
consulting physicians. This study highlights an opportunity to educate primary care and emergency room pro-
viders as well as otolaryngology residents on the value of comprehensive physical exam over radiographic
imaging in the work-up of isolated nasal fractures. In addition, widespread adoption of a “no x-ray policy” in this
setting may result in better resource utilization.

1. Introduction properly treated with appropriate fracture reduction [2,5].

The management of a nasal bone fracture is dependent upon the
Nasal bone fractures are exceedingly common in facial trauma due clinical presentation. Radiographic imaging is recommended in the
to the central location, prominent projection, and thin nature of the setting of high energy craniomaxillofacial trauma to include loss of
nasal bones [1,2]. These fractures most frequently occur in males in consciousness [8]. However, in the setting of isolated nasal trauma
their 2nd and 3rd decades of life, but they also constitute 30% of pe- without evidence of other craniofacial injuries or trauma, plain film
diatric facial fractures [1–6]. Left untreated, these fractures can lead to radiographs have repeatedly been shown to be noncontributory in
nasal obstruction including nasal valve collapse, cosmetic deformity further management [9–14]. In settings where imaging is indicated due
and additional long term sequelae including chronic sinusitis and nasal to other suspected injuries, the majority of the otolaryngologic litera-
growth retardation in children [3,7]. Concurrent septal injury can lead ture advocates for a computed tomography (CT) maxillofacial scan as
to further destabilization of the nose, nasal airway obstruction, lateral opposed to a facial x-ray [5,6,9–15]. Overall, CT scans may provide
nasal tip deviation, and decreased tip projection in patients who are not high resolution imaging of isolated nasal fractures, but it is debatable

☆
Financial disclosures: none.
☆☆
Meeting information: This work has not been presented previously.
⁎
Corresponding author at: Department of Otolaryngology—Head and Neck Surgery, Indiana University Health Physicians, Indiana University School of Medicine,
1130 W. Michigan Street, Suite 400, Indianapolis, IN 46202, United States of America.
E-mail address: tshipcha@iupui.edu (T.Z. Shipchandler).

https://doi.org/10.1016/j.amjoto.2019.102295
Received 27 August 2019
0196-0709/ © 2019 Elsevier Inc. All rights reserved.

Please cite this article as: Edward Westfall, et al., Am J Otolaryngol, https://doi.org/10.1016/j.amjoto.2019.102295
E. Westfall, et al. Am J Otolaryngol xxx (xxxx) xxxx

Fig. 1. This is the complete 8-question survey that was distributing to otolaryngology residents, attendings at academic programs, and private-practice otolar-
yngologists.

whether any imaging beyond the clinical exam improves patient man- This study's importance lies in the fact that isolated nasal bone
agement. fractures are relatively common, and reliance on excessive imaging can
This study aims to evaluate the current radiographic practice pat- amplify the cost of care [14,16–18]. Determining the use of radio-
terns among otolaryngologists and residents who treat patients with graphy by otolaryngologists in such instances is vital for effective and
isolated nasal bone fractures. We hypothesized that otolaryngologists in cost-efficient management.
current practice rely upon physical examination as opposed to imaging
in the identification and management of isolated nasal bone fractures. 2. Methods
In addition, we hypothesized that consultants do not routinely obtain
imaging for isolated nasal bone fractures, but primary care teams in- The Indiana University Institutional Review Board approved this
cluding emergency department (ED) providers routinely order such project. An anonymous, electronic survey was designed using the
imaging as part of their work-up for isolated nasal trauma. Google documents online survey creation tool (Google, Mountain View,

2
E. Westfall, et al. Am J Otolaryngol xxx (xxxx) xxxx

Fig. 1. (continued)

CA). A copy of the final survey is shown in Fig. 1. The survey identified pattern differences between otolaryngology residents in training versus
respondent's years in practice, resident versus board certified otolar- practicing otolaryngologists. A two-tailed Chi-Squared analysis was
yngologist, the number of fractures regularly encountered, and the used to determine resident and staff perceived differences in the utility
presence of imaging prior to consultation. Questions were incorporated of nasal fracture imaging. p < 0.05 was deemed statistically sig-
to determine the role imaging plays in the consultant's management nificant.
plan (e.g. frequency, modality, and reasons for request). Two hundred
surveys were distributed to several otolaryngology training program
directors in the United States as well as associated faculty and residents 3. Results
at their respective institutions. In addition, the study was distributed
regionally to private otolaryngology practices. Incomplete surveys were A total of 200 surveys were distributed. 140 surveys were com-
not included in data analysis. Monetary and gift compensation was not pleted, yielding a response rate of 70%. Otolaryngology practice ex-
provided for participation. perience is summarized in Fig. 2. 78 (56%) respondents were in aca-
The survey data and demographics were analyzed using descriptive demic or private practice while the remaining 62 (44%) were
statistics. The primary outcome measure was the frequency, type, and otolaryngology residents. The majority of respondents (60; 43%) had
utility of radiographic imaging in the work-up of isolated nasal frac- 10 or more years of trauma experience post-residency/fellowship
tures. Subgroup analysis was performed to identify potential practice training.
Most respondents (56%) treated between 1 and 5 nasal bone

3
E. Westfall, et al. Am J Otolaryngol xxx (xxxx) xxxx

Fig. 2. This survey question asked practitioners about their years of experience treating nasal bone fractures. As demonstrated, 43% of survey respondents
had > 10 years of experience, and nearly 50% had at least 5 years of experience post-residency.

Fig. 3. This survey question asked otolaryngologists how often imaging was obtained prior to consultation on a patient with an isolated nasal bone fracture. As
demonstrated, 80% of otolaryngologists stated that imaging was “always” or “often” obtained prior to consultation. The imaging modalities obtained were plain films
or maxillofacial computed tomography scans, or both.

fractures per month. In total, 80% reported imaging being ‘always/ isolated nasal fracture [17]. The strength of this study lies in capturing
often’ obtained prior to otolaryngology consultation (Fig. 3). Specifi- current practices among otolaryngology residents, faculty, and non-
cally, 39% reported receiving plain films, while 61% reported prior CT otolaryngology physicians. We have importantly identified a high rate
imaging. In the event that imaging was desired, 110 respondents (79%) of radiographic imaging for isolated nasal trauma among consulting
requested maxillofacial/sinus CT (Fig. 4). 42 (68%) residents reported (non-otolaryngology) physicians, with nearly 40% of survey re-
that imaging was helpful in their management of nasal fractures which spondents stating that imaging was obtained by the consulting team
was statistically higher than the 22 (28%) practicing otolaryngologists prior to the involvement of the otolaryngologist. This finding identifies
who found imaging helpful (p < 0.001). Twenty-five (42%) of re- a knowledge gap and an opportunity for quality improvement.
sidents and 16 (20%) of practicing otolaryngologists reported asking for It has previously been postulated that junior level residents less
imaging when it was not already obtained. In addition, 33 (24%) re- familiar with ideal practice standards contribute to the unnecessary use
spondents reported ‘never’ obtaining imaging when consulted, while 62 of plain films for nasal trauma work up [14]. An interesting finding in
(44%) ‘rarely’ obtain imaging (Fig. 5). this study is the significant practice difference that exists between re-
sidents and non-residents within our own field of otolaryngology.
Otolaryngology residents are more likely to order radiographs for iso-
4. Discussion lated nasal bone injuries (42%) compared to non-residents (20%).
Otolaryngology residents reported imaging to be useful in treatment
This study demonstrates that otolaryngologists do not routinely planning whereas non-residents did not. Lastly, a trend towards in-
order radiographic imaging to assess isolated nasal trauma. This sup- creased use of CT imaging for the work up of nasal fractures was
ports previous findings by Logan et al. who succinctly demonstrated identified among residents, whereas non-residents were largely
that radiography rarely affects the treatment plan for those with an

4
E. Westfall, et al. Am J Otolaryngol xxx (xxxx) xxxx

Fig. 4. This survey question asked survey respondents which imaging modality they would request if they were interested in obtaining imaging for nasal bone
fracture. Nearly 80% of respondents stated that they preferred CT (computed tomography) Maxillofacial scans, while there was little interest in obtaining plain films.

Fig. 5. This survey question asked how often otolaryngologists requested imaging. 68% of respondents stated that they ‘never’ or ‘rarely’ request imaging.

impartial to x-rays vs CT when examining nasal bone fractures. These suggests that clinical experience favors physical examination as op-
data suggest that, as experience in clinical exam related to nasal bone posed to imaging when diagnosing fractures.
injuries increases, the usefulness of radiographic imaging decreases. The use of plain films in isolated nasal bone fractures is another
This highlights the importance of emphasizing clinical examination in important radiographic practice that has been studied in the past.
the work up of isolated nasal fractures early in residency training. Craniomaxillofacial trauma studies have emphasized that plain films
In the case of complex facial trauma, CT findings often affect have very limited use in the diagnosis and treatment of isolated nasal
management strategies [12]. However, current literature repeatedly fractures [10,12,14]. Plain films have been shown to have high false
emphasizes that CT imaging is not indicated for isolated nasal bone positive rates for nasal fracture and septal deviation, and they can be
fractures unless concomitant symptoms or physical exam findings difficult to interpret for radiologists and consultants alike [1,8,15,19].
warrant a more robust work up [1,16,18]. Despite these re- In addition, nasal injuries are frequently associated with cartilaginous
commendations, this study suggests that in current practice, CT max- avulsions and separations which go undetected on plain films [2].
illofacial/sinus scans are still routinely obtained for isolated nasal Sharp and Denholm conducted a prospective study analyzing the
trauma prior to otolaryngology consultation. While CT is the preferred utility of plain film imaging in the management of isolated nasal trauma
modality to assess complex facial trauma, consultants reported limited [14]. The authors failed to identify a case where the films altered
utility of CT imaging for isolated nasal fractures, and otolaryngologists treatment plan [14]. Their findings correlate strongly with the results of
overwhelmingly declined further imaging to evaluate a nasal bone our survey. Their study led to a fundamental change in hospital policy
fracture. Of the respondents who ‘never’ obtained imaging, the majority with a creation of ‘no x-ray policy’ for isolated nasal trauma [14]. Given
were board certified otolaryngologists with over 5 years of experience. that the nasal bone is among the most, if the not the most, commonly
In addition, as the number of nasal fractures seen per month increased, fractured bone in the human body, this simple change in eliminating
the utility of radiography decreased in our survey. This finding again routing radiographic imaging, if applied on a wider scale, could lead to

5
E. Westfall, et al. Am J Otolaryngol xxx (xxxx) xxxx

significant reduction in both cost and radiation exposure [1,7,8,16,18]. Declaration of competing interest
The major limitations of this study are the selection and recall bias
inherent to all survey studies. We attempted to be comprehensive in Authors disclose no conflict of interest.
evaluating practice patterns by including otolaryngology residents,
academic faculty, as well as private practitioners. In doing so, practice References
variations related to clinical setting were negated as much as possible.
Another limitation of this study is that it does not answer the question [1] Alvi A, Doherty T, Lewen G. Facial fractures and concomitant injuries in trauma
of which patient group is more likely to undergo radiographic imaging. patients. Laryngoscope 2003;113(1):102–6.
[2] Holt GR. Biomechanics of nasal septal trauma. Otolaryngol Clin North Am
It would be especially useful to determine if children receive imaging 1999;32(4):615–9.
more frequently base on difficultly performing a clinical exam or the [3] Carvalho TB, Cancian LR, Marques CG, Piatto VB, Maniglia JV, Molina FD. Six years
higher risk of midfacial growth retardation [4]. It is possible that fear of of facial trauma care: an epidemiological analysis of 355 cases. Braz J
Otorhinolaryngol 2010;76(5):565–74.
potential litigation surrounding missed facial injuries contributes to [4] Rohrich RJ, Adams Jr WP. Nasal fracture management: minimizing secondary nasal
overutilization of CT imaging, especially among children [16]. Our deformities. Plast Reconstr Surg 2000;106(2):266–73.
study does not help answer this question, and future studies would be [5] Anderson PJ. Fractures of the facial skeleton in children. Injury 1995;26(1):47–50.
[6] East CA, O’Donaghue G. Acute nasal trauma in children. J Pediatr Surg
helpful in investigating this further. 1987;22(4):308–10.
[7] Imahara SD, Hopper RA, Wang J, Rivara FP, Klein MB. Patterns and outcomes of
5. Conclusion pediatric facial fractures in the United States: a survey of the National Trauma Data
Bank. J Am Coll Surg 2008;207(5):710–6.
[8] Finkle DR, Ringler SL, Luttenton CR, Beernink JH, Peterson NT, Dean RE.
Isolated nasal fractures are a common injury which can be diag- Comparison of the diagnostic methods used in maxillofacial trauma. Plast Reconstr
nosed and treated effectively without radiographic imaging. Most oto- Surg 1985;75(1):32–41.
laryngologists do not request imaging in order to identify and treat [9] Chou C, Chen CW, Wu YC, Chen KK, Lee SS. Refinement treatment of nasal bone
fracture: a 6-year study of 329 patients. Asian J Surg 2015;38(4):191–8.
isolated nasal fractures. On the contrary, data from this survey de- [10] Clayton MI, Lesser TH. The role of radiography in the management of nasal frac-
monstrates that imaging is frequently obtained prior to otolaryngology tures. J Laryngol Otol 1986;100(7):797–801.
consultation (plain film radiographs and CT). Primary care services [11] Mondin V, Rinaldo A, Ferlito A. Management of nasal bone fractures. Am J
Otolaryngol 2005;26(3):181–5.
(first point of care) are more likely to obtain radiographic imaging [12] Nigam A, Goni A, Benjamin A, Dasgupta AR. The value of radiographs in the
compared to otolaryngologists. In addition, otolaryngology residents in management of the fractured nose. Arch Emerg Med 1993;10(4):293–7.
training are more likely to rely on radiographic imaging compared to [13] Rhee SC, Kim YK, Cha JH, Kang SR, Park HS. Septal fracture in simple nasal bone
fracture. Plast Reconstr Surg 2004;113(1):45–52.
practicing otolaryngologists, especially those with multiple years of [14] Sharp JF, Denholm S. Routine X-rays in nasal trauma: the influence of audit on
experience. clinical practice. J R Soc Med 1994;87(3):153–4.
Ultimately, nasal bone plain films and CT scans have limited clinical [15] de Lacey GJ, Wignall BK, Hussain S, Reidy JR. The radiology of nasal injuries:
problems of interpretation and clinical relevance. Br J Radiol 1977;50(594):412–4.
utility in isolated nasal bone fracture management and unnecessarily [16] Illum P. Legal aspects in nasal fractures. Rhinology 1991;29(4):263–6.
add to healthcare costs. This study identifies a knowledge gap and an [17] Logan M, O’Driscoll K, Masterson J. The utility of nasal bone radiographs in nasal
associated opportunity to educate primary care providers to include trauma. Clin Radiol 1994;49(3):192–4.
[18] Turner BG, Rhea JT, Thrall JH, Small AB, Novelline RA. Trends in the use of CT and
emergency room staff, as well as otolaryngology residents, in the work-
radiography in the evaluation of facial trauma, 1992–2002: implications for current
up of isolated nasal fractures. This workup should emphasize a com- costs. AJR Am J Roentgenol 2004;183(3):751–4.
prehensive physical exam over radiographic imaging. In addition, [19] Adeyemo WL, Akadiri OA. A systematic review of the diagnostic role of ultra-
widespread national adoption of a “no x-ray policy” in the management sonography in maxillofacial fractures. Int J Oral Maxillofac Surg
2011;40(7):655–61.
of isolated nasal fractures will likely result in better resource utilization
and improve the quality of patient care.