a b s t r a c t

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 18 years 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 +- 5.05 years, with the greatest proportion (21.8%, n = 29) of patients in the age ranges of 0-2 and 6- 8 years. 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 emer- gency 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.

(C) 2016

Introduction

The nose is the most protruding and weakest feature of the face. Nasal bone fractures are commonly observed in maxillofacial trauma cases [1]. Nasal bone fractures are also observed twice as often in males, most frequently between the ages of 15 and 25 years and over 60 years [2]. Although a physical examination remains the gold stan- dard for the diagnosis of nasal fractures, a hematoma and/or edema that have formed around the nose may complicate the diagnosis. Additionally, identifying nasal fractures during early childhood can be difficult, because the cartilage ratio is higher [3].

The standard imaging method used to diagnose nasal fractures is di-

rect radiography. However, false-positive and -negative findings may present in diagnostic examinations using lateral direct nasal radiogra- phy in the presence of a hematoma and/or edema in the nasal zone. In- deed, applying a high dose of X-ray radiation may be necessary in the nasal zone to reach a correct diagnosis [4].

Ultrasonography (USG) is a simple and inexpensive imaging method that does not involve exposure to radiation. The value of USG in

* Corresponding author.

E-mail address: [email protected] (S. Dogan).

identifying bone (hip, rib, skull, long bones) fractures has been demon- strated [3]. Similar results have been reported among studies that com- pared the sensitivity and specificity of USG with those of computed tomography (CT) in the detection of nasal fractures [5]. Indeed, it has been shown that the sensitivity of USG is higher than that of CT, espe- cially for fractures that involve separation without depression [6].

Our primary objective in this research was to diagnose nasal frac- tures in children who presented at the emergency department with nasal trauma, without exposing them to radiation. The secondary objec- tive was to demonstrate the diagnostic value of USG, which does not in- volve radiation and can be provided readily and inexpensively at the bedside for the identification of nasal fractures. Other objectives were to reduce emergency department congestion and the negative effects of the emergency department environment on children.

Equipment and methods

Research design

This research was descriptive and performed at a single center. It was a prospective study conducted at the Istanbul Kanuni Sultan

http://dx.doi.org/10.1016/j.ajem.2016.11.056

0735-6757/(C) 2016

Suleyman Training and Research Hospital Emergency medical clinic from April 10 to July 10, 2015. Ethical board approval (April 6, 2015, no. 2015/4) was received from the Istanbul Kanuni Sultan Suleyman Training and Research Hospital Clinical Research Ethics Board. In total, 133 patients under 18 years of age who presented at the emergency de- partment with isolated nasal trauma from April 10 to July 10, 2015 were included in the study.

Observations, measurements, and data collection

Patients who presented at the emergency department in an ambula- tory state with a Glasgow Coma Scale (GCS) of 15 who did not have multiple traumas or an indication for CT were included. Patients youn- ger than 18 years who met these criteria were assessed by the emergen- cy medicine specialist in charge, and their demographic data, trauma type, trauma time, GCS, and physical examination results were record- ed. Whether there was any crepitation, septal hematoma, edema, defor- mity, epistaxis, ecchymosis, or open injury was noted during the physical examination. Direct radiographs were taken for all patients and interpreted by a radiologist; the presence of a fracture was recorded on the research form. A bedside superficial facial USG was performed on the same patients by a radiologist, and the results were reported.

Radiological analysis

First, direct nasal radiographs, bilateral radiographs, and Waters’ ra- diographs (Illustration 1) [3], were performed in the patients. For the bedside USG, transverse, longitudinal, and oblique examinations were performed using a Linear probe (Toshiba Xario XG, 7.2-14 MHz), and images were recorded (Illustration 2) [6].

Research inclusion and exclusion criteria

Patients under 18 years of age with isolated nasal trauma who pre- sented at the emergency department, agreed to participate in the study, and completed the consent form were included. Patients aged 18 years of age or older who had serious open injuries involving the nasal bones, multiple traumas, a GCS b 15, an indication for CT, a previ- ous history of nasal fractures, and who did not complete the consent form were not included.

Statistical analysis

The Number Cruncher Statistical System 2007 (Kaysville, Utah, USA) software was used for statistical analyses. The Mann-Whitney U test was used for two-group comparisons of parameters that did not show a normal distribution, and the average, standard deviation, median,

Illustration 1. Direct nasal radiographs.

frequency, ratio, minimum, and maximum values were presented for the comparisons of quantitative data. Logistic regression analysis was used to analyze the independent variables. The Kruskal-Wallis test was used for comparisons of three or more groups that did not show a normal distribution, followed by the Mann-Whitney U test to deter- mine the specific differences. Pearson’s ?² test, Fisher’s exact test, and Yates’ continuity correction test (Yates’ corrected ?² test) were used to compare quantitative data. The McNemar test was used to assess the conformity of the direct radiography and USG results. The sensitivity, specificity, precision, positive predictive values (PPVs), and Negative predictive values , along with 95% confidence intervals, were de- termined. Statistical significance was set at p b 0.01 and p b 0.05.

Findings

In total, 133 patients, 34.6% female and 65.4% male, were analyzed in this study. All patients arrived at the emergency department in an ambu- latory state with a GCS of 15. The patients did not have severe trauma or an indication for CT. There was no crepitation or septal hematoma in any patient on physical examination. Of the 133 patients, 50 (37.6%) had nasal fractures according to physical examinations conducted by emergency medicine specialists (Fig. 1). The demographics of the patients and the presence of the nasal fracture, accepting the assessment by the emergen- cy medicine specialists as the gold standard, are provided in Table 1.

The average patient age was 7.44 +- 5.05 years, with the greatest proportion (21.8%, n = 29) of patients in the age ranges of 0-2 and 6- 8 years. Falls were the most commonly reported trauma type (61.7%, n = 82), and of those reporting falls, 54% had fractures.

According to the logistic regression analysis after age and sex dis- crimination, the diagnosis of nasal fractures by USG (p = 0.009, OR= 3.051, 95% CI = 1.317-7.071), the diagnosis of nasal fractures by phys- ical examination (p b 0.0001, OR = 6.622, 95% CI = 2.425-18.082), and the observation of edema on USG were all independent variables (p b 0.0001, OR = 1.048, 95% CI = 0.969-1.134). In addition, on physical examination, fractures were present in 50 of the 52 patients with ecchy- mosis (p b 0.0001).

When we examined the radiography and USG results to identify fractures, of the 25.6% (n = 34) of cases diagnosed with fractures by USG, only 8.3% (n = 11) were diagnosed by radiography, with no frac- tures found in the other 17.3% (n = 23). Moreover, all of the cases who were not diagnosed with fractures by USG were also not diagnosed with fractures by radiography (p = 0.001; Table 2).

According to the age distribution of the patients with fractures diag- nosed by USG, the rate of diagnosis increased with age. The ages of those diagnosed with fractures were significantly higher than the ages of those who were not diagnosed with fractures (p = 0.008).

The sensitivity, specificity, NPV, and PPV of the physical examination and the imaging findings are provided in Table 3.

Discussion

Nasal bone fractures are generally diagnosed by physical examina- tion, regardless of whether supporting imaging methods are also used. A physical examination is important, especially in children, due to the relatively low sensitivity of radiology [7]. However, even though it re- mains the gold standard for the diagnosis of nasal bone fractures, a physical examination alone cannot determine the structure of a fracture [3]. Imaging methods are also required in the emergency department to confirm the diagnosis.

Direct radiography was used as the standard imaging method for

many years, until published reports showed that direct radiography was negative in 25% of patients with nasal bone fractures requiring sur- gical interventions [8]. Other research showed that USG is a more effec- tive method than direct radiography for the diagnosis of nasal bone fractures [9]. Gurkov et al. recommended USG as the first imaging meth- od to use for diagnosing nasal bone fractures because it is typically

Illustration 2. Transverse, longitudinal, and oblique USG images.

available [10]. Mohammadi et al. concluded that dissociations of even

0.1 mm in the nasal bone can be detected by USG [11]. We believe that diagnosing patients with nasal bone fractures using USG scans in the transverse, longitudinal, and oblique directions is a more accurate detection method than direct radiography. We also determined a high PPV of 96.2% for USG.

CT scans can show detailed anatomical features of the nasal bone and soft tissue. Furthermore, CT is essentially user independent. Howev- er, image detail and quality may be decreased as a result of a partial vol- ume artifact in CT imaging. Thus, CT may not always be ideal, especially for identifying fracture lines [3]. The sensitivity and specificity of direct radiography are relatively low, especially for the diagnosis of nasal frac- tures. Moreover, CT is not always readily accessible or cost-effective [12]. In contrast to CT and direct radiography, USG is applied readily, in- expensive, and not associated with radiation risks [3,11,13]. Thus, USG is more convenient than CT or direct radiography [12]. Previous reports have also demonstrated the diagnostic value of USG for nasal fractures [3,11,13]. For example, Lee et al. reported higher specificity, PPV, and NPV values for USG compared with CT [14]. In a study of 87 patients, Mohammadi et al. compared USG with CT used for the identification of fracture lines and reported a sensitivity of 100% and specificity of 91% for USG. In this study, which involved 133 patients, we determined the sensitivity of USG to be 22.5% and the specificity to be 83.1%. We be- lieve that the reasons for the lower values in our study were the pediat- ric age and higher numbers of patients enrolled.

Lee et al. reported that USG is more valuable than direct radiography for imaging the cartilage sections of the nose [6]. In our study, the diag- nostic value of USG was higher than that of direct radiography in pedi- atric patients. Furthermore, USG has high sensitivity and specificity for identifying soft tissue pathologies, such as edema, ecchymosis, and swelling in the nasal zone [6]. Soft tissue edema and subperiostal hema- toma were identified in 67 of 72 patients with nasal fractures in one re- port [15]. In our study, we also observed edema and/or hematomas in 50 of the 133 patients who presented with nasal trauma. Moreover, we found fractures in 34 (68%) of these patients.

In a study by Liu et al., the average age of the 100 study patients pre- senting with nasal bone trauma was 13 years; 55% of these patients were males, and 70% were older than 12 years. The most frequent cause of injury was sports related [16]. In another report, the most fre- quent cause of facial injuries in children was falls, and the majority of in- juries were nasal fractures [17]. We also found that the most frequent cause of nasal fracture was falls (61.6%).

Beck et al. reported that all nasal bone fractures identified by direct radiography were also identified by USG [18] In a study involving 26 children with nasal trauma, while nasal fractures were demonstrated in all cases by USG, they were demonstrated in only 14 of the 26 cases by direct radiography [3]. In our research, we confirmed the physical ex- amination as the gold standard for nasal bone fracture identification in children using direct radiography and USG. We examined 133 patients in total, and fractures were suspected in 50 (37.6%) patients on physical

Fig. 1. Flow chart of patients under 18 years of age who presented at the emergency department with nasal trauma.

Table 1

Presence of nasal fractures and demographic data of the patients.

Table 3

Sensitivity, specificity, NPV, and PPV of the physical examination (considered the gold standard) and imaging findings.

Characteristic Fracture % (n) No fracture % (n) p value Total % (n)

examination. Fractures were then diagnosed in 11 patients by direct ra- diography and in 34 patients by USG. Moreover, nasal bone fractures were identified by USG in all 11 patients who had been diagnosed by di- rect radiography. However, nasal bone fractures were not identified by direct radiography in the 23 patients who had been diagnosed by USG. Furthermore, the patients who were not diagnosed with nasal bone fractures by USG were also not diagnosed by direct radiography.

In a study investigating the diagnostic value of USG for nasal bone fractures, the sensitivity, specificity, NPV, and PPV values were 84%, 75%, 91%, and 61%, respectively; in comparison, the respective values for lateral direct radiography were 50%, 72%, 84%, and 32%. In this study, USG was significantly better than direct radiography for fracture identification [19]. Gurkov et al. reported high sensitivity and specificity values for USG and direct radiography for identifying nasal bone frac- tures (98% and 88% sensitivity and 95% and 95% specificity, respective- ly). The specificity of direct radiography for identifying lateral nasal bone fractures was higher compared with USG (94% vs. 75%). However, they also found a significantly higher sensitivity for USG than for direct radiography for detecting lateral nasal bone fractures (98% vs. 28%, re- spectively) [10]. In a study of 18 patients by Danter et al., the sensitivity and specificity of USG were 94% and 83%, respectively, compared with direct radiography [19]. Mohammadi et al. found the sensitivity and specificity to be 86% and 87%, respectively, for CT and 72% and 73%, re- spectively, for direct radiography, compared with physical examination [15]. In our study, the sensitivity, specificity, PPV, and NPV were 38.2%, 97.6%, 96.2%, and 100%, respectively, for physical examinations; 22.5%,

83.1%, 96.2%, and 69.7%, respectively, for USG; and 6.1%, 92.8%, 54.6%, and 63.1%, respectively, for direct radiography. Additionally, we found the sensitivity of USG to be higher than that of direct radiography for de- tecting nasal bone fractures, consistent with the literature.

In their study involving patients of all age groups, Atighechi et al. re- ported that the sensitivity of USG was 84%, whereas that of direct radi- ography was 50% for detecting nasal fractures [20]. In our study, the sensitivity values (USG: 22.5%, direct radiography: 6.1%) were lower than those in the literature. This is because the value in diagnosing nasal bone fractures by both USG and direct radiography increases with age, as we confirmed. Because much of the research in the litera- ture includes adult patients, the sensitivity and specificity values are considerably higher than those in our research.

Conclusions

Nasal bone fractures are the most commonly encountered fractures associated with maxillofacial trauma. It is important to diagnose such

Table 2

Evaluation of direct radiography and USG results.

Ultrasonography

fractures quickly and accurately, with minimal side effects, in pediatric patients. In our examination of 133 cases, we found that USG is a rapid, inexpensive, and easily applied method, which does not involve radiation and has a high diagnostic value for nasal bone fractures, espe- cially in pediatric patients. We also predict that the use of USG to iden- tify suspected fractures will minimize the time spent in the emergency department, thereby minimizing its negative influences on children.

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    No fracture Fracture Total

    p value

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    Direct radiography No fracture	99 (74.4%)	23 (17.3%)	122 (91.7%) 0.001
    Fracture	0 (0%)	11 (8.3%)	11 (8.3%)
    Table	99 (74.4%)	34 (25.6%)	133 (100%)