Otolaryngology -- Head and Neck Surgery

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Patient Self-assessment of Nasal Fractures and Self-referral to an Ear, Nose, and Throat Department : A Prospective Study David E. C. Baring, Duncan J. Bowyer and Richard Adamson Otolaryngology -- Head and Neck Surgery 2012 146: 913 originally published online 27 January 2012 DOI: 10.1177/0194599811435892 The online version of this article can be found at: http://oto.sagepub.com/content/146/6/913

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Original Research—General Otolaryngology

Patient Self-assessment of Nasal Fractures and Self-referral to an Ear, Nose, and Throat Department: A Prospective Study

Otolaryngology– Head and Neck Surgery 146(6) 913–917 © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599811435892 http://otojournal.org

David E. C. Baring, FRCS1, Duncan J. Bowyer, FRCS2, and Richard Adamson, FRCS2

No sponsorships or competing interests have been disclosed for this article.

Abstract Objective. To assess if patients can safely self-assess their need for ear, nose, and throat (ENT) review following initial emergency department attendance for nasal trauma. Study Design. This prospective study was divided into 2 parts. The initial part evaluated an information sheet for patients to lead them through a self-assessment to establish if they require ENT review following nasal injury. The second part of the study investigated outcomes following the introduction of the self-assessment. Setting. This work was conducted at a District General Hospital in Scotland. Subjects and Methods. Forty-nine consecutive patients underwent self-assessment plus blinded otolaryngology assessment, after which self-assessment was introduced as routine. This was evaluated comparing outcomes of 49 new consecutive nasal injuries against the original group using subjective patient scores of nasal cosmesis and nasal airway following injury and any subsequent treatment. Results. There was no significant difference in outcome between the 2 study periods. After the introduction of selfassessment, there was a large reduction in the nonattendance rate for nasal injuries and in the attendances of patients with nasal injuries not requiring manipulation. Conclusion. In our institution, patients can be relied on to safely self-assess their nasal injuries to decide if they need ENT review when provided with appropriate information. This reduces the outpatient burden on the ENT department with no deterioration in subjective patient outcomes.

T

he nasal bones are the most commonly fractured bone of the facial skeleton1 (the third most common bone fractured overall),2 and these injuries are frequently part of otolaryngology practice. Such fractures are most commonly due to road traffic accidents, sporting injuries, assaults, and falls.3 Displaced fractures require reduction within 2 weeks of injury to achieve an optimum outcome.4 Assessment also requires exclusion of potential complications (eg, septal hematoma, cerebrospinal fluid leak) due to their adverse consequences. A delay in diagnosis or treatment beyond the therapeutic window can lead to persistent functional deficit, deformity, or the need for more extensive reconstructive surgery.5 In our institution, patients have previously been seen in a weekly nasal fracture clinic run by a junior ear, nose, and throat (ENT) trainee. Patients were assessed 5 to 10 days after their injury and had arrangements for treatment made as required. This clinic had a high nonattendance rate, and many patients were found to have minor injuries that required no intervention. It was postulated that enabling patients themselves to arrange assessment after any initial swelling had resolved could minimize such problems. This study was designed to test if patients were able to self-assess and selfrefer their nasal injury on the basis of information in an advice sheet without a detrimental effect on long-term outcomes.

Materials and Methods First Study Period All patients attending a weekly fractured nose clinic at an otolaryngology department over a 4-month period were invited to participate in the study. Referrals were accepted from the local emergency department or general practice. 1

Keywords nasal fracture, assessment, self-assessment, patient-assessment Received July 22, 2011; revised December 8, 2011; accepted December 22, 2011.

Southern General Hospital, Glasgow, Scotland, UK St John’s Hospital at Howden, Livingston, UK

2

Corresponding Author: David E. C. Baring, FRCS, Southern General Hospital, 28 Chamberlain Road, Glasgow, Scotland, G51 4TF Email: [email protected]


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Otolaryngology–Head and Neck Surgery 146(6)

Patients were assessed in the clinic 5 to 10 days following the date of nasal injury as per usual practice. After obtaining written consent for enrollment in the study, patients were given an information sheet on nasal fractures and their assessment, detailing how, when, and why treatment could be given (Figure 1). After demographic information was obtained, subjects assessed their own injury using the provided pro forma (Table 1a). Patient’s self-assessments were sealed in an envelope prior to medical review. Subjects were subsequently assessed by an otolaryngologist (lead author) who was blinded to the patient-rated outcomes. In addition to the injury self-assessment, patients were asked if they considered a nasal manipulation was required and if they would have telephoned for a clinic appointment 1 week after injury if the patient information sheet had been provided at the time of acute presentation (ie, if they felt there was a cause for concern). After all treatment was completed, all subjects were recontacted by telephone 12 to 18 months after initial injury. Both those who had attended and those who had not were included on an intention-to-treat basis. Patients were asked to subjectively rate current bony deformity and nasal airway compared with preinjury by asking if the airway and cosmesis were the same, better, or worse than their preinjury state (see Table 1b). Subjects were also asked if any adverse events had occurred following their injury.

Second Study Period A change to referral practice was made prior to commencement of the second study period. Upon seeking initial assessment within the emergency department, patients were given an instructional booklet based on the first study information sheet (see Figure 1). This replaced the previous practice of automatically booking all patients into an otolaryngology clinic. Subjects were asked to self-assess their nose 5 to 7 days postinjury using the instructional booklet. In the presence of new bony deformity or nasal obstruction, nasal discharge, or other concerns, subjects were advised to telephone for an appointment to be assessed. Patients who were unable to read or understand the information sheet were managed according to the previous protocol. During the second study period, conducted over 7 months, the management pathway of each patient was recorded. Subjects were contacted by telephone for final follow-up in the same manner as those in the first study period 12 to 18 months after initial injury. The cosmetic and functional outcomes of patients were compared with patient preinjury status using the Mann-Whitney U test (VasserStats, Poughkeepsie, New York). The protocols used were approved as complying with the audit policy of St John’s Hospital, Livingston, addressing ethical concerns.

Results During the first study period, 61 consecutive patients were referred to the fractured nose clinic, of which 49 (80%) attended for assessment; all agreed to participate in the study. The demographic details are shown in Table 2. The remaining

12 patients (20%) failed to attend their clinic. Twenty-three of the enrolled subjects (47%) were assessed to be suitable and underwent nasal manipulation under anesthesia (MUA) by an otolaryngologist (Table 3). The self-assessment of nasal injuries by patients with regard to their need for MUA had a sensitivity of 35% and specificity of 54% against the gold standard of an ENT doctor assessment. Four patients (8%) who were considered suitable for MUA stated that they would not have telephoned for an appointment after reading the information sheet. Further investigation of these cases showed mitigating factors for this decision; these will be considered in the Discussion section. Nineteen subjects were lost to follow-up, and the reasons for this are given in Table 4. The remaining 42 of the original 61 patients who had been given appointments responded to telephone follow-up, and outcome data were collected (Tables 5 and 6). During the second study period, 49 consecutive patients were given self-assessment information sheets by the emergency department. The demographic details of this group are shown in Table 2; they are comparable with subjects in the first study group. Within the second study population, 7 patients (14%) self-referred for otolaryngology assessment by telephoning for an appointment, and 2 patients (29%) underwent subsequent MUA of a nasal fracture (Table 3). Thirtysix patients (74%) were successfully contacted for final follow-up; those patients with whom contact was not possible are detailed in Table 4. Posttreatment outcome measures of nasal cosmesis (Table 5) and nasal airway patency (Table 6) show similar results between the 2 study groups. Statistical analysis showed no significant difference between the 2 study referral pathways in either nasal cosmesis outcome (P = .88) or nasal patency outcome (P = .87). In particular, it can be seen that there is no deterioration in the proportions of those having a less than perfect outcome for the 2 measures when moving to the patient self-assessment pathway. Data for the outcomes of those who underwent MUA in the 2 groups are included and appear satisfactory, but statistical analysis was not performed because this was not part of the aims of the study (in addition, the numbers in the second group are to low too give any meaningful results).

Discussion Nasal injuries are extremely common in otolaryngology practice. Only a minority of injuries require any further management, and thus, new strategies to minimize the number of unnecessary referrals and nonattendances at clinic are welcome. Prior to instituting a management algorithm change, this study demonstrated a high referral rate for nasal injuries associated with a significant subsequent nonattendance rate (20%). Following otolaryngology assessment, 23 (47%) subjects underwent manipulation of their nasal pyramid. Final follow-up revealed high levels of subject satisfaction with both nasal cosmesis and nasal patency. Of those eligible for surgical correction, 4 subjects after self-assessment stated that they would not have telephoned for an appointment for consideration of surgical intervention. Of


Baring et al

915 You have injured your nose. When you injure your nose it becomes very swollen, this makes it difficult to work out what has happened. The swelling goes down over several days. Once the swelling has gone down OR 1 week after your injury (whichever is sooner) run through the checklist: Checklist • • • • •

Is your nose still swollen 1 week after your injury? Has your nose changed shape AND would you like it corrected? Has your nose felt permanently blocked since your injury? Has fluid been running out of your nose since your injury? Do you have any other concerns about your injury to your nose?

YES or NO YES or NO YES or NO YES or NO YES or NO

If you have answered NO to all of the checklist you will not need any further treatment. Just remember to look after your nose! A broken nose heals in 4-6 weeks, so avoid knocking your nose during this time (e.g., by playing contact sports). If you have answered YES to any of the checklist, please telephone XXXX to arrange an appointment. The ENT (Ear, Nose & Throat) Doctor will then see if you need treatment. You only need treatment if: • • •

The nose has changed shape AND you wish it to be corrected. You cannot breathe through your nose. There is fluid leaking out of the nose.

Treatment Options: If you have broken your nose there are two main options, which the Doctor will discuss with you. •

An Operation - If your nose has changed shape we can try to return it to its previous shape by a short operation. This is done with you asleep and you go home on the same day. This is done before the bones set, 2-3 weeks following your injury.

•

No Operation - Just protect the nose until it heals up. If nothing is done the shape of the nose should not get any worse (unless you are still growing) but it will not get any better. If you are concerned that your nose has changed shape it is better to get it treated before it sets. This is because operations done later take longer and are more complicated.

Figure 1. Instructional booklet (based on original information sheet).

these, 1 subject had a history of previous nasal fracture, and the new injury added to the preexisting deformity. A second case was under review by the maxillofacial surgeons for a facial fracture and did not appreciate the need for additional assessment by the otolaryngology service. The third case was of a young male who sustained an injury during a football match with resulting deformity. It is possible his younger age or desire to continue to play football may have contributed to his responses. The final case gave paradoxical responses, stating he felt he needed a manipulation but would not have phoned for an appointment. Following a change in referral pathway, which allowed subjects to self-assess their injury and self-refer to clinic as required, the number of referrals dropped to just 14% of the nasal injuries treated acutely by the emergency department. Of these, all patients attended their requested otolaryngology

assessment. The number of attending subjects undergoing nasal manipulation was also reduced (9% of total injuries, 29% of self-assessors attending). Long-term subject satisfaction was no different from those going through a more traditional management pathway in the first study group for nasal cosmesis (P = .88) and patency (P = .87). There were no adverse outcomes for either patient group, and the only patient expressing ongoing concern about his nose at telephone follow-up had been an attender in the second group who had gone on to have septal surgery at a later date. While he was dissatisfied with the eventual outcome, the process itself was not at fault. There was a difference in the number of cases considered eligible for MUA between the 2 study cohorts. This may have been compounded by the low number of patients who attended for assessment in the second study group; the low number could be


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Otolaryngology–Head and Neck Surgery 146(6)

Table 1a. Patient and Doctor Nasal Fracture Assessment Tool Yes Is your nose still swollen 1 week after your injury? Has your nose changed shape to the extent that you would like it corrected? Has either side of your nose felt permanently blocked since your injury? Has fluid persistently run out of your nose since your injury? Do you have any other concerns about your injury to your nose?

No

Table 1b. Outcome Telephone Survey Assessment Tool Question How do you feel about the shape of your nose since your injury? How well can you breathe through your nose since your injury?

Answer Options 1. Same as before injury 2. Slightly worse, but not causing any problems 3. Significantly worse, would like something done about it 1. Same as before injury 2. Slightly worse, but not causing any problems 3. Significantly worse, would like something done about it

involvement, and with alleged assault) or among a population with high illiteracy rates or ethnic diversity that precludes First Study Second Study reading and understanding written information. The outcomes Group Group of the initial study would suggest that this was not a factor Number of patients 61 49 within the population studied. Mean age, y 26 23 Long-term follow-up data were available from 69% of the M:F ratio 1.78:1 2.5:1 first study group and 74% of the second study group. Given Alleged assault (%) 36 (59) 23 (47) the long time between the injury and follow-up (12-18 months Alcohol involved (%) 19 (31) 6 (12) to ensure that complete healing had occurred) and the young and transient nature of the study population, this loss to follow-up is within anticipated parameters. There was no signifiTable 3. Attendance and Intervention Rates cant difference in dropout rates between the 2 study groups. First Study Second Study The use of subjective outcome measures inevitably has Group Group potential for bias. However, attempts at objective measures would have been impractical as preinjury data could not be colNumber of patients 61 49 lected (be it cosmetic or functional data), and even if this were Appointment booked (%) 61 (100) 7 (14) not an issue, the logistics and resources required to obtain cliniAttended ENT clinic (%) 49 (80) 7 (100) cal photography and functional measures would have placed an Nonattendance (%) 12 (20) 0 (0) Nasal manipulation (%) 23 (47) 2 (29) undue burden on the unit so as to make it impossible to run this Final follow-up (%) 42 (86) 36 (74) study. Ultimately, it is patients’ subjective perception of their outcomes that is the important factor, and this is what we aimed to record with the telephone survey. for a variety of factors relating to the injury (mechanism, alcohol While the study demonstrated no change in outcome folintake, or time of year). There were more assaults in the initial lowing the use of self-assessment, it should be borne in mind group (59% vs 47%), and alcohol was more often involved when that there is an increased emphasis on the emergency departacquiring the injury in this group (30% vs 12%). These factors ment team initially assessing the patient to exclude occult may be relevant in the severity of the trauma sustained. injuries and that they spend sufficient time going through the This study demonstrates that patients within the referral information sheet with the patient to ensure that the patient population were able to safely and effectively self-assess their understands all that is involved. Should the initial assessment own nasal trauma. This had a beneficial impact on clinic raise any concerns regarding the patient’s ability to perform appointments and no adverse effect on the patients’ long-term self-assessment, there should still be an avenue for direct outcome. This is the first study to demonstrate that patients referral to the otolaryngology department. with nasal trauma may be managed in this way. It should not be forgotten that the aim of this approach is to Limitations of the study include the use of an information improve the patients’ journey following their nasal injury, sheet that relies on patients being able to understand the inforaddressing their concerns while minimizing unnecessary medmation and retain it until the appropriate time for self-assessment. ical attendances. The results obtained from this work in our This could be a problem given the circumstances under which institution suggest this novel approach achieves this and mainmany nasal injuries occur (ie, late Downloaded at night, with alcohol good outcomes. Implementation in other units should be from oto.sagepub.com at SOCIEDADEtains BRASILEIRA DE CIRUR on June 27, 2012 Table 2. Study Population Demographics

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Table 4. Telephone Follow-up Response Rates First Study Group (n = 61)

Second Study Group (n = 49)

33/49 9/12 19/61 8

5/7 31/42 13/49 6 1 (patient died) 6 0

Follow-up rate for attenders Follow-up for nonattenders Follow-up not possible Incorrect telephone number No response No telephone number Declined to participate

10 1 (in prison)

Table 5. Final Posttreatment Nasal Cosmesis Compared with Preinjury First Study Period (n = 42) Patient-Rated Cosmesis Score

Second Study Period (n = 36)

Total (n = 42)

Attenders (n = 33)

Nonattenders (n = 9)

Total (n = 36)

Attenders (n = 5)


30 (71%) 12 (29%)

24 (12 MUA) 9 (6 MUA)

6 3

25 (69%) 11 (31%)

3 (1 MUA) 2 (1 MUA)

22 9

0

0

0 (0%)

0

0

Same Slightly worse, not concerning Significantly worse, concerning

0 (0%)

Table 6. Final Posttreatment Nasal Airway Compared with Preinjury Status First Study Period (n = 42) Patient-Rated Airway Score Same Slightly worse, not concerning Significantly worse, concerning

Total (n = 42)

Attenders (n = 33)


29 (69%) 13 (31%) 0 (0%)

25 (15 MUA) 8 (2 MUA) 0

4 5

subjected to all the usual clinical governance safeguards and appropriate evaluation to maintain standards.

Conclusion Patient self-assessment of nasal injury accurately selects a group containing those who require surgical intervention. This has no adverse effect on long-term subjective patient cosmesis and airway outcomes. Such a management algorithm reduces the number of unnecessary clinic appointments and nonattendance rates, saving patient visits and reducing the burden on the outpatient resources.

Summary

Second Study Period (n = 36) Total (n = 36)

Attenders (n = 5)


26 (72%) 9 (25%) 1 (3%)

4 (2 MUA) 0 1

22 9 0

Author Contributions David E. C. Baring, study design, data collection, writing of manuscript; Duncan J. Bowyer, data collection, writing of manuscript; Richard Adamson, study design, writing of manuscript.

Disclosures Competing interests: None. Sponsorships: None. Funding source: None.

References 1. Rhee SC, Kim YK. Septal fracture in simple nasal bone fracture.

•• This study shows patients can safely self-assess their Plast Reconstr Surg. 2004;113:45-52. nasal injuries and arrange follow-up by otolaryngol2. Rubenstein B, Strong EB. Management of nasal fractures. Arch ogy as required. Fam Med. 2000;8:738-742. •• This reduces burden on outpatient appointments 3. Murray JAM, Maran AGD, Mackenzie IJ. Open v closed and prevents unnecessary attendances, minimizing reduction of the fractured nose. Arch Otolaryngol. 1984;110: patient inconvenience. 797-802. •• This process needs appropriate local implementation 4. Staffel G. Optimizing treatment of nasal fractures. Laryngoscope. with the support of the emergency departments and 2002;112:1709-1719. safeguards for those with difficulty accessing the ser5. Mondin V, Rinaldo A, Fertilo A. Management of nasal bone fracvice combined with ongoing audit. tures. Am J Otolaryngol. 2005;3:181-185. Downloaded from oto.sagepub.com at SOCIEDADE BRASILEIRA DE CIRUR on June 27, 2012