Local Versus General Anesthesia for the Management of Nasal Bone Fracture

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Local Versus General Anesthesia for theManagement of Nasal Bone Fractures:A Systematic Review and Meta-Analysis

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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:

[email protected]

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

Delta:1_given name

Delta:1_surname

mailto:[email protected]

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.


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


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


patient

Khwaja et al7 2007 RCT G1:28, G2:29 G1:60, G2:49 74 65 2 wk patient satisfaction with

esthetics, subsequent

surgery


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.


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



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.



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.


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.



FIGURE 7. Funnel plot of publication bias according to the reported incidence of subsequent corrective surgeries, showing a symmetric dis-tribution.



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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Local Versus General Anesthesia for the Management of Nasal Bone Fracture