What is the recommended local anaesthetic technique for nasal bone fractures?

Recommended Local Anesthetic Technique for Nasal Bone Fractures

The recommended local anesthetic technique for nasal bone fractures includes topical nasal vasoconstrictors followed by lidocaine infiltration, with a maximum dose not exceeding 9 mg/kg lean body weight. 1

Anesthetic Options and Considerations

Local Anesthesia Technique

1. Vasoconstriction:

   • Apply topical nasal vasoconstrictors before any manipulation 1
   • Phenylephrine in combination with lidocaine is recommended over cocaine 1
   • Co-phenylcaine (lidocaine 5%/phenylephrine 0.5%) is effective 1

2. Local Anesthetic Administration:

   • Lidocaine is preferred due to favorable cardiovascular and systemic toxicity profile 1
   • Maximum dose should not exceed 9 mg/kg lean body weight 1
   • Consider lower concentrations of lidocaine which can be as effective as higher concentrations 1

3. Delivery Methods:

   • Options include mucosal atomization, spray-as-you-go, or nebulization 1
   • Invasive techniques (glossopharyngeal and superior laryngeal nerve blocks) should be reserved for those with expertise due to higher risk of complications 1

Advantages of Local Anesthesia for Nasal Fractures

Local anesthesia for nasal fracture reduction has several advantages over general anesthesia:

• Earlier treatment (average 9 days vs 15 days for GA) 2
• Higher likelihood of achieving successful manipulation (83% vs 76% for GA) 2
• No significant difference in need for further surgery compared to GA 2
• High patient satisfaction rates (80-84.6%) 3, 4
• Comparable pain scores to general anesthesia 4
• Cost-effective and resource-efficient 3, 5
• Can be performed in outpatient settings 6, 3

Patient Selection and Technique

Ideal Candidates

• Simple nasal fractures with unilateral depression or minimal displacement 4
• Patients over 14 years of age (94% preferred LA over GA) 3
• No significant septal deviation requiring additional procedures

Technique Steps

1. Apply topical vasoconstrictors to reduce epistaxis risk 1
2. Infiltrate lidocaine using appropriate delivery method (atomizer preferred for mucosal coverage)
3. Test adequacy of topicalization before manipulation in an atraumatic manner 1
4. Perform closed reduction of the nasal fracture
5. Consider supplemental oxygen during the procedure 1

Safety Considerations and Monitoring

1. Local Anesthetic Toxicity:

   • Calculate maximum dose based on patient's lean body weight 1
   • Consider total dose of all local anesthetics administered regardless of route 1
   • Have lipid emulsion available for emergency treatment of local anesthetic toxicity 1

2. Monitoring:

   • Pulse oximetry is recommended during the procedure 1
   • Observe for signs of local anesthetic toxicity
   • Consider supplemental oxygen during the procedure 1

Special Considerations

• For complex nasal fractures with significant septal deviation, general anesthesia may be preferred to allow for simultaneous septoplasty 7
• CT imaging may be necessary for complex nasal injuries to fully characterize the extent of injuries 1
• If reduction under local anesthesia is inadequate, general anesthesia reduction is still possible as a backup option 5

Local anesthesia for nasal fracture reduction is a safe, effective, and resource-efficient approach with high patient satisfaction when appropriate patient selection is applied.