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When can patients blow their nose and fly after treatment for fractures of zygomatic complex: the need for a consensus
Injury, Int. J. Care Injured 34 (2003) 908–911
When can patients blow their nose and fly after treatment for fractures of zygomatic complex: the need for a consensus Shaukat Mahmood∗ , David J.W. Keith, Glenn Edward Lello Regional Oral and Maxillofacial Surgery, St. Johns Hospital, Livingston EH54 6PP, Scotland, UK Accepted 28 January 2003
Abstract Purpose: To determine current professional advice to patients about refraining from nose blowing and air travel following treatment of zygomatic fractures. Methods: A postal questionnaire was sent to 261 consultant oral and maxillofacial surgeons (OMFS) in the UK. They were asked about advice given to patients regarding length of time to refrain from nose blowing and air travel following treatment of zygomatic fractures. Results: A total of 184 (71%) replies were received. Advice regarding the length of time to refrain from nose blowing and air travel ranged from no advice to 8 weeks. About 90% of respondents based their advice on common sense and traditional practice. Conclusions: Advice given to the patients following the treatment of zygomatic fractures varies widely. Most consultants based their advice on traditional practice and common sense. In the absence of widely accepted guidelines, there is a need for an agreement among clinicians on advice given to the patients. © 2003 Elsevier Science Ltd. All rights reserved.
1. Introduction Fractures of the zygomatic complex, and often their treatment, involve the paranasal sinuses. The pressure changes brought about in the paranasal sinuses by nose blowing and descent during an aeroplane flight in these patients can lead to escape of air into the soft tissues resulting in surgical emphysema [3,4,6]. Although a common question posed by patients, a systematic literature search revealed no consensus regarding either the length of time nose blowing or flying should be avoided after the treatment of a zygomatic complex fracture. An overview of pertinent current advice given to the patients after treatment of their zygomatic complex fractures by the maxillofacial surgeons in the UK was sought in this study.
2. Methods A questionnaire was sent to 261 practising consultant oral and maxillofacial surgeons (OMFS) in the UK. They were asked over what length of time they would advise a patient to refrain from nose blowing after treatment of a zygomatic fracture. Similarly, the OMFS were asked about their advice ∗
Corresponding author. E-mail address: [email protected] (S. Mahmood).
regarding length of time to refrain from aeroplane travel following treatment of a zygomatic fracture (Table 1). 3. Results A total of 184 replies were received representing a response rate of 71%. For both questions, only 10 surgeons (5% of respondents) stated that their advice was based on published research/evidence. A large majority of respondents (n = 165, 90%) based their advice on common sense and traditional practice. 3.1. Length of time to refrain from nose blowing The surgeons advice regarding the length of time to refrain from blowing the nose after zygomatic fracture treatment ranged from no advice to 8 weeks (Table 2). The most common response was 2 weeks. A significantly longer time to avoid nose blowing was advised following open reduction and internal fixation compared to non-operative management (P = 0.013, z = −2.476, Wilcoxon Signed-Rank test). 3.2. Length of time to refrain from travelling by air The surgeons advice regarding the length of time to refrain from air travel after zygomatic fracture treatment ranged from none to 8 weeks (Table 3).
0020-1383/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(03)00057-3
S. Mahmood et al. / Injury, Int. J. Care Injured 34 (2003) 908–911
909
Table 1 Questionnaire: advice to the patients following the treatment of zygomatic fractures
A significant number of surgeons did not advise any avoidance of flying following zygomatic fracture treatment (40, 42 and 47%, after open reduction and internal fixation, closed reduction, and non-operative management, respectively). Of those advising patients to refrain from flying, the commonest length of time to avoid flying was 2 weeks, for all treatment options. A significantly longer time to avoid flying was advised for closed reduction (P = 0.000, z = −4.331, Wilcoxon Signed-Rank test) and open reduction and internal fixation (P = 0.000, z = −4.583, Wilcoxon Signed-Rank test) when each was compared with non-operative management. Also, a significantly longer time was advised to avoid flying after open reduction and internal fixation when compared to closed reduction (P = 0.039, z = −2.066, Wilcoxon Signed—Rank test).
4. Comment Among the midfacial fractures, injuries to the zygomaticoorbital complex are second only to nasal fractures [5]. An analysis of these fractures over a 10 year period in the west of Scotland showed an incidence of 207 patients reporting
for treatment per million population per year [2]. Patients with these fractures are considered to be at increased risk (up to 65%) of developing surgical emphysema [1]. Fracture of the zygomatic complex may cause a communication between the paranasal sinuses and the soft tissues of the head and neck through a tear in the paranasal sinus lining. Sequelae are generally self-limiting and resolve spontaneously. Surgical emphysema usually resolves after 2–7 days [6]. However, serious complications such as loss of vision, orbital infection and, rarely, pneumomediastinum following orbital emphysema can occur [1,3,4]. Surgical emphysema can be aggravated or initiated by an increase in the air pressure in the paranasal sinuses by nose blowing or rapid descent in an aeroplane [7]. The aeroplane cabin pressurisation system maintains the cabin pressure at a given altitude. During descent to land the atmospheric pressure within the aeroplane typically increases from 523 mmHg at 2286 m to near 760 mmHg at ground level at most international airports [7]. The volumetric expansion of air in the paranasal sinuses during aircraft descent can force air into soft tissues planes through breaches in the lining of the sinuses which exist due to zygomatic complex fractures. The advice given to the patients following the treatment of zygomatic fractures in the UK was widely inconsistent
910
S. Mahmood et al. / Injury, Int. J. Care Injured 34 (2003) 908–911
Table 2 Advice to patients following the treatment of zygomatic fractures: length of time to refrain from nose blowing Recommended length of time to refrain from nose blowing
Responding surgeons (n = 184)
After open reduction and internal fixation No answer 1 None 6 (3) 1–7 days 34 (19) 8–14 days 93 (51) 15–21 days 20 (11) 22–28 days 24 (13) 6 weeks 5 (3) 8 weeks 1 After closed reduction/elevation No answer 1 None 7 (4) 1–7 days 35 (19) 8–14 days 91 (50) 15–21 days 20 (11) 22–28 days 25 (14) 6 weeks 4 (2) 8 weeks 1 After conservative (non-operative) treatment No answer 2 (1) None 8 (4) 1–7 days 39 (21) 8–14 days 87 (47) 15–21 days 20 (11) 22–28 days 23 (13) 6 weeks 5 (3) 8 weeks –
Advice based on published data (n = 7)
Advice based on common sense and traditional practice (n = 165)
Advice based on both published data, common sense and traditional practice (n = 3)
Did not comment on the basis of their advice (n = 9)
– – – 5 1 1 – –
– 6 31 87 17 19 4 1
– – 1 – – 2 – –
–
(4) (19) (53) (10) (12) (2)
– – – 5 1 1 – –
– 7 32 85 17 20 3 1
(4) (19) (51) (10) (12) (2)
– – 1 – – 2 – –
– – – 5 (71.4) 1 (14.3) 1 (14.3) – –
– 8 36 81 17 19 3 –
(5) (22) (49) (10) (12) (2)
– – 1 – – 2 – –
2 1 2 2 1
– 2 1 2 2 1
– – 2 1 2 1 2 –
Figures are number (percentage). Table 3 Advice following treatment of zygomatic fractures: length of time to refrain from travelling by commercial aeroplane Recommended length of time to refrain from travelling by aeroplane
Responding surgeons (n = 184)
After open reduction and internal fixation No answer 2 None 74 (40) 1–7 days 23 (13) 8–14 days 57 (31) 15–21 days 11 (6) 22–28 days 14 (8) 6 weeks 2 (1) 8 weeks 1 After closed reduction/elevation No answer 2 (1) None 77 (42) 1–7 days 23 (13) 8–14 days 54 (29) 15–21 days 11 (6) 22–28 days 14 (8) 6 weeks 3 (2) 8 weeks – After conservative (non-operative) treatment No answer 3 (2) None 87 (47) 1–7 days 27 (15) 8–14 days 45 (25) 15–21 days 8 (4) 22–28 days 12 (7) 6 weeks 2 (1) 8 weeks – Figures are number (percentage).
Advice based on published data (n = 7)
Advice based on common sense and traditional practice (n = 165)
Advice based on both published data, common sense and traditional practice (n = 3)
Did not comment on the basis of their advice (n = 9)
– 1 1 5 – – – –
– 70 21 49 9 12 2 1
(42) (13) (30) (6) (7) (1)
– 2 – 1 – – – –
– 1 1 2 2 2 – –
– 1 1 5 – – – –
1 73 21 46 9 12 3 –
(44) (13) (28) (6) (7) (2)
– 2 1 – – – –
1 1 1 2 2 2 – –
– 2 2 3 – – – –
2 80 24 40 6 11 2 –
– 2 1 – – – – –
1 3 – 2 2 1 – –
(1) (49) (15) (24) (4) (7) (1)
S. Mahmood et al. / Injury, Int. J. Care Injured 34 (2003) 908–911
(Tables 2 and 3). Most consultant OMFS based their advice on traditional practice and common sense. However, there was a wide variation within the ‘traditional practise and common sense’. In this survey, 50% of consultant maxillofacial surgeons advised their patients to refrain from nose blowing for 8–14 days after different forms of treatment of zygomatic fractures. Another 26% of surgeons advised their patients to refrain from nose blowing for a varying length of time ranging from 3 to 8 weeks. About 30% of respondents advised their patients to avoid air travel for 8–14 days. Another 15% of surgeons advised their patients to refrain from air travel for 3–8 weeks. A significant number of respondents (40%) did not warn their patients against flying after treatment of zygomatic complex fracture. Ideally clinicians should be able to provide patients with consistent and evidence-based advice about the length of time to refrain from nose blowing and air travel. In the absence of evidence-based guidelines, there is a need for debate and discussion among clinicians to reach an agreement on the advice given to the patients regarding length of time
911
to refrain from nose blowing and air travel following treatment of zygomatic complex fractures. References [1] Birrer RB, Robinson T, Papachristos P. Orbital emphysema: how common, how significant? Ann Emerg Med 1994;24:1115–8. [2] Ellis III E, El-Attar A, Moos KF. An analysis of 2067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg 1985;43:417–28. [3] Flood TR. Mediastinal emphysema complicating a zygomatic fracture: a case review and review of literature. Br J Oral Maxillofac Surg 1988;26:141–8. [4] Kourtidou-Papadeli C, Paspatis A, Mohler S. Pneumomediastinum during flight secondary to facial fractures—a case report. Aviat Space Environ Med 1996;67:1201–3. [5] Lundin K, Ridell A, Sandberg N, Ohman A. One thousand maxillofacial and related fractures at the ENT-clinic in Gothenberg. A two-year prospective study. Acta Otolaryng 1973;75:359–61. [6] Smith SN, Nortje CJ. Surgical emphysema following an undisplaced fractured zygoma: an unusual radiographic appearance. Br J Oral Maxillofac Surg 1980;18:202–4. [7] Wood BJ, Mirvis SE, Shanmuganathan K. Tension pneumocephalus and tension orbital emphysema following blunt trauma. Ann Emerg Med 1996;28:446–9.
When can patients blow their nose and fly after treatment for fractures of zygomatic complex: the need for a consensus Shaukat Mahmood∗ , David J.W. Keith, Glenn Edward Lello Regional Oral and Maxillofacial Surgery, St. Johns Hospital, Livingston EH54 6PP, Scotland, UK Accepted 28 January 2003
Abstract Purpose: To determine current professional advice to patients about refraining from nose blowing and air travel following treatment of zygomatic fractures. Methods: A postal questionnaire was sent to 261 consultant oral and maxillofacial surgeons (OMFS) in the UK. They were asked about advice given to patients regarding length of time to refrain from nose blowing and air travel following treatment of zygomatic fractures. Results: A total of 184 (71%) replies were received. Advice regarding the length of time to refrain from nose blowing and air travel ranged from no advice to 8 weeks. About 90% of respondents based their advice on common sense and traditional practice. Conclusions: Advice given to the patients following the treatment of zygomatic fractures varies widely. Most consultants based their advice on traditional practice and common sense. In the absence of widely accepted guidelines, there is a need for an agreement among clinicians on advice given to the patients. © 2003 Elsevier Science Ltd. All rights reserved.
1. Introduction Fractures of the zygomatic complex, and often their treatment, involve the paranasal sinuses. The pressure changes brought about in the paranasal sinuses by nose blowing and descent during an aeroplane flight in these patients can lead to escape of air into the soft tissues resulting in surgical emphysema [3,4,6]. Although a common question posed by patients, a systematic literature search revealed no consensus regarding either the length of time nose blowing or flying should be avoided after the treatment of a zygomatic complex fracture. An overview of pertinent current advice given to the patients after treatment of their zygomatic complex fractures by the maxillofacial surgeons in the UK was sought in this study.
2. Methods A questionnaire was sent to 261 practising consultant oral and maxillofacial surgeons (OMFS) in the UK. They were asked over what length of time they would advise a patient to refrain from nose blowing after treatment of a zygomatic fracture. Similarly, the OMFS were asked about their advice ∗
Corresponding author. E-mail address: [email protected] (S. Mahmood).
regarding length of time to refrain from aeroplane travel following treatment of a zygomatic fracture (Table 1). 3. Results A total of 184 replies were received representing a response rate of 71%. For both questions, only 10 surgeons (5% of respondents) stated that their advice was based on published research/evidence. A large majority of respondents (n = 165, 90%) based their advice on common sense and traditional practice. 3.1. Length of time to refrain from nose blowing The surgeons advice regarding the length of time to refrain from blowing the nose after zygomatic fracture treatment ranged from no advice to 8 weeks (Table 2). The most common response was 2 weeks. A significantly longer time to avoid nose blowing was advised following open reduction and internal fixation compared to non-operative management (P = 0.013, z = −2.476, Wilcoxon Signed-Rank test). 3.2. Length of time to refrain from travelling by air The surgeons advice regarding the length of time to refrain from air travel after zygomatic fracture treatment ranged from none to 8 weeks (Table 3).
0020-1383/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(03)00057-3
S. Mahmood et al. / Injury, Int. J. Care Injured 34 (2003) 908–911
909
Table 1 Questionnaire: advice to the patients following the treatment of zygomatic fractures
A significant number of surgeons did not advise any avoidance of flying following zygomatic fracture treatment (40, 42 and 47%, after open reduction and internal fixation, closed reduction, and non-operative management, respectively). Of those advising patients to refrain from flying, the commonest length of time to avoid flying was 2 weeks, for all treatment options. A significantly longer time to avoid flying was advised for closed reduction (P = 0.000, z = −4.331, Wilcoxon Signed-Rank test) and open reduction and internal fixation (P = 0.000, z = −4.583, Wilcoxon Signed-Rank test) when each was compared with non-operative management. Also, a significantly longer time was advised to avoid flying after open reduction and internal fixation when compared to closed reduction (P = 0.039, z = −2.066, Wilcoxon Signed—Rank test).
4. Comment Among the midfacial fractures, injuries to the zygomaticoorbital complex are second only to nasal fractures [5]. An analysis of these fractures over a 10 year period in the west of Scotland showed an incidence of 207 patients reporting
for treatment per million population per year [2]. Patients with these fractures are considered to be at increased risk (up to 65%) of developing surgical emphysema [1]. Fracture of the zygomatic complex may cause a communication between the paranasal sinuses and the soft tissues of the head and neck through a tear in the paranasal sinus lining. Sequelae are generally self-limiting and resolve spontaneously. Surgical emphysema usually resolves after 2–7 days [6]. However, serious complications such as loss of vision, orbital infection and, rarely, pneumomediastinum following orbital emphysema can occur [1,3,4]. Surgical emphysema can be aggravated or initiated by an increase in the air pressure in the paranasal sinuses by nose blowing or rapid descent in an aeroplane [7]. The aeroplane cabin pressurisation system maintains the cabin pressure at a given altitude. During descent to land the atmospheric pressure within the aeroplane typically increases from 523 mmHg at 2286 m to near 760 mmHg at ground level at most international airports [7]. The volumetric expansion of air in the paranasal sinuses during aircraft descent can force air into soft tissues planes through breaches in the lining of the sinuses which exist due to zygomatic complex fractures. The advice given to the patients following the treatment of zygomatic fractures in the UK was widely inconsistent
910
S. Mahmood et al. / Injury, Int. J. Care Injured 34 (2003) 908–911
Table 2 Advice to patients following the treatment of zygomatic fractures: length of time to refrain from nose blowing Recommended length of time to refrain from nose blowing
Responding surgeons (n = 184)
After open reduction and internal fixation No answer 1 None 6 (3) 1–7 days 34 (19) 8–14 days 93 (51) 15–21 days 20 (11) 22–28 days 24 (13) 6 weeks 5 (3) 8 weeks 1 After closed reduction/elevation No answer 1 None 7 (4) 1–7 days 35 (19) 8–14 days 91 (50) 15–21 days 20 (11) 22–28 days 25 (14) 6 weeks 4 (2) 8 weeks 1 After conservative (non-operative) treatment No answer 2 (1) None 8 (4) 1–7 days 39 (21) 8–14 days 87 (47) 15–21 days 20 (11) 22–28 days 23 (13) 6 weeks 5 (3) 8 weeks –
Advice based on published data (n = 7)
Advice based on common sense and traditional practice (n = 165)
Advice based on both published data, common sense and traditional practice (n = 3)
Did not comment on the basis of their advice (n = 9)
– – – 5 1 1 – –
– 6 31 87 17 19 4 1
– – 1 – – 2 – –
–
(4) (19) (53) (10) (12) (2)
– – – 5 1 1 – –
– 7 32 85 17 20 3 1
(4) (19) (51) (10) (12) (2)
– – 1 – – 2 – –
– – – 5 (71.4) 1 (14.3) 1 (14.3) – –
– 8 36 81 17 19 3 –
(5) (22) (49) (10) (12) (2)
– – 1 – – 2 – –
2 1 2 2 1
– 2 1 2 2 1
– – 2 1 2 1 2 –
Figures are number (percentage). Table 3 Advice following treatment of zygomatic fractures: length of time to refrain from travelling by commercial aeroplane Recommended length of time to refrain from travelling by aeroplane
Responding surgeons (n = 184)
After open reduction and internal fixation No answer 2 None 74 (40) 1–7 days 23 (13) 8–14 days 57 (31) 15–21 days 11 (6) 22–28 days 14 (8) 6 weeks 2 (1) 8 weeks 1 After closed reduction/elevation No answer 2 (1) None 77 (42) 1–7 days 23 (13) 8–14 days 54 (29) 15–21 days 11 (6) 22–28 days 14 (8) 6 weeks 3 (2) 8 weeks – After conservative (non-operative) treatment No answer 3 (2) None 87 (47) 1–7 days 27 (15) 8–14 days 45 (25) 15–21 days 8 (4) 22–28 days 12 (7) 6 weeks 2 (1) 8 weeks – Figures are number (percentage).
Advice based on published data (n = 7)
Advice based on common sense and traditional practice (n = 165)
Advice based on both published data, common sense and traditional practice (n = 3)
Did not comment on the basis of their advice (n = 9)
– 1 1 5 – – – –
– 70 21 49 9 12 2 1
(42) (13) (30) (6) (7) (1)
– 2 – 1 – – – –
– 1 1 2 2 2 – –
– 1 1 5 – – – –
1 73 21 46 9 12 3 –
(44) (13) (28) (6) (7) (2)
– 2 1 – – – –
1 1 1 2 2 2 – –
– 2 2 3 – – – –
2 80 24 40 6 11 2 –
– 2 1 – – – – –
1 3 – 2 2 1 – –
(1) (49) (15) (24) (4) (7) (1)
S. Mahmood et al. / Injury, Int. J. Care Injured 34 (2003) 908–911
(Tables 2 and 3). Most consultant OMFS based their advice on traditional practice and common sense. However, there was a wide variation within the ‘traditional practise and common sense’. In this survey, 50% of consultant maxillofacial surgeons advised their patients to refrain from nose blowing for 8–14 days after different forms of treatment of zygomatic fractures. Another 26% of surgeons advised their patients to refrain from nose blowing for a varying length of time ranging from 3 to 8 weeks. About 30% of respondents advised their patients to avoid air travel for 8–14 days. Another 15% of surgeons advised their patients to refrain from air travel for 3–8 weeks. A significant number of respondents (40%) did not warn their patients against flying after treatment of zygomatic complex fracture. Ideally clinicians should be able to provide patients with consistent and evidence-based advice about the length of time to refrain from nose blowing and air travel. In the absence of evidence-based guidelines, there is a need for debate and discussion among clinicians to reach an agreement on the advice given to the patients regarding length of time
911
to refrain from nose blowing and air travel following treatment of zygomatic complex fractures. References [1] Birrer RB, Robinson T, Papachristos P. Orbital emphysema: how common, how significant? Ann Emerg Med 1994;24:1115–8. [2] Ellis III E, El-Attar A, Moos KF. An analysis of 2067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg 1985;43:417–28. [3] Flood TR. Mediastinal emphysema complicating a zygomatic fracture: a case review and review of literature. Br J Oral Maxillofac Surg 1988;26:141–8. [4] Kourtidou-Papadeli C, Paspatis A, Mohler S. Pneumomediastinum during flight secondary to facial fractures—a case report. Aviat Space Environ Med 1996;67:1201–3. [5] Lundin K, Ridell A, Sandberg N, Ohman A. One thousand maxillofacial and related fractures at the ENT-clinic in Gothenberg. A two-year prospective study. Acta Otolaryng 1973;75:359–61. [6] Smith SN, Nortje CJ. Surgical emphysema following an undisplaced fractured zygoma: an unusual radiographic appearance. Br J Oral Maxillofac Surg 1980;18:202–4. [7] Wood BJ, Mirvis SE, Shanmuganathan K. Tension pneumocephalus and tension orbital emphysema following blunt trauma. Ann Emerg Med 1996;28:446–9.