Population:

Adults with acute nasal bone fractures

Setting:

Inpatient

Intervention:

General anesthesia

Comparator:

Local anesthesia

Population:

Adults with mandibular fracture

Setting:

Inpatient

Intervention:

General anesthesia

Comparator:

Sedation with a regional block, with the use of a peripheral nerve stimulator

American Association of Oral and Maxillofacial Surgeons. Clinical Practice Guidelines for Oral and Maxillofacial Surgery, 2012. (AGREE II Score: Unavailable)

• •
  

  This guideline recommends assessment of favorable therapeutic outcomes from anesthesia:

  
  
  
  
  • •
    

    Recovery of the patient from the anesthetic effects, returning to his or her preanesthetic physiological and psychological state within an appropriate time after the cessation of the administration of the anesthetic drugs

    
    
  • •
    

    Agreement that the anesthetic experience was satisfactory by both the surgeon and the patient

    
    
  • •
    

    Recovery from the administration of sedatives, anesthetic agents, and other adjunctive medications

    
    
  • •
    

    Patient (family) acceptance of procedure and understanding of outcomes

  
  
  
  
• •
  

  This guideline recommends general or local anesthesia, depending on patient preferences and at the discretion of the treating surgeon and anesthesiologist.

Background

Facial trauma presents difficulties in managing the patient’s airway and sharing it between the anesthesiologists and surgeons. We systematically reviewed the comparative benefits and harms of general and local anesthesia in patients with facial trauma.

Methods

Our team conducted a comprehensive search in PubMed, EMBASE, the Cochrane Library, the Elsevier text mining tool database including the National Institutes of Health RePORTER Grant database, and the clinicaltrials.gov trial registry up to June 2016 and did a hand-search of the reference lists. We searched for studies of children or adults with facial fractures due to facial trauma. We included all studies that examined the benefits and harms of general and local anesthesia.

Results

We identified a meta-analysis of 3 randomized and 5 nonrandomized studies and the additional publication of a single RCT. All studies reported outcomes in adult patients. We found no pediatric studies.

Limitations

We downgraded the quality of evidence due to risk of bias in the body of evidence and imprecision in treatment effects from small studies. The evidence regarding comparative effectiveness and harms of specific pharmacological agents used in anesthesiology regimens was insufficient.

We found one guideline that describes general goals of various types of anesthesia but does not recommend specific indications to select general over local anesthesia. Future research is needed to examine the comparative effectiveness and safety of anesthesia regimens and agents in subpopulations by demographics, comorbidities, and provider experience and the quality of provided care.

Conclusions

In adults with acute facial trauma in order to improve patient satisfaction and reduce pain and adverse effects, anesthesiologists, surgeons, and patients should participate in shared decision-making regarding selection of local or general anesthesia based on fracture localization, severity, comorbidities, and individual patient preferences.

Population:

Adults with upper facial fractures: basilar skull fractures

Setting:

Inpatient

Intervention:

Preventive antibiotics administered at the time of primary treatment of the basilar skull fracture

Comparator:

No preventive antibiotics

Population:

Adults: orbital blow-out fractures

Setting:

Inpatient

Intervention:

Amoxicillin/clavulanic acid 1.2 g intravenously every 8 hours from admission until 24 hours postoperatively, followed by amoxicillin/clavulanic acid 625 mg orally every 8 hours for another 4 days

Comparator:

Amoxicillin/clavulanic acid 1.2 g intravenously every 8 hours from admission until 24 hours postoperatively

Population:

Adults with middle facial fractures

Setting:

Inpatients

Intervention:

Preventive postoperative antibiotics administered after pre- and perioperative antibiotics

Comparator:

Preventive pre- and perioperative antibiotics without postoperative antibiotics

Population:

Adults with lower facial fractures

Setting:

Inpatient

Intervention:

Preventive postoperative antibiotics administered after pre- and perioperative antibiotics

Comparator:

Preventive pre- and perioperative antibiotics without postoperative antibiotics

American Association of Oral and Maxillofacial Surgeons. Clinical Practice Guidelines for Oral and Maxillofacial Surgery, 2012. (AGREE II Score: Unavailable)

• •
  

  This guideline recommends the use of antimicrobial rinses and systemic antibiotics to prevent infections related to surgery in certain circumstances.

  
  
• •
  

  The decision to employ prophylactic perioperative antibiotics is at the discretion of the treating surgeon and should be based on the patient’s clinical condition as well as other comorbidities that may be present, including diabetes mellitus, malnutrition, and autoimmune or immune-deficit disorders.

Background

Prevention of infectious complications is among the most important goals in the management of facial injuries. We systematically reviewed benefits and harms from preventive antibiotic treatments in patients with upper, middle, and lower facial trauma.

Methods

Our team conducted a comprehensive search in PubMed, EMBASE, the Cochrane Library, the Elsevier text mining tool database including the National Institutes of Health RePORTER Grant database, and the clinicaltrials.gov trial registry up to June 2016 and did a hand-search of the reference lists. We searched for studies of children or adults with facial fractures due to facial trauma and analyzed the data separately for upper (cranial base, orbital roof, or frontal sinus), middle (nasal, naso-orbito-ethmoid, zygoma, zygomaticomaxillary complex, Le Fort, orbital floor, or medial wall), and lower (mandibular) fracture. We included all studies that examined the benefits and harms of preventive antibiotics administered before, during, and after surgery.

We abstracted the number of patients with and without outcomes among treatment groups and means and standard deviations of continuous measures of pain and quality of life. We used random effects models with inverse variance weighting at 95% confidence limits and examined heterogeneity based on I-squared variation in relative risk or absolute risk difference attributable to heterogeneity in treatment effects. We used Stata software for all calculations. Correction coefficients for zero events were used as a default option in Stata software, and intention to treat analyses were used for evidence synthesis. For statistically significant differences in absolute risk difference, we calculated number needed to treat and attributable events per 1000 treated.

For randomized studies, we used the Cochrane Risk of Bias tool at outcome level. A low risk of bias was assumed when RCTs met all the risk-of-bias criteria, and a high risk of bias was assumed if 1 or more risk-of-bias criteria were not met. An unknown risk of bias was assigned for the studies with poorly reported risk-of-bias criteria. We assigned the quality of evidence ratings as high, moderate, low, or very low, according to risk of bias in the body of evidence, directness of comparisons, precision and consistency in treatment effects, and the evidence of reporting bias, using GRADE methodology. Treatment effect estimates were defined as precise when the total number of events was greater than 250. Justification of the sample size was not included in grading of the evidence. We did not conduct post hoc statistical power analyses. A high quality of evidence was assigned to well-designed RCTs with consistent findings. The quality of evidence was downgraded to moderate if at least 1 of 4 quality-of-evidence criteria was not met; for example, moderate quality of evidence was assigned if there was a high risk of bias in the body of evidence or if the results were inconsistent or imprecise. The quality of evidence was downgraded to low if 2 criteria were not met, and to very low when >2 criteria are not met.

A low quality of evidence was assigned to nonrandomized studies and upgraded if there was a strong (relative risk > 2) or dose–response association. Evidence was defined as insufficient when no studies provided valid information about treatment effects. This approach was applied regardless of whether the results were statistically significant.

Results

We identified 1 high-quality meta-analysis, 5 systematic reviews, 8 RCTs, and 12 nonrandomized studies. All studies reported outcomes in adult patients. We found no pediatric studies.

Conclusions

In adults with facial trauma, in order to reduce mortality and infection rates, clinicians should not recommend postoperative antibiotics in addition to pre- and perioperative antibiotics.

Population:

Adults with facial fractures

Settings:

Any

Intervention:

Unfavorable postprocedural imaging

Comparator:

Unremarkable (favorable) postprocedural imaging

American Association of Oral and Maxillofacial Surgeons. Clinical Practice Guidelines for Oral and Maxillofacial Surgery, 2012. (AGREE II Score: Unavailable)

• •
  

  This guideline does not address postprocedural imaging in patients with facial trauma but acknowledges that outcomes assessment may include an imaging evaluation.

Background

Therapeutic goals in treating patients with facial trauma include patient satisfaction with facial appearance and function without complications or repeated surgical procedures. Postsurgical panoramic radiography is common as a part of routine clinical practice in many hospitals. However, the benefits of postsurgical imaging for clinical decisions and patient outcomes are unclear. We systematically reviewed the association between postsurgical imaging and complications requiring repeated surgery in patients with facial trauma.

Methods

We conducted a comprehensive search in PubMed, EMBASE, the Cochrane Library, the Elsevier text mining tool database including the National Institutes of Health RePORTER Grant database, and the clinicaltrials.gov trial registry up to June 2016 and did a hand-search of the reference lists. We searched for studies of children or adults with facial fractures due to facial trauma. We included all studies that examined the benefits and harms of postsurgical imaging.

Results

We identified one qualitative narrative review, one cost-effectiveness analysis, and several poor-quality observational studies for this review. None of the studies compared patient outcomes in patients who had versus did not have postoperative imaging. Observational studies included adults with various facial fractures undergoing various imaging methods and did not use adjustment in reporting the rates of reoperation.

Very low-quality evidence suggests that unfavorable postprocedure imaging is not associated with lower rates of reoperation and has very low predictive value for early detection of postsurgical complications ( Table 1 ). The systematic review and an economic analysis concluded that routine postoperative imaging is cost-effective only in settings with a complication rate above 17.7%.

Limitations

We downgraded the quality of evidence due to risk of bias in the body of evidence and imprecision in treatment effects in small nonrandomized studies. The evidence regarding the effects of postsurgical imaging on quality of life, patient satisfaction, and medicolegal actions was insufficient.

Future research is needed to examine the comparative effectiveness and safety of various imaging techniques in association with provider experience and the quality of provided care.

Conclusions

In adults with acute facial trauma in order to ensure correct alignment, facial surgeons should practice postoperative imaging. Provider experience, baseline complication rates and the quality of provided care should guide a decision to use post-surgical imaging in individual patients instead of routine post-surgical imaging.

Population:

Adults with orbital fractures

Setting:

Inpatient

Intervention:

Shorter timing between the trauma and surgical intervention

Comparator:

Delay in timing between the trauma and surgical intervention

American Association of Oral and Maxillofacial Surgeons. Clinical Practice Guidelines for Oral and Maxillofacial Surgery, 2012. (AGREE II Score: Unavailable)

• •
  

  This guideline considers time elapsed since injury as a risk factor for poor outcome but does not specify the optimal time for the surgery of orbital fractures.

Background

Orbital fractures are common and result in patients suffering with enophthalmos (displacement of the eyeball within the orbit), diplopia, orbital soft tissue entrapment, and nerve injury. There is no consensus around optimal timing for surgical repair of the fractured orbital floor. We systematically reviewed benefits and harms from early versus delayed surgery for orbital fractures.

Methods

We conducted a comprehensive search in PubMed, EMBASE, the Cochrane Library, Elsevier text mining tool database including National Institutes of Health RePORTER grant database, and clinicaltrials.gov trial registry up to June 2016 and did a hand-search of the reference lists. We included all studies that examined timing of surgical treatments for orbital fractures.

Results

We identified one clinical and two systematic reviews, 1 RCT, and 16 nonrandomized studies. The RCT was designed to examine treatment options and provide post hoc analysis of the association between timing and patient outcomes. A very small observational case series compared different timing and failed to provide reproducible data and to adjust for patient characteristics, surgical techniques, or the quality of the provided care. Adult case series analyzed various orbital fractures. Pediatric case series analyzed mostly blow-out orbital fractures.

Very low-quality evidence suggests that a delay in surgical repair is associated with poor clinical outcomes in most case series ( Table 1 ). The data is insufficient to determine the optimal surgical timing. A clinical review speculated that immediate, within 24 hours, surgical repair should be recommended for younger patients and patients with nonresolving oculocardiac reflex, blow-out orbital fractures, and early enophthalmos ( Appendix ). Studies did not stratify outcome rates by baseline entrapment. However, pediatric case series acknowledge a poor sensitivity in diagnosis of entrapment by radiologists and poor prognosis of pediatric orbital fracture with entrapment, resulting in a rapid development of muscle fibrosis and persistent diplopia.

Conclusions

In children and adults with orbital fractures, in order to achieve a complete recovery and prevent postsurgical enophthalmos and residual diplopia, clinicians should not delay indicated surgical repair.

Population:

Adolescents or adults with traumatic nonpenetrating optic nerve compression

Setting:

Inpatient

Intervention:

Systemic steroids within 7–14 days after injury

Comparator:

Placebo, no active treatment, or active comparators

Population:

Adolescents or adults with traumatic nonpenetrating optic neuropathy

Setting:

Inpatient

Intervention:

Surgical optic nerve canal decompression

Comparator:

Systemic Corticosteroids or Observation

American Association of Oral and Maxillofacial Surgeons. Clinical Practice Guidelines for Oral and Maxillofacial Surgery, 2012. (AGREE II Score: Unavailable)

This guideline lists the following procedures for the management of orbital injuries but does not address preferred treatments for optic nerve compression:

• A.
  

  Observation based on limited severity of fracture, displacement, and mobility

  
  
• B.
  

  Open treatment (including endoscopically assisted and computed tomography-guided navigation)

  
  
• C.
  

  Orbital reconstruction

  
  
• D.
  

  Medial and/or lateral canthopexy

  
  
• E.
  

  Nasolacrimal reconstruction

  
  
• F.
  

  Antimicrobials as indicated

  
  
• G.
  

  Control of pain

  
  
• H.
  

  Drains for management of dead spaces or contaminated wounds when judgment dictates

  
  
• I.
  

  Instructions for posttreatment care and follow-up

Background

Treatment options for traumatic optic nerve compression include observation, large dose of systemic corticosteroids, or surgical treatments, with no consensus on which option is superior to the others in preventing devastating blindness. The lack of direct randomized trials results in variable usual practices among hospitals and clinicians. We systematically reviewed the comparative effectiveness of surgical and medical treatment options for children and adults with traumatic optic nerve compression.

Methods

We conducted a comprehensive search in PubMed, EMBASE, the Cochrane Library, Elsevier text mining tool database including National Institutes of Health RePORTER Grant database, and clinicaltrials.gov trial registry up to August 2016 and did a hand-search of the reference lists. We used random effects models to pool relative risk from RCTs, Peto odds ratios from sparse controlled nonrandomized studies, and arcsine transformed crude rates of the outcomes from uncontrolled case series and case reports.

Results

We identified 4 meta-analyses, 1 systematic review, 3 RCTs, 1 controlled International Optic Nerve Trauma Study, and 42 publications of case series. Three Cochrane reviews did not provide quantitative data. Primary studies included children and adults and rarely reported results by age groups. The exact treatment regimens and outcomes measurements varied across individual reports. Primary studies of surgical treatments inconsistently reported concomitant use of pre- and postoperative systemic steroids. Many retrospective case series reported outcomes in patients who received surgery after systemic corticosteroids failed to improve visual acuity. Surgical techniques included extra- or intracranial, orbital, transethmoidal, or endoscopically assisted transconjunctival approaches. Studies did not compare different surgical techniques and did not explain the selection of the techniques used depending on patient characteristics.

Low-quality evidence suggests that systemic corticosteroids increase the rates of improved visual acuity when compared with observation in adolescents and adults with traumatic nonpenetrating optic nerve compression ( Table 1 ). Very low-quality evidence suggests that there are no differences in the rates of improved visual acuity between methylprednisolone versus placebo, between dexamethasone versus methylprednisolone, or between megadoses versus high doses of methylprednisolone ( Table 1 ).

Early (within 24 hours from trauma) versus delayed (within 7 days from trauma) prednisolone administration does not result in greater rates of improved visual acuity in children with traumatic nonpenetrating optic nerve compression ( Table 1 ).

Very low-quality evidence suggests that surgical optic nerve canal decompression alone or in combination with systemic corticosteroids increases the rates of improved visual acuity when compared with observation in adolescents and adults with traumatic nonpenetrating optic nerve compression ( Table 2 ). However, surgical optic nerve canal decompression is not better than systemic corticosteroids in improving visual acuity ( Table 2 ). Surgical optic nerve canal decompression combined with systemic corticosteroids is not better in improving visual acuity than systemic corticosteroids alone or surgery alone ( Table 2 ). Early surgery results in greater rates of improvement in visual acuity than later surgery in adults and children ( Table 2 ).

Indirect comparison of uncontrolled case series suggests that the rates of the improved visual acuity are slightly lower after observation and are very similar after systemic corticosteroids alone or after surgery in patients who did not experience improved vision after systemic corticosteroids ( Appendix Table 1 ). Uncontrolled case series suggest that patients with optic canal fracture and patients without baseline light perception have poor prognosis. The rates varied substantially among single institutions, probably because of differences in hospital protocols regarding indication for steroids or surgery, and probably due to differences in the quality of provided care.

Limitations

We downgraded the quality of evidence due to high risk of bias in the body of evidence and heterogeneity and imprecision in treatment effects from small studies. The evidence regarding comparative effects from various steroids and surgical techniques on complete vision restoration, mortality, quality of life, and treatment utilization was insufficient. Small studies attempted to examine correlation between baseline vision loss and treatment outcomes but failed to identify valid evidence for individualized treatment decisions. Authors came to the somewhat obvious conclusion that patients with minimal baseline vision loss have better vision after the treatments. Studies did not report outcomes in patients with different demographics or comorbidities.

We found one guideline that describes treatment options for orbital injuries but does not address preferred treatments for indirect optic nerve compression. Future research is needed to examine the comparative effectiveness and safety of surgical versus medical treatments in patients with traumatic optic nerve compression and various demographic groups and comorbidities.

Conclusions

In children and adults with traumatic optic nerve compression, in order to achieve some improvement in visual acuity, clinicians should recommend systemic corticosteroids and consider rescue surgery in individual patients who do not improve after systemic corticosteroids.