Impact of video clinics in the management of fracture nasal bones in COVID times*

Since a significant number of patients in our practice with nasal bone trauma do not require surgical intervention, we planned to identify these patients through a video clinic. In our study we were successful in identifying nearly 42% of patients who could be discharged with high patient satisfaction scores thus saving time and revenue. In a situation where it may be difficult to perform a clinical examination, like current COVID pandemic, this model can be used as an effective alternative emergency diagnostic solution. Abstract Background: The COVID -19 pandemic created a panic situation where patient interaction with the other patients and health care staff had to be restricted to avoid spreading the disease. We planned an innovative strategy to restrict the inflow of patients to those who may need nasal bone manipulation by using Video Clinics (VC).


Introduction
We describe an innovative approach in managing patients referred for nasal bone trauma to the NHS system during the COVID pandemic time. The nose is known to house high concentration of corona virus in infected individuals (1) .
We ran a nasal fracture video clinic (VC) to minimize the risk of transmission of the virus to the public and hospital staff.
Since a significant number of patients in our practice with nasal bone trauma do not require surgical intervention, we planned to identify these patients through a video clinic. In our study we were successful in identifying nearly 42% of patients who could be discharged with high patient satisfaction scores thus saving time and revenue. In a situation where it may be difficult to perform a clinical examination, like current COVID pandemic, this model can be used as an effective alternative emergency diagnostic solution.

Materials and Methods
All patients presenting with suspected closed fracture nasal bones were included in the prospective observational study for a period of three months starting 15th July 2020. The Accident & Emergency (A&E's) of three acute University Hospital sites of our Health Board were circulated the following new instructions: • To assess patients as per usual protocols and exclude septal hematoma in A&E by the health care professional and a medico legal record was created if required. Patients with septal hematoma to be managed by the ENT on call team.
• All patients to be booked for a VC in 7 to 14 days of injury.
The VC was held once per week and the patients were requested to connect using a QR code or a web address.
These were printed and mailed to their current residential address.
The shape of the nose was examined in frontal and profile views by the lead author in VC. The nasal passage was assessed by requesting patients to gently press the ala against the septum and breathe from the other side. An attempt was made to compare the photograph of the face prior to injury with the present shape of the nose, which usually was the case.
All the patients with straight noses and normal breathing were were contacted after 4 to 6 weeks via telephone, to gather their feedback to VC and reconfirm their outcomes.

Results
A total of 42 patients (23 males and 19 females) with complains of nasal bone injury were referred from A&E to VC. Thirteen (30.95%) were children less than 18 years of age. The male to female ratio was 1.21:1.
Seventeen adults were injured because of spontaneous fall and the remaining twelve sustained injury due to accident, assault and sports. Children were more often injured more oftenbecause of assault and sports, five in each category and the remaining three were due to spontaneous fall.
Thirty-one patients (74 %) out of forty-two could attend the video clinic. Of patients failing to attend VC, three could be reached on their mobile phones, three were lost to follow up and five were booked directly for the Face-to-Face clinic ( Table   1).
Thirteen (42%) out of thirty-one patients attending VC were discharged and eighteen were booked for face 2 face clinic appointment ( Table 2). Twenty-three (54.8%) out of 42 patients attended the F2F clinic. Eighteen were booked from VC and another five were booked directly. Eleven patients were discharged after VC and twelve (28.5%) required NBM as final outcome.
Ten patients (23.8%) had NBM performed under LA and two (4.8%) were scheduled for Septorhinoplasty under GA later. Twenty-five (80.6%) out of 31 patients attending VC were very satisfied and two (6.4%) were satisfied (Table 3). Two patients (6.4%) expressed dissatisfaction and two (6.4%) were lost to follow up as they failed to answer telephone calls.

Discussion
The institutional and individual behavior in society greatly affects the spread of the infectious diseases (2) . The strategy in managing fracture nasal bones was to keep personal interaction to a minimum without compromising the patient's interest.
The focus in VC was on the nasal shape and breathing. Dedicated fracture clinics are seen to reduce time to assessment and management (3) , but the authors could not trace any literature on VC. Merging the techniques of dedicated clinic and use of video seemed highly relevant in pandemic times and we wanted to share our results for the wider benefit.
No radiological procedure was performed to diagnose closed fracture nasal bones, which are generally simple in nature and clinical assessment is the key (4) . One-to-two-week interval to VC helped oedema to subside and offer NBM under 3 weeks (5) .
Nasal bone fracture is the most common facial bone injury accounting for 39-45% of all facial fractures (6) . The male to female ratio can vary from 2:1 (6,7) to a ratio of 72:28 (8) . Our figures of The discharged patients were happy with the shape of their nose and breathing and assessing surgeon was also satisfied.
They gained the maximum from VC as they avoided a return visit to the hospital, escaped proximity to other patients and attended appointment from the privacy of their homes or workplace.
Three patients (7.1%) were happy to self-discharge themselves.
They were contacted via telephone as they failed to connect on VC. They were happy with their noses and we accepted their decisions. Three patients (7.1%) failed to connect and also failed to answer telephonic calls; hence, they were lost to follow up.
In any circumstances where the patients could not be reviewed within two weeks of injury, they were booked directly for Faceto-Face clinic, which happened in five (11.9%) of our patients.
Two patients had problems with their phone cameras, one elderly patient found it challenging to connect and the remaining two missed their appointment due to a public holiday.
Missed appointments due to public holidays can be addressed by arranging the clinic twice a week, as our dedicated clinic was limited to once a week.
Eighteen out of 31 patients attending VC had to be called again to the Face-to-Face clinic on the next working day due to apparent nasal deviation or suspected reduced nasal airflow. They were joined by five patients who were booked directly thus forming a group of 23. Two patients in this group insisted to be seen in clinic before discharge.
Twelve patients out of twenty-three booked in Face-to-Face clinic required further management by NBM. Eleven patients were discharged after evaluation as needed no further intervention.
We expect the ratio of patients requiring NBM to discharge without intervention, to improve in future as the idea of VC gains acceptance of the people and clinicians gain more experience. NBM at an optimal time is key to successful management.
Testing COVID-19 positive on the morning of surgery without any symptoms, points to presence of asymptomatic carriers and deferring surgery helped prevent further spread of the virus (9) .

Satisfaction score
The patients attending VC were contacted after 4 to 6 weeks of appointment via telephone to collect their feedbacks and ensure satisfaction with their outcomes. Twenty-nine patients (93.5%) could be contacted out of thirty-one, and two (6.4%) failed to answer the telephone call, hence remained untraceable.

Conclusions
In our opinion, management of suspected fracture nasal bones can be helped in a safe and an effective way by using Video Consultations. We recommend this process as an alternative emergency diagnostic solution in situations like the current COVID-19 pandemic. 42% patients with an undisplaced fracture could be discharged from VC without a recall. A high satisfaction rate of 87% with the VC consultation process is very encouraging.
The appointments for VC can be easily built into the existing system by using the existing multi-media facility present at most of the hospitals without extra costs.