Medical Care: No Wonder it Costs So Much!

Recently, we reviewed an article in an established medical journal.  The article reported on the use of ultrasound (a non-X-ray form of imaging) in “defining nasal fractures.”

The study wanted to find if using an ultrasound examination would be helpful in making an accurate diagnosis of a nasal fracture or broken nose.

Frankly, it has long been taught that, of all the types of broken bones in which technology has almost no role, nasal fractures lead.  Here’s why:

1.         A nasal fracture is never an emergency. Thus, one can allow swelling and bruising to subside before a definitive diagnosis is reached.

2.         The diagnosis of nasal fracture is always based on two simple issues:

• Has the nose changed in shape?
• Has breathing changed

Swelling usually goes down about the seventh day; the patient knows if his nose looks like it did before, but if he is uncertain, a quick glance at a driver’s license photo will tell the tale about the nose’s present and pre-injury states.

(Read the broken nose timetable.)

Likewise, patients well know if they can breathe.  If a change in breathing is present, it’s highly suggestive that there has been a nasal fracture with some significant change in the internal architecture of the nose which accounts for the breathing problem.

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The patient below broke his nose playing basketball; on the left, his nose had completely collapsed and also gave him breathing problems. After surgery, right, his nose and profile was corrected with a plastic insert put in through an incision while correcting hisbreathing blockage. (Robert Kotler,M.D. photo)

Before and After Nose Surgery

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Classically, nose surgeons make the diagnosis of nasal fractures on the basis of their examinations including:

• Nasal crookedness or deformity
• Out of position bones

An internal nasal examination by a nose specialist will tell if the septum is broken or deviated, or if the lining skin has been torn.

(Read more about a deviated septum.)

Here are are the common diagnostic criteria for a broken nose:

1.         Change in shape

2.         Change in position

3.         An audible “snap” at the time of injury

4.         Internal bleeding

Immediately after the injury, people often find that swelling and bruising obscure the findings. But because the bones can be gently manipulated back into position at some point before 10 days, there should be no rush to intervene.

Nose specialists merely give the patient:

• Some pain medications
• Some cold packs to apply to the nose
• Perhaps some anti-inflammatories like Advil or aspirin

Then the patient returns in several days to see how the nose looks.  It may take even another day or two before the examiner can feel the bones once the swelling has settled down.

Today — despite the wonders of radiology and various X-ray and non-X-ray techniques – we think no substitute exists for taking a careful history plus a complete examination.

X-rays, CT scans and ultrasounds rarely offer any benefit and should be reserved for extremely unusual cases in which extraneous factors are at play.

Nonetheless, the conclusion of the study was:  “Ultrasonography, particularly in later review, can be useful in identifying fractures.”

“Can be” is nice, but I hope not every emergency room doctor decides to consume more valuable health dollars by ordering such a study in every case. It will hardly be worth the money.

Ultrasound charges vary tremendously from $1,500 in New York City to $155 near Palm Springs, California.