Introduction
Background
"If thou examinest a man having a break in the column of his nose, his nose being disfigured, and a depression being in it, while the swelling that is on it protrudes, he has discharged blood from both his nostrils. Thou shouldst say concerning him: 'One having a break in the column of his nose. An ailment which I will treat.'"
—Ancient Egypt, Edwin Smith Surgical Papyrus, 3000 BC
Although nasal fractures are the most common facial fracture, they often go unnoticed by both physicians and patients. Patients with nasal fractures usually present with some combination of deformity, tenderness, hemorrhage, edema, ecchymosis, instability, and crepitation; however, these features may not be present or may be transient.1 To further complicate the matter, edema can mask underlying nasal deformity, crepitation, and instability; thus, many physicians and patients fail to pursue further diagnosis and appropriate treatment. If untreated, nasal fractures can result both in unfavorable appearance and in unfavorable function, especially when the underlying structural integrity of bone and cartilage is lost.2,3
Untreated nasal fractures account for the high percentage of rhinoplasty and septoplasty procedures performed months to years after the initial trauma occurs. Thus, appropriate treatment is best rendered in a timely manner, before scarring and soft tissue changes occur. As always, thorough history taking and physical examination should precede radiographic evaluation. If radiographic evaluation is warranted, it is best used when other facial fractures are suspected in combination with a nasal fracture, because isolated nasal fractures are treated on the basis of the physical examination alone. The fact that patients may have displaced nasal fractures and normal-appearing plain radiographic findings should be emphasized.1,4,5,6,7,8,9,10,11,12
For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles, Broken Nose and Facial Fracture.
Nasal fractures. Waters view shows a deviated nasal septum, quadrangular cartilage displaced from the maxillary crest, and a nasal root deviated to the right.
Nasal fractures. Coronal CT scan demonstrates a nasal fracture with root deviation to the right. Note that the fracture has occurred in the weaker lower portion of the nasal bones.
Nasal fractures. Axial CT scan demonstrates a nasal fracture with root deviation to the right. Note that the fracture involves the septum as well and that the septum is severely deviated.
Recent studies
Bremke et al performed a retrospective analysis of 300 patients treated from 1999-2004 for simple and complex nasal fractures and found closed repositioning to be the therapy of choice in uncomplicated fractures. They noted that for patients older than 60 years, inpatient treatment should be considered because of the presence of comorbidities. In their study, 77% of patients were male, average age was 29.6 ± 15.6 years, and falls were the cause in 30%. The most frequent findings were deviation of the longitudinal axis (59%) and traumatic deviation of the nasal septum (50%). Open nasal bone fractures were present in 22% of patients, and 5% had a septal hematoma.2
In another study by Bremke and coworkers, digital volume tomography (DVT) was used in 65 patients suspected of having a nasal bone fracture to determine whether DVT could detect fractures not seen by conventional radiography. In 5 of the patients, DVT identified fracture lines that were not identified on lateral radiographs. The authors also noted that DVT classified fractures according to dimensions, enabled reconstruction of 3D volume images, and provided imaging of extent of fracture and dislocation.13
Lee et al compared high-resolution ultrasonography (HRUS) with CT in diagnosing nasal fractures in 140 patients with nasal trauma from 2004-2007. The accuracy rates for HRUS, CT, and conventional radiography were 100%, 92.1%, and 78.6%, respectively. Compared with HRUS, CT revealed only 196 of 233 lateral nasal bone fractures. In high-grade fractures, the accuracy of CT was 87%, but it decreased to 68% in low-grade fractures.14
Pathophysiology
The nasal bones and underlying cartilage are susceptible to fractures because the nose maintains a prominent position and central location on the face and because it has a low breaking strength. Patterns of fracture are known to vary with the momentum of the striking object and the density of the underlying bone.5 As with other facial bones, younger patients tend to have larger nasoseptal fracture segments, whereas older patients are more likely to present with more comminuted fracture patterns.4,6,8,9,12,15Weak areas are noted in the cartilage framework and the junctions of the upper lateral cartilages with the nasal bones and the septal cartilage at the maxillary crest. The weak areas account for an increase in the rate of fracture/dislocation after nasal trauma. A lateral force of only 16-66 kPa and a greater frontal force of 114-312 kPa can displace the bony dorsum.5 A large force in any direction can cause comminution of the nasal bones with an associated C -shaped deformity of the nasal septum. The C -shaped deformity usually begins under the dorsum of the nose, extends posteriorly and inferiorly through the perpendicular plate of the ethmoid, and ends with an anterior curve in the cartilaginous septum approximately 1 cm above the maxillary crest.5
Murray et al reported that almost any deviation of the fractured nasal bones involves a concomitant fracture of the septal cartilage.5 Cartilage fracture lines are often oriented vertically in the caudal septum and horizontally in the posterior portions.
Lateral impact injuries are the most common type of nasal injury leading to fracture.7 Lateral injury produces a depression of the ipsilateral nasal bone that usually involves the lower one half of the bone, the nasal process of the maxilla, and a variable portion of the pyriform margin. Nasal fracture and displacement without septal fracture usually occur with weaker applied forces; however, with increased force, displacement of the bilateral nasal bones may be noted, and the septum is usually dislocated and fractured as well.6
Other injuries that are commonly associated with nasal fractures include midface injuries involving the frontal, ethmoid, and lacrimal bones; nasoorbital ethmoid fractures; orbital wall fractures; cribriform plate fractures; frontal sinus fractures; and maxillary Le Fort I, II, and III fractures (see Images below and Images 1-6, 16-22 in Multimedia).1,4,8,9,12,15
Nasal fractures. Patient presenting 48 hours after an assault, with complaints of right eye pain, nasal airway obstruction, and deformity. Note the asymmetry of the nasal bones and dorsal nasal column (same patient in Images 1-6 in Multimedia).
Nasal fractures. Patient presenting 48 hours after an assault, with complaints of right eye pain, nasal airway obstruction, and deformity (same patient in Images 1-6 in Multimedia).
Nasal fractures. Patient presenting 48 hours after an assault, with complaints of right eye pain, nasal airway obstruction, and deformity (same patient in Images 1-6 in Multimedia).
Nasal fractures. Patient presenting 2 weeks after nasal osteotomies and closed nasal reduction, which were performed after an assault (same patient in Images 1-6 in Multimedia). The patient had multiple previous nasal fractures and refused open septorhinoplasty. Note the broad nasal dorsum.
Nasal fractures. Patient presenting 2 weeks after nasal osteotomies and closed nasal reduction, which were performed after an assault (same patient in Images 1-6 in Multimedia). The patient had multiple previous nasal fractures and refused open septorhinoplasty.
Nasal fractures. Patient presenting 2 weeks after nasal osteotomies and closed nasal reduction, which were performed after an assault (same patient in Images 1-6 in Multimedia). The patient had multiple previous nasal fractures and refused open septorhinoplasty. Note the broad nasal dorsum.
Frequency
United States
Fracture of nasal bones is the most common site-specific bone injury of the facial skeleton. Nasal fractures account for 39-45% of all facial fractures.8
Mortality/Morbidity
- The morbidity of nasal fractures includes nasal airway obstruction resulting from dorsal nasal collapse; septal deviation; valvular collapse; epistaxis; or a poor cosmetic outcome.
- Perhaps the worst morbidity results from septal hematoma, leading to septal perforation and necrosis, which causes severe nasal collapse and deformation.
Sex
The male-to-female ratio in nasal fractures is greater than 2:1.
Age
- The incidence is increased in patients aged 15-30 years.9
- A small but significant increase in the number of nasal fractures is noted in the elderly population because of a higher rate of falls.
- Most nasal bone fractures in young adults are related more to altercations and sporting injuries and less to motor vehicle accidents; these rates vary according to the location of the conducted study and the association with alcohol.8,9,12,16
Anatomy
The nasal skin is thin and loosely adherent over the superior two thirds of the nose. The skin thickens and adheres more tightly over the caudal one third of the nose. Sensory innervation of the nose is supplied by the supratrochlear, infratrochlear, anterior ethmoid, and infraorbital nerves. Blood is supplied to the external nose by the dorsal nasal, external nasal, lateral nasal, and septal arteries.
The paired, rectangular, flat nasal bones project from the frontal processes of the maxilla, joining in the midline and articulating with the nasal process of the frontal bone at the nasion. The thinner caudal portion of the nasal bones articulate with the upper lateral cartilages; this area is vulnerable to dislocation as a result of trauma. The nasion is more stable than the midline scaffolding provided by the cartilaginous septum. The ethmoid air cells are situated posterior to the nasal bones. Approximately 80% of fractures occur at the lower one third to one half of the nasal bones.5 This area represents a transition zone between the thicker proximal and thinner distal segments.
The cartilaginous septum is a quadrangle-shaped cartilage set between 2 bony structures: the vomer and the perpendicular plate of the ethmoid. The septovomerine angle is the center of growth for the cartilaginous septum. The hard palate represents the floor of the nasal cavity, and the cribriform plate constitutes the roof.
Presentation
Patients with nasal fractures usually present with some combination of dorsal or septal deformity, tenderness, hemorrhage,17 hematoma, edema, ecchymosis, instability, and crepitation. However, these features may not be present, or they may be transient.
Preferred Examination
Although the use of plain images is not suggested (see Limitations of Techniques, below), the preferred examination includes the acquisition of Waters and lateral nasal views.
Limitations of Techniques
Controversy regarding radiologic techniques
The use of plain images and computed tomography (CT) scans for the diagnosis and management of nasal fractures has been controversial. Several small studies have shown that use of these modalities is neither cost-effective nor beneficial to the patient or physician. Nasal fractures are usually evident and can be elicited by means of careful history taking and physical examination. Rarely is the radiologic confirmation of these injuries needed.18 However, some clinicians still use plain images and CT scans, and the radiologist must understand some of the diagnostic pitfalls to reduce the rate of erroneous readings.19,13,14
De Lacey et al evaluated 100 consecutive patients presenting to the emergency department with a history of trauma to the nose.20 Nasal radiographs were obtained in each patient, including both the Waters and lateral views. There were no radiographic findings of fracture in 65 of the 100 patients. Nasal fractures were depicted in 45 patients, yet only 3 patients required reduction, and 31 of 45 patients were discharged without treatment. The authors then compared the lateral radiographs in 50 control subjects and 50 persons with dry skulls.
When images from control subjects were compared with images of persons with dry skulls, misreads were identified and classified as midline defects, high lateral-wall defects, and low lateral-wall defects. In 50 control subjects, 33 cortical defects were observed. After close inspection, the misreads were found to be the result of the midline nasal suture, the nasomaxillary suture (low defect), and thinning of the nasal wall (high defect). De Lacey et al concluded that the lateral view was unreliable for the evaluation of nasal fractures because of the high incidence of similar defects found in noses from control subjects and in patients with dry skulls when evaluated using plain radiography.20
Clayton and Lesser prospectively evaluated 54 patients clinically, radiologically, and under anesthesia within 19 days after nasal injury.21 At each stage, these examinations were evaluated to assess the contribution of each study to the care of the patient. Occipitomental (Waters) views and lateral views were obtained in all patients. External examination and nasal rhinoscopy were performed to evaluate the patients clinically. The patients were grouped into 3 categories: patients not needing manipulation, patients requiring manipulation, and patients requiring later review because of edema. Manipulation was required in 24 patients, and 19 patients underwent further examination with anesthesia at the time of repair.
Six patients had no clinical evidence of a fracture despite radiographic evidence of a fracture. None of these 6 patients required manipulation. Examination under anesthesia changed the type of repair necessary in 5 patients: 1 patient was found not to have a septal fracture, and 4 were found to have bilateral fractures. The authors concluded that examination under anesthesia provided more accurate information than radiography or clinical examination alone or together. The authors also found that the Waters view, the lateral view, or the 2 views in combination did not provide useful information, as compared with physical examination alone. Standard radiographs were not helpful in deciding whether to perform manipulation or when and how to perform manipulation for repair.21
Logan et al prospectively examined 100 consecutive patients seeking treatment in an emergency department for nasal trauma.16 Both Waters and lateral views were obtained in all patients. Of the 100 patients, 19 were discharged home from the emergency department with radiographic evidence of a fracture, and 35 were referred to an ear, nose, and throat surgeon for treatment (31 of these were believed to have fracture on the basis of the radiographic findings). Only 24 of the 35 referred patients kept their appointments; of these, 8 required manipulation. The authors clearly state that the radiographs and the radiologist's report failed to influence the final management of even a single patient in this study.16
In 2006, Hwang et al compared 503 nasal bone fractures.22 The fractures were analyzed with plain-film radiographs in both lateral and Waters views, as well as with CT. Only 82% of nasal fractures were identified with plain films, as compared with CT scans. These authors felt that plain films were unreliable in the diagnosis of nasal bone fractures.
When evaluation of children is necessary and one wishes to limit exposure to radiation, sonography has been helpful to some in evaluating nasal fractures, septal deviation, and level of comminution. This can be accomplished with a 7-15 MHz linear array transducer.23
In the utilization of 3-dimensional (3D) CT for facial and nasal fractures, better evaluation scores were achieved with surface rendering protocols than with volume rendering protocols. Surface rendering offered better overall image quality than volume rendering.24
Differential Diagnoses
Other Problems to Be Considered
Previous nasal fractures
Associated facial fractures
More on Nasal Fractures |
 Overview: Nasal Fractures |
| Imaging: Nasal Fractures |
| Follow-up: Nasal Fractures |
| Multimedia: Nasal Fractures |
| References |
| Further Reading |
| Next Page » |
References
Tremolet de Villers Y, Schultz RC. Nasal fractures. J Trauma. Apr 1975;15(4):319-27. [Medline].
Bremke M, Gedeon H, Windfuhr JP, Werner JA, Sesterhenn AM. Nasal Bone Fracture: Etiology, Diagnostics, Treatment and Complications. Laryngorhinootologie. Jun 26 2009;[Medline].
Carboni A, Perugini M, Palla L, Ramieri V, Taglia C, Iannetti G. Frontal sinus fractures: a review of 132 cases. Eur Rev Med Pharmacol Sci. Jan-Feb 2009;13(1):57-61. [Medline].
McRae M, Momeni R, Narayan D. Frontal sinus fractures: a review of trends, diagnosis, treatment, and outcomes at a level 1 trauma center in Connecticut. Conn Med. Mar 2008;72(3):133-8. [Medline].
Murray JA, Maran AG, Mackenzie IJ, Raab G. Open v closed reduction of the fractured nose. Arch Otolaryngol. Dec 1984;110(12):797-802. [Medline].
Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology Head and Neck Surgery. Vol II. 3rd ed. St Louis: Mosby-Year Book;1998.
Illum P, Kristensen S, Jorgensen K, Brahe Pedersen C. Role of fixation in the treatment of nasal fractures. Clin Otolaryngol. Jun 1983;8(3):191-5. [Medline].
Hussain K, Wijetunge DB, Grubnic S, Jackson IT. A comprehensive analysis of craniofacial trauma. J Trauma. Jan 1994;36(1):34-47. [Medline].
Muraoka M, Nakai Y, Shimada K, Nakaki Y. Ten-year statistics and observation of facial bone fracture. Acta Otolaryngol Suppl. 1991;486:217-23. [Medline].
Fraioli RE, Branstetter BF 4th, Deleyiannis FW. Facial fractures: beyond Le Fort. Otolaryngol Clin North Am. Feb 2008;41(1):51-76, vi. [Medline].
Doerr TD, Arden RL, Mathog RH. Otolaryngology-head & neck surgery. In: Cummings CW, Fredrickson JM, Krause CJ, Harker LA, eds. Nasal Fractures. 3rd ed. Mosby-Year Book;1998: 866-82.
Scherer M, Sullivan WG, Smith DJ Jr, et al. An analysis of 1,423 facial fractures in 788 patients at an urban trauma center. J Trauma. Mar 1989;29(3):388-90. [Medline].
Bremke M, Wiegand S, Sesterhenn AM, Eken M, Bien S, Werner JA. Digital volume tomography in the diagnosis of nasal bone fractures. Rhinology. Jun 2009;47(2):126-31. [Medline].
Lee MH, Cha JG, Hong HS, Lee JS, Park SJ, Paik SH, et al. Comparison of high-resolution ultrasonography and computed tomography in the diagnosis of nasal fractures. J Ultrasound Med. Jun 2009;28(6):717-23. [Medline].
Redman HC, Purdy PD, Miller GL. Facial trauma. In: Redman HC, Miller GL, Purdy PD, eds. Emergency Radiology. Philadelphia:. WB Saunders Co;1993: 96-105.
Logan M, O''Driscoll K, Masterson J. The utility of nasal bone radiographs in nasal trauma. Clin Radiol. Mar 1994;49(3):192-4. [Medline].
Liu WH, Chen YH, Hsieh CT, Lin EY, Chung TT, Ju DT. Transarterial embolization in the management of life-threatening hemorrhage after maxillofacial trauma: a case report and review of literature. Am J Emerg Med. May 2008;26(4):516.e3-5. [Medline].
Jones TR. The nose. In: Greco RJ, ed. Emergency Plastic Surgery. Boston:. Little, Brown & Co;1991: 365-72.
Gürkov R, Clevert D, Krause E. Sonography versus plain x rays in diagnosis of nasal fractures. Am J Rhinol. Nov-Dec 2008;22(6):613-6. [Medline].
de Lacey GJ, Wignall BK, Hussain S, Reidy JR. The radiology of nasal injuries: problems of interpretation and clinical relevance. Br J Radiol. Jun 1977;50(594):412-4. [Medline].
Clayton MI, Lesser TH. The role of radiography in the management of nasal fractures. J Laryngol Otol. Jul 1986;100(7):797-801. [Medline].
Hwang K, You SH, Kim SG, Lee SI. Analysis of nasal bone fractures; a six-year study of 503 patients. J Craniofac Surg. Mar 2006;17(2):261-4. [Medline].
Hong HS, Cha JG, Paik SH, Park SJ, Park JS, Kim DH, et al. High-resolution sonography for nasal fracture in children. AJR Am J Roentgenol. Jan 2007;188(1):W86-92. [Medline].
Rodt T, Bartling SO, Zajaczek JE, Vafa MA, Kapapa T, Majdani O, et al. Evaluation of surface and volume rendering in 3D-CT of facial fractures. Dentomaxillofac Radiol. Jul 2006;35(4):227-31. [Medline].
Keats TE, Anderson MW. The nose; the facial bones. In: Keats TE, Anderson MW, eds. Atlas of Normal Roentgen Variants that May Simulate Disease. St Louis:. Mosby-Year Book;2001: 150-2.
Ruenes R, Couto F. Radiology of the nose. In: Taveras JM, Ferrucci JT, eds. Radiology Imaging and Intervention. Philadelphia: Lippincott Williams & Wilkins;2001: 1-12.
Illum P. Legal aspects in nasal fractures. Rhinology. Dec 1991;29(4):263-6. [Medline].
Wexler MR. Reconstructive surgery of the injured nose. Otolaryngol Clin North Am. Oct 1975;8(3):663-77. [Medline].
Fielding JA. Improving accident and emergency radiology. Clin Radiol. Mar 1990;41(3):149-51. [Medline].
Further Reading
Related eMedicine topics
Facial Trauma, Nasal Fractures
Fracture, Face
Nasal Fracture (Sports Medicine)
Nasal Fracture Reduction
Nasal and Septal Fractures
Keywords
nasal fractures, nasal trauma, septal fracture, nasoorbital ethmoid fracture, orbital fracture, ethmoid fracture, frontal sinus fracture, maxillary fracture, broken nose, nose fracture, facial fracture
