Nasal Fracture Surgery

Nasal fractures are the most prevalent type of facial fracture, with the nasal bone also being the third most commonly broken bone in the body.[1] Despite the frequency of their occurrence, nasal fractures are often undertreated. As a consequence, significant long-term functional and cosmetic problems may result. Treatment of long-term complications after significant injury is difficult.

For patient education resources, see the Back, Ribs, Neck, and Head Center and Breaks, Fractures, and Dislocations Center, as well as Broken Nose and Facial Fracture.

In 1947, Maliniac published a classic description of the treatment of nasal fractures. Since then, considerable controversy has existed regarding the optimum treatment of nasal fractures. The debate concerns timing of repair,[2] open versus closed reduction, and specific techniques. In recent years, the trend has been toward open reduction and repair.

Nasal fractures occur in a great number of patterns. The complex 3-dimensional anatomy of the nasal bones, upper and lower lateral cartilages, and bony and cartilaginous septum underscores the importance of a precise assessment of the specific injury to maximize the results of treatment. Blunt trauma may occur anteriorly or laterally, and the resulting pattern of fractures reflects this direction of force. Optimum management is particularly important because of the unique forces of contraction that occur on this complex 3-dimensional structure over the ensuing months following injury. External nasal deformities and significant airway obstruction occur in a significant number of patients, and their presentation may be delayed by as many as several months.

Blunt trauma is the most common cause of nasal fractures.[1] Automobile accidents, altercations, and falls account for approximately 85% of nasal fractures. A study by Liu et al of 100 cases of pediatric nasal deformity from an urban, tertiary pediatric otolaryngology practice found sports-related trauma to be the most common injury mechanism (28%), with the next most common mechanisms being accidental trauma (21%), interpersonal violence (10%), motor vehicle collision (6%), and alcohol-related trauma (2%).[3]

For more information on the treatment of all kinds of trauma, visit Medscape’s Trauma Resource Center.

The pattern of nasal fractures varies depending on the direction of force applied. Force applied from a frontal direction may cause an injury as simple as the infracture of the lower margin of the nasal bones (which are thinner than the heavier, upper portion) or a severe flattening of the nasal bones and septum. (Nasoethmoid complex fractures are discussed in the article Facial Trauma, Nasoethmoid Fractures.) Splaying of the nasal bones with widening of the nasal width may occur.

Lateral forces may cause only a depression of the ipsilateral nasal bone or may also be forceful enough to outfracture the contralateral nasal bone. When twisting or buckling of the nose is present, the fractured bony and/or cartilaginous fragments are often interlocked. This is important to identify because achieving an adequate result with a closed technique is likely impossible in such a situation. The septum is often fractured and may be dislocated off the maxillary crest. Proper reduction of the septum is critical to obtaining optimum results. The fracture pattern of the septum varies according to the location of the fracture. Anterior fractures tend to be vertical, while posterior fractures are usually horizontal in orientation.

Forces from below may cause a third pattern of fractures. In these instances, the septum in particular is fractured and dislocated. The quadrangular cartilage is often dislocated from the crest of the maxilla.

The history should note the mechanism of injury. The patient may note the immediate change in nasal appearance that accompanies a significantly displaced nasal fracture. Epistaxis may indicate the presence of a fracture.

The nose must be inspected both internally and externally. Adequate anesthesia, decongestion, lighting, suction, and, preferably, endoscopic equipment are imperative to examine the internal nose. Lacerations, ecchymosis, hematomas, mucosal tears, and epistaxis internally strongly suggest fracture. Septal hematomas require prompt diagnosis and treatment with drainage and packing to prevent subsequent complications such as cartilage necrosis and resultant saddle nose deformity. The septum may be displaced off the maxillary crest. Externally, ecchymosis is often observed. If a significant amount of edema has not yet occurred, the displacement of the bone and cartilage may be apparent. A stepoff may be palpated. Nasal fractures are frequently accompanied by lid edema, periorbital ecchymosis, chemosis, and subconjunctival hemorrhage.

Pseudotelecanthus may be noted. Telecanthus noted during the physical examination is an indication of a more severe telescoping naso-orbito-ethmoid complex fracture, and further workup (including CT scanning) with more extensive reconstruction is required.

The initial evaluation may be compromised by the amount of edema present. In such cases, once other injuries have been excluded and if the patient is stable and does not require immediate intervention (eg, for epistaxis or septal hematoma), then the physical examination may be repeated in 3-5 days. Photographs of the patient taken preinjury are helpful. Some nasal deformities may have been present prior to the current injury.

Click here to complete a Medscape CME activity on physical examination of the ears, nose, and oral cavity in older patients.

Reduction of a nasal fracture is indicated in any patient with a significant cosmetic deformity or functional compromise. The best time for reduction may be within the first 3 hours following injury. Otherwise, most believe that waiting 3-7 days is preferable. This allows edema to resolve, and positioning the bones correctly with more stability may be easier because inflammation and fibrosis may make the fragments less mobile by this time. If reduction is not possible within the first 7-10 days, then the fractured segments begin forming a fibrous union. This may make manipulation quite difficult. In this scenario, in which the fractured segments are no longer mobile, many surgeons advocate delaying treatment (up to several months) to allow for full healing prior to performing corrective rhinoplasty in which osteotomies are necessary. This may enable a more predictable rhinoplasty (particularly the osteotomies) at that time.

Indications for closed reduction are as follows:

• Unilateral or bilateral fracture of the nasal bones

• Fracture of the nasal septal complex that is deviated less than one half of the width of the nasal bridge

Indications for open reduction are as follows:

• Extensive fractures

• Deviation of the nasal pyramid greater than one half of the width of the nasal bridge[4]

• Displaced fracture of the caudal septum

• Open septal fracture

• Persistent deformity after closed reduction

The bony nasal pyramid consists of the paired nasal bones and the frontal process of the maxilla bilaterally. The nasal bones are thick superiorly at the attachment to the frontal bone and thin inferiorly at the point where they attach to the upper lateral cartilages. They are more susceptible to fracture in this region. Fractures of the nasal bone account for 40% of all facial fractures.

The upper lateral cartilages insert on the undersurface of the nasal bones and are important determinants of nasal appearance. Trauma to this complex can result in internal collapse of the upper lateral cartilages. The upper lateral cartilages articulate with the lower lateral cartilages. This articulation defines the region of the nasal valve, critical to nasal airflow dynamics. The paired lower lateral cartilages define the contour of the tip and the shape of the nostrils, and they provide much of the tip support.

The nasal septum includes the quadrangular cartilage anteriorly, the vomer inferiorly, and the perpendicular plate of the ethmoid posteriorly. Fractures may result in displacement of the bony and cartilaginous septum. These fragments can become interlocked, which is difficult to reduce in a closed technique.

Blood supply

The ophthalmic artery branches off of the internal carotid artery, which subsequently subdivides into the anterior and posterior ethmoidal artery and dorsal nasal artery. Facial and internal maxillary branches off of external carotid artery.

Nerve supply

The internal nose is supplied by the ethmoidal nerve, the sphenoidal nerve, and the nasopalatine nerve. The external nose is supplied by the anterior ethmoid nerve, the supratrochlear nerve, and the infraorbital nerve.

Many cases of nasal fracture do not require treatment when the fragments are not displaced. In cases of severe nasoethmoid complex fractures, simple reduction of the nasal fracture is contraindicated.[5] This does not adequately address the patient's injury and may precipitate or worsen a cerebrospinal fluid (CSF) leak.

Measure hemoglobin values as indicated, particularly if significant epistaxis present.

Imaging studies are rarely needed in the evaluation of nasal fractures.

Plain films are often obtained in emergency departments, but the diagnosis is made based on physical examination findings. As many as 47% of patients with nasal fractures have negative findings on x-ray films. However, see the images below.

CT scan is also not routinely required. An exception is made for patients in whom more significant injuries are suggested.[6] The force applied to the mid face may cause Le Fort or other midface fractures, orbital blowouts, and naso-orbito-ethmoid complex fractures. In patients with the latter, a CSF leak is possible, with CSF rhinorrhea. Nasal fractures are often associated with such severe injuries. The decision to order CT scans is made based on the history and associated physical examination findings that raise the physician's index of suspicion regarding associated injuries.

Ice packs and head elevation are advised initially after injury. If the reduction is not to be performed immediately, then a period of 3-5 days precedes further evaluation. Fractures that are not displaced do not require treatment. Because as many as 30% of patients have a deviation that was present prior to injury, in many cases, obtaining photographs for review is helpful.

For an illustrated description of treating a nasal fracture, see the Clinical Procedures article Nasal Fracture Reduction.

The reduction of nasal fractures may be performed using an open or closed technique. Most may be reduced successfully with closed reduction. Indications for open reduction and closed reduction are listed Indications.[7]

Proper instrumentation is essential. This includes adequate anesthesia, lighting, suction, and instruments. The sensation to the nose derives from the infratrochlear, infraorbital, supratrochlear, and anterior ethmoidal nerves. The base of the nose at the anterior septum, the nasal root, dorsum, and lateral nasal walls are injected with 1-2% lidocaine with 1:100,000 epinephrine. This field block is more effective than targeted nerve blocks. The nose is packed with 4% cocaine pledgets. This may be preceded by topical decongestion and anesthesia (eg, oxymetazoline, Cetacaine) to aid in more comfortable introduction of the pledgets. The physician must wait an adequate period (approximately 15-20 min) to allow the anesthesia and vasoconstriction to be effective. Careful administration of these techniques allows the closed reduction to be performed painlessly in the clinic.

Closed reduction

Use a Boise elevator or other such instrument (an empty knife handle in a glove with surgical lubricant also suffices if necessary) to reduce the fractured segment(s). Externally measure the distance from the nostril rim to the nasion, and introduce the elevator into the nose to a distance 1 cm less than the distance from the nostril rim to the nasion.

Apply controlled force by elevating in the direction opposite of the fracturing force. This is often in an anterolateral direction. Laterally displaced segments may be reduced externally with direct pressure. Often, these maneuvers also adequately reduce associated displaced septal fractures. If not, then an instrument such as Asch forceps may be introduced with one blade in each nostril or with one in the nostril and one outside the nostril. This is then used to reduce the fractured segment. Take care to not apply too much force with this instrument because mucosal tears and bleeding are easily produced.

The patient may have multiple fractures, and some digital molding may be necessary.

Not all nasal fracture reductions require internal packing or splints. If the septum required reduction, then silastic splints may be placed and sutured into place. Depending on the mobility of the segments and the amount of bleeding, antibiotic-impregnated gauze packing may be placed in each nostril for 1-5 days. Stabilize fracture segments that are mobile to gentle palpation with internal packing. Take care to not overpack the nose, thus displacing reduced fractured segments. Externally, apply a layer of surgical tape followed by a rigid nasal splint. This is left in place for 1 week.

A retrospective study by Yi et al suggested that absorbable intranasal splints made from synthetic polyurethane foam (SPF) are an acceptable replacement for splints made from nonabsorbable material, following closed reduction of fractured nasal bones in hospitalized patients. The study involved 111 patients who were underwent closed nasal bone fracture reduction and were splinted intranasally with either SPF (29 patients) or a nonabsorbable polyvinyl alcohol sponge (PVA; 82 patients).[8]

Patients in the SPF group suffered significantly more headache pain on the day of surgery than did those in the PVA group, as well as more nasal pain 1 day postoperatively, but they experienced significantly less bleeding on the fourth postoperative day than did patients in the PVA group. Nasal obstruction was worse on the day of surgery and 1 day postoperatively, for the SPF patients, but on the third and fourth postoperative days it was less than that for the PVA patients. Moreover, the incidences of pain and bleeding associated with the packing materials’ removal were lower in the SPF group.[8]

A study by Yu et al suggested that in closed reduction of type II and III nasal bone fractures, Kirschner wire (K-wire) splinting may have advantages over intranasal gauze packing in terms of patient comfort. Compared with patients treated with gauze packing, individuals who underwent K-wire splinting had significantly fewer complaints regarding nasal obstruction, dry mouth, appetite loss, and sleep disturbance. Reduction accuracy and support to the reduced bones did not significantly differ between the two treatments.[9]

Open reduction

The septum is the key structure that may prevent the reduction of the nasal pyramid. In patients in whom the septal fragments are interlocked, the inability to reduce the septum results in the bony pyramid remaining deviated. In such patients, an open approach is necessary. These procedures are performed in the operating room.

Approach the septum via a hemitransfixion incision. Raise mucoperichondrial flaps. Access the dorsum by bilateral intercartilaginous incisions.

Removal of some of the septum may be necessary to provide adequate reduction. Often, the inferior portion of the septum is displaced off the floor. The reduction of the septum is then stabilized best by an anchoring suture of 5-0 polydioxanone from the caudal septum to the periosteum of the nasal spine. Close mucosal incisions and lacerations and the raised mucoperichondrial flaps after reduction.

Be cautious when elevating the periosteum off the nasal bones because the fractured segments may become unstable, devitalized, or lost. For this reason, a conservative approach to exposure of the bony pyramid is warranted.

Packing and postoperative care are the same as described for closed reduction.

Most patients who undergo closed reduction do so in the clinic and may be discharged home following the procedure. Ice packs and head elevation are helpful in the immediate postoperative period.

If intranasal packing is required, it is removed in 1-5 days. The intranasal splint, if used, is removed in 5-7 days. The external nasal splint and tape are removed in 1 week. Encourage the patient to use intranasal saline spray at this point to aid in the removal of blood clots and crusting.

Early

Epistaxis is common with nasal fractures and may recur with the reduction. Hematoma is always a concern and must be excluded for each patient. Infection is uncommon, although some advocate antibiotic prophylaxis for patients with intranasal packing to prevent toxic shock syndrome. The efficacy of this practice is debatable. CSF rhinorrhea is uncommon but may occur when fractures extend to include the cribriform plate.

Late

Late complications include nasal obstruction, secondary nasal deformity, saddle nose deformity, synechia, and septal perforation.[10] Proper initial management significantly decreases the incidence of such long-term complications.[11]

Most patients do well after properly managed nasal fractures. However, significant fractures that are not reduced properly can initially become difficult problems to treat satisfactorily. In patients with significant twisting or deviation that persists after initial efforts at reduction, a definitive rhinoplasty in the operating room is required. Waiting an adequate period prior to attempting this procedure (minimum 3-6 mo) is best. These procedures can be very challenging, even with the best efforts at the time of initial treatment. However, proper application of current rhinoplastic techniques results in a satisfactory outcome in most patients.

A study by Kang et al indicated that in pediatric patients with nasal fractures, the outcomes of early and delayed closed surgical reduction do not significantly differ. Of 51 patients who underwent early reduction (within 7 days of the injury), excellent results were found in 82%, and good results were seen in 18%. Of the 47 patients who underwent delayed reduction (more than 7 days post injury), the results were 83% and 17%, respectively.[2]

Opinions differ regarding the importance of the moderate septal deviation in the management of acute fractures. This may be due to the acknowledgment of the presence of some degree of deviation in many patients prior to injury. Debate also exists over the indications for open repair in the initial management. Recently, somewhat of a trend toward open reduction has occurred.