Nasal Fracture Surgery Treatment & Management

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.