Nasal and Septal Fractures 

Updated: Jul 30, 2018
Author: Daniel G Becker, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Nasal fractures are the most common types of facial fractures; however, they are often unrecognized and untreated at the time of injury. Its central position and anterior projection on the face predisposes the nose to traumatic injury. Studies have shown that most nasal fractures involve the septum, which can be an obstacle to successful reduction.

Fractures can be classified as open or closed, depending on the integrity of the mucosa. Prompt identification and management of the injury in the early postinjury period is imperative to avoid the potential complications of nasal and septal fractures. Confirming that septal hematoma is not present is crucial to avoid further compressive damage to native tissue and dangerous infectious complications. Longer-term follow-up allows the surgeon to assess for both early and late sequelae of injuries to the nasal complex. Surgical intervention may be appropriate in the early postfracture period or much later, after the fracture has healed.[1]

For excellent patient education resources, see eMedicineHealth's patient education article Broken Nose.

An oblique view of nasal fractures is depicted below.

Oblique view. Oblique view.

Epidemiology

Frequency

Nasal fractures are the third most common types of fractures, behind fractures of the clavicle and wrist. Nasal fractures are often cited as the most common type of facial fracture, accounting for approximately half of all facial fractures in several studies. Zygomatic (22%), blowout (12%), mandibular bone (8%), and maxillary bone (9%) fractures follow in frequency.

Etiology

Most commonly, nasal bone fractures are sustained in fights (34%), accidents (28%), and sports (23%). A 2009 study of 236 patients with facial fractures incurred while playing sports determined that fractures of the nasal bone were most common.[2]

With increasing use of air bags in automobiles, a shift in the mechanism of injury and the type of nasal fractures has occurred; therefore, the incidence of septal injury in nasal fractures, without concurrent nasal bone fracture, has increased.

In a study of 2023 adults with facial fracture, including 209 patients over age 64 years, Atisha et al determined that nasal fractures were more common in elderly persons than in nonelderly ones (54.1% vs 45.3%, respectively).[3]

In children, nasal fractures are most commonly due to falls. In a study of 100 children with traumatic nasal deformity, Liu et al determined that such injuries were most often the result of sports-related trauma (28%), with accidental trauma (21%), interpersonal violence (10%), motor vehicle collisions (6%), and alcohol-related trauma (2%) being the next most common reasons for injury.[4] The possibility of child abuse should be considered in every child presenting with a nasal fracture.

Pathophysiology

The direction of force to the nose during injury determines the pattern of the fracture.

  • Frontal force causes damage ranging from simple fracture of the nasal bones to flattening of the entire nose.

  • Lateral force may depress only one nasal bone; however, with sufficient force, both bones may be displaced. Lateral force can cause severe septal displacement, which can twist or buckle the nose. Septal fragments may interlock, creating further difficulty in reduction.

  • Superior-directed force (from below) rarely occurs. It may cause severe septal fractures and dislocation of the quadrangular cartilage.

Presentation

Clinical findings in patients with a history of trauma to the nose or face may include the following[5] :

  • Epistaxis, which is common in nasal fractures due to mucosal disruption

  • Change in nasal appearance

  • Nasal airway obstruction

  • Infraorbital ecchymosis

Indications

Indications for repair of nasal fractures include abnormal nasal function, abnormal appearance, and presence of early postinjury complications. Several methods of reduction and repair can be performed to achieve good cosmetic and functional results.

  • Closed reduction may be performed under local anesthesia or local anesthesia with mild sedation. Indications include the following[6] :

    • Simple fracture of nasal bones

    • Simple fracture of nasal-septal complex

  • Open reduction requires deeper sedation or a general anesthetic. Indications include the following:

    • Extensive fracture-dislocation of nasal bones and septum

    • Fracture dislocation of caudal septum

    • Open septal fractures

    • Persistent deformity after closed reduction

    • Relative indications, eg, septal hematoma, inadequate bony reduction due to septal deformity, cartilaginous deformities, displaced nasal spine, and recent intranasal surgery

Relevant Anatomy

See the list below:

  • Nasal skin has an abundant blood supply and tends to be thinner over the rhinion and thicker over the nasion. Nasal skin thickness varies among individuals.

  • The nasal pyramid is composed of 2 nasal bones and the frontal process of the maxilla. The thickness of the bones decreases toward the tip of the nose; as a result, most fractures occur in the lower half.

  • Upper lateral cartilages form the middle nasal vault. Upper lateral cartilages are attached to the nasal bones superiorly, the quadrangular cartilage of the septum medially, and the lower lateral cartilages (ie, tip cartilages) inferiorly.

  • The images below depict the oblique and lateral view of the nasal anatomy.

    Oblique view. Oblique view.
    Lateral view. Lateral view.
  • Sesamoid cartilages are less important and lie in the fat pad between lower lateral cartilages and the piriform aperture.

  • The nasal septum (as seen in the image below) has a cartilaginous and bony component that is lined with mucoperichondrium and mucoperiosteum, from which the cartilage and bone receive their blood supply. Interruption of the opposition of perichondrium to cartilage (as with septal hematoma) may interrupt the blood supply and lead to resorption of septal cartilage and possibly subsequent saddle-nose deformity.

    Nasal septum. Nasal septum.

Contraindications

Some fractures do not need correction, providing the patient is satisfied with the appearance and function of the nose. In more severe injuries, one must entertain the option of deferring a nasal procedure until the patient has become stabilized.

 

Workup

Imaging Studies

See the list below:

  • The use of radiography is controversial. Old fractures, vascular markings, and suture lines can lead to false-positive results. A Water's view can be used to evaluate the bony septum, dorsal pyramid, and lateral nasal walls. However, studies have shown that radiographs are not helpful in the diagnosis or management of nasal fractures.[7]

  • CT is more useful to assess for other associated injuries, as well as extent of nasal injury. Septal fractures may be more obviously depicted on these films. Because the nose occupies such a prominent and accessible position, careful examination is possible and may obviate any need for radiographic study.

  • Photographs are useful and necessary for documentation and for comparison with preinjury photos. Photographs should include the standard angles used in facial analysis: frontal, left and right lateral, left and right oblique, base view, and often a bird's eye or partial base view. A smiling lateral view can also be helpful to evaluate depressor septae nasalis function. While 35-mm film and cameras still allow a superior resolution, digital photography is quickly becoming more prevalent.

 

Treatment

Medical Therapy

Elevation of the head and use of cold compresses in the periorbital and nasal region can be helpful while waiting for edema to subside. Even in the presence of significant edema, a nasal deformity often may be obvious. In a patient with no apparent abnormality at the initial visit, reassessment of the nose after the edema subsides may reveal findings necessitating repair. Surgical intervention may then be undertaken.

Surgical Therapy

No clear recommendation exists regarding the type of surgical approach or the timing of surgery in patients with nasal fractures. Standard therapy instructs the surgeon to perform closed or open reduction between 3 and 7 days, and up to 2 weeks, depending on which source is consulted. The potential for optimal results lies in the reduction of the fracture within the first several hours following the injury before significant edema has appeared. If this window has passed, subsequent reassessment of the injury is advisable, with correction planned between 4-7 days following the injury.

Studies have shown that as the significance of the nasal deviation increases, successful reduction of the nasal fracture becomes more difficult. Recent literature indicates a significant dissatisfaction with closed reduction results, suggesting that open approaches may reduce the need for future revision procedures. Clearly, each fracture and patient must be individually assessed, and proper clinical judgment must be applied to achieve overall patient satisfaction. A further delayed approach can be taken if the fracture is first identified after significant bony healing has occurred. Waiting at least 3-6 months to perform surgery allows fractures to stabilize and wounds to heal.

Most surgeons agree that closed reduction is often an imperfect solution to restore the nose to its preinjury condition. However, note that the satisfaction of the surgeon and the satisfaction of the patient are generally discordant.[8] That is, patient satisfaction after closed reduction is significantly higher than that of the surgeon. If the patient is made aware of this issue, a decision can be made as to whether to defer surgery or to proceed with an attempt at reduction; the procedure results in improvement, but the results are not perfect.

For further reading, please see the Medscape Reference article Nasal Fracture Reduction.

Preoperative Details

Nasofrontal and ethmoid fractures must be ruled out because these may require other types of surgical intervention. Injury to the nasofrontal duct, cribriform plate, or medial canthal ligaments must be recognized.

Dorsal nasal reconstruction with rib graft or calvarial bone grafts is necessary in patients with severe nasal injuries, significant saddle-nose deformity, loss of dorsal projection, and shortened nasal length; the reconstruction must be discussed with the patient.

Intraoperative Details

See the list below:

  • An approach to closed reduction

    • Anesthetize the nose first by using a topical anesthetic (eg, cocaine, Pontocaine), followed by injections of lidocaine (1:100,000 epinephrine) at the base of the anterior septum and along the nasal dorsum, lateral and medial to the nasal pyramid.

    • Using Boies, Ballenger, Sayer, or another appropriate elevator, elevate the depressed fragment by using force opposite to that which caused the injury (usually pulling anterolaterally).

    • Reduction of the nasal bones may also affect the correction of existing acute septal deformity; if this reduction does not occur, Asch forceps or other appropriate instrumentation can be used to manipulate the septum.

    • Reduce all injuries before repairing lacerations.

    • Stabilize the fracture. An external nasal splint may be sufficient, but silastic splints or intranasal packing may also be needed.

  • An approach to open reduction

    • Using traditional septoplasty and rhinoplasty techniques, approach, assess, and reduce the septum and nasal structures through appropriate incisions when necessary.

    • Pack and splint as in closed reduction.

Postoperative Details

Points to remember include the following:

  • Splints and packs may be left in place for 7-10 days when necessary

  • Typically, simple closed or open reduction requires no packing

  • Patients with packs should continue taking antibiotics to avoid toxic shock

  • The use of cold compresses for 1-2 days reduces edema and discomfort

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).[9]

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.[9]

Follow-up

See the list below:

  • Treat nasal crusting, remove splints and packing, and carefully reassess the cosmetic result as routine postoperative care.

  • Assess airway patency.

  • Assess the need for further intervention (eg, septorhinoplasty).

Complications

Complications from nasal fractures include cosmetic deformity and airway obstruction. Problems arising from nasal fracture complications may be mitigated by adequately recognizing and treating the injury at the time it occurs.

  • Hematoma (may require drainage to avoid septal necrosis and superinfection that exacerbates septal deterioration)

  • Unremitting epistaxis

  • CSF rhinorrhea

Delayed complications

See the list below:

  • Airway obstruction

  • Scar contracture

  • Nasal deformity

  • Saddle-nose deformity (due to injury or ischemic necrosis of nasal septum secondary to hematoma formation, followed by loss of dorsal nasal support)

  • Septal perforation

Outcome and Prognosis

The treatment of nasal and septal fractures must be instituted only after a thorough evaluation and an accurate assessment of the severity of injury. Patients should expect to have an excellent recovery of nasal respiration as well as cosmetic restoration, but they should be warned that injuries to the nose alter the anatomy permanently. Therefore, one should hope for, but not expect, a complete return to the prior state.

A retrospective study by Li et al indicated that in patients treated for isolated nasal fracture, the likelihood for subsequent septorhinoplasty is greater in patients who, having had no preexisting diagnosis of nasal obstruction or defect, underwent open treatment within 3 weeks postfracture (adjusted odds ratio [aOR], 1.76) or between 3 weeks and 6 months following a fracture (aOR, 1.52). In cases of a preexisting nasal obstruction or defect, the study suggested that the need for subsequent septorhinoplasty is greater in patients who underwent closed reduction, in those in whom open treatment was administered within 3 weeks postfracture, and, especially, in patients who had been treated with observation. A higher likelihood for subsequent septorhinoplasty was also seen in patients younger than age 65 years (particularly in those aged 18-34 years), in urban area residents, and in patients with a history of anxiety.[10]

Future and Controversies

The future of the management of nasal and septal fractures involves a better assessment of diagnostic and reparative techniques. At present, clinical judgment guides the physician in the selection of radiographs; whether any radiographs are of practical benefit in the management of nasal fractures is controversial. Although recent studies seem to indicate less of a need for revision after using open approaches to nasal fractures, further studies involving multiple surgeons and larger patient populations are still needed. The role of antibiotic prophylactic treatment is unclear. Resolving these issues may help to reduce cosmetic and functional complications of nasal and septal fractures.