Nasal and Septal Fractures Treatment & Management

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.

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. The 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. ^[12] 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.

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.

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.

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). ^[13]

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. ^[13]

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 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

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. ^[14]

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.