Open Treatment of Nasal Fractures
Jeyhan S. Wood
DEFINITION
Open treatment of nasal fractures involves making an incision to provide direct visualization of the fractures and achieve reduction or use of lacerations that are already present.
The nose sits prominently on the central face and as such is the most commonly fractured facial bone, compromising up to 50% of all facial fractures1:
Nasal bone fractures can occur in isolation or be associated with other facial fractures, such as those of the orbits, frontal bone, or midface.
ANATOMY
Nasal anatomy is complex, made up of the bony vault, cartilaginous vault (paired upper lateral and lower lateral cartilages), bony septum, and cartilaginous septum (FIG 1):
The nasal bones decrease in thickness caudally; therefore, most fractures occur in the lower half of the bone.2
The “keystone area,” made up of the caudal aspect of the nasal bones, the cranial aspect of the upper lateral cartilages, the perpendicular plate of the ethmoid, and the cartilaginous septum, maintains support for the nasal dorsum (FIG 1A).
The nose receives its rich blood supply from branches of both the external and internal carotid arteries. Because of this, nasal fractures are almost always associated with epistaxis, which most often stems from the Kiesselbach plexus of the anteroinferior septum.2
Fractures can involve any of the above structures and in any combination, leading to obvious external deformity and/or functional compromise with difficulty breathing.
PATHOGENESIS
Nasal fractures are most often the result of motor vehicle accidents, falls, altercations, and sports injuries.1,3
Nasal fractures are most often seen in males 15 to 30 years of age.
There is no single consensus for nasal fracture classification; however, nasal fractures are often classified as lateral oblique vs frontal per the Stranc classification.1,3 Higuera et al. have more recently proposed a clinical classification system based on soft tissue vs bony injury, unilateral vs bilateral involvement, and simple vs comminuted fractures.2
 FIG 1 • AP (A) and lateral (B) view of nasal anatomy. ULC, upper laberal cartilage; LLC, lower lateral cartilage. |
NATURAL HISTORY
Patients with untreated nasal fractures may experience an undesirable appearance, chronic nasal obstruction, and chronic sinusitis. This is especially true if a septal injury is not adequately addressed.2
With septal trauma, blood can accumulate between the mucosa and cartilage of the septum (septal hematoma), which if left undrained can eventually lead to fibrosis and resorption of the septal cartilage. This is demonstrated clinically as a saddle nose deformity.
PATIENT HISTORY AND PHYSICAL FINDINGS
Patient history:
Assess the mechanism of injury (including the vector and magnitude of the force),2 timing of injury, and preoperative state regarding the ability to breath out of each nostril.
Does the patient complain of a different appearance of the nose?
Does the patient have a history of previous nasal trauma or nasal surgery?
For significant maxillofacial trauma, the patient may need a complete trauma workup and appropriate precautions taken (cervical spine immobilization).
Consider reviewing a photograph of the patient, such as a driver’s license, to determine the patient’s premorbid appearance.2
Physical examination:
Perform an external exam looking for obvious nasal deformity (note caudal and dorsal deformity),4 tenderness, epistaxis, edema, periorbital ecchymoses, instability of nasal bones on palpation, step-offs, and crepitus:
Depending on the timing of presentation, obvious deformity may be masked by edema.
Note any lacerations or canthal disruption, which would indicate a naso-orbital-ethmoid (NOE) fracture.
Perform an intranasal examination with a nasal speculum and adequate light source, evaluating for septal hematoma, mucosal injury, septal deviation, airway obstruction, and clear rhinorrhea, which could be a sign of a cerebrospinal fluid (CSF) leak. Internal exam may be facilitated by using a topical decongestant.
Assess for other facial fractures and consider nasolacrimal duct injury if the medial orbit is injured.
Assess for uncontrollable hemorrhage. Nasal fractures may cause significant bleeding, which usually stops with manual pressure. However, persistent epistaxis may require nasal packing with Vaseline gauze or a Pope pack for anterior bleeds or intranasal placement of a Foley catheter for posterior bleeds:
If bleeding is uncontrollable with these measures, consider interventional radiology for embolization.
If the patient is unstable without other obvious sources of hemorrhage, consider ligation of the external carotid artery.
IMAGING
Imaging for isolated nasal fractures is often not indicated, as treatment is based on physical exam findings.
Plain films miss cartilaginous injury and often cannot clearly identify bony injury, with one study finding only 82% of nasal fractures successfully identified on plain film5:
Waters view (occipitomental) (FIG 2A) and lateral nasal views (FIG 2B) are the plain film examinations of choice, with demonstration of the orbits, maxillae, zygomatic arches, and the nasal pyramid, sidewalls, and septum.
If nasal bones are found to be displaced on x-ray, then those patients are at higher risk for long-term nasal deformity, and reduction is highly recommended.4
The internasal suture, nasomaxillary suture, and even the coronal suture can be mistaken for fractures on plain film.
Computed tomography (CT) with or without 3D reconstruction has largely replaced all other modalities as far as clinical use (FIG 2C,D):
For maxillofacial CT scans, three views are ideal (axial, coronal, and sagittal) for complete evaluation of the facial skeleton.
DIFFERENTIAL DIAGNOSIS
Nasal bone fracture/dislocation
Cartilage injury
Septal fracture/dislocation
Contusion
NONOPERATIVE MANAGEMENT
Indications:
Nondisplaced or minimally displaced fractures.
The patient desires no intervention.
Options for conservative treatment:
A splint for external protection
Elevation of the head of the bed to decrease edema
Ice application
Nasal saline irrigation and/or Afrin (oxymetazoline) for nasal congestion
Intranasal packing for epistaxis as needed
SURGICAL MANAGEMENT
Indications include severely displaced fractures and/or dislocations of the nasal bones and/or cartilaginous vault (more than half the bridge width of the nose), fracture/dislocation of the caudal septum, open septal fracture, persistent deformity after attempted closed reduction,3 nasal fracture with substantial soft tissue injury,2 or those with a delayed presentation (over 2 weeks since the injury):
If presenting more than 2 weeks after the initial injury, consider delaying open approach approximately 3 months to allow resolution of edema and healing of fractures.
Some surgeons advocate open reduction as soon as the early edema has resolved.2
It is important for patients to have realistic expectations of outcomes. Discuss operative goals: fracture reduction and establishment of premorbid form and function vs altering the appearance of the nose with a cosmetic rhinoplasty.
Discussion should also address the possible need for future nasal procedures.4Related posts:
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