Repair of Acute Nasal Fracture
Rami K. Batniji, M.D.*, Kamal A. Batniji, M.D., F.A.C.S.#
*Batniji Facial Plastic Surgery, 361 Hospital Road, Suite #329, Newport Beach, CA 92663. Attending, Department of Plastic Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA 92663.
#Chairman, Department of Otolaryngology-Head & Neck Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA 92663.
*corresponding author: Rami K. Batniji, M.D., 949.650.8882/949.650.2293 (facsimile)
The nasal bones are the most commonly fractured bones in the face. Acute nasal fracture may result in both nasal deformity as well as nasal airway obstruction. However, some controversy still surrounds the management of acute nasal fractures, in that a review of the literature demonstrates a lack of consensus with respect to the timing of repair of the acute nasal fracture, the anesthesia used during repair, and the type of procedure performed. Furthermore, post-reduction nasal deformities reportedly requiring subsequent rhinoplasty or septo-rhinoplasty range from 14-50%.
A thorough history of the mechanism of injury and a detailed physical examination provide the surgeon with information to adequately decide how to treat the acute nasal fracture, with special attention dedicated to the septum as improper reduction of the injured septum is the usual cause for the high incidence of post-reduction nasal deformities. In this chapter, we review the management of the acute nasal fracture.
Nasal bones are the most commonly fractured bones in the face. While reports estimate the annual incidence of nasal fractures in the United States as 52,000, the actual number may be higher for a variety of reasons, including the fact that severely traumatized patients with life-threatening injuries may concurrently present with nasal fractures which go unrecognized. The mechanism of injury is usually blunt trauma and can be attributed to assault, motor vehicle accidents, a fall, or a sports related injury. Previous nasal surgery may have an impact on the incidence of acute nasal fracture; a patient who undergoes rhinoplasty is at an increased risk of nasal fracture, particularly within the first year following the rhinoplasty procedure.
Nasal fractures in the pediatric population may be overlooked. The pediatric nose is mostly cartilaginous and the nasal bones are small; therefore, the pediatric nose is softer, more compliant and is therefore less likely to sustain displacement than the adult nose when fractured. Despite these attributes, pediatric nasal fractures do occur. A review of the pediatric facial fractures in the National Trauma Data Bank demonstrated a 30.2% incidence of nasal fractures in children and adolescent trauma patients (ages 0-18 years).iv The most common mechanisms of injury are motor vehicle collisions, violence, falls, and sports-related injuries. Another potential cause of nasal fracture in the pediatric population is birth trauma. Birth trauma, from intrauterine forces, breech delivery, or forceps-assisted delivery, may result in congenital deviation of the nasal septum.v Although these deviations can be treated easily, expeditiously, and usually without complication in the neonatal period, the identification of a deviated septum can be overlooked. The pediatric nose is very susceptible to septal hematoma following blunt trauma. Unfortunately, childhood nasal trauma is often underappreciated and nasal fracture and/or septal injury is overlooked, resulting in external and internal nasal deformities in adulthood.
Mechanism of Injury
Murray’s seminal work in detailing the pathophysiology of nasal bone fractures in fresh cadaver specimens provided valuable insight into the mechanism of injury for nasal trauma.vi Nasal fractures are most commonly due to a lateral force; this results in two fracture lines running parallel on the ipsilateral thin nasal bone along the dorsum meeting at the junction of the thick and thin bones. In this type of injury, the nose may appear deviated due to the depression of the unilateral bony fragment.
A frontal force must be of greater magnitude to produce a nasal fracture because the nasal bones are buttressed by the frontal process of the maxilla, the nasal spine, and the perpendicular plate of the ethmoid. The resultant injury includes not only a nasal bone fracture (which may be comminuted), but also a C-shaped fracture in the septum extending from just beneath the dorsum of the nose, inferiorly and posteriorly through the perpendicular plate of the ethomid and curving anteriorly to the inferior cartilaginous septum near the maxillary crest and the angle of the vomer. Frequently the inferior end of the septum becomes dislodged from its groove and is deflected obliquely into the nasal cavity.
As a result, the ala and nostril on the deflected side are widened, while the opposite side is flattened and narrowed. A high impact frontal force injury to the nose, such as that sustained during a motor vehicle collision may produce comminuted or compound nasal fractures. If a patient sustains this type of injury, one must rule out a nasal orbital ethmoid (NOE) complex fracture after the cervical spine, skull and ophthalmic injuries are cleared. Signs of NOE complex fractures include telecanthus, epiphora, periorbital emphysema, clear rhinorrhea secondary to cerebrospinal fluid leak, and a flattened nasofrontal root. Surgeons should have a low threshold for requesting a non-contrasted Computerized Tomography of the facial skeleton if the slightest clinical suspicion for an orbital or facial fracture arises. Further work-up and management of NOE injuries is beyond the scope of this chapter.
Identification of a nasal fracture is primarily a clinical diagnosis and plain radiographs are rarely, if ever, necessary. Patients may experience epistaxis, edema, ecchymosis, and nasal obstruction. Upon palpation, tenderness, crepitus and step-off deformities may be appreciated. An obvious deformity may be appreciated, such as a conspicuous concavity or convexity of the nasal bones resulting in a twisted nose appearance. In the acute setting, evidence of nasal deformity may be hidden secondary to the masquerading effects of edema.
Avulsion of the upper lateral cartilage attachments may also result in a concave appearance of the middle third of the nose. The cephalic portion of the upper lateral cartilage is attached to the caudal border of the nasal bone. The medial portion of the upper lateral cartilage is attached to the dorsal cartilaginous septum; this attachment constitutes the internal nasal valve and has been described as a 10-15 degree angle on intranasal examination.vii Placement of a cotton-tipped applicator in the region of the internal nasal valve with subsequent improvement in nasal airway obstruction confirms the diagnosis of internal nasal valve collapse. Closed reduction of the fractured nasal bone may re-approximate the avulsed upper lateral cartilage to the caudal border of the nasal bone. However, avulsion of the upper lateral cartilage from the dorsal cartilaginous septum may require placement of a spreader graft to address the concavity of the middle third of the nose as well as improve nasal function by reconstituting the internal nasal valve.viii
Intranasal examination should be performed after decongesting the nasal cavities. Topical oxymetazoline is effective and, when mixed with 4% topical lidocaine, can achieve both decongestion as well as anesthesia. Intranasal examination is performed to evaluate the status of the septum and identify mucosal injuries. If a bulge is appreciated along the septum, this may signify a septal hematoma. If a septal hematoma is suspected, a helpful maneuver is to palpate the intranasal bulge with a cotton-tipped applicator and, if it is compressible with a cotton-tipped applicator, a fine needle aspiration is performed and is diagnostic. In the pediatric patient, the nose tends to buckle and twist rather than fracture. As such, there is a higher incidence of separation of the perichondrium from the septal cartilage and subsequent potential for hematoma formation. Digital photography of the subsequent nasal deformity is obtained for the medical record.
Timing of Repair
Some controversy surrounds timing of repair for the acute nasal fracture. Edema follows shortly after the initial injury, making it difficult to allow for precise reduction. Therefore, it is best to institute conservative measures to minimize edema and allow for proper analysis of potential deformity three to five days after injury.ix These conservative measures include: soft diet, head of bed elevation, and the application of an ice compress to the area of injury. Definitive treatment can be carried out five to twelve days after the initial injury. During this period, the fractured components of the nasal bone can be easily manipulated. However, if definitive treatment is delayed beyond this time period, fibrosis may result in decreased mobility of the nasal bones making the closed reduction of the nasal bone fracture more challenging.
Another area of controversy in the management of the acute nasal fracture is the type of anesthesia administered during the surgical repair.x Local anesthesia with IV sedation, for instance, minimizes the potential risks of general anesthesia, such as nausea. General anesthesia, however, provides the benefit of a controlled airway as well as the opportunity for uncompromised nasal examination, reduction, and manipulation. Typically, topical vasoconstrictive agent such as Oxymetazoline or 4% liquid cocaine are applied to cottonoid pledgets and placed in the nasal passageway to minimize bleeding while a local anesthetic, such as 1% lidocaine with epinephrine (1:100,000) provides further anesthesia and vasoconstriction.
Several factors should be weighed when deciding between local or general anesthesia for the management of nasal fractures. The first consideration is the patient’s airway. If the surgeon anticipates significant bleeding following reduction of the nasal fracture, then the surgeon should consider the use of a short acting general anesthetic while the airway is secured and protected.
Another consideration is the severity of the nasal fracture as well as the presence of an associated septal fracture. Since one of the most common causes for persistent nasal deformity following closed reduction of a nasal fracture includes unrecognized septal fracture or inadequate reduction, the surgeon should consider the use of a short acting general anesthetic to properly address the causes of the nasal deformity.xi Pediatric patients should undergo reduction of the nasal fracture under general anesthesia since they are not able to comply with local anesthesia. Finally, patient comfort should also be considered when making this decision. While some patients may tolerate reduction of nasal fracture under local anesthesia, other patients may prefer a short acting general anesthetic.
Closed Reduction of Acute Nasal Bone Fracture
The authors prefer the use of the Boise elevator to perform closed reduction of acute nasal bone fractures. The Boise elevator is placed intranasally and the impacted nasal bone is reduced, thus restoring the nasal length. The thumb of the contralateral hand is placed over the nasal bone externally to palpate subtle osseous movements. If the impacted nasal bone is locked under the ascending process of the maxilla, the Boise elevator is used in an upward and outward motion to reduce the fractured nasal bone; the instrument must not be inserted too deeply, as it may rest under the nasal process of the frontal bone and will be of no value. An external splint is always utilized. Additionally, in an effort to minimize the possibility of repeat impaction of the recently reduced nasal bone, an internal nasal splint could also be used in the form of nasal packing. A small amount of absorbable packing (Gelfoam®, Pfizer) covered with antibiotic ointment strategically positioned intranasally along the medial aspect of the nasal bone usually suffices in maintaining the position of the reduced nasal bone; at the same time, this is well tolerated by the patient and does not require removal given its dissolvable nature. While a variety of dorsal nasal splints are available, the authors prefer the use of Aquaplast®. First, liquid adhesive (Mastisol®) is applied to the skin. Then, the soft tissues of the nose are taped using ¼ inch paper tape; taping begins at the supratip break to drape the soft tissue in this location intimately to the underlying skeleton. Strips of different lengths are then applied in a transverse fashion over the nose, avoiding excessive pressure. The Aquaplast® splint is then applied. The external dorsal splint remains in place for one week.
Repair of Septal Fracture
If the septum is deviated, it can be reduced with either an Asch forceps or the Boise elevator to relocate the displaced base to the midline. Following this, the septum should be re-evaluated to ensure that proper reduction is achieved. If the septum remains posteriorly displaced or irreducible, then the authors proceed with an open approach to the septum via a hemitransfixion incision. Once bilateral mucoperichondrial flaps are elevated, complete visualization of the septum provides the opportunity to properly identify the extent of the septal injury. In the authors’ experience, a small hematoma may be identified at the bony-cartilaginous junction; this is evacuated with suction. If the inferior aspect of the quadrangular cartilage remains dislodged from the vomerine groove, an inferior strip of quandrangular cartilage can be resected, the septum can be re-positioned into the vomerine groove in a swinging door fashion, and a figure of eight suture with 5-0 Monocryl can be used to keep the posterior caudal septum attached to the anterior septal spine in the midline. Once the hemitransifixion incision is re-approximated using interrupted 5-0 plain gut sutures, internal nasal septal splints are placed. Silicone septal splints are favored to ensure atraumatic placement and removal. Prophylactic gram-positive antibiotic coverage (typically cephalexin) is prescribed following surgical repair and is continued until the silicone splints are removed on postoperative day seven.
In the literature, some authors advocate an open approach to the nasal pyramid at the time of initial repair utilizing accepted rhinoplasty techniques, including rasping, osteotomies, and cartilaginous resection or augmentation of the dorsum.xii However, due to the numerous existing variables involved in an acute nasal fracture such as irregularity and/or comminution, the nasal bones may not be easily controlled via the external approach. Also, the healing process and unavoidable fibrosis following surgical repair of the acute nasal fracture may cause shifts in the nasal structures. Ultimately, the absence of a detailed and elective preoperative consultation with the inherent imposition of a time-pressured decision for surgery may generate a series of expectations and obscure the transparency required in the patient’s personal decision to go through an elective aesthetic procedure. Therefore, for patients with acute nasal fractures who are interested in cosmetic septorhinoplasty, it behooves both the surgeon and patient to consider delaying treatment for at least a few months for selected cases. However, it is clear that changes will continue to evolve until approximately one year after any given traumatic injury. xiii
Repair of the Pediatric Nasal Fracture
While it is unclear whether disruption of the human pediatric septal growth center affects the development of the nose, there is clear evidence to support the importance of such growth centers in animal models.xiv Therefore closed reduction is the preferred method of treatment of acute nasal fracture in the pediatric population. In order to facilitate a thorough examination and complete reduction, general anesthesia is used for the pediatric patient. The technique for closed reduction is similar to that previously described. However, there are a few caveats. For example, internal splinting is typically performed with light absorbable packing such as Gelfoam®, thus obviating the need for removal during the postoperative period. Finally, the guardians of the pediatric patient should be properly counseled with respect to the possibility of the child developing delayed nasal deviation and obstruction and may, therefore be informed of the possibility of a formal septorhinoplasty in the future.
Potential complications following repair of the acute nasal fracture include, among other possibilities, epistaxis and septal hematoma. Epistaxis is usually self-limiting; however, if persistent, Oxymetazoline nasal spray, head of bed elevation, and application of cold compress can be utilized to decrease or stop bleeding. If a septal hematoma is appreciated in the post-operative period, it is dealt with in a manner similar to that described earlier in this chapter. Post-traumatic nasal deformity following reduction efforts is another potential complication. A review of the medical literature demonstrates this complication ranges from 14-50%.xv Further analysis of this data suggests the possible reason for such a high complication rate is the use of closed techniques to repair the fractured nasal bone, failing to address septal injuries. Indeed, Rohrich and Adams demonstrated a much smaller rate of 9% for post-traumatic nasal deformity following reduction efforts when the septum is properly evaluated and open treatment of the septum is performed when indicated.
A detailed history, including the mechanism of injury and a thorough physical examination provide important information in the treatment of acute nasal fractures. Soft tissue edema, which inevitably accompanies acute nasal fractures, may limit the physical examination, therefore the decision for definitive therapy should be delayed until the edema has resolved and any underlying acquired nasal deformity can be fully appreciated. It is important to identify and treat septal hematoma early in the process. Definitive treatment should not be delayed beyond two weeks as fibrosis will settles in making mobilization of the fractured nasal bones more difficult. While there are different of methods to reduce and treat acute nasal fractures, it is important not to overlook the septum addressing any existing deviations or fractures at the same time as the fractured nasal bones in order to minimize the incidence of post-reduction nasal deformities requiring subsequent surgical interventions.
Perkins SW, Dayan SH. Management of nasal trauma. Aesthetic Plast Surg 26 Suppl 1:S3, 2002.
Erdman D, Fllmar KE, Debruijin M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 60(4): 398-403, 2008.
Guyuron B. Does rhinoplasty make the nose more susceptible to fracture? Plast Reconstr Surg 93(2):313-7, 1994.
Imahara SD, Hopper RA, Wang J, et al. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg 207(5):710-6, 2008.
Hughes CA, Harley EH, Milmore G, et al. Birth trauma in the head and neck. Arch Otolaryngol Head Neck Surg 125(2):193-9, 1999.
Murray JA, Maran AG, Busuttil A, et al. A pathological classification of nasal fractures. Injury 17(5):338-44, 1986.
Ridder GJ, Boedeker CC, Fradis M, et al. Technique and timing for closed reduction of isolated nasal fractures: a retrospective study. Ear Nose Throat J 81(1): 49-54, 2002.
Rohrich RJ, Adams WP. Nasal fracture management: minimized secondary nasal deformities. Plast Reconstr Surg 106(2):266-73, 2000.
Khwaja S, Pahade AV, Luff D, et al. Nasal fracture reduction: local versus general anesthesia. Rhinology 45(1):838, 2007.
Renner GJ. Management of nasal fractures. Otolaryngol Clin North Am 24(1):195-213, 1991.
Reilly MJ, Davison SP. Open vs closed approach to the nasal pyramid for fracture reduction. Arch Facial Plast Surg 9(2):82-6, 2007.
Sarnat BG. Normal and abnormal growth at the nasoseptovomeral region. Ann Otol Rhinol Laryngol 100(6):508-515, 1991.
Rohrich RJ, Adams WP: Acute nasal fracture management: minimizing secondary deformities. In: Gunter JP, Rohrich RJ, Adams WP (eds.) Dallas Rhinoplasty. St. Louis: Quality Medical Publishing, 2007, pp. 957-971.
i Perkins SW, Dayan SH. Management of nasal trauma. Aesthetic Plast Surg 26 Suppl 1:S3, 2002.
ii Erdman D, Fllmar KE, Debruijin M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 60(4): 398-403, 2008.
iii Guyuron B. Does rhinoplasty make the nose more susceptible to fracture? Plast Reconstr Surg 93(2):313-7, 1994.
iv Imahara SD, Hopper RA, Wang J, et al. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg 207(5):710-6, 2008.
v Hughes CA, Harley EH, Milmore G, et al. Birth trauma in the head and neck. Arch Otolaryngol Head Neck Surg 125(2):193-9, 1999.
vi Murray JA, Maran AG, Busuttil A, et al. A pathological classification of nasal fractures. Injury 17(5):338-44, 1986.
vii Teichgraeber JF, Wainwright DJ. The treatment of nasal valve obstruction. Plast Reconstr Surg 93:1174-1182, 1994.
viii Fischer H, Gubisch W. Nasal valves: importance and surgical procedures. Facial Plast Surg 22:266-280, 2006.
ix Ridder GJ, Boedeker CC, Fradis M, et al. Technique and timing for closed reduction of isolated nasal fractures: a retrospective study. Ear Nose Throat J 81(1): 49-54, 2002.
x Khwaja S, Pahade AV, Luff D, et al. Nasal fracture reduction: local versus general anesthesia. Rhinology 45(1):838, 2007.
xi Rohrich RJ, Adams WP. Nasal fracture management: minimized secondary nasal deformities. Plast Reconstr Surg 106(2):266-73, 2000.
xi iReilly MJ, Davison SP. Open vs closed approach to the nasal pyramid for fracture reduction. Arch Facial Plast Surg 9(2):82-6, 2007.
xiii Renner GJ. Management of nasal fractures. Otolaryngol Clin North Am 24(1):195-213, 1991.
xiv Sarnat BG. Normal and abnormal growth at the nasoseptovomeral region. Ann Otol Rhinol Laryngol 100(6):508-515, 1991.
xv Rohrich RJ, Adams WP: Acute nasal fracture management: minimizing secondary deformities. In: Gunter JP, Rohrich RJ, Adams WP (eds.) Dallas Rhinoplasty. St. Louis: Quality Medical Publishing, 2007, pp. 957-971.