You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > TRAUMA Nasal and Septal FracturesArticle Last Updated: Dec 12, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Adam T Ross, MD, Director, Division of Facial Plastic and Reconstructive Surgery, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina Adam T Ross is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and South Carolina Medical Association Coauthor(s): Daniel G Becker, MD, Clinical Associate Professor, Department of Otorhinolaryngology-Head and Neck Surgery, Division of Facial Plastics and Reconstructive Surgery, University of Pennsylvania Editors: Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: nasal fractures, septal fractures, open fractures, closed fractures, nasal bone fractures, facial fractures, nasal trauma, nasal fractures, broken nose, nasal septum, fractured nasal septum, fractured nose INTRODUCTIONSection 2 of 12
  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. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Nose. FrequencyNasal 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. EtiologyMost commonly, nasal bone fractures are sustained in fights (34%), accidents (28%), and sports (23%). 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 children, nasal fractures are most commonly due to falls. The possibility of child abuse should be considered in every child presenting with a nasal fracture. PathophysiologyThe direction of force to the nose during injury determines the pattern of the fracture.
ClinicalClinical findings in patients with a history of trauma to the nose or face may include the following:
INDICATIONSSection 3 of 12
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.
RELEVANT ANATOMYSection 4 of 12
CONTRAINDICATIONSSection 5 of 12
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. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Medical therapyElevation 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 therapyNo 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. 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.1 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 eMedicine article Nasal Fracture Reduction. Preoperative detailsNasofrontal 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
Postoperative details
Follow-up
COMPLICATIONSSection 8 of 12
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.
Delayed complications
OUTCOME AND PROGNOSISSection 9 of 12
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. FUTURE AND CONTROVERSIESSection 10 of 12
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. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Nasal and Septal Fractures excerpt Article Last Updated: Dec 12, 2007 | |||||||||||||||||||||
