Nasal Fracture Surgery

Nasal fractures are the most prevalent type of facial fracture, with the nasal bone also being the third most commonly broken bone in the body. ^[1] Despite the frequency of their occurrence, nasal fractures are often undertreated. As a consequence, significant long-term functional and cosmetic problems may result. Treatment of long-term complications after significant injury is difficult.

For patient education resources, see the Back, Ribs, Neck, and Head Center and Breaks, Fractures, and Dislocations Center, as well as Broken Nose and Facial Fracture.

In 1947, Maliniac published a classic description of the treatment of nasal fractures. Since then, considerable controversy has existed regarding the optimum treatment of nasal fractures. The debate concerns timing of repair, ^[2] open versus closed reduction, and specific techniques. In recent years, the trend has been toward open reduction and repair.

Nasal fractures occur in a great number of patterns. The complex 3-dimensional anatomy of the nasal bones, upper and lower lateral cartilages, and bony and cartilaginous septum underscores the importance of a precise assessment of the specific injury to maximize the results of treatment. Blunt trauma may occur anteriorly or laterally, and the resulting pattern of fractures reflects this direction of force. Optimum management is particularly important because of the unique forces of contraction that occur on this complex 3-dimensional structure over the ensuing months following injury. External nasal deformities and significant airway obstruction occur in a significant number of patients, and their presentation may be delayed by as many as several months.

Blunt trauma is the most common cause of nasal fractures. ^[1] Automobile accidents, altercations, and falls account for approximately 85% of nasal fractures. A study by Liu et al of 100 cases of pediatric nasal deformity from an urban, tertiary pediatric otolaryngology practice found sports-related trauma to be the most common injury mechanism (28%), with the next most common mechanisms being accidental trauma (21%), interpersonal violence (10%), motor vehicle collision (6%), and alcohol-related trauma (2%). ^[3]

For more information on the treatment of all kinds of trauma, visit Medscape’s Trauma Resource Center.

The pattern of nasal fractures varies depending on the direction of force applied. Force applied from a frontal direction may cause an injury as simple as the infracture of the lower margin of the nasal bones (which are thinner than the heavier, upper portion) or a severe flattening of the nasal bones and septum. (Nasoethmoid complex fractures are discussed in the article Facial Trauma, Nasoethmoid Fractures.) Splaying of the nasal bones with widening of the nasal width may occur.

Lateral forces may cause only a depression of the ipsilateral nasal bone or may also be forceful enough to outfracture the contralateral nasal bone. When twisting or buckling of the nose is present, the fractured bony and/or cartilaginous fragments are often interlocked. This is important to identify because achieving an adequate result with a closed technique is likely impossible in such a situation. The septum is often fractured and may be dislocated off the maxillary crest. Proper reduction of the septum is critical to obtaining optimum results. The fracture pattern of the septum varies according to the location of the fracture. Anterior fractures tend to be vertical, while posterior fractures are usually horizontal in orientation.

Forces from below may cause a third pattern of fractures. In these instances, the septum in particular is fractured and dislocated. The quadrangular cartilage is often dislocated from the crest of the maxilla.

The history should note the mechanism of injury. The patient may note the immediate change in nasal appearance that accompanies a significantly displaced nasal fracture. Epistaxis may indicate the presence of a fracture.

The nose must be inspected both internally and externally. Adequate anesthesia, decongestion, lighting, suction, and, preferably, endoscopic equipment are imperative to examine the internal nose. Lacerations, ecchymosis, hematomas, mucosal tears, and epistaxis internally strongly suggest fracture. Septal hematomas require prompt diagnosis and treatment with drainage and packing to prevent subsequent complications such as cartilage necrosis and resultant saddle nose deformity. The septum may be displaced off the maxillary crest. Externally, ecchymosis is often observed. If a significant amount of edema has not yet occurred, the displacement of the bone and cartilage may be apparent. A stepoff may be palpated. Nasal fractures are frequently accompanied by lid edema, periorbital ecchymosis, chemosis, and subconjunctival hemorrhage.

Pseudotelecanthus may be noted. Telecanthus noted during the physical examination is an indication of a more severe telescoping naso-orbito-ethmoid complex fracture, and further workup (including CT scanning) with more extensive reconstruction is required.

The initial evaluation may be compromised by the amount of edema present. In such cases, once other injuries have been excluded and if the patient is stable and does not require immediate intervention (eg, for epistaxis or septal hematoma), then the physical examination may be repeated in 3-5 days. Photographs of the patient taken preinjury are helpful. Some nasal deformities may have been present prior to the current injury.

Click here to complete a Medscape CME activity on physical examination of the ears, nose, and oral cavity in older patients.

Reduction of a nasal fracture is indicated in any patient with a significant cosmetic deformity or functional compromise. The best time for reduction may be within the first 3 hours following injury. Otherwise, most believe that waiting 3-7 days is preferable. This allows edema to resolve, and positioning the bones correctly with more stability may be easier because inflammation and fibrosis may make the fragments less mobile by this time. If reduction is not possible within the first 7-10 days, then the fractured segments begin forming a fibrous union. This may make manipulation quite difficult. In this scenario, in which the fractured segments are no longer mobile, many surgeons advocate delaying treatment (up to several months) to allow for full healing prior to performing corrective rhinoplasty in which osteotomies are necessary. This may enable a more predictable rhinoplasty (particularly the osteotomies) at that time.

Indications for closed reduction are as follows:

• Unilateral or bilateral fracture of the nasal bones

• Fracture of the nasal septal complex that is deviated less than one half of the width of the nasal bridge

Indications for open reduction are as follows:

• Extensive fractures

• Deviation of the nasal pyramid greater than one half of the width of the nasal bridge ^[4]

• Displaced fracture of the caudal septum

• Open septal fracture

• Persistent deformity after closed reduction

The bony nasal pyramid consists of the paired nasal bones and the frontal process of the maxilla bilaterally. The nasal bones are thick superiorly at the attachment to the frontal bone and thin inferiorly at the point where they attach to the upper lateral cartilages. They are more susceptible to fracture in this region. Fractures of the nasal bone account for 40% of all facial fractures.

The upper lateral cartilages insert on the undersurface of the nasal bones and are important determinants of nasal appearance. Trauma to this complex can result in internal collapse of the upper lateral cartilages. The upper lateral cartilages articulate with the lower lateral cartilages. This articulation defines the region of the nasal valve, critical to nasal airflow dynamics. The paired lower lateral cartilages define the contour of the tip and the shape of the nostrils, and they provide much of the tip support.

The nasal septum includes the quadrangular cartilage anteriorly, the vomer inferiorly, and the perpendicular plate of the ethmoid posteriorly. Fractures may result in displacement of the bony and cartilaginous septum. These fragments can become interlocked, which is difficult to reduce in a closed technique.

Blood supply

The ophthalmic artery branches off of the internal carotid artery, which subsequently subdivides into the anterior and posterior ethmoidal artery and dorsal nasal artery. Facial and internal maxillary branches off of external carotid artery.

Nerve supply

The internal nose is supplied by the ethmoidal nerve, the sphenoidal nerve, and the nasopalatine nerve. The external nose is supplied by the anterior ethmoid nerve, the supratrochlear nerve, and the infraorbital nerve.

Many cases of nasal fracture do not require treatment when the fragments are not displaced. In cases of severe nasoethmoid complex fractures, simple reduction of the nasal fracture is contraindicated. ^[5] This does not adequately address the patient's injury and may precipitate or worsen a cerebrospinal fluid (CSF) leak.