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NASAL BONE FRACTURES

Overview
The most common facial fracture is a nasal bone fracture making these a frequent consult from the primary care as well as the emergency department setting. These fractures vary from subtle and incidentally found on CT to disfiguring with significant underlying septal fractures or skull base fractures and are commonly associated with concomitant facial fractures or lacerations that may be the primary presenting concern. Therefore, the acute management of nasal bone fractures is triaged according to priority when considering other potentially more urgent injuries the patient has sustained. Potential long-term effects of untreated nasal fractures include nasal obstruction, nasal deformity, chronic sinusitis, septal perforation and midface and nasal growth retardation in pediatric patients. The risk of these poor outcomes can be mitigated by appropriate treatment. The septum must be evaluated in all patients to rule out a septal fracture and/or septal hematoma. If left untreated, cosmetic and functional sequelae of an untreated hematoma including septal abscess, perforation, and saddle nose deformity. If a patient presents immediately following injury and before significant facial swelling (typically within 2-4 hours) it is possible to set the fracture immediately. However, more commonly swelling is present that complicates both the pre and post-reduction evaluation making it advisable to delay approximately 7 days. While closed reduction is most common, open reduction will be required in some patients with complicating factors such as bilateral fractures with severe displacement and comminution, complex septal involvement, or dislocation or disruption of the upper lateral cartilage or scroll area. Open reduction in appropriately selected patients decreases the likelihood of requiring a rhinoplasty in the future by allowing better visualization and appropriate management of cartilaginous injuries. Following reduction, proper splinting and care must be taken by the provider and patient to maintain the reduction and optimize the outcome. 

Management 

  • Complete history including mechanism of injury and past medical history

  • Comprehensive head and neck exam with attention to possible additional injuries; always palpate orbital rims and midface as high association with orbital and ZMC fractures

  • Exam should include anterior rhinoscopy and manual palpation of the septum to rule out septal hematoma

  • Urgently drain septal hematoma if present

    • After injecting 1% Lidocaine with 1:100,000 epinephrine to septum just caudally to the hematoma, make caudal septal incision through mucosa and perichondrium down to cartilage, express hematoma, flush cavity thoroughly with saline syringe with attached angiocath, place septal stent (Doyle splints) to prevent reaccumulation

    • Antistaphyloccocal antibiotics should be given while splints are in place (cephalexin or amoxicillin are reasonable options)

    • Follow up in 2-3 days for bolster removal and to ensure no reaccumulation of hematoma

  • If significant swelling is present it is generally advised to wait until swelling has resolved before attempt at reduction

  • If minimal swelling, consider immediate reduction

  • If unable to reduce immediately after injury, bring patient back approximately 7 days after injury to reassess and consider in office vs OR reduction if patient unable to tolerate closed reduction in clinic or if need for open reduction    

  • After reduction of the nasal bone fractures, an external nasal splint (typically made of aquaplast) is placed and kept in place for 7 days. 

  • Patients should be advised to avoid nasal trauma for 8-12 weeks (specially designed face masks to avoid nasal trauma are available)

  • If patient unhappy with appearance or has bothersome nasal obstruction, can consider rhinoplasty usually 6 months following injury     

Closed Reduction of Nasal Bone Fracture     

  • Obtain informed consent after discussion of risks (pain, bleeding, intranasal and external deformity, need for future procedures and surgery) 

  • If not performed under general anesthesia, consider a nasal block with bilateral packing of cotton pledgets soaked in 1% Lidocaine with 1:100,000 epinephrine or 4% Cocaine (contraindicated in patient’s with cardiovascular disease) for 5-10 minutes followed by injection of 1% lidocaine with 1:100,000 epinephrine (infraorbital, supraorbital, supratrochlear, lateral dorsum, midline dorsum from rhinion to supratip region, columellar base, and nasal septum)

  • Ensure nasal septum integrity or attempt to reduce septal fracture with use of Asch forceps with an arm in each nostril along dorsal septum, elevate the septum with force directed away from face while simultaneously attempting to realign septal fragments by pushing with the ends of the arms

  • After septal reduction, introduce Boies elevator intranasally with tip at the premeasured distance from nasal tip to intercanthal line 

  • Elevate depressed portion of fracture using Boies elevator in one hand with other hand palpating externally during reduction or attempting to simultaneously reduce the contralateral side if it is out fractured

  • Once adequate reduction is achieved, consider placing absorbable intranasal packing (bactroban coated nasopore) high in the nasal vault under the nasal bones to support them, then place trimmed Doyle splints and suture in place with 3-0 Nylon

  • Apply external nasal splint (clean skin with alcohol swabs, apply mastisol followed by steri strips then apply prepared splint with careful application taking care not to depress any fragments) 

Key Supplies for Closed Nasal Bone Reduction

  • Cotton pledgets

  • Oxymetazoline (Afrin)

  • 1% lidocaine with 1:100,000 epinephrine

  • Alcohol or iodine swabs

  • 10ml syringe with 18-gauge and 27-gauge needles

  • Nasal speculums of various sizes

  • Bayonet forceps

  • Boies elevator

  • Asch forceps 

  • Absorbable nasal packing (firm Nasopore)

  • Doyle Splints and 3-0 Ethilon suture

  • Supplies for nasal cast: mastisol, steri-strips, Aquaplast thermoplastic splint

  • Bacitracin ointment 

Example Procedure Notes:

Procedure: Closed Reduction of Nasal Bone Fractures under General Anesthetic 
The risks, benefits and alternatives to treatment were discussed with the patient who elected to proceed with the procedure. Written informed consent was obtained. The patient was brought to the operating room and identified by name and MRN. After an adequate plane of general anesthesia was obtained by the anesthesia team, the patient’s airway was secured with a Down RAE endotracheal tube which was taped to the chin. The lacrilube ointment was placed in the eyes followed by tegaderms to protect the eyes during surgery. The nasal cavity was carefully examined with a nasal speculum and headlight and Afrin pledgets were placed in bilateral nasal passages. The patient was prepped and draped in the standard fashion. Pledgets were removed and nasal cavities were re-examined. No obstructing fractures or septal hematomas were noted. The nasal bones were palpated. The right nasal bone was noted to be fractured medially and the left nasal bone laterally. A Boies elevator was then inserted intranasally on the right with tip at the premeasured distance from nasal tip to intercanthal line, and used to out-fracture the nasal bone into alignment. Manual digital pressure against the left nasal bone reduced it medially into alignment. The nose was carefully examined and nasal bones deemed to be straight. An external aquaplast nasal cast was applied. This completed the procedure. The patient was extubated and transferred to the PACU in stable condition. No complications. Minimal blood loss.

Procedure: Nasal Bone Reduction with Local Anesthetic
The risks, benefits and alternatives to treatment were discussed with the patient who elected to proceed with the procedure.Written informed consent was obtained.  Local anesthetic was injected, 1% lidocaine with 1:100,000 epinephrine, to bilateral V2, supratrochlear, supraorbital, lateral and midline dorsum, and the internal septum. After local anesthetic was applied, the Boies elevator was used to manipulate the nasal bones bilaterally. Reduction was achieved and confirmed by visual inspection and palpation. The patient was satisfied and there was minimal epistaxis following the reduction. External thermoplastic splints were applied. The septum was inspected after the procedure with no sign of a septal hematoma or fracture. The patient tolerated the procedure well.

References

  1. Chegar, B.E., Tatum, S.A. (2020). Nasal Fractures. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 457-469). Philadelphia, PA: Elsevier.

  2. Gillman, G.S., Rivera-Serrano, C.M. (2013). Nasal Fractures. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1241-1254). Baltimore, MD: Lippincott Williams & Wilkins.

  3. Fusetti, S., et al. “Treatment of Nasal Bone.” AO Foundation Surgery Reference, https://surgeryreference.aofoundation.org/cmf/trauma/midface