Nasal Fractures

Stephen Kinyanjui

BDSC/ 4837/161/DF
Introduction
• Definition
• Anatomy in brief
• Clinical aspects
• Classification
• Evaluation
• Management
• Complications
• References
 DEFINITION
• The prominence and delicate structure of the nose make it vulnerable to a
broad spectrum of injury, which accounts for why it is the most
frequently fractured facial bone.

• Most common facial fracture (between 40–50%).

• 3rd most common fracture of the bony skeleton (Nasal, Mandible,

Zygomatic, Maxilla, Frontal, Orbital)

• Force required to create a fracture of the nasal structure is small, possibly

as little as 25 pounds of pressure
 Sequencing Pan-Facial Trauma Repair
BOTTOM UP ,INSIDE OUT TOP-DOWN,OUTSIDE IN

Starting with the reduction and fixation at

Re-establish the maxillo-mandibular unit
as the first major step of the sequencing the level of the calvarium and working in
a caudal direction
Repair of palatal fracture  Repair of frontal sinus fracture
Maxillomandibular fixation  Repair of ZMC(bilateral) # including
Repair of mandibular # arches
Repair of condyle #  Repair of NOE complex
Repair of frontal sinus #  Repair of le fort including mid palatal
split
Repair of NOE complex
 Maxillomandibular fixation
Repair of ZMC # including arches  Repair of bi-condyle #
Repair of maxilla  Repair of mandibular #
 Surgical Anatomy
OSSEOUS FRAMEWORK
External
Internal

CARTILAGENOUS FRAMEWORK
External
Internal
 Osseous framework
EXTERNAL OSSEOUS FRAMEWORK
Consists of two nasal bones
Concave/ convex from above downwards
Convex from side to side.
Traversed above downwards by a groove for anterior ethmoidal nerve.
Superior border articulates with nasal portion of frontal bone
Inferior border articulates with lateral cartilage of the nose.
INTERNAL OSSEOUS FRAMEWORK
Perpendicular plate of ethmoid bone articulates
Posteriorly with the sphenoidal crest of sphenoid.

Postero-inferiorly with superior aspect of vomer.

Each Lateral nasal wall contains 3 conchae.
 Cartilaginous Framework
External
Upper nasal cartilage
Lower nasal cartilage

Internal cartilaginous framework

o Septal cartilage is quadrilateral in shape,

o Upper portion articulates with internasal suture,

o Middle portion articulates with lateral cartilages,

o Lower portion attached to these cartilages by perichondrium.

CAUSES

Physical fights, assaults , domestic violence.

Contact sports

Falls (common in children)

Motor vehicle accidents

Falls from syncope or impaired balance in the elderly

 Clinical Features of Nasal Fractures
o Flattened nasal bridge with splaying of nasal complex.

o Saddle shaped deformity of nose from side.

o Epistaxis (Kiesselbach’s plexus)

o Tenderness ,crepitus and mobility of nasal complex

o Reduced nasal projection and height.

o Septal deviation or dislocation.

o Anosmia caused by damage to the cribriform plate.

o Nasal congestion secondary to septal hematoma

 HISTORY
Any history of a fall or force directed toward the mid face
Details of the injury either assault or any RTA (mechanism, speed,
location, direction of force , any restraining force)
Was there an epistaxis at the time of trauma? Or any watery discharge
Loss of sense of smell ( can also be due to oedema hence should be re
assessed after the oedema subsides)
Was there a previous history of facial trauma or surgery?
The difference from the nasal appearance before the trauma (for
medicolegal and future treatment as well. )
Was there a previous functional impairment in breathing before the
trauma? etc.
 PATHOGENESIS
Direction of the force:
Frontal direction : in fracture of the lower margin of the nasal bones

High frontal : nasal orbital ethmoid fracture

Heavier force : severe flattening or splaying of the nasal bones and fracture
of the septum

Lateral forces : depression of the ipsilateral nasal bone, out fracture of the
contralateral nasal bone
If twisted or buckled : the fractured bony and/or cartilaginous fragments
are often interlocked, septum dislocated off the maxillary crest

Note. This is important to identify because achieving an adequate result

with a closed technique may be impossible in such a situation.

Children’s noses: mostly cartilaginous and their nasal bones are softer
and more compliant, absorbing little of the energy from the force of
trauma. It is also a common fact that birth trauma could be the cause for
septal deviations in these patients.

Septal hematoma is more common in children. In children it is better to

avoid open reduction procedures and stick to closed manipulation
technique.
Classification system
Rowe & Killey ‘s classification.

Strance & Robertson’s classification.

Harrison’s classification.

Murray & Maran’s pathological classification.

Rorich et al’s classification.

AO classification.
Stranc & Robertson 1979
Subdivided frontal impact fracture into 3 planes of injury
Plane 1 Injuries do not extending till the lower end of
nasal bones to the anterior nasal spine.

Plane 2 Injuries extending till the external nose but not

till the orbital rims.

Plane 3 Injuries involving orbital and possibly

intracranial structures
 Rorich et al (2000) proposed a simple
classification that might guide treatment
Type Description
1 Simple unilateral
2 Simple bilateral
3 Comminuted
a. Unilateral
b. Bilateral
c. Frontal process of maxilla

4 Complex
a) Associated with septal hematoma
b) Associated with open nasal laceration

5 Associated with NOE fracture / midface fracture

AO (Arbeitsgemeinschaft fur Osteosynthese)
surgery provides a simple classification system
based on clinical findings (2009)

1. Laterally displaced.

2. Posteriorly depressed fractures

3. Disarticulation of upper lateral cartilage

4. Anterior nasal spine fracture

5. Involvement of nasal septum

Challenges of Septal Deviation

1.Difficulty breathing
2.Sinus infections
3.Sleep disturbances
4.Nosebleeds
5.Asthma
6.Turbinate Hypertrophy
SYMPTOMS
Bruising of the skin and subcutaneous tissues

Pain

Swelling

Deformity

Difficulty breathing

Nosebleeds

Deviation and asymmetry

Epiphora
 PHYSICAL EXAMINATION
Adequate lighting
Acute edema may hide deformities; however, a careful search for intranasal
injury must take place
Patient should be placed in a comfortable, slightly reclined position
Nose should be externally observed from all angles
Bleeding can be controlled with topical cotton pellets soaked in vasoconstrictors
0.25%phenylephrine –
4% cocaine, which also provides anesthesia .
Any open wound
Nasal airway evaluation :
a. Obstruction
b. Hematoma
c. Septal deviation
Other signs: –
a. Oedema
b. Skin laceration
c. Periorbital ecchymosis
d. cerebrospinal fluid (CSF) rhinorrhoea
e. Olfactory disorders

Palpation : Evidence of nasal fracture

Mobility : of the nasal bones is assessed by grasping the dorsum

btw two fingers and firmly rocking the pyramid back & forth

Crepitations can also be felt

 Internal examination
• Assessment of nasal cavity using speculum via direct visualization or using
endoscopy ( use of 0 or 30 degree 4mm rod telescope) -Not entirely necessary
• However may provide additional information and rule out the following:
a. Mucosal tears
b. Lacerations
c. Ecchymosis
d. Hematoma
• Push the tip of the nose upward to check for integrity of the septal support
system.
• Retained blood clots should be removed with suctioning or swabbing using a
frazier suction procedure.
 Radiography
Plain X-ray films High resolution USG CT SCAN
Most commonly done Ultrasound using 10 MHz probe In cases of only
gives a clear view severe injury
Advantage Easily accessible & cheap . Excellent sensitivity & specificity In injuries involving
esp regarding lateral nasal wall naso-orbital-ethmoidal
fracture complex.
Can not be missed even in presence of
edema
No radiation injury
Disadvantage Inability to show Limited scope that may miss
cartilaginous injury esp in fracture outside the area of
children. interest &
Can misinterpret normal anatomical issues that prevent
suture lines , adequate transducer contact
vascular indentation lines, &
developmental thinning of
nasal
bones
 Management

Management of nasal fracture can do in two ways

1) Emergency management
2) Surgical management
 Emergency management
Elevation of the head
• Use of cold compresses in the peri orbital and nasal regions can be helpful
for subside the edema

• Nasal packing is the most common method of controlling bleeding within

the nose. The packing should be placed precisely at the
bleeding site(s) to provide uniform pressure over the entire area.
In most patients packing will control nasal bleeding. After 2 to 5 days the
packing can be removed

• Posterior nasal pack is needed when obstruction of the airway because of

hemorrhage into the nasopharynx
 Anterior Nasal Packing
This packing is done if localized bleeding is profuse or bleeding point
is not localized.
Use of a ribbon gauze soaked with liquid paraffin(1 m gauze; 2.5 cm gauze in
adult and 12 mm in children).
It can be done with vertical layer and horizontal layer.
It can be removed with 24 hour and can be kept up to 2-3 days.
Systemic antibiotic should be given to prevent sinus infection and toxic shock
syndrome.
 Posterior Nasal Packing
Foley catheter, and insert the device into the nostril.

Visualize the catheter tip in the back of the throat. Inflate the balloon with up to 10 mL of
sterile water

Withdraw the balloon gently until it seats posteriorly.

Pack the anterior nasal cavity with a balloon device or layered ribbon gauze.

Apply a padded umbilical clamp across the catheter to prevent alar necrosis and to keep
the balloon from dislodging.

Other techniques for posterior nasal packing; Silver Nitrate, Endoscopic cautery,
diathemize etc.
 TIMING OF REDUCTION
• Selection of appropriate timing is very important to obtain the best re-
alignment possible
• The development of fibrous connective tissue within the fracture line
becomes the limiting factor starting at around 10 days to 2 weeks after
injury.
• Hence the best time is to start before this phase.
• A short period of delay is recommended during first 2-3 days to allow
diminution of oedema so that the nasal bone position is best appreciated.
• Treatment before this delay is reasonable only if patient comes to medical
attention within an hour or two after injury before edema has obscured
the underlying structure.
 Closed reduction Open reduction

CR involves manipulation of OR may include a range of

the nasal bones without including septoplasty , osteotomy
incision & is generally the or
preferred septorhinoplasty.
choice

Indication: 1. Unilateral / bilateral # of 1. Bilateral # with dislocation of

nasal bones nasal
2. # of nasal septal complex dorsum & significant pathological
with nasal deviation of less changes
than half of the width of 2. Infracture of nasal dorsum
nasal bridge
 Closed Reduction
 Most preferred treatment modality

 Even if large deviations are seen closed reduction can be attempted prior to
rhinoplasty as this would simplify the task of the plastic surgeon

 In mild cases when fragments are still in contact finger manipulation alone is
sufficient but in this surgeon doesn’t have much control & often will fail if there
is impaction and can even result in worse deformity than before.
 Anesthesia for closed reduction
Topical Infiltration
Cotton pledgets soaked in 4% cocaine or 0.05% 1% lidocaine with 1:100,000epinephrine is injected
oxymetazoline combined with 4% topical along the septum, lateral wall & floor of nasal cavity
lidocaine are placed strategically in the nasal External nasal branch is blocked by via an inter
cavity cartilaginous injection of the dorsum from rhinion to
supratip
Target: Branches of anterior or posterior Target: Branches of nasopalatine nerve are blocked
ethmoid , sphenoplataine & nasopalatine with an injection at the base of columella & nasal tip
nerves just inside the nasal sill.

Challenges with Using cocaine as anaesthetic

 Compromise of end arterioles

 Addiction
 Severe Rhinosinusitis
 Epistaxis,
 perforation of the nasal septum,
 oropharyngeal ulcers secondary to vasoconstriction and ischemic necrosis
REDUCTION INSTRUMENTS

(Left) Asch Septum Straightening Forceps

(Center) Walsham Septum forceps

(Right) Boies Nasal Fracture elevator

Using a blunt elevator
USE OF GRASPING INSTRUMENTS
 Causes of failure of closed reduction

• Most common cause within 1st week to 10 days is unreduced septal

fracture

• Beyond 2nd week is fibrous tissue formation causing inadequate

remodeling.

• Even after proper timely reduction there is persistent deviation, then it

can be a Green stick fracture
 Care after reduction
Avoidance of activity that can lead to further trauma for next 6-8 weeks.

Regular nasal saline spray or irrigation are recommended to remove blood and to avoid
adhesions

Antibiotic coverage should also be given

Refraining from nasal blowing.

 Immobilization of Nasal fractures
Intranasal Splintage
• Ribbon gauze
• Silastic
• Stainless steel intranasal splint

Advances in intranasal splints

• Doyle lumen splint / Airway splint obturator
• Doyle combo splint
• Bivalve nasal splint
• Nasal Elliptical septal button
External splintage
a. Plaster of Paris splint

b. Collodium gauze and soft metal sheet

c. Aluminum nasal splints

d. Skin-friendly adhesive tapes/Steri-Strips

e. Denver splint set

 Open reduction

Immediate repair Delayed repair

In case the closed reduction fails Usually 6 months or more
Using standard method of
rhinoplasty
 Surgical Approach

1. Through existing laceration.

2. Bi-coronal approach.
3. Endonasal
a. Trans-cartilaginous (Intra-cartilaginous, Cartilage splitting)
b. Retrograde
c. Bi-pedicled chondrocutaneous flap (delivery)

4. External (open)
Approach

Nasal fractures are often associated with

lacerations.

These existing soft-tissue injuries can be

used to access directly the nasal bones for
management of the fractures
 Bi-coronal approach

The bicoronal or bitemporal incision is used to

approach the anterior cranial vault, the forehead,
and the upper and middle regions of the facial
skeleton
Trans cartilaginous Approach- Retrograde Approach

Bi-pedicled chondrocutaneous flap

 FIXATION
o A Small gauze wires (26 or more ) passed through pre drilled holes can secure
fragments to stable parts of maxillary of frontal bone

o Use of slow absorbing sutures instead wires

o Titanium microplates & fibrin glue can also be used (alt bio-absorbale fixation
method that may help in speed wound healing & reduce post op hematoma)

o Use of cantilever bone in case of significant loss of dorsum

o Autologus cranial bone or rib bone or cartilage or homograft bone or cartilage

can also be used
 Post operative care
• Postoperative positioning : Keeping the patient’s head in a raised
position both preoperatively and postoperatively may significantly
improve edema and pain.

• Nose-blowing : To prevent orbital emphysema, nose-blowing should be

avoided.

• Ice packs for reduce the nasal edema.

 COMPLICATIONS

Early Late
1. Septal hematoma 1. Untreated hematoma : lead to sub peri-chondrial
fibrosis & partial nasal airway obstruction
2. Edema 2. synechiae
3. Ecchymosis 3. Residual osteitis
4.Csf leak 4. Chronic rhinosinusitis
5. Epistaxis 5. Cosmetic Deformity
References
1. Diseases of the Ear, Nose and Throat and Neck Surgery, 6th
Edition, PL Dhingra, Elsevier
2. Peterson’s Principles of Oral and Maxillofacial Surgery –
2nd Edition
3. Rowe & Williams Maxillofacial Injuries
4. Fonseca’s Trauma
5. Complications in oral and maxillofacial surgery - Kaban