return to: Facial Fracture Management Handbook - Nasoethmoid fractures; Facial Fracture Management Handbook - Applied Anatomy; Reconstructive Protocols Home Page

update March 4 2024 by Eddie Tannenbaum BA  (Univ of Iowa School of Medicine) and Shaun Edalati BS (Mount Sinai School of Medicine)

Background

The most common fractures of the face and the third most common fractures of the body are nasal bone fractures (Mondin et al., 2005). Nasal injuries can have significant consequences to respiratory function and facial appearance (Trujillo and Lee, 2023). The central and protruding location of the nose not only contribute to its aesthetic role but also to its risk of injury (Landeen et al., 2021). Compared to any other facial bone, the least amount of force is needed to fracture the nasal bones (Fattahi and Salman, 2019). As such, nasal fractures frequently occur due to trauma from falls, motor vehicle collisions, sports injuries, and physical altercations (Alvi and Patel, 2023).

Since antiquity, closed reduction has been the standard treatment for nasal fractures (Mondin et al., 2005). Although this approach is seemingly straightforward and has reported rates of success of 60%-90% (Alvi and Patel, 2023), the incidence of post-reduction rhinoplasty or septorhinoplasty has been found to range from 14% to 50% (Mondin et al., 2005). As nasal fractures frequently occur with trauma to other areas, they are often not promptly identified and managed (Mondin et al., 2005). Thus, early diagnosis and appropriate treatment are vital in caring for patients with nasal fractures (Fattahi and Salman, 2019).

Anatomy

The nose is supported by a framework of bone and cartilage. Two paired, wedge-shaped nasal bones comprise the superior bony wall of the nasal cavity (Landeen et al., 2021). The superior component of the nasal bone is thicker and supported by the frontal bone and frontal process of the maxilla (Mondin et al., 2005). In contrast, the inferior aspect of the nasal bone is thin and broad, making it more prone to injury (Mondin et al., 2005). Caudally, the nasal bone articulates with the upper lateral cartilage at the keystone area, providing support to the nasal dorsum (Trujillo and Lee, 2023). Continuing inferiorly to the scroll region, the upper lateral cartilages contact with the lower lateral cartilages, which form the nasal tip (Alvi and Patel, 2023). The nasal septum supports the external nose and divides the left and right nasal cavities (Alvi and Patel, 2023). It comprises the perpendicular plate of the ethmoid, the vomer, and the quadrangular cartilage. The septum contains an abundant vascular supply with contributions from both the internal and external carotid arteries. Kiesselbach's plexus is formed in the anterior septum from the confluence of the anterior and posterior ethmoidal, greater palatine, sphenopalatine, and superior labial arteries (Trujillo and Lee, 2023). In the posterior septum, the Woodruff plexus comprises the anastomoses of the sphenopalatine and posterior pharyngeal arteries (Landeen et al., 2021). This rich blood supply can lead to epistaxis following nasal trauma. The trigeminal nerve provides sensory innervation to the nose via the ophthalmic and maxillary branches (Trujillo and Lee, 2023).

Evaluation 

• History (Bhama and Cheney, 2023.; Fattahi and Salman, 2019; Landeen et al., 2021; Trujillo and Lee, 2023)
  • Mechanism of injury
    • Anterior force can cause flattening of nasal bones. Lateral force can cause C- or S-shaped deformity
  • Time and location of injury
  • Usually preceding trauma (MVC, physical altercation, sports)
  • Loss of consciousness
  • Head and neck pain/paresthesia
  • Changes to vision, dental occlusion, hearing, smell, and/or taste
    • Anosmia may indicate involvement of the cribriform plate of the ethmoid bone
  • Epistaxis
  • Nasal obstruction
  • Clear rhinorrhea
  • Swelling of nasal bridge
  • Change in appearance, deviation
  • Periorbital ecchymosis
  • Use of alcohol or recreational drugs
  • Previous trauma, injury, surgery, obstruction, deformity

• Exam (Alvi and Patel, 2023; Bhama and Cheney, 2023.; Landeen et al., 2021; Mondin et al., 2005)
  • Airway, breathing, circulation
  • Exam should include anterior rhinoscopy and endonasal palpation
  • Clear nasal fluid
    • This can indicate possible cerebrospinal fluid (CSF) leak. Beta-2 transferrin testing or halo test may be helpful in assessing
  • Septal hematoma
    • Widening of nasal tip and nasal obstruction or ecchymosis and edema of septum may represent septal hematoma
    • Requires immediate drainage due to risk of septal necrosis, abscess formation, and saddle nose deformity
  • Deformity and shape
    • Cartilaginous vs. bony deformity
    • May be helpful to see photo of patient prior to injury
    • Decreased anterior projection of nose and increased intercanthal distance may indicate naso-orbital-ethmoid fracture
  • Swelling
    • Ice may be helpful in reducing swelling
    • As initial swelling may disguise or exacerbate deformity, reexamination and photos may be useful
  • Epistaxis
    • Initial management may entail pinching the lateral walls against the septum for 15 minutes. If bleeding continues, can attempt nasal suctioning, application of oxymetazoline for vasoconstriction, and pinching for 15 minutes again. If epistaxis still cannot be controlled, may attempt packing of nasal cavities (absorbable nasal packing preferred as minimizes trauma to mucosa)   
  • Eye movement
    • Extraocular muscle entrapment and gaze restriction may indicate orbital blowout fracture
  • Instability to midface or dental malocclusion
    • May represent Le Fort fracture
  • Ecchymosis
  • Septal deformity/deviation
  • Tenderness
  • Nasal bone mobility
  • Crepitus
  • Bony step-offs
  • Open fractures
  • Paresthesia
  • Narrowing of nasal valve
  • Mucosal laceration

• Imaging (Alvi and Patel, 2023; Bhama and Cheney, 2023.; Landeen et al., 2021; Mondin et al., 2005; Trujillo and Lee, 2023)
  • Isolated nasal fractures rarely require imaging. CT scans can be performed to assess for suspected head injuries, complex facial injuries, and basal skull fractures. Trujillo and Lee report that although radiographic imaging is not indicated in isolated nasal bone fractures, a surgeon should review a CT scan prior to closed reduction to rule out cribriform plate fracture to minimize the risk of CSF leak or damage to olfactory cleft.

• Indications for Repair (Alvi and Patel, 2023; Bhama and Cheney, 2023.; Landeen et al., 2021; Mondin et al., 2005; Trujillo and Lee, 2023)
  • Nasal obstruction
  • Deviation with change from baseline appearance
    • If patient not concerned with aesthetic changes, should note that the wearing of glasses could be affected
  • Reduction immediately within 3-6 hours, prior to onset of swelling
  • Reduction 3-10 (max 14) days after injury after resolution of swelling and prior to setting of fracture fragments (3-7 days for pediatric fractures)
    • Short course of oral steroids may help with severe edema

• Contraindications (Alvi and Patel, 2023; Landeen et al., 2021; Mondin et al., 2005)

• Severely comminuted or extensive fractures of nasal bones and septum
• Open fractures of septum
• Fracture and dislocation of caudal septum
• Injury occurred over 2 weeks prior to initial presentation
• Naso-orbital-ethmoid fracture
• Le Fort fracture
• Nasal pyramid deviation greater than half nasal bridge width

Procedure

• May be done as office/emergency department procedure or in the operating room with anesthesia (MAC or general) - studies show that equally effective in terms of functional and aesthetic outcomes
• Place patient in supine or reclined position
• Apply topical anesthetic: ½ x 3 cm pledgets soaked in afrin, or 1% lidocaine with 1:100,000 epinephrine, or 4% viscous cocaine, lay along the septum and nasal floor bilaterally (2 pledgets on each side).
• Local injections: inject bilateral infraorbital nerves at the infraorbital foramen with 1% lidocaine with 1:100,000 epinephrine, as well as supratrochlear nerves and nasal dorsum
• Allow vasoconstrictor and anesthetic to take effect for 10-15 minutes.
• Measure the distance from the alar rim to the nasal bone using the Boies elevator and mark this distance with your thumb (should not extend past medial canthus). Insert the elevator into the side with the depressed fragment and apply pressure outward pressure with application of counterpressure external with the other hand.
• May need to apply outward or inward pressure to the contralateral nasal bone following reduction of the fractured side depending on its location.
• If unable to reduce the fracture with Boies elevator may use the Walsham forceps to grasp the fractured bone intranasally with the other blade externally and manipulate bone into position (good for impacted nasal bone fracture).
• Make sure to assess the nasal cartilage and if displaced use the Boies elevator to reduce at the time of bony reduction
• May place internal packing (ex. Sialastic splints, merocel).
• Place external cast: gently apply benzoin to the skin of nasal dorsum and extend on to the cheek. Place steri-strips across the nasal dorsum. Place the splint in boiling hot water and leave in place until it changes from white to clear, remove excess water and place over the steri-strips, molding the cast by pushing towards the floor, to fit the shape of the nose.

Complications

• Incomplete correction of a nasal deformity can result in symmetry issues, nasal irregularities, and palpable or visible deformities in the bone, cartilage, or skin, ultimately resulting in patient dissatisfaction
• Severe bleeding 
• Septal perforation
• Infection in cartilage leading to collapse of external nose (saddle nose)
• Scarring and adhesions
• Need for further procedures and or surgeries

Follow-up

• Remove external cast and internal packing in 5-7 days
• Continue antibiotics while packing in place
• May require more extensive repair with septorhinoplasty with osteotomies if patient continues to have nasal obstruction or is unhappy with external appearance (or presents outside the 10 day window for closed nasal reduction). Should wait at least 6 months from the time of injury prior to attempting repair.

References

Alvi S, Patel BC. Nasal fracture reduction. StatPearls. April 3, 2023. Accessed December 20, 2023. https://www.ncbi.nlm.nih.gov/books/NBK538299/.

Bailey BJ. Nasal fractures. In: Bailey BJ, et al, eds. Head and Neck Surgery- Otolaryngology. Vol 1. Philadelphia: Lippincott Williams & Wilkins; 2006:995-1008.

Basheeth N, Donnelly M, David S, Munish S. Acute nasal fracture management: A prospective study and literature review. Laryngoscope. 2015;125(12):2677-2684. doi:10.1002/lary.25358

Bhama P, Cheney M. Open access atlas of otolaryngology, head & neck operative surgery - vula. Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery. Accessed December 20, 2023. https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586f....

Fattahi T, Salman S. Management of Nasal Fractures. Atlas Oral Maxillofac Surg Clin North Am. 2019;27(2):93-98. doi:10.1016/j.cxom.2019.04.002

Landeen KC, Kimura K, Stephan SJ. Nasal Fractures. Facial Plast Surg Clin North Am. 2022;30(1):23-30. doi:10.1016/j.fsc.2021.08.002

Mondin V, Rinaldo A, Ferlito A. Management of nasal bone fractures. Am J Otolaryngol. 2005;26(3):181-185. doi:10.1016/j.amjoto.2004.11.006

Trujillo O, Lee C. Nasal Fractures: Acute, Subacute, and Delayed Management. Otolaryngol Clin North Am. 2023;56(6):1089-1099. doi:10.1016/j.otc.2023.05.004