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Closed Nasal Reduction

Nasal fractures are the most common facial fracture, third most common fracture of the body

History and Exam:

• Usually preceding trauma (MVC, physical altercation, sports)
• +/- Epistaxis
• Nasal obstruction
• Swelling of nasal bridge
• Change in appearance, deviation
• Previous trauma
• Periorbital ecchymosis
• Palpation and direct visualization of nasal septum to rule out septal hematoma
• Helpful to see photo of patient prior to injury
• Does not require radiographic imaging. Plain films have a high rate of false positives.

Indications for repair:

• Nasal obstruction
• Deviation with change from baseline appearance
• Immediate intervention if septal hematoma
• 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)

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 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 skin of nasal dorsum and extending on to the cheek. Place steri-strips across the nasal dorsum. Place the splint in boiling hot water and leave in place until 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.

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 time of injury prior to attempting repair.

References:

1.       Mondin V, Rinaldo A, Ferlito A. Management of Nasal Bone Fractures. Am J Otolarngol. 2005; 26(3): 181-5.

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