Amit Patel OMFS PGY 1

Chapter 24: Nasal Fractures

Most frequently fractured bones of the face.
Less force required to fracture this area than any other facial bone.
Seemingly simple approach to management
Incident of unfavorable results are as high as 62%.
Etiology factors
Motor vehicle collision
interpersonal altercations
Sport-related injury

A. Surgical Anatomy
Nasal mucosa and turbinates
Upper and lower cartilages
Cartilaginous and bony septum in middle
Primary support mechanism of nasal complex
Anterior: cartilage (thicker posteriorly)
Posterior: ethmoid and vomer bones
Paired nasal bones
Cephalically: Nasofrontal suture
Caudally: Upper lateral cartilages
Laterally: Frontal processes of maxilla
Vascular supply
Arteries
Interna carotid branches
Ophthalmic >>> Anterior and posterior Ethmoid arteries
External Carotid branches
Superior labial, angular, sphenopalatine, and greater palatine arteries.
External nose: Facial artery > angular artery
Veins follow arterial pattern. Significant for direct communication with cavernous sinus and lack of
valves.
Innervation
Second division (Maxillary) of the Trigeminal nerve

B. Clinical and Radiographic Diagnostic Tools
Address life threatening and major organ injuries first
Obtain complete history
Mechanism and timing of injury
Force perpendicular to nasal dorsum >>> bony complex fractured laterally
Force lateral to nose (Right handed punch to left side of nose) >>> bony complex will deviate
away from vector of force with one nasal bone medially displaced and other laterally displaced.
Previous nasal trauma or preexisting nasal deviations
Examination
Epistaxis common
Clinical signs of nasal complex fracture
Amit Patel OMFS PGY 1

Periorbital ecchymosis
Nasal swelling
Nasal complex deviation
CSF rhinorrhea
Lack of Nasal projection
Increased intercanthal distance
Mobility or crepitus upon palpation
Anosmia (difficulty smelling) - Late finding occurs if cribriform plate of ethmoid bone is involved
Internal exam with good lighting, speculum and suction
Intranasal laceration
Septal deviation off the nasal crest of maxilla
Nasal septal hematoma
Must be drained to prevent vascular complications associated with devitalized cartilage pre-
disposing to the development of septal perforation.
If cribriform plate of ethmoid bone is fractured >>> perform double-halo test to ascertain presence
of CSF.
Imaging: CT scan without contrast
Clearly delineates nasal bone injuries and septal deviations and fractures
Premorbid photographs are helpful for documentation and comparison purposes.
Classifications
Open vs Closed
Fracture through an external or internal laceration
Deviated vs Non-deviated
Appearance of nasal bones and septum
Comminuted vs Non-comminuted
Status of nasal bones and surrounding bony pyramid (frontal process of maxilla anterior nasal
spine, ethmoidal bones)

C. Surgical Management
Goals
Prevent development of post-traumatic nasal deformity
Restoration of proper nasal air flow
Prevention of cosmetic deformity
Maintenance of proper nasal complex topography and projection
Restoration of sense of smell.
Treatment can be performed under local anesthesia , conscious sedation or general anesthesia
Most efficient and comfortable method: Repair under general endotracheal intubation
Close reduction of nasal complex is most commonly performed procedure
Incidence of patient requiring post-traumatic rhinoplasty >>> 9% - 62%
Procedure:
Intubation
Thorough manual examination of nasal complex
Assess and note crepitus, mobility, depressions, asymmetries, perinasal lacerations, etc
Intranasal exam
Via Endoscopy or nasal speculum and good lighting
Inject local anesthesia and vasoconstrictor into nasal cavity
Amit Patel OMFS PGY 1

Pack nasal cavity with Cottonoid strips soaked in vasoconstrictive solution >>> improves intranasal
visualization
Examination of cavity after 10-15 minutes
Used nasal reduction forceps to reduce nasal ones and septum fractures in appropriate vector
Intranasal packing/splint to maintain reduction
If not successful >>> Perform extensive procedures such as septoplasty (with or without harvest of
cartilage) or bony osteotomies.
Septoplasty
Approached through hemitransfixion incision
Maintain all septal cartilage at initial repair
May be of use in post-traumatic nasal deformity repair
If nasal septum deviates off of ANS, subperichondrial and subperiosteal dissections must be per-
formed in ANS region >>> manually separate septum from ANS >>> reattach septum to ANS using
sutures.
Bony vault deviation not repaired with close reduction may require open reduction or osteotomies.
Callus forms after 10-14 days
Transoral approach to nasomaxillary buttresses, frontal processes of maxilla and nasal bones may
facilitate Open reduction with or without internal fixation
Approaching bones through perinasal lacerations is also acceptable
Use intranasal packing/splint to maintain mobilized bony segments in place5 days
Use external splint: aid in elimination of dead space and maintenance of reduction 7 days

D. Postoperative care and complications
Recommend prolonged antibiotics when internal nasal packings used.
Recommend sinus precautions
Incidence for residual nasal deformity after close reduction: up to 62%
Follow patients progress to ensure acceptable functional and cosmetic outcome
Wait up to 1 year before addressing residual post-traumatic deformity
Grossly deviated nose 1 months s/p repair will remain grossly deviated 1 yr s/p repair.
Post-traumatic rhinoplasty is recommended earlier in such cases.