Nasal Bone Fractures

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Nasal Bone Fractures

Trauma
Author Credentials 

Jason Goodwin, MD
Staff Otolaryngologist
United States Air Force
Eglin AFB Hospital
307 Boatner Rd
Eglin AFB, FL
32542

Module Summary

Nasal injuries can create a functional as well as cosmetic deficit. The patient with nasal injuries may present a diagnostic and therapeutic dilemma. Often, the associated edema and ecchymosis can mask the extent of the underlying deformity. Careful followup examinations may be necessary in order to make appropriate treatment decisions. The necessity and timing of closed manipulation of nasal fractures must be weighed against open reduction and delayed surgical management, such as a septorhinoplasty procedure. It is important to be familiar with the pathophysiology of nasal injuries, their diagnostic features, and the treatment options. A multitude of functional and cosmetic rhinoplasty techniques come into play in managing these injuries. The associated problems of saddle nose deformity and posttraumatic nasal (and septal) deformity must also be managed appropriately.

Module Learning Objectives 

 

  1. Review the types of soft tissue and skeletal injuries that may occur.
  2. Recognize nasal fractures, septal hematoma, septal dislocation, and other nasal injuries.
  3. Appropriately order and interpret imaging.
  4. Explain the mechanisms of injury associated with the different types of nasal injuries.
  5. Note any differences associated with pediatric nasal trauma.
  6. Recognize the indications and limitations for closed reduction, open reduction, and delayed treatment for nasal fractures.
  7. Review the treatment options applicable for management of septal hematoma.
  8. Summarize the issues involved in decision making relating to delayed treatment of nasal injuries.
  9. Relate the associated complications (early and late) of nasal injuries and their treatment.

Embryology

Learning Objectives 
  1. Become familiar with the three basic anatomic components of the nose (septum, tip, and dorsum).
  2. Be able to describe the relationship of the cartilaginous, bony, and soft tissue anatomic structures.
References 
  1. Flint, Paul W and Charles W. Cummings. Cummings Otolaryngology Head and Neck Surgery. Philedelphia: Elsevier, Saunders, 2015
  2. Toriumi DM, Becker DG. Rhinoplasty dissection manual. Philadelphia: Lippincott Williams and Wilkins; 1999.

Pathogenesis

Learning Objectives 
  1. Understand the various force vectors of trauma and the resulting types of nasal injuries.
  2. Become familiar with the pathophysiology of septal hematomas and the natural history of unrecognized injuries.
References 
  1. Renner GJ. Management of nasal fractures. Otolaryngol Clin North Am. 1991;24:195-213.
  2. Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries and management. Facial Plast Surg. 2011 Oct;27(5):483-90

Incidence

Learning Objectives 
  1. Be aware of the incidence and epidemiology of nasal fractures.
  2. Be familiar with the most common causes of nasal injuries.
References 
  1. Flint, Paul W and Charles W. Cummings. Cummings Otolaryngology Head and Neck Surgery. Philedelphia: Elsevier, Saunders, 2015
  2. Hoffmann JF. An Algorithm for the Initial Management of Nasal Trauma. Facial Plast Surg. 2015 Jun;31(3):183-93
  3. Renner GJ. Management of nasal fractures. Otolaryngol Clin North Am. 1991;24:195-213.

Patient Evaluation

Learning Objectives 
  1. Recognize the signs and symptoms associated with nasal injuries (soft tissue injuries, septal hematomas, nasal fractures).
  2. Be familiar with the signs and symptoms that occur in patients with untreated nasal injuries.
References 
  1. Hoffmann JF. An Algorithm for the Initial Management of Nasal Trauma. Facial Plast Surg. 2015 Jun;31(3):183-93
  2. Ondik MP, Lipinski L, Dezfoli S, Fedok FG. The treatment of nasal fractures: a changing paradigm. Arch Facial Plast Surg. 2009 Sep-Oct;11(5):296-302
  3. Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries and management. Facial Plast Surg. 2011 Oct;27(5):483-90

Imaging

Learning Objectives 

Understand appropriate imaging for nasal fractures. Realize the limitations of plain film imaging.

References 
  1. Logan M, O'Driscoll K, Masterson J. The utility of nasal bone radiographs in nasal trauma. Clin Radiol. 1994 Mar;49(3):192-4.
  2. de Lacey GJ, Wignall BK, Hussain S, Reidy JR. The radiology of nasal injuries: problems of interpretation and clinical relevance. Br J Radiol. 1977 Jun;50(594):412-4.

Treatment

Learning Objectives 
  1. Recognize the indications for emergent treatment of nasal fractures and soft tissue injuries.
  2. Be familiar with the issues surrounding closed versus open reduction of nasal fractures.
  3. Be aware of the optimal timing for closed reduction of nasal fractures.
References 
  1. Rohrich RJ, Adams WP. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. 2000;106:266-73
  2. Ondik MP, Lipinski L, Dezfoli S, Fedok FG. The treatment of nasal fractures: a changing paradigm. Arch Facial Plast Surg. 2009 Sep-Oct;11(5):296-302
  3. Hoffmann JF. An Algorithm for the Initial Management of Nasal Trauma. Facial Plast Surg. 2015 Jun;31(3):183-93

Surgical Therapies

Learning Objectives 
  1. Understand the surgical treatment for posttraumatic nasal deformity, with and without nasal obstruction.
  2. Be aware of the indications and surgical techniques available for the treatment of septal hematoma.
  3. Be able to discuss the various surgical techniques and materials that apply to the correction of saddle nose deformity.
References 
  1. Cook JA, McRae RDR, Irving RM, et al. A randomized comparison of manipulation of the fractured nose under local and general anesthesia. Clin Otolaryngol. 1990;15:343-46.
  2. Chua DY, Park SS. Posttraumatic Nasal Deformities: Correcting the Crooked and Saddle Nose. Facial Plast Surg. 2015 Jun;31(3):259-69
  3. Rohrich RJ, Adams WP. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. 2000;106:266-73.
  4. Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries and management. Facial Plast Surg. 2011 Oct;27(5):483-90

Staging

Learning Objectives 

Be aware that classification systems do exist for nasal fractures (Rohrich, Ondik, Hoffman) but are not commonly used in clinical settings

References 
  1. Rohrich RJ, Adams WP. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. 2000;106:266-73.
  2. Ondik MP, Lipinski L, Dezfoli S, Fedok FG. The treatment of nasal fractures: a changing paradigm. Arch Facial Plast Surg. 2009 Sep-Oct;11(5):296-302
  3. Hoffmann JF. An Algorithm for the Initial Management of Nasal Trauma. Facial Plast Surg. 2015 Jun;31(3):183-93

Case Studies

  1. 8-year-old female suffers a nasal injury playing at school and fell on the bleachers, striking her nose. She initially has some epistaxis that has now resolved. She has some bleeding coming from the asal bridge and sidewall.
    1. On examination, she has moderate edema and ecchymosis over the nasal dorsum and lateral nasal walls. She has a laceration of the nasal sidewall, which is bleeding. This is closed with a suture which stops bleeding. She has a relatively straight septum that appears uninjured with no evidence of septal hematoma. The nose appears relatively straight, but there is moderate swelling. The mother thinks there has been a change in appearance to the nose.
    2. Initial treatment consists of repairing the laceration. She was seen one week later and the suture was removed. The swelling has reduced. There is no apparent deviation. Despite this the mother is insistent that the nasal appearance has changed.
    3. This is a difficult situation that is also fairly common. Despite no objective evidence, sometimes parents will insist that there is a problem or that some intervention should be done.
    4. This patient was followed with repeat examinations. A trusted colleague was also consulted. After repeated examinations and reassurance the patient had no need for intervention and the mother was satisfied.
  2. A 32-year-old male suffers a fall at his construction site and is in the emergency department for evaluation of his nasal injuries.
    1. Examination shows deviation of the nasal dorsum to the right with flattening of the upper nasal dorsum. Anterior rhinoscopy shows an acutely dislocated septum that is off the maxillary crest in the right nasal cavity.
    2. Treatment of the patient in this scenario will vary significantly from one institution to another. Options include closed reduction of the nasal fracture with an attempted reduction of the septal dislocation or closed reduction of the nasal fracture with anticipated septorhinoplasty 6 to 8 weeks later. Another alternative consists of closed reduction of the nasal fracture with a septoplasty within the first 2 weeks following the injury.

Complications

Learning Objectives 
  1. Be familiar with the various acute and delayed complications of nasal injuries.
  2. Be able to describe the most common findings in a patient with posttraumatic nasal deformity.
  3. Recognize the typical physical findings in a patient with saddle nose deformity.
  4. Be able to relate the common factors that lead to saddle nose deformity.
References 
  1. Chua DY, Park SS. Posttraumatic Nasal Deformities: Correcting the Crooked and Saddle Nose. Facial Plast Surg. 2015 Jun;31(3):259-69
  2. Rohrich RJ, Adams WP. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. 2000;106:266-73.
  3. Farber SJ, Nguyen DC, Parikh RP, Jang JL, Woo AS. Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity. Plast Reconstr Surg. 2017 Jan;139(1):51-59

Review

Review Questions 
  1. What is the relationship of the upper lateral cartilage with the nasal bone?
  2. What are the most common signs and symptoms in a patient with a septal hematoma?
  3. Describe the optimal treatment for a 25-year-old male with a septal hematoma. Describe the same for a pediatric patient.
  4. Discuss the advantages and disadvantages of closed reduction for a nasal fracture.
  5. What is the optimal timing for closed reduction of nasal fractures?
  6. Discuss the optimal timing for septorhinoplasty in the treatment of traumatic nasal and septal deformity.
  7. Describe the pathophysiology of saddle nose deformity and some of the treatment options available.
References 
  1. Chua DY, Park SS. Posttraumatic Nasal Deformities: Correcting the Crooked and Saddle Nose. Facial Plast Surg. 2015 Jun;31(3):259-69
  2. Cook JA, McRae RDR, Irving RM, et al. A randomized comparison of manipulation of the fractured nose under local and general anesthesia. Clin Otolaryngol 1990;15:343-46.
  3. de Lacey GJ, Wignall BK, Hussain S, Reidy JR. The radiology of nasal injuries: problems of interpretation and clinical relevance. Br J Radiol. 1977 Jun;50(594):412-4.
  4. Farber SJ, Nguyen DC, Parikh RP, Jang JL, Woo AS. Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity. Plast Reconstr Surg. 2017 Jan;139(1):51-59
  5. Flint, Paul W and Charles W. Cummings. Cummings Otolaryngology Head and Neck Surgery. Philedelphia: Elsevier, Saunders, 2015
  6. Hoffmann JF. An Algorithm for the Initial Management of Nasal Trauma. Facial Plast Surg. 2015 Jun;31(3):183-93
  7. Logan M, O'Driscoll K, Masterson J. The utility of nasal bone radiographs in nasal trauma. Clin Radiol. 1994 Mar;49(3):192-4.
  8. Ondik MP, Lipinski L, Dezfoli S, Fedok FG. The treatment of nasal fractures: a changing paradigm. Arch Facial Plast Surg. 2009 Sep-Oct;11(5):296-302
  9. Renner GJ, Management of nasal fractures. Otolaryngol Clin North Am 1991;24:195-213.
  10. Rohrich RJ, Adams WP. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg 2000;106:266-73.
  11. Toriumi DM, Becker DG. Rhinoplasty dissection manual. Philadelphia: Lippincott Williams and Wilkins; 1999.
  12. Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries and management. Facial Plast Surg. 2011 Oct;27(5):483-90
Resources 

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