Continuing Education Activity
Nasal bone and septal fractures are the most commonly fractured bone in the facial skeleton. These injuries can affect not only the cosmetic appearance of the nose but also the function. This article outlines the evaluation and management of nasal bone and septal fractures and illustrates the need for an interdisciplinary team to improve care for these patients.
- Identify the etiology of nasal bone and septal fractures.
- Outline the appropriate evaluation of nasal bone and septal fractures.
- Review the treatment options available for nasal bone and septal fractures.
- Describe the interprofessional team strategies for improving care coordination and communication to advance and improve outcomes.
The nasal bones are the most frequently fractured in the maxillofacial area due to both the relative weakness of the bones, and the outward projection of the nose on the face. Nasal septal fractures have been associated with nasal bone fractures in 42% to 96% of patients. Nasal bone and septal fractures have an impact not only on cosmetic appearance but also on functional nasal breathing as well.
The structural support of the nose is comprised mainly of cartilage, bone, and skin. The paired nasal bones are attached to the frontal bone superiorly and the frontal process of the maxilla on either side laterally. They are attached to the nasofrontal and nasomaxillary suture lines, respectively. The nasal bones tend to be thicker above the level of the medial canthus.
The nasal septum is comprised posteriorly of bone and anteriorly of cartilage. The perpendicular plate of the ethmoid bone superiorly and the vomer inferiorly, make up the bony septum. These fuse with the quadrangular cartilage, which makes up the anterior portion of the nasal septum. The quadrangular cartilage provides support for the nasal dorsum from the keystone area to the supratip of the nose. This keystone area is a major structural support of the middle one-third of the nose. The upper lateral cartilages fuse to the cartilaginous septum, which is firmly attached to the perpendicular plate of the ethmoid bone. The final element of the keystone area is the attachment of the upper lateral cartilages to the nasal bony vault. The septum is attached to the nasal floor anteriorly at the nasal spine and posteriorly at the nasal crest of the maxilla and palatine bones.
Nasal bones can be fractured by a variety of traumas to the maxillofacial skeleton. The most common causes of nasal bone fractures globally are interpersonal violence, motor vehicle accidents, sporting accidents, and falls. In North America, traffic accidents account for more nasal bone fractures than interpersonal violence. In children, the most common cause tends to be sporting accidents or motor vehicle accidents, depending on the source. Interestingly, ball-related sports such as soccer, basketball, baseball, and rugby have a higher incidence of nasal bone fractures compared to fighting-related sports.
Nasal bone and septal fractures are much more common in men and boys compared to women and girls. This has been attributed to the higher incidence of interpersonal violence between males. Incidence of nasal bone fractures peak in the second and third decades of life. On a national level, rates of nasal bone and other facial fractures have steadily increased since 2000, but rates of repair have remained stable, suggesting an increase in nonoperative fracture patterns as well as increased use of computed tomography (CT) imaging to help guide management.
No classification of nasal bone fractures has been collectively established, but generally, a frontal or side impact to the nose induces a fracture of the nasal bones and/or nasal septum. Fractures can be unilateral or bilateral, nondisplaced or severely depressed, greenstick, or comminuted. Fractures may involve the nasal bones, nasal cartilage, septal cartilage, as well as the surrounding facial skeleton in more severe injuries.
History and Physical
Patients who have undergone trauma to the maxillofacial region should first have a primary trauma survey performed, addressing Airway, Breathing, and Circulation, and Disability. After life-threatening issues have been addressed, a thorough history and secondary physical examination may be performed.
It is important first to delineate the mechanism of trauma to the maxillofacial region. Higher impact injuries, as seen in motor vehicle accidents, are prone to more severe injuries and may be associated with multiple facial fractures. The direction of impact may be important to understand the underlying fracture pattern better. Lateral blows tend to cause an infracture on the impacted side and outfracture on the opposite side, while impact directed straight onto the nasal dorsum tends to cause splaying outfractures of the bilateral nasal bones. It is also essential to get a sense of premorbid appearance. Patients should be asked if they notice an obvious deviation or deformity compared to before the injury. Difficulty breathing through either side of the nose should be explored, as this can signify injury to the nasal septum. The patient should also be questioned on any prior nasal trauma or surgeries. Symptoms that may indicate more extensive injuries include telecanthus, diplopia, loss of vision, clear rhinorrhea, malocclusion, facial weakness, or numbness.
Physical examination should include a thorough examination of the entire head and neck region to include skin, ocular examination, otoscopic exam, intraoral, and intranasal examination. A complete examination of the nasal dorsum and nasal cavity should be performed with the aid of a headlamp as well as a nasal speculum or rigid endoscope. The external nose should be closely evaluated for the presence of lacerations and exposed bone or cartilage. Any deviation of the bony nasal pyramid should be documented. Increased intercanthal distance suggests a nasoorbitoethmoid fracture. The nasal tip should be palpated to assess for adequate support, and the nasal dorsum should be evaluated for a saddle-nose deformity, which indicates significant septal fracture or dislocation. An intranasal examination should first rule out a septal hematoma, which is seen as a fluctuant red or blue discoloration along the nasal septum. This submucoperichondrial collection of blood needs an urgent incision and drainage to prevent abscess development and/or septal cartilaginous necrosis, which may occur within 24 hours. Over time, the resulting cartilage necrosis leads to septal perforation or saddle nose deformity. Significant dislocations of the septum should be noted, and any intranasal lacerations or mucosal disruptions should be noted as well. Care should be taken to inspect for clear rhinorrhea, which may suggest a cerebrospinal fluid (CSF) leak.
Imaging is generally not warranted for simple nasal bone fractures. Plain film X-rays are not typically useful. A CT scan without intravenous contrast of the facial bones is the gold standard for evaluation of bony trauma of the maxillofacial area if there is a concern for more extensive facial injuries. Concerning symptoms, as previously noted, should prompt providers to order imaging. More recently, ultrasonography has been explored to help aid in the diagnosis of nasal bone fractures but proved inferior to CT.
Laboratory evaluation is generally not required in a simple nasal bone fracture or septal hematoma. A complete blood count and coagulation studies may be considered in patients with epistaxis who have lost a considerable amount of blood or who take anticoagulant medication. Patients with persistent clear rhinorrhea can have this collected and sent for beta-2-transferrin, which can be used to help confirm a CSF leak.
Treatment / Management
Initial management should include control of epistaxis and closure of any lacerations of the external skin or internal nasal lining whenever possible. Epistaxis may be conservatively controlled with digital pressure, pushing the nasal alae against the septum. More serious epistaxis may require cauterization or nasal packing.
Observation without surgical intervention is recommended in patients who do not have an obvious cosmetic deformity or nasal obstruction. Conservative measures such as elevating the head and icing the area are recommended until local edema subsides. Patients should be closely followed within three to five days for reexamination, as nasal deviation can be unmasked with the resolution of edema.
Closed reduction of nasal bone and septal fractures is generally recommended for fractures that cause nasal deviation or airway obstruction. It may be performed under local anesthetic or minimal sedation, but general anesthesia is most often preferred due to improved airway protection and overall patient comfort. Timing of closed reduction is varied in the literature, with some sources advocating early intervention within five to seven days, while others state that edema should completely resolve, and closed reduction should be performed within one to two weeks of injury. After two weeks, patient satisfaction with cosmetic outcomes significantly decrease. Later intervention risks callus formation and difficulty reducing nasal bones into their premorbid location. In this case, an endonasal or percutaneous open reduction can be performed using osteotomies. In a typical closed reduction, a flat, broad instrument such as a Boies or Sayre elevator is introduced endonasally to reduce fractures with a postoperative splint applied to the nasal dorsum.
Closed reduction may also be performed on the nasal septum using a Boies elevator or Asch forceps. If adequate reduction of the nasal septum cannot be performed in a closed fashion, some have advocated for an open septoplasty in the acute setting, showing that patients have significant improvement in nasal obstruction postoperatively. Intranasal splints or packing may also be used to help keep the septum reduced, but this is typically not used unless a septoplasty has been performed. Septoplasty is avoided if there is significant mucosal disruption along the septum due to the risk of postoperative septal perforation.
An open septorhinoplasty is generally avoided in the acute setting as there are frequently nasal lacerations or cartilage disruptions. Further dissecting these cartilage structures can devascularize them in the acute setting, and any cartilage grafts may be more susceptible to infection and rejection. It is therefore often recommended septorhinoplasty be delayed 3 to 6 months post-injury.
The differential diagnosis for nasal bone fractures should include bony injuries to the surrounding facial skeleton. These include the following:
Nasoorbitoethmoid (NOE) Complex Fracture
- These are nasal bone fractures that extend posteriorly into the ethmoid air cells and involve the medial canthus of either or both eyes. The hallmark of this condition is telecanthus.
- An orbital fracture is suggested by periorbital edema or ecchymosis. In the case of an orbital floor fracture, patients may have hypoesthesia of the cheek or limitation in ocular movements.
Skull Base Fracture
- High-velocity impacts can cause fractures of the skull base. Patients can have characteristic bilateral periorbital ecchymosis or “raccoon eyes,” as well as bilateral postauricular ecchymosis, which is also known as “Battle's sign.” Patients with skull base fractures are at higher risk for CSF leak.
Patients typically recover well after the reduction of nasal bone fractures, but there is a great variance in the success of surgical intervention. Nasal deformity remains present in 9% to 50% postoperatively. This may be improved by adequately addressing nasal septal fractures or deviations at the time of injury. Residual deformity or nasal obstruction may be adequately addressed in a delayed fashion with a septorhinoplasty. Patients are at higher risk for need for revision surgery if they had nasal deformity or nasal obstruction before a nasal or septal fracture.
Residual nasal deformity is present in varying amounts following surgery.
Saddle nose deformity and septal perforations are dreaded complications after septoplasty, septal hematoma, or severe septal injury.
Olfactory disturbances are relatively common, occurring in up to one-third of patients with nasal bone fractures. This may be due to the manipulation of the olfactory neuroepithelium during closed reduction, which can be present on the superior or supreme turbinate.
Postoperative and Rehabilitation Care
External and internal nasal splints should be removed within one week. If nasal packing was placed, it is commonplace to place patients on antibiotics to prevent toxic shock syndrome. Strenuous activity should be avoided, and physical activity that could result in further trauma to the nose should be avoided in the acute setting. Nasal hygiene with saline sprays should be performed to prevent recurrent epistaxis. It will be important for close follow up to monitor for residual nasal deformity or obstruction, which may necessitate revision surgery.
Initial consultations should be with a surgeon comfortable managing the spectrum of facial trauma. This generally includes an oral maxillofacial surgeon, otolaryngologist, or plastic surgeon.
Deterrence and Patient Education
It is very important to set expectations prior to surgery regarding nasal bone fractures due to the possibility of residual deformity or nasal obstruction. It is also important to educate patients that close follow-up is necessary, as initial surgery is best performed early on. Further education on wearing seatbelts or protective equipment during sporting events may help in the prevention of further nasal trauma.
Pearls and Other Issues
- The nasal bones are the most frequently fractured bone in the maxillofacial area.
- A high percentage of patients with nasal bone fractures also have an injury to the nasal septum, which may go unrecognized.
- Imaging studies should be avoided in isolated nasal bone fractures unless history or physical exam suggest more extensive injuries.
- Closed reduction of the nasal bones is best performed before 2 weeks to achieve better cosmetic outcomes.
- Septoplasty should be considered in the acute setting for a severely deviated or fractured septum without extensive mucosal injury.
- Septorhinoplasty for residual nasal deformity or nasal obstruction should be delayed 3 to 6 months to allow lacerations and cartilaginous injuries to heal.
Enhancing Healthcare Team Outcomes
Nasal bone fractures are a very common injury that may have lasting effects on the function and appearance of a patient’s nose. These patients must be referred promptly to a provider that manages facial trauma. Early treatment with closed reduction may prevent more extensive surgery in the future. Emergency room physicians or primary care providers are typically the first providers that these patients encounter. Recognizing concerning symptoms and early communication with a facial trauma specialist may serve to improve outcomes in these patients. [Level 3]