Nasal bony fractures are the most common type of facial bone fractures representing 40% to 50% of cases. Nasal fractures are commonly associated with physical assaults, falls, sports injuries and road traffic accidents. The bony nasal trauma may be isolated injuries or may occur in combination with other soft tissue injuries, and other facial bony injuries.  The protrusion of the nasal bones and the central location on the face predisposes the nose to injury. Nasal fractures are found to be twice as common in males compared to females. Although nasal fractures tend to be the most common types of facial fractures, they may be associated with fractures of the zygomatic-orbital complex and fractures of the skull base; these should not be missed when assessing the patient.
Anatomy and Physiology
The nose is made up of a bony and cartilaginous framework. The bony nasal pyramid consists of paired nasal bones and the frontal process of the maxilla bilaterally. Cartilaginous structures include the upper and lower lateral cartilages and the septum. Both of these frameworks are susceptible to fracture.
Nosebleeds are common with nasal fractures. The blood supply to the nose originates from the ophthalmic artery, which is a branch of the internal carotid artery, branching to give the anterior and posterior ethmoidal arteries and the facial and internal maxillary arteries from the external carotid artery. Trauma to the nose may cause anterior septal bleeding from Kiesselbach's plexus. The Kiesselbach plexus is on the anteroinferior nasal septum and is formed by the anastomosis of the following arteries:
The anterior ethmoidal artery which is a branch of the ophthalmic artery
The sphenopalatine artery which is a branch of the maxillary artery
The greater palatine artery, also a branch of the maxillary artery
The superior labial artery, a branch of the facial artery
This plexus of vessels is important as more than 90% of patients presenting with epistaxis, will be found to be bleeding from this area.
Trauma to the nasal bones can also cause transection of the anterior ethmoidal artery with resultant brisk, heavy intermittent bleeding. This may require the artery to be clipped.
With nasal fractures, associated fractures of the orbits, maxillary sinus, ethmoid sinus, and cribriform plates are all possible.
Classification of Nasal Trauma
Nasal fractures can be classified on a scale depicting the severity of the injury. An isolated nasal fracture is usually caused by low-velocity trauma. If the nose is fractured by high-velocity trauma then facial fractures are often an accompaniment.
Type IIa: Simple, unilateral nondisplaced fracture
Type IIb: Simple, bilateral nondisplaced fracture
Type III: Simple, displaced fracture
Type IV: Closed comminuted fracture
Type V: Open comminuted fracture or complicated fracture
The history of the injury should document the mechanism of the injury, the direction of the forces and documentation of any prior nasal fractures and surgeries.
In the acute phase, the simple application of ice and analgesia may be suitable. More severe facial trauma will require assessment and stabilization of the airway, using appropriate Advance Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) protocols.
A general examination is always performed to rule out severe, life-threatening conditions.
Inspection of the Nose and Face
Deformity and swelling
The shape of the nose: loss of anterior projection of nose with increased intercanthal distance suggests naso-orbital-ethmoid fracture
Eye movements: blowout fracture may cause extra-ocular muscle entrapment
Tenderness: Widening of the tip of the nose and nasal obstruction may represent a septal hematoma
Orbital rim step-off
Examination of Nares
Elevate the tip of the nose to get a good view
Use a headlight/thudicums nasal speculum or an otoscope/speculum
Swelling to the septum which is boggy to touch with a cotton bud, and which has a blue/purple appearance is a septal hematoma and will require emergency drainage
The presence of clear nasal fluid may indicate a CSF leak from an associated basal skull fracture
Mid-face instability or dental malocclusion is indicative of a midfacial Le Fort fracture
Imaging for isolated nasal fractures is rarely needed. CT scans are performed for suspected head injuries, basal skull fractures or complex facial injuries.
Soft Tissue Injury
Nasal wounds are cleaned and foreign bodies removed. Small lacerations can be closed with porous surgical tape strips or with fine sutures.
Reduction of nasal fractures is not always required. If there is no fracture, or no deformity or the patient is happy to live with a minor deformity then nothing further needs to be done. If swelling interferes with an adequate examination, the patient should be reassessed after 5 to 7 days. Manipulation should never be delayed more than 2 weeks following injury as the nasal bones heal and fixate: manipulation at this stage will be difficult or impossible. After this time only a formal septorhinoplasty would be possible.
This is caused by a collection of blood underneath the mucoperichondrial layer of the nasal septum. it normally presents with pain and nasal obstruction with a boggy swelling to the septum. If not managed this can lead to a septal abscess, cartilage necrosis and even a nasal saddle deformity can ensue. Aspiration with a syringe and needle may suffice. Some cases may require formal drainage in the operating theatre with an insertion of a small drain or the use of quilting sutures (to obliterate the dead space) to prevent recollection.
Cerebrospinal Fluid (CSF) Leaks
Clear rhinorrhoea following nasal trauma should raise the suspicion of a CSF leak. The cribriform plate is thin bone and a likely area to fracture. Confirmation of diagnosis is obtained by sending a sample of the clear fluid for beta-2 transferrin assays. A high-resolution CT may help delineate the fracture.
Severely comminuted fracture of the nasal bones and septum
Open septal fractures
Fractures examined 3 to 4 weeks or longer after the initial injury
Topical decongestant: Oxymetazoline, lignocaine with phenylephrine spray
Local anesthetic infiltration
Consideration of Anesthesia
Many studies have been carried out looking at general anesthetic vs. local anesthesia for reduction of nasal fractures. The main concerns regarding cooperativeness should be assessed preoperatively. Pediatric patients pose additional challenges and should be done under general anesthetic. Most adults with type IIa to type IV fractures can be successfully reduced with a combination of topical and infiltrative local anesthesia.
Local Anaesthetic Reduction
Nasal fracture reduction with a combination of topical and local anesthetics, in an outpatient/office setting, is, in the majority of cases well-tolerated with regards to pain. Results are comparable to having it done under general anesthetic. Topical agents can be applied with pledgets. The local anesthesia injection is infiltrated along the lateral aspects of the nasal bones, the premaxilla, and intranasally along the septum. Key injections to the infraorbital nerve, infratrochlear and V1 branch of trigeminal nerve can provide additional field blocks.
General Anaesthetic Reduction
The patient needs to be seen within 5 to 7 days of the injury to allow enough time for nasal swelling to settle.
This is the most straightforward approach, with success rates of 60% to 90%. it is usually reserved for simple noncomminuted fractures. The fundamental principle is to apply a force opposite to the vector of trauma to achieve fracture reduction. Depressed segments of nasal bone can be reduced using an elevator. Alternatively, Walsham's forceps can be inserted into the nasal cavity and rotated laterally to out fracture the bones. A force in the opposing direction can digitally manipulate laterally displaced segments of the bony pyramid. Remember that sometimes with fractures the fracture line has to be widened first and then closed especially if bones are overriding each other. Attention should be paid to the nasal septum here, and where possible, the septal base should be repositioned into the vomerine groove. Patients should be prepared for the possibility that a future septorhinoplasty may be required with reoperation rates of 9% to 17%.
All nasal bone reductions should wear a dorsal splint for 7 days. Not only does it help hold bones in place but reminds the patient and others around them to be careful as the bones can quite easily displace again. Most closed reductions do not require internal splints, but they have been used in comminuted fractures, septal dislocation, and with inwardly collapsing nasal bones.
Fractures that cannot be reduced by closed techniques are candidates for formal open reduction via an open septorhinoplasty. Sometimes the injuries between bones and cartilages may be complex and fixing one without the other will leave the patient with ongoing nasal breathing issues. The greater exposure and direct visualization is a major benefit over closed reduction. One may need to wait 4 to 6 months after the initial injury to allow tissues to settle before formal open septorhinoplasty can be considered.
Avascular necrosis of nasal septal cartilage leading to saddle deformity
Blowout fractures: Extraocular muscle entrapment and diplopia
Nasolacrimal duct injury: Due to the close relationship of the duct to the nasal bones
Fracture of cribriform plate and cerebrospinal fluid (CSF) rhinorrhoea
Inability to reduce: Fractures that cannot be reduced by closed techniques are candidates for open reduction.
Traumatic nasal fractures occur commonly. A closed reduction under local anesthesia or general anesthetic is appropriate in uncomplicated cases. Time is of the essence to reduce these due to fractured bones fusing within their current position. Open septorhinoplasty is sometimes required to deal with a persistent nasal deformity or nasal obstruction.
Enhancing Healthcare Team Outcomes
Nasal fractures can be managed with relatively good outcomes in the vast majority of patients. There can be outliers to this mainly in the elderly and pediatric population. Furthermore, the timing of the nasal injury greatly influences the outcome. Treatment of nasal injuries begins with excellent preoperative screening and having the appropriate diagnosis. For long term aesthetic and functional results the surgeon needs to deal with the bony, septal and cartilaginous deformities together to have a good outcome.
(Click Image to Enlarge)
The Organ of Smell, Cartilages of the nose, Side view, Lateral; Greater; Lesser Alar Cartilage, Cartilage of Semptum
Contributed by Gray's Anatomy Plates
(Click Image to Enlarge)
A 32-year old male had naso-orbito-ethmoid (NOE) fracture repair 12 months ago, after a motor vehicle accident. He had open repair of his nasal fractures and transnasal wires placed. He now presents with a complaint of intermittent tearing from the right side since the surgery and a mucoid discharge from the left side. Photos show appearance at time of injury (above) and appearance 12 months after repair.
Contributed by Prof. Bhupendra C. K. Patel MD, FRCS
Swenson DM,Yard EE,Collins CL,Fields SK,Comstock RD, Epidemiology of US high school sports-related fractures, 2005-2009. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2010 Jul; [PubMed PMID: 20606515]
Hwang K,Jung JS,Kim H, Diagnostic Performance of Plain Film, Ultrasonography, and Computed Tomography in Nasal Bone Fractures: A Systematic Review. Plastic surgery (Oakville, Ont.). 2018 Nov; [PubMed PMID: 30450348]