Introduction

Nasal bony fractures are the most common type of facial bone fractures representing 40% to 50% of cases.[1][2] Nasal fractures are commonly associated with physical assaults, falls, sports injuries and road traffic accidents.[3] The bony nasal trauma may be isolated injuries or may occur in combination with other soft tissue injuries, and other facial bony injuries. [4] 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.

Classification[5]

• Type I: Injury restricted to soft tissue
• 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 

Indications

History

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.  

Physical Examination

A general examination is always performed to rule out severe, life-threatening conditions.

Inspection of the Nose and Face 

• Deformity and swelling
• Ecchymosis
• Epistaxis  
• 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

Palpation

• Tenderness: Widening of the tip of the nose and nasal obstruction may represent a septal hematoma
• Deformity
• Crepitus
• Orbital rim step-off
• Infraorbital paresthesia 

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  

Imaging for isolated nasal fractures is rarely needed.[6] CT scans are performed for suspected head injuries, basal skull fractures or complex facial injuries.[7]

Management 

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.

Nasal Fractures

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. 

Septal Hematoma

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.

Contraindications

• Severely comminuted fracture of the nasal bones and septum
• Open septal fractures
• Fractures examined 3 to 4 weeks or longer after the initial injury

Equipment

• Topical decongestant: Oxymetazoline, lignocaine with phenylephrine spray
• Local anesthetic infiltration 
• Headlight 
• Thulium's speculum
• Nasal speculum
• Boies elevator
• Walsham forceps
• External splint 

Technique

Consideration of Anesthesia

Many studies have been carried out looking at general anesthetic vs. local anesthesia for reduction of nasal fractures.[8] 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.[9][10] 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.[9]

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.

Closed Reduction

This is the most straightforward approach, with success rates of 60% to 90%.[11] 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%.[12]

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. 

Open Reduction

Fractures that cannot be reduced by closed techniques are candidates for formal open reduction via an open septorhinoplasty.[13][14] 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.

Complications

• Septal hematoma
• Septal abscess 
• Avascular necrosis of nasal septal cartilage leading to saddle deformity
• Nasal obstruction 
• 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.[13]

Clinical Significance

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.