Nasal Fractures

EPIDEMIOLOGY

-of maxillofacial fractures, nasal fractures constituted 39%.

- males in favor by 2 to 1 and higher incidence 15- to 30-year age group

PATHOGENESIS

-nasoethmoidal complex has a maximum tolerable impact force before fracture of 35 to 80g.

-- 80% of #’s occur at transition zone b/w thicker proximal & thinner distal segments in lower1/3- 1/2 of the nasal bones

- upper lateral and lower lateral cartilages; dislocation, displacement, or avulsion injuries are more common than true fractures. vs cartilaginous septum(high incidence of fracture-dislocations)

CLASSIFICATION

Concept of forces of impact and levels (planes) of destruction. A, With frontal forces, fracture can involve (1) nasal tip; (2) nasal dorsum, septum, and anterior nasal spine; and (3) frontal processes of maxilla, lacrimal, and ethmoid bones. B, With laterooblique forces, fractures can involve (1) ipsilateral nasal bone; (2) contralateral nasal bone and septum; and (3) nasal bones, frontal processes of maxilla, and lacrimal bone.

Stranc and Robertson (1979)

Frontal types (ie: frontal impact)

Plane 1:

-injuries do not extend behind line from lower end of nasal bones to anterior nasal spine.

-majority of impact is transmitted to lower cartilaginous vault and tip of nasal bones. -avulsion injuries of upper lateral cartilages +/- post dislocation of septal & alar cartilages Plane 2:

- injuries involve both external nose, nasal septum, anterior nasal spine.

- More extensive deviations of nasal bones (splaying apart) and septal cartilage (mucoperichondrial tears, segmental overiding, or loss of central support)

Plane 3:

- injuries: nasal bones, orbital, frontal processes of maxilla, ethmoids, lacrimal bones

+/- intracranial structures.

-nasal septum injuries are severe,(collapse and telescoping of septal fragments).

Subclassifcn:

- fractures of nasal tip and anterior nasal spine, comminuted nasal fractures

Lateral types ( ie lateral impact injuries)

-more common injury pattern (approx 66% of all #’s)

- depression of ipsilateral nasal bone occurs,

(esp lower half of nasal bone, part of nasal process of maxilla, and pyriform margin).

+/- septal # or lateral displacement of contralateral nasal bone depending on force severity

Septal injuries classified as:

- dislocation, fracture, or fracture-dislocation (Holt, 1978).

Deformity following nasal trauma

hump, a wide nasal dorsum, depresson of the nasal dorsum, depression of the cartilaginous tip, deviation of the nose, splaying of the tip, saddle deformity, and columella retraction.

Septal deflections, spurs, and complex angulations can also occur.

DIAGNOSTIC ASSESSMENT

History

-The blow(s): location, magnitude, and direction of

-nose before injury (appearance and function)

-previous injuries to nose (30% of patients had pre-existing nasal deformities).........Photographs

-focal symptoms: nasal obstruction, loss of smell (anosmia or hyposmia), nasal bleeding

-local symptoms: visual acuity, diplopia, regional anesthesia/hypoesthesia, or epiphora

CSF leak, maxillary injury (malocclusion & sensory deficits in cheek & teeth)

-PMHx: (nasal allergy, sinusitis) previous septonasal surgery, systemic

Physical examination

-nb: more accurate external examination is possible after resolution of swelling 2 to 4 days after injury.

-intranasal preparation Þ Cophenylcaine.

-external nose examine from:

-frontal view and from both sides in oblique and lateral views.

-Changes in dorsal contour ( humps, elevations or depressions)

-Abnormal shortening (suggests loss of central support and telescoping of cartilage)

often coexists with a retracted columella, Ý columellar-labial angle, widening of nose base.

-palpation of: -bony pyramid (check for mobility, crepitance, specific areas of tenderness).

-anterior nasal spine (via sublabial route)

-ascending processes of maxilla and adjoining orbital rim

-bimanual exam of frontal process of maxilla using finger and hemostat to assess stability

-intranasal anatomy: -positioning, stability, movements of upper / lower lateral cartilages

-mucosal lacerations.

-septum (check for discoloration, dislocation, abnormal swelling)

-if ??? septal hematomaÞ aspirate

-bimanual palpation, using cotton-tipped applicators (assesses mobility)

Radiographic evaluation

-high incidence of false-positive and false-negative interpretations

-greatest weakness in using plain films is their inability to evaluate injury for appropriate management.

-McArthur (1971) found a correlation between fracture and need for reduction in only 10% (2 of 20),

-when associated midfacial injuries are suspected after physical assessment, Þ facial x-ray series.

-CT when extensive fractures are present.

MANAGEMENT

Control of bleeding

-Cophenylcaine +/- packing

Timing of reduction

-5 to 10 days after injury nasal bones become somewhat adherent and difficult to move.

-Fixation is observed within 2 to 3 weeks if patient is young and healthy.

-fracture fixation in children requires only 25-50% of time it requires in adults.

-usual recommendation for closed reduction is:

-3-7 days for children

-5-10 days for adults.

-In patients with very little swelling, early reduction can be performed.

Open versus closed reduction

-if closed reduction is not maintained, open reduction can be done months later by septorhinoplasty.

-Open techniques may be used when it is apparent that attempts at closed reduction are inadequate

nb: open approaches should e preserve cartilage, mucoperichondrial flaps and investing soft tissue.

Prophylactic antibiotics and decongestants

-prophylactic antibiotics are desirable b/c most nasal fractures are associated with lacerations of mucosa & protection against infection if a hematoma should form.

-saline irrigations also useful to maintain humidification and to clean mucosa.

-decongestants can be added if obstruction of nose or paranasal sinuses occurs.

Anesthesia

-child or young adult Þ GA

-simple nasal fractures in adults can usually be managed with topical & local anesthetics. + sedation.

-cotton pledgets moistened in 8 cc of 4% cocaine + 5 drops of 1:10,000 epinephrine

-pledgets are placed: -beneath nasal dorsum (ethmoidal nerves),

-at posterior edge of middle turbinate (sphenopalatine nerve),

-along septum,

-on floor of nose for 10 minutes

-infiltrate a local anesthetic to provide external nasal anesthesia and vasoconstriction.

Sites for injection of local anesthesia:

1, above nasal bones and beneath skin of dorsum to block infratrochlear nerve;

2, into the infraorbital foramen bilaterally to block infraorbital nerve;

3, greater palatine nerve at incisive foramen;

4, nasal tip & base of columella.

-nb:Profound local anesthesia is rarely achieved in a recently injured nose because tissue acidosis

interferes with conversion of anesthetic agents to their active state (Clark, 1983).

-alternative technique using topical anesthesia for simple fractures in adult combination of:

-EMLA cream applied externally (each gram containing equal parts of lignocaine & prilocaine) -plus intranasal cocainization.

-nb: need to wait 1 hour following topical application.

REDUCTION AND FIXATION

Closed techniques

-fractures involving bony nasal pyramid are reduced first, then reduction and stabilization of the septum.

-simple, depressed, unilateral, nasal bone #, an elevator is inserted into nose under depressed fragment nb: depth of insertion is determined by measuring distance from alar rim to depressed segment.

-steady outward & forward pressure should be applied.

-Walsham's forceps are used to grasp and manipulate the nasal bones directly.

-Asch's forceps are used to elevate dorsum and disimpact displaced septum simultaneously

-Deformities of bony pyramid that persist despite efforts at manual reduction imply incomplete

(greenstick type) or impacted fractures or may indicate pre-existing deformities.

-significantly comminuted bones may present problems needing internal splinting (eg small high pack)

-dislocated septum is best managed by first elevating the nasal pyramid and then applying pressure

directly to the displaced portion of the septum to move it back into its proper position.

-Following reduction of fractures of nasal bones and septum, stabilized with small amounts of packing and/or septal splints & external suppport.

-All packing and splints are removed 5 days after the reduction.

-Normal saline douches or Ocean Mist nasal spray reduces crust formation.

-results of closed reduction as reported in many series have been disappointing (Bowers/Lynch, 1970;

Dickson and Sharpe, 1986; Harrison, 1979; Mayell, 1973; Moran, 1977). Murray /Maran (1980)

reported a failure rate of 20% to 40%.

Open reduction

-indicn: when nasal bones are comminuted and fail to reduce properly

-Exposure thru either intercartilaginous or intracartilaginous incisions extended into hemitransfixion.

-dorsal nasal skin is elevated from upper lateral cartilages in supraperichondrial plane, with further cephalad dissection proceeding in subperiosteal plane to expose nasal bones directly.

nb: care with lateral undermining, elevate soft tissue only slightly beyond the fracture lines.

-small osteotome is tapped into fracture lines & nasal bones are gently mobilized & moved into positn.

-lateral # lines are approached thru small pyriform margin incisions anterior to inf turbinate attachment.

-goals of treatment include:

-conservative debridement of any devitalized tissues,

-extraction of periosteum and soft tissues from the fracture sites,

-proper reduction-stabilization of fractured segments.

-if a closed nasal fracture requires direct access, Þ elective transverse incision at nasofrontal angle

-primary bone grafting can be considered +/-screw fixation

COMPLICATIONS

Septal hematoma

-persistent nasal pain and excessive swelling of the septum.

Nasal dorsum hematoma

-due to tearing of upper lateral cartilages from the nasal bones.

-hematoma must be evacuated through external or internal incisions, + AB’s.

Infection

-rare (persistent pain, swelling, and redness)

External and internal deformities

-residual deformity and/or nasal obstruction after closed reduction

these need open septorhinoplasty usually 3 to 6 months after injury, once all swelling has disappeared and the bones have become completely stable

-In children, the timing of revisional surgery is somewhat controversial.

-if minimal deformity, Sx delayed until child is 15-16 yrs when facial growth is nearly complete. -if significant deformity or dysfunction exists, early precise intervention is indicated.

Bibliography:

Cummings, C. Otolaryngology. 

Gates G, Current Therapeutics.