Nasal Bone Fractures

Most frequently fractured bones in the maxillofacial region due to their relative weakness and prominence on the face.
Associated with nasal septal fractures in 42% to 96% of cases.
Impact both cosmetic appearance and nasal airway function.

Structural Support of the Nose:
- Composed mainly of cartilage, bone, and skin.
- Nasal Bones:
  - Paired bones attached to the frontal bone superiorly and the frontal processes of the maxillae laterally.
  - Attached at nasofrontal and nasomaxillary suture lines.
  - Thicker above the level of the medial canthus.
- Nasal Septum:
  - Consists of bone posteriorly and cartilage anteriorly.
  - Bony Septum:
    - Superiorly formed by the perpendicular plate of the ethmoid bone.
    - Inferiorly formed by the vomer.
  - Cartilaginous Septum:
    - Anterior portion formed by the quadrangular cartilage.
    - Supports the nasal dorsum from the keystone area to the supratip.
- Keystone Area:
  - Major structural support of the middle one-third of the nose.
  - Located at the bony-cartilaginous septal junction, inferior to the rhinion.
  - Upper lateral cartilages articulate with the caudal edges of the nasal bones and attach to the dorsal margin of the cartilaginous septum.
  - Septum attached to the nasal floor anteriorly at the nasal spine and posteriorly at the nasal crest of the maxilla and palatine bones.

Initial Trauma Survey:
- Address airway, breathing, circulation, and disability (ABCDs).
- Perform a thorough history and secondary physical examination after life-threatening issues are managed.
History:
- Determine the mechanism of trauma.
- High-energy impacts, such as motor vehicle accidents, may cause severe injuries and multiple facial fractures.
- Direction of impact influences the fracture pattern (lateral blows vs. frontal impacts).
- Assess premorbid appearance for any noticeable deviation or deformity.
- Evaluate breathing difficulty, indicating potential septal or intranasal injury.
- Inquire about prior nasal trauma or surgeries.
- Symptoms indicating extensive injuries: telecanthus, diplopia, vision loss, clear rhinorrhea, malocclusion, facial weakness, numbness.
Physical Examination:
- Assess the entire head and neck region.
- Use headlamp and nasal speculum or rigid endoscope for thorough nasal examination.
- External nose evaluation: check for lacerations, exposed bone/cartilage, and deviations.
- Palpate nasal tip for support assessment.
- Evaluate nasal dorsum for saddle nose deformity.
- Intranasal examination: rule out septal hematoma, significant septal dislocations, intranasal lacerations, mucosal disruptions, and clear rhinorrhea (CSF leak).

Imaging:
- Generally not warranted for simple nasal bone fractures.
- Plain film X-rays are typically not useful.
- CT Scan:
  - Gold standard for evaluating bony trauma if there is concern for extensive facial injuries.
- Ultrasonography:
  - Studied but found inferior to CT scanning for diagnosing nasal bone fractures.
Laboratory Evaluation:
- Not required for simple nasal bone fractures or septal hematomas.
- Complete blood count and coagulation studies for patients with significant epistaxis or on anticoagulants.
- Beta-2-transferrin test for persistent clear rhinorrhea to confirm or rule out CSF leak.

Initial Management:
- Control epistaxis: conservative measures (digital pressure), cauterization, or nasal packing if severe.
- Close any external skin or internal nasal lining lacerations.
Observation:
- Recommended for patients with no cosmetic deformity or nasal obstruction.
- Conservative measures: elevate head, ice area until edema subsides.
- Reexamine within 3 to 5 days as nasal deviation may be unmasked with edema resolution.
Closed Reduction:
- Indicated for fractures causing deviation or airway obstruction.
- Performed under local anesthesia, minimal sedation, or general anesthesia (preferable for airway protection and patient comfort).
- Timing: early intervention within 5 to 7 days or after edema resolution within 1 to 2 weeks. After 2 weeks, satisfaction with cosmetic outcomes decreases.
- Techniques: use flat, broad instruments (e.g., Boies or Sayre elevator) for endonasal reduction, apply postoperative splint to nasal dorsum.
- Closed reduction of nasal septum: use Boies elevator or Asch forceps. Open septoplasty if closed reduction is inadequate.
- Avoid open septorhinoplasty in acute setting due to risk of devascularization and complications; delay 3 to 6 months post-injury.
- CT guidance for osteotomies in healed fracture lines as an adjunct months to years post-injury.

NOE Complex Fracture:
- Extends into ethmoid air cells and involves medial canthus.
- Traumatic telecanthus is a hallmark.
- Occurs in all LeFort type III midface fractures.
Orbital Fracture:
- Indicated by periorbital edema or ecchymosis.
- Orbital floor fracture may cause cheek hypoesthesia or ocular movement limitation.
Skull Base Fracture:
- Caused by high-velocity impacts.
- Symptoms: bilateral periorbital ecchymosis (“raccoon eyes”), postauricular ecchymosis (“Battle’s sign”).
- Increased risk of CSF leak and spinal fracture.

Residual nasal deformity after reduction of nasal bone and septal fractures.
Saddle nose deformity and septal perforations post-septoplasty or severe septal injury.
Olfactory disturbances in up to one-third of patients due to manipulation of olfactory neuroepithelium during closed reduction.

Remove external and internal nasal splints within 1 week.
Oral antibiotics for patients with nasal packing to prevent toxic shock syndrome.
Avoid strenuous activity and further nasal trauma in the acute setting.
Perform nasal hygiene with saline sprays to prevent recurrent epistaxis.
Close follow-up to monitor for residual deformity or obstruction, which may require revision surgery.