24. nasal fractures

8/12/2019 24. Nasal Fractures

1/3

Amit Patel OMFS PGY 1

Chapter 24: Nasal Fractures

Most frequently fractured bones of the face.

Less force required to fracture this area than any other facial bone.

Seemingly simple approach to management

Incident of unfavorable results are as high as 62%.Etiology factors

Motor vehicle collision

interpersonal altercations

Sport-related injury

A.Surgical Anatomy

Nasal mucosa and turbinates

Upper and lower cartilages

Cartilaginous and bony septum in middle

Primary support mechanism of nasal complexAnterior: cartilage (thicker posteriorly)

Posterior: ethmoid and vomer bones

Paired nasal bones

Cephalically: Nasofrontal suture

Caudally: Upper lateral cartilages

Laterally: Frontal processes of maxilla

Vascular supply

Arteries

Interna carotid branches

Ophthalmic >>> Anterior and posterior Ethmoid arteriesExternal Carotid branches

Superior labial, angular, sphenopalatine, and greater palatine arteries.

External nose: Facial artery > angular artery

Veins follow arterial pattern. Significant for direct communication with cavernous sinus and lack of

valves.

Innervation

Second division (Maxillary) of the Trigeminal nerve

B.Clinical and Radiographic Diagnostic Tools

Address life threatening and major organ injuries firstObtain complete history

Mechanism and timing of injury

Force perpendicular to nasal dorsum >>> bony complex fractured laterally

Force lateral to nose (Right handed punch to left side of nose) >>> bony complex will deviate

away from vector of force with one nasal bone medially displaced and other laterally displaced.

Previous nasal trauma or preexisting nasal deviations

Examination

Epistaxis common

Clinical signs of nasal complex fracture


2/3


Periorbital ecchymosis

Nasal swelling

Nasal complex deviation

CSF rhinorrhea

Lack of Nasal projection

Increased intercanthal distance

Mobility or crepitus upon palpationAnosmia (difficulty smelling) - Late findingoccurs if cribriform plate of ethmoid bone is involved

Internal exam with good lighting, speculum and suction

Intranasal laceration

Septal deviation off the nasal crest of maxilla

Nasal septal hematoma

Must be drained to prevent vascular complications associated with devitalized cartilage pre-

disposing to the development of septal perforation.

If cribriform plate of ethmoid bone is fractured >>> perform double-halo test to ascertain presence

of CSF.

Imaging: CT scan without contrastClearly delineates nasal bone injuries and septal deviations and fractures

Premorbid photographs are helpful for documentation and comparison purposes.

Classifications

Open vs Closed

Fracture through an external or internal laceration

Deviated vs Non-deviated

Appearance of nasal bones and septum

Comminuted vs Non-comminuted

Status of nasal bones and surrounding bony pyramid (frontal process of maxilla anterior nasal

spine, ethmoidal bones)

C.Surgical Management

Goals

Prevent development of post-traumatic nasal deformity

Restoration of proper nasal air flow

Prevention of cosmetic deformity

Maintenance of proper nasal complex topography and projection

Restoration of sense of smell.

Treatment can be performed under local anesthesia , conscious sedation or general anesthesia

Most efficient and comfortable method: Repair under general endotracheal intubationClose reduction of nasal complex is most commonly performed procedure

Incidence of patient requiring post-traumatic rhinoplasty >>> 9% - 62%

Procedure:

Intubation

Thorough manual examination of nasal complex

Assess and note crepitus, mobility, depressions, asymmetries, perinasal lacerations, etc

Intranasal exam

Via Endoscopy or nasal speculum and good lighting

Inject local anesthesia and vasoconstrictor into nasal cavity


3/3


Pack nasal cavity with Cottonoid strips soaked in vasoconstrictive solution >>> improves intranasal

visualization

Examination of cavity after 10-15 minutes

Used nasal reduction forceps to reduce nasal ones and septum fractures in appropriate vector

Intranasal packing/splint to maintain reduction

If not successful >>> Perform extensive procedures such as septoplasty (with or without harvest of

cartilage) or bony osteotomies.Septoplasty

Approached through hemitransfixion incision

Maintain all septal cartilage at initial repair

May be of use in post-traumatic nasal deformity repair

If nasal septum deviates off of ANS, subperichondrial and subperiosteal dissections must be per-

formed in ANS region >>> manually separate septum from ANS >>> reattach septum to ANS using

sutures.

Bony vault deviation not repaired with close reduction may require open reduction or osteotomies.

Callus forms after 10-14 days

Transoral approach to nasomaxillary buttresses, frontal processes of maxilla and nasal bones mayfacilitate Open reduction with or without internal fixation

Approaching bones through perinasal lacerations is also acceptable

Use intranasal packing/splint to maintain mobilized bony segments in place5 days

Use external splint: aid in elimination of dead space and maintenance of reduction7 days

D.Postoperative care and complications

Recommend prolonged antibiotics when internal nasal packings used.

Recommend sinus precautions

Incidence for residual nasal deformity after close reduction: up to 62%

Follow patientsprogress to ensure acceptable functional and cosmetic outcomeWait up to 1 year before addressing residual post-traumatic deformity

Grossly deviated nose 1 months s/p repair will remain grossly deviated 1 yr s/p repair.

Post-traumatic rhinoplasty is recommended earlier in such cases.

24. nasal fractures

Documents