Within 1–3 hours of the time of injury before significant edema has developed, simple closed fixation of nasal fracture is possible given a cooperative patient and uncomplicated clinical findings. However, patients rarely present this early and often require reevaluation within 3–7 days to allow for extensive facial edema to subside. In adults, closed reduction can be performed within 5–11 days after injury before the fractured nasal skeleton becomes adherent and difficult to manipulate, with fixation occurring in 2–3 weeks. In children, healing is more rapid, with adherence and fixation occurring in roughly half that time. Thus, given a significant therapeutic delay, the necessity for osteotomy and bony reconstruction becomes more likely, which is a particular concern for the pediatric population. Regardless of patient age, however, severe nasal trauma that results in more significant injury, such as septal hematoma, open fractures, or associated fractures of the midface and cranium, requires immediate surgical attention.
In choosing a method of anesthesia to use when repairing nasal fracture, both the severity of the injury and the patient's preference should be considered. General anesthesia is necessary for significant trauma that requires operative intervention. With simple nasal trauma, local anesthesia, with or without sedation, is generally preferred. Local anesthesia is safer and considered as effective in providing for adequate fracture reduction when compared to general anesthesia. However, with nasal trauma in children, general anesthesia provides more control than is usually provided by an uncooperative minor. In either case, the physician should decide which method would provide the optimal comfort necessary to allow for the application of force necessary to reduce the nasal fracture. It has been our experience that in a properly prepared patient and with an experienced surgeon, local anesthesia using only topical cotton-soaked nasal packs is adequate for comfortable closed reduction and stabilization of most nasal fractures in all age groups. It is necessary to remember that the anesthetic-soaked cotton must be placed superiorly between the nasal bones and the septum rather than along the inferior septum or along the inferior turbinates, as is commonly done for other intranasal interventions.
Closed reduction is safe and easy to perform. Reasonable cosmetic and functional results are attainable with closed reduction, obviating the need, when applicable, to subject the patient to unnecessary risk, procedure, and cost. Treatment should be geared toward the best long-term results possible, given the least invasive technique available. However, the failure rate of closed-reduction procedures may require a secondary open reduction or delayed reconstruction, an inevitability that many proponents of primary open reduction strive to avoid.
Ideally, the presentation of injury suitable for closed reduction includes injury in the first plane as either a fracture of the nasal tip or depressed fracture of the nasal bone on one side. To proceed, local anesthesia should be provided along the distributions of the infraorbital and supratrochlear nerves and at the base of the anterior nasal septum. If needed, nerve blocks are achieved using 1–2% lidocaine with epinephrine. Once the nose has been anesthetized, a Boies elevator, the back of a metal knife handle, or even the closed tips of a straight Mayo scissors can be inserted under the depressed nasal fragments to within approximately 1 cm of the nasofrontal angle. Elevation is accomplished by exerting force in the direction opposite to the direction of the fracture. Pressure is then applied externally with a free hand on any segment that is displaced laterally. If manipulation of the fracture proves difficult owing to impaction or locking of the fragments, Walsham forceps may be used to directly manipulate the nasal bones and facilitate reduction. Occasionally, free-hand manipulation of more mobile fragments may be necessary to achieve adequate repositioning. It is common to need to rotate the depressed fragment first medially, then superiorly and laterally, to dislodge it. In many cases, a satisfying “click” is felt as the bone repositions into the proper location.
Adequate closed reduction in the nasal pyramid often allows for the spontaneous reduction in a displaced or fractured septum. If this is not the case, Asch forceps may be used to gently elevate the nasal dorsum and allow for replacement of the septum into its anatomic position. In the case of a difficult reduction, a perichondrial elevator may be required to expose an overriding segment of cartilage for resection.
Structural support after a successful reduction can be provided using cotton pledgets soaked in an appropriate intranasal antibiotic. It is preferable, however, not to leave in any nonabsorbable material; therefore, we recommend small pieces of surgical oxycellulose (eg, Surgicell), if necessary. Silastic splints may also be desirable to stabilize the septum. Externally, Steristrips or other protective tape should cover the nasal dorsum before applying a malleable thermoplastic or plaster splint that has been conformed to the shape of the nasal reduction (Figure 12–2). After approximately 3–5 days, the internal packing can be removed, followed by removal of the external splint by day 7–10 if stability has been accomplished.
Same patient as in Figure 12–1 after closed reduction in nasal fracture in the office with local anesthesia. Note that a thermoplastic splint holds nasal bones in a “straight” reduced position.
The reduction of nasal fractures using open techniques is usually reserved for cases in which either a prior closed reduction has failed or malunion has occurred. Other cases where primary open reduction would be appropriate include third-plane fractures, fractures involving the orbit or maxilla, and Le Fort fractures of the midface. Depending on the indication for open reduction, most cases can be adequately reduced with a standard endonasal rhinoplasty. This approach provides for a more appealing cosmetic result while allowing for direct fragment manipulation. Operative exposure, however, is limited. For cases involving the orbit or injury to the frontal sinuses, an external approach from incisions made distal to the nose may be required. Other more complex fractures may require degloving techniques, a coronal approach, or even a lateral rhinotomy.
In most cases, nasal trauma that requires open reduction involves interlocking segments with dislocation of the quadrangular cartilage or a C-shaped septal deformity. After the appropriate administration of anesthesia, open reduction begins with hemitransfixion of the nasal septum on the affected side and septoplasty. Lateral intercartilaginous incisions are then made, allowing for both elevation of the nasal dorsum off of the upper lateral cartilages and elevation of the nasal periosteum. Lateral fracture lines may be accessed via incisions made at the piriform aperture. Affected cartilaginous segments are then exposed and reduced.
With nasoseptal injury, a Cottle elevator is used to strip cartilage from buckled or telescoping portions of the septum, allowing for the spontaneous return of the septum to the midline. Structural support may be lost with excessive resection, and aggressive periosteal elevation may result in necrosis or subsequent malunion. For C-shaped deformities, separation of the upper lateral cartilages from the dorsal septum is necessary. Once reduction is accomplished, additional support for the septum may be provided with stay sutures placed through the periosteum at the anterior nasal spine and the inferior aspect of the septal cartilage.
If encountered, displacement of the maxilla may require the complete removal of the maxillary crest. Any unstable fragments, as seen with comminuted fractures, can be secured using fine wire or miniplate fixation and a minidrill. Using a “figure 8” configuration, wires should not be palpable below the skin. Intranasal packing is rarely necessary, although prophylactic oral antibiotics are administered for at least 5 days. With septal injury, splints may also be applied.
The treatment of nasal trauma in children must be based on the potential for developmental dysfunction as a result of therapy and the consequences of delayed intervention. In cases of minimal injury, the child's nose may spontaneously return to an anatomic position with only an external splint to protect the nasal dorsum during the healing process. The integrity of the nasal septum, however, is vital to nasal skeletal and anterior maxillary growth and therefore requires specific attention.
Operative intervention is required for nasal septal displacement that results in significant cosmetic or functional impairment. As with the adult population, closed reduction is preferred, although general rather than local anesthesia is usually necessary with children. Simple reductions can often be performed with digital manipulation; otherwise, the standard procedure for closed reduction should be used. Fracture dislocations that do not reduce with closed techniques are approached very carefully, making sure no measures are undertaken that might compromise normal growth and development. Aggressive resection is avoided altogether, and any septorhinoplasty deemed necessary to restore appearance or function is delayed until the teenage years. With reasonable conservative correction of the deformity and restoration of a patent airway, adequate surgical management will not result in a disruption of nasal growth centers or the creation of significant structural abnormalities.