Chapter 12. Nasal Trauma

• History of recent trauma to midface; should assess mechanism of injury, presence of epistaxis or rhinorrhea, history of previous injury, and new onset of nasal airway obstruction or deformity.
• On examination, note any mucosal laceration, septal disruption, or septal hematoma.
• Depending on severity of insult, must rule out concurrent injury to eyes, lacrimal system, paranasal sinuses, teeth, and oral cavity.

Nasal fracture as a result of trauma to the midface is considered the most common of head and neck fractures. Frequently the result of physical altercation, nasal trauma is most often not life-threatening; however, significant functional and aesthetic impairment may result if these injuries are not accurately diagnosed and addressed in a timely fashion.

The incidence of nasal fracture is high in both adults and children. Of maxillofacial injuries, fractures of the nasal bones account for up to 39–45% of cases reported in adults, and up to 45% of injuries in children. In adults, the highest rates of incidence are found among men, with a 2:1 predominance over cases reported in women. In men, nasal fracture is most often associated with intentional trauma and is clearly more common in the 15- to 25-year age group. In women, nasal trauma is usually the result of personal accidental injury; most commonly the result of falls and is often seen in patients over the age of 60.

In children, a clear gender predilection for injury is less likely, although cases are more often reported in boys. Also, more cases of nasal trauma in children are the result of accidental injury related to sports and play rather than physical confrontation. It is important to note, however, that anywhere from 30% to 50% of all pediatric victims of abuse present with maxillofacial injury, a concern not to be overlooked, particularly when evaluating the possibility of fracture concealed by the presence of facial edema.

Given the central and prominent position of the nasal bones and the significant lack of skeletal support for their position, the nose is particularly vulnerable to fracture as a result of maxillofacial injury. Reports indicate that the amount of force required to create a fracture of the nasal structure is small, possibly as little as 25 pounds of pressure. Superiorly, the structure of the nasal bones thickens with support from the underlying nasal spine of the frontal bone, an area more resistant to injury than the distal, thinning segment of the nose, which is unsupported and much more often the location of a fracture.

Trauma to the nasal cartilage, either from a directed frontal or inferior assault or from an indirect lateral injury, often results in displacement, dislocation, or avulsion rather than true fracture. The physical elasticity and flexible attachments of the nasal cartilage allow for the significant absorption and dissipation of energy, thus preventing considerable injury from a greater amount of force than the bony structure would tolerate. The nasal septum, however, is less apt to avoid injury given its rigid osteochondral junctions, which include the perpendicular plate of the ethmoid bone and the vomer anteriorly and its relatively weak association with the maxillary crest. As such, a higher incidence of true fracture can be found with the cartilaginous septum as a result of trauma to the midface, usually with a vertical orientation caudally and a horizontal orientation posteriorly.

In children, the nasal bones retain their elasticity with stability resulting from development and immature pneumatization. These factors, combined with a child's proportionally smaller nasal bones and proportionally larger cartilaginous structures, produce a greater tendency for cartilaginous injury to occur. However, in most cases of nasal trauma, the nasal cartilage fractures without significant displacement and, given the inherent flexibility of a child's nose, often returns to its anatomic position.

The classification of nasal injuries can be separated into two groups: those created by lateral or oblique impact and those created by frontal impact.

Lateral Injuries

Lateral injury, the more common variety given the absence of structural support on either side of the nasal pyramid, can be divided into three planes, with the extent of involvement dependent on the force of impact. Injury in the first plane results only in fracture of the ipsilateral nasal bone, by far the most common occurrence, which usually results in a visible depression of the bony surface two thirds of the way down its slope. With greater force, injury in the second plane would also involve the contralateral nasal bone and septum. In the third plane, enough force would be provided to fracture the frontal process of the maxilla and the lacrimal bone, possibly resulting in fragmentation, a total dislocation of the nasal architecture, or even injury to the lacrimal apparatus.

With lateral injuries, fractures of the nasal septum usually extend posteriorly into the perpendicular plate of the ethmoid bone, but without extension to the cribriform plate.

Frontal Injuries

Frontal injuries generally require a greater amount of force and are divided into three planes as well. The first plane is limited to the nasal tip and does not extend beyond an anatomic line separating the lower part of the nasal bones from the nasal spine. With most of the impact absorbed by the nasal cartilage, injury usually involves avulsion of the upper lateral cartilages. Posterior dislocation of the septal and alar cartilages is also possible, but less likely. Injury in the second plane includes the nasal spine as well as the nasal dorsum and the nasal septum. Injuries in this plane produce a flattening and splaying of the nasal bones with deviation of the septum, overriding segmentation, mucosal tearing, and fracture of the nasal spine. Injury in plane 3 requires a substantial force of impact and may involve fractures of the orbit or extend to structures within the cranial vault. The nasal bones are often comminuted and associated with fractures of the frontal process of the maxilla, lacrimal, and ethmoid bones, and occasionally the cribriform plate. Fracture and dislocation of the nasal septum are severe, with collapse of the dorsal plane and telescoping of the septal fragments.

The nasal septum may be involved in approximately 20% of all traumatic fractures of the nose. A substantially greater impact, however, whether frontal, lateral or oblique, consistently produces a C-type fracture of the septum just posterior to the nasal spine and extending posteriorly and superiorly into the perpendicular plate. It then changes direction anteriorly, ending just before and below the cribriform plate, along the posterosuperior aspect of the nasal bones. This finding can be demonstrated on physical exam by noting displacement of the caudal septum to one side and deviation of the posterior septum to the other.

Nasal Pyramid

The structure of the nasal pyramid projects anteriorly from the midface, attached to the facial skeleton at its base superiorly. From the apex or nasal tip, the columella projects inferoposteriorly toward the center of the superior lip, adjacent on either side to the nares. Encompassing the border of the nares are the alae of the nose superiorly and laterally, and the floor of the nose inferiorly. At the posterior aspect of the base of the nose is the piriform aperture, bordered superiorly and laterally by the frontal processes of the maxilla and the nasal bones. The inferior portion of the cartilaginous nose, otherwise considered the base of the nose, includes the lobule, which consists of the lower lateral cartilages, the tip, the alae, and the columella. In the midline, the posterior aspect of the medial crura of the lower lateral cartilages articulates with the caudal membranous septum. Anteriorly, the medial crura are enclosed within the columella. The lateral crura of the lower lateral cartilages project superiorly to overlap the inferior aspect of the upper lateral cartilages in the midline. Laterally, these crura loosely attach to the piriform aperture. The superior portion of the cartilaginous nose includes the two upper lateral cartilages and the quadrilateral cartilage of the septum, all of which are invested by a common perichondrial sheath. Laterally, the superior aspects of the upper lateral cartilages are also loosely attached to the piriform aperture.

Nasal Vault

Superior to the nasal base is the bony vault of the nose, which is bound by the frontal processes of the maxilla, the nasal bones, and the alveolar process. Through the midline of this vault runs the anterior nasal spine inferiorly and the perpendicular plate of the ethmoid bone superiorly. At the superior aspect of where the nasal bones meet the frontal bone is the nasion, which is the midline portion of the nasofrontal suture. At the inferior aspect of where the nasal bones meet the nasal cartilages is the rhinion, which is also in the midline. The septum of the nose includes the quadrilateral cartilage and the anterior nasal spine anteroinferiorly, and the perpendicular plate of the ethmoid bone, the sphenoid crest, the vomer, and the maxillary crest posterosuperiorly. At the roof of the nose within the nasal cavity is the cribriform plate, and at the posterior aspect of this roof is the choana, through which the nasal cavities and the nasopharynx communicate. At the floor of the nasal cavity are the palatine process of the maxilla and the horizontal process of the palatine bone, with the medial pterygoid plates located laterally on either side.

Nasal Turbinates

The nasal turbinates are found on the medial aspects of the nasal cavities. The inferior turbinate lies superior to the inferior meatus and is the largest of the three. Inferior to the turbinate within the inferior meatus is the opening of the ipsilateral nasolacrimal duct. The middle meatus lies between the inferior and middle turbinates and accepts drainage from the frontal sinus, the maxillary sinus, and the anterior ethmoid air cells. The superior turbinate lies above the superior meatus, which drains the posterior ethmoid air cells. Posterosuperior to this structure lays a sphenoethmoid recess on either side of the anterior aspect of the sphenoid sinus.

External Blood Supply

The external blood supply of the nose includes indirect contributions from both the external and the internal carotid arteries. From the external carotid artery, branches of the facial artery supply the inferior aspects of the nose and include the superior labial and lateral nasal arteries. These branches join with the dorsal nasal artery, a terminal point for the ophthalmic artery from the internal carotid artery. The internal blood supply of the nasal pyramid and superior portion of the nasal cavity also include an indirect contribution from the internal carotid artery by way of the anterior and posterior ethmoid branches of the ophthalmic artery. The maxillary artery off of the external carotid artery provides most of the blood supply to the nasal cavity by way of the sphenopalatine artery. At the posterior aspect of the middle turbinate, the sphenopalatine artery splits into the posterolateral nasal and septal arteries, the septal branches of which communicate anteriorly with the anterior ethmoid arteries—an important anastomosis between the external and internal arterial systems.

Venous Drainage

Venous drainage of the nose follows the accompanying arterial supply, with facial veins emptying into the external and internal jugular veins. In the nasal cavity, venous drainage from the ethmoid bones enters the orbit, thereby communicating via the ophthalmic veins with the cavernous sinus and dural venous system. Posteriorly, venous drainage from the nasal cavity follows the sphenopalatine veins into the pterygopalatine fossa and plexus, also communicating with the dural venous system. This posterosuperior venous drainage of the nose is thus a potential vehicle for extracranial infections to spread intracranially.

Nerve Supply

The nerve supply of the nose includes general somatic efferent innervation from buccal branches of the facial nerve. General somatic afferent innervation is supplied by the first two branches of the trigeminal nerve. From the ophthalmic branch arise the anterior and posterior ethmoid nerves and the infratrochlear nerve. From the maxillary branch arise the posterolateral and posteroinferior nasal nerves, the nasopalatine nerve, and the infraorbital nerve, which joins with the infratrochlear nerve and external nasal branch of the anterior ethmoid nerve to innervate the skin. Sympathetic innervation to the nasal mucosa is derived from postganglionic fibers of the maxillary nerve via the nerve of the pterygoid canal, which originates via the deep petrosal nerve from the superior cervical sympathetic ganglion. Parasympathetic innervation in the nose includes zygomaticotemporal distribution to the lacrimal gland, also via the maxillary nerve and the nerve of the pterygoid canal. Special sensory innervation via the olfactory nerve pierces the cribriform plate at the roof of the nasal cavity from the inferior aspect of the olfactory bulbs to innervate the superior aspect of the nasal septum and the superior turbinate. A terminal nerve also pierces the cribriform plate to innervate the cartilaginous septum anteriorly from a terminal ganglion located medially to the olfactory bulbs.

History

The mechanism of injury in nasal fracture usually involves some variety of blunt traumas to the midface. However, information regarding the direction, force, and exact location of the impact is valuable in determining the probable extent of injury. Given the nature of severe edema associated with midface trauma, an evaluation of the extent of injury can be hindered if a significant delay exists between the time of injury and the time of examination. Early treatment is important because most nasalseptal fractures can be managed by closed reduction within a few hours. Thus, if the timing of the injury has allowed for a hindrance to proper inspection, repair must be delayed from 3 to 11 days, depending on the time required for the inflammation to subside. If enough time has passed for the initial insult to heal, the management required to repair the fracture could be extensive.

Symptoms and Signs

Additional history regarding the findings associated with nasal trauma can also be paramount in determining the extent of the injury. In most cases, a history of epistaxis is noted, the severity of which depends on the extent of mucosal laceration sustained at the time of injury. Rhinorrhea may also be noted and, depending on the accuracy of the patient's description of his or her nasal discharge, may be indicative of trauma intracranially (eg, cerebrospinal fluid [CSF] rhinorrhea). Deformity of the nose and airway obstruction can be severe, but a history of insult, including fracture, obstruction, or reconstructive surgery, may interfere with determining the degree of the deformity sustained acutely. If the mechanism of injury is severe, a regional review of systems may be required, including a history of oculomotor or visual dysfunction, anosmia independent of mucosal injury, and dental or facial sensory deficits often associated with maxillary involvement.

Physical Examination

With the patient seated and comfortable, the nose should be viewed externally from all angles, with any unusual variations in contour, size, anatomic angles, lacerations of the skin, and hematomas noted. The presence and severity of epistaxis and, if applicable, CSF rhinorrhea should also be noted. A proper internal examination of the nose requires mucosal decongestion with either 0.25% phenylephrine or oxymetazoline hydrochloride administered as a spray or with careful placement of cotton pledgets. If desired, 4.0% cocaine may be used, which has the advantage of providing anesthesia in addition to local vasoconstriction. Following this preparation, palpation of the nasal skeleton and cartilages may reveal abnormal variations in position and stability, as well as the presence of crepitus or point tenderness. Using a nasal speculum, each nasal cavity should be assessed either via direct visualization or, if necessary, with the aid of endoscopy. The nasal septum should be examined for the presence of deformity, dislocation, swelling, laceration, and hematoma (Figure 12–1).

During examination, an unusually wide or flat nasal base or nasal tip, along with abnormal nasal tip deflections, suggests prior injury or deformity. Injury extending to the orbit may include loss of the glabellar angle and the presence of telecanthus. CSF rhinorrhea indicates extension to the cribriform plate, frontal sinuses, or nasoethmoid complex. Medial maxillary involvement includes maxillary wall depression and a C-shaped nasal-septal deformity, with or without concurrent depression of the frontal process of the maxilla or inferior orbit. The stability of this process may be assessed further with bimanual examination using a Kelly clamp internally and a finger externally.

Unusual mobility of the nasal cartilages is consistent with avulsion, a finding often associated with mucosal laceration. Acute injury to the nasal septum is better differentiated from prior injury by the presence of motion tenderness with bimanual palpation. Pain localized to the anterior nasal spine, with or without dislocation, is also indicative of acute injury and should be assessed by sublabial palpation. A septal hematoma, if present, usually involves only the cartilaginous septum. It is associated with widening of the septum and persistent discoloration and should be pursued further with direct aspiration or mucosal incision.

Imaging Studies

Although still controversial, in most cases, the use of imaging studies in the diagnosis of nasal trauma is unnecessary. With radiographs, studies have demonstrated poor sensitivity and specificity in diagnosing nasal fractures; therefore, even in patients whose abnormalities were not demonstrated, management was unaffected. In addition, differentiating prior fracture from acute injury in the case of minimal displacement is unlikely. Thus, since the assessment and intervention of acute nasal injury are determined by clinical presentation, obtaining radiographs is not recommended except when legal documentation is necessary, as in the case of suspected abuse, or when the presence of additional fractures to the midface is suspected, as in more extensive injury. With severe trauma that includes involvement of the orbit, the ethmoid bones, or the cribriform plate, coronal sections with computed tomography (CT) should be obtained.

Although simple nasal fractures remain the most common of all facial fractures, they must be distinguished from the more serious maxillofacial and nasoethmoid fractures. As mentioned previously, nasoethmoid fractures include extension into and through the nasoethmoid complex, often resulting in dural tears and CSF rhinorrhea. Fractures of the zygoma usually involve a V-shaped deformity with three separate breaks, two occurring along each end and one in the middle of the arch. On physical exam, trismus of the temporalis muscle may be elicited, depending on the degree of bony impingement. A tripod or zygomaticomaxillary fracture may be found with force that has been directed at the cheek; it usually involves one or more of the articulations among the zygoma, the frontal bone, and the maxilla, with extension through the orbital floor. On physical exam, paresthesia may be found along the distribution of the ipsilateral infraorbital nerve. With force directed at the inferior maxilla, alveolar fractures may be found along the superior aspect of the dental margin, often associated with loosened dentition and gingival ecchymosis or hemorrhage.

In ruling out additional fractures of the midface that are seen with nasal trauma, the Le Fort classification denotes three classic patterns of injury associated with blunt midfacial injury. Type I injury involves separation of the maxillary process from the maxilla itself, with extension to the maxillary sinuses. This typically results from force directed horizontally across the midface below the level of the orbit. Type II injury occurs in association with fracture of the nasal bones extending through the lacrimal bone toward and through the zygomaticomaxillary junction. In addition, the fracture extends posteriorly just below the zygoma and along the superior border of the pterygoid plates. Infraorbital paresthesia and bilateral subcutaneous hematomas are often found on examination. Type III injury is also associated with nasal fracture, but courses posteriorly through the ethmoid bones and laterally through the orbits below the optic foramen and through the pterygomaxillary suture into the sphenopalatine fossa. This results in craniofacial dysjunction and the appearance of a long, flat, facial deformity.

In children, additional fractures of the face associated with significant nasal trauma are not uncommon. Given the lack of significant nasal projection and inherent cartilaginous flexibility of the pediatric nasal skeleton, trauma to the midface is more evenly distributed to the maxilla. This provides for a significant risk of maxillofacial and midface fracture as well as extensive facial edema, which often obscures the diagnosis. Such injuries have been associated with disturbances in the normal growth and development of the facial structure—as with premature ossification of the septovomerine suture, which is found with injuries of the nasoethmoid complex—and thus require a conservative approach to diagnosis and management.

Cosmetic Deformity

External physical deformities that result from nasal trauma include the creation of a dorsal hump, lateral deviation of the dorsum and tip, a widened nasal base, and depression and splaying of the nasal tip. Complex (and obstructing) septal deformities may also result, including the appearance of bony spurs, complex alterations in nasal symmetry, and angular deflections of the septum itself. Internally, synechiae may develop where mucosal lacerations are found, particularly between the septum and adjacent turbinates. Most deformities require reconstructive septorhinoplasty to restore function and cosmetic appearance. In cases of pediatric deformity, a delay of revision is often required to allow for normal facial growth and development. With obstructive scar tissue and synechiae, simple division and separation with pledgets coated with antibiotic ointment are usually effective in allowing for reepithelialization.

Epistaxis and CSF Leak

The initial edema and epistaxis of nasal trauma usually resolve without intervention; however, persistent epistaxis may require tamponade with nasal packing or, rarely, identification and coagulation or ligation of the bleeding vessel. With CSF leak, the injury is significantly more severe and may require consultation with a neurosurgeon. Therapy usually includes close observation and may involve bone grafting or placing a drain in the lumbar spine.

Septal Hematoma and Saddle Nose Deformity

Septal hematoma results from bleeding, often bilateral, within the subperichondrial plane of the septum. If left unattended, fibrosis of the septal cartilage may occur, followed by necrosis and perforation within 3–4 days. The loss of structural support leads to septal collapse, which results in a characteristic saddle nose deformity of the nasal dorsum and retraction of the columella. A hematoma is often suspected given excessive septal edema and severe localized tenderness on examination. Treatment is urgent and includes a horizontal incision made at the septal base to provide for mucoperichondrial drainage. Reaccumulation is prevented with the application of plastic splints or intranasal packing. Antibiotic prophylaxis is also required. Saddle nose deformity may require an extensive reconstruction to restore the structure and shape of the nose. We prefer split calvarial bone grafting for reconstruction of this deformity, although rib cartilage and other materials have been used with success.

Airway Obstruction

Fibrosis of the nasal septum, as occurs with septal hematoma, may become organized, creating cartilaginous thickening and resulting in partial airway obstruction. Obstruction may also occur at the nasal vestibule from a traumatic loss of epithelium or the malunion of a nasal fracture. The treatment of nasal septal reorganization may be accomplished with submucosal resection, although some cases require partial turbinectomy. Soft tissue injury and contracture that occur at the nasal vestibule may require excision of the resultant scar and reconstruction with composite or autologous grafts. Malunion is treated with simple osteotomy.

Timing of Repair

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.

Anesthesia

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

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.

Open Reduction

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.

Pediatric Considerations

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.

In general, uncomplicated fractures heal within 2–3 weeks with good cosmetic and functional results. Refractory cosmetic complications, however, are possible with both open and closed techniques and usually involve septal deviation. Reductions that result in malunion or deformity may require further reduction or reconstruction, depending on the severity of injury and the difficulty the reduction in the primary injury presents. Septorhinoplasty remains the standard of care for unsatisfactory results and is often necessary in cases of failed reduction attempts.

We would like to acknowledge Benjamin R. Sigmond, MD for his contribution to this chapter in the previous editions of CDT.