NASAL FRACTURES
 most common type of facial fracture and the third most common fracture of the
human skeleton
o weakest bone and in a central and prominent position
 high incidence of posttraumatic nasal deformity (14 to 50 percent).
 Factors that contribute to suboptimal aesthetic and functional end results include
timing, edema, undetected preexisting nasal deformity, and occult septal
deviation/injury.
 Patients with traumatic septal deviation have a high chance of requiring secondary
surgery - 40 to 42 percent had a significant septal deformity at 3 months that
required septorhinoplasty.
Pathogenesis of nasal fractures
 A strong force from any direction can comminute the nasal bones, giving rise to
the “open book” type of fracture.
 When fracture of the thick bone at the root of the nose occurs, it is usually
associated with fractures of other parts of the facial skeleton
Pathogenesis of septal fractures
 three septal zones with thicker cartilage where it attaches to bone -dorsoposterior,
basal, and caudal.
 central caudal portion of the septum is thin.
 The thicker, posterior septal cartilage provides the primary support for the nasal
dorsum.
 Low-velocity injuries usually lead to septal fractures or dislocations along the
vomerine groove; high-velocity injuries or frontal impacts result in more extensive
septal fractures through the thin central region of the quadrangular
cartilageprogressive distortion of fractured septal cartilage caused by the release of
locked internal stresses
 septum does not remain straight after manipulation and that the nasal bones tend to
unite in the direction of the deviated septum.
 Acute open reduction with submucous septal resection results in an improved longterm cosmetic and functional outcome due to the alleviation of overlapped,
interlocking fragments of the septum that usually resulted in the secondary nasal
bone deformity.
 Thus septum is the key structure with which to align/correct and optimize
nasal fracture management and to minimize secondary deformity
Classification (Rohrich)
Type 1
Type 2
Type 3
Type 4
Simple – Unilateral
Simple – Bilateral
Comminuted
A - unilateral
B – bilateral
C – frontal
Complex – includes septum
A – septal hematoma
B – open laceration
Type 5
NOE
Management
Important to establish- Cause of the trauma (the 4 main causes of nasal trauma are
personal assault, sport injuries, personal accidents, and road accidents)
1. History of previous facial injuries
2. Any prior nasal deformity
3. History of nasal obstruction
 Complete nasal assessment (bony and septum), use of outpatient controlled general
anesthesia, and primary septal reconstruction in cases with severe septal fracture
dislocation
 internal examination requires halogen lighting, good suction, a nasal speculum,
vasoconstrictive anesthesia, and a 30-degree, 3-mm rigid nasal endoscope of type
III or greater.
 Drain septal hematomas - reduces fibrosis and subsequent septal distortion,
abscess, and complete necrosis with saddle nasal deformity.
 If the patient is seen in the first 3 to 6 hours (before significant distorting edema
sets in), reduction of the fractured nose should be performed immediately.
 Soft tissue edema usually masks mild-to-moderate nasal fracture and hinders any
immediate closed reduction, so the patient has to be reassessed 3 to 4 days later
 Reduction should be done within 10 days of the trauma for adults and within 7
days for children
Indications for closed reduction in adult patients are
1) unilateral or bilateral nasal bone fracture
2) fracture of the nasal-septal complex with nasal deviation less than half the
width of the nasal bridge.
Indications for open reduction
1) extensive fracture-dislocation of the nasal bones and septum
2) nasal pyramid deviation exceeding one half the width of the nasal bridge,
3) fracture and dislocation of the caudal septum
4) open septal fracture,
5) persistent deformity after closed reduction.
 Anaesthesia
o GA vs local anaesthetic
o Most studies found local anesthesia to be as clinically effective as and less
expensive than general anesthesia for closed reduction.
 Local anaesthesia
o topical intranasal solution using pledgets soaked with a vasoconstrictive agent
(ie, 1:100 000 epinephrine) and an anesthetic (ie, 4% cocaine or 2%
lidocaine) for nasal mucosa anesthesia and hemostasis.
o externally infiltrative field anesthesia to the nasal dorsum is as effective as and
better tolerated than bilateral specific internal blocks of the infraorbital,
infratrochlear, and external nasal nerves.
o externally infiltrative field anesthesia -bilateral percutaneous infiltration over
the whole of the bony dorsum with a total of 4 mL of 0.5% bupivacaine and
1:200 000 adrenaline
o alternative to the external percutaneous method involved the application of a
eutectic mixture of local anesthetic cream, containing lignocaine and
prilocaine, to the nasal bridge to induce topical skin anesthesia, with
concomitant intranasal cocaine,
o Oral or intravenous sedation may be given to enhance the anesthesia.
 Method
o Reduction nasal bones
 reduction of external nasal bones to their anatomic position is initially
accomplished by recreating the fracture; molding the nasal bones with
the fingers is the simplest approach
 Impacted nasal bones require instrumentation for reduction and
restoration of nasal length, which is the most critical dimension to
regain.
 The Walsham forceps are designed for the reduction of impacted
nasal bones, whereas the Asch forceps are designed for reduction of
the nasal septum, although they may also successfully restore the
alignment of impacted nasal bones.
 To avoid the mucosal damage caused by these instruments, some
surgeons prefer to use a less traumatic Boies elevator
 Comminuted nasal bones may be reduced and dorsal-posterior intranasal
packing with gel foam used to prevent collapse after reduction.
o Relocating septum
 Attempt to get it back into the vomerine groove
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nonreducible posteroinferior or anterior septum is considered for acute
septal reconstruction
hemitransfixion or Killian incision is made on the side of the
dislocation, and the bilateral inferior mucoperichondrial flaps are
developed.
Further access to the fracture line is gained through a lateral
intercartilaginous incision. The dorsal skin is lifted off the upper lateral
cartilage and the periosteum is pulled away from the nasal bones
Intranasal and external splints are used for 5 to 7 days, as are
prophylactic antibiotics (Cephalexin) and 3-day steroid dose packs to
reduce postreduction nasal ede
An inferior and posterior septal resection to dislodge and align the
septum and/or to implement septal repositioning may be performed with
anterior septal spine figure-of-8 sutures
Above) Submucous resection of an inferior septum. (Below) Midline fixation
of a dislocated septum using a figure-of-8 suture at the nasal spine.
Post op
 After repositioning, fractured nasal bones can move due to further minor trauma or
drift back toward their position before the reduction, hence, the importance of
reviewing patients after nasal fracture reduction, instead of discharging them
without follow-up (a common practice)
 Nasal fracture patients also tend to be less meticulous in their follow-up than
rhinoplasty patients
NASOOBITOETHMOID FRACTURES (NOE #)
ANATOMY
 Interorbital space. Defined by
1. Anteriorly the frontal process of the maxilla, spine of the frontal bone and
nasal bones
2. Laterally by the lamina papyracea and lacrimal fossa
3. Inferiorly by the lower border of the ethmoidal labyrinths
 Fractures of the nasoorbitoethmoid complex are the result of a blow to the upper
bridge of the nose, such as occurs when the face hits the dashboard or steering
wheel in an automobile accident.
 Associated fractures of the orbital floor, maxilla and zygoma are common
 Brain injury and CSF rhinorrhea
CLINICALLY
 Flattened nose
 wollen medial canthal areas
 Fractures of the nasal septum and bones
 Obviously oedema and haematoma
 TELECANTHUS (12-20%)
o Involvement of the medial canthal tendon is demonstrated by grasping
the lower eyelid with a forceps and displacing it laterally
 Anosmia
 Look for septal hematoma and deviation
 CSF leak
o Halo sign when doplet on cloth
o Glucose >30mg
o Beta transferrin
o inject radioactive label or a fluorescent dye into the spinal fluid and
test for the label or dye in the fluid. - nasal pledgets can be left in the
nose for extended periods, enabling detection of intermittent rhinorhea.
o beta-trace protein assay – very promising newsimple and rapid
method for the detection of liquorrhoea with high sensitivity and
specificity
o treat with bed rest, steroids, antibiotics intially
CLASSIFICATION
Markowitz
TYPE I: central segment is single
TYPE II: central segment is comminuted
TYPE III: attachment of the medial canthal tendon is avulsed
TREATMENT
 In type I injuries, stabilization of the bone fragments suffices to correct the position
of the medial canthus.
 In some type II injuries and all type III injuries, transnasal canthopexy is
necessary
 Should be undertaken as soon as the patient’s general condition permits
 ORIF via coronal incision mandatory
 Landmarks
o Nasofrontal suture – cribriform plate at this level
o Ethmoidal foramen – stay below this too and anterior to the posterior
ethmoidal foramen to avoid the optic nerve
o Lacrimal crests
 Method
o Restoration of the bony contour – build stable platform on nasal dorsum first
(M Hansen)
o Nasofrontal separation treated by elevation of the nasal bones and
stabilization
o Nasal bones stabilized with wires or plates
o May require dorsal nasal bone graft
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Reestablishment of the continuity of the lacrimal system
Medial canthoplasty and canthopexy
Stabilize the nasomaxillary buttress
Transnasal reduction of the medial wall of orbit is crucial. The wire should
pass posterior and superior to the lacrimal system
Nasal considerations (PRS CME Jan 06)
 Severe naso-orbital ethmoid fractures compromise dorsal support to the nose
through loss of both cartilaginous and bony support.
 There is extensive comminution of the perpendicular plate of the ethmoid,
vomerine bone, maxillary crest, and nasomaxillary buttress
 The distal nose telescopes into the piriform aperture with pressure applied to the tip
 Principles
1. Rigid fixation of the nasal pyramid and restoration of nasal height and length
2. Restoration of tip projection
3. Septal reduction/reconstruction
4. Lateral nasal wall augmentation
Restoring height
 use of primary cantilevered dorsal nasal bone grafts in restoring the dorsal profile
is well established – calvarial or rib graft
 As height increases, appearance of widened intercanthal distance reduces
 Also helps to camouflage irregularities particularly at the keystone area.
Restoring tip projection
 Columella strut graft
Reconstruction of nasal septum
 Limited septoplasty and soring techniques
 Suture techniques to fix septum caudally and dorsally
 Avoid SMR as it may compromise dorsal support further
Augmentation of lateral nasal wall
 Onlay grafts used to prevent future contour irregulaties
COMPLICATIONS
TELECANTHUS
 Secondary to inadequate or delayed primary treatment
 Results of secondary correction is not as good as primary correction
 Normal IC distance
1) 33-34mm Caucasian male
2) 32-33 mm female
DISPUPTION OF THE LACRIMAL SYSTEM
incidence <20%
 Routine exploration of the canaliculi is not justified because the incidence of injury
to the lacrimal apparatus in NOE fractures is less than 20%.
 If persistent dacrocystitis or obstruction, a DCR or cDCR can be performed.
MENINGITIS
NASAL DEFROMITY
FRONTAL SINUS FRACTURES
 Prone to fracture with high velocity trauma
 Size of the sinus is a factor in whether the posterior table fractures - If the sinuses
are large, the posterior wall usually remains intact because the force is dispersed
over a wide, pneumatised surface.
DIAGNOSIS
1) supraorbital nerve anesthesia
2) CSF rhinorrhea
3) Depressed frontal region
4) Subconjunctival ecchymosis
5) Xray and CT scan
TREATMENT
 Nondisplaced linear anterior table fractures-conservative management
Indications for surgery
1) Displaced fractures of the anterior table with contour depression
2) Injury or obstruction of the nasofrontal duct
 ostium of the nasofrontal duct is located medially in the sinus floor.
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If duct patency is questionable, fluorescein or other dye should be instilled:
If disrupted or occluded then sinus should be obliterated
all of the mucosa within the sinus must be removed, otherwise it will
continue to secrete and may produce a mucocele.
3) Significantly displaced fractures of the posterior table
Method
 Anterior table removed – use endoscope light to illuminate the extent
 Posterior table removed if dural repairs required
 Mucosa is removed with resection and the use of a high speed burr
 Plug the nasofrontal duct with anterior based pericranial flap, temporalis fascia,
bone graft
 Another option is nasofrontal stenting and intranasal anterior ethmoidectomy.
Stents removed in 6-8 weeks
 Options:
1) Sinus obliteration
 Indicated if nasofrontal duct damaged
 Options include spontaneous osteoneogenesis, autologous fat, temporalis
muscle, bone graft, hydroxyapatite
2) Cranialisation
 Indicated if posterior table removed due to depression or CSF leak.
 Pericranial flaps usually raised to seal off the nasal cavity and obliterate
dead space.
COMPLICATIONS
EARLY OR LATE
Early
 Defined as occurring in the 1st 6 months
 Frontal sinusitis most common
 Meningitis rare
 Transient CSF leak
Late
 Mucocele and mucopyocele
o Untreated, the infectious process can extend through the posterior table
of the frontal sinus and lead to brain abscess.