1 General considerations topenlarge
Most nasal fractures cause significant bleeding. Proper techniques for hemostasis should be applied prior to any diagnostic procedure and any definitive treatment of nasal fractures.
Click here for more details on hemostasis.
Choice of anesthesia
Closed reduction of nasal fractures can be performed under local anesthesia in the majority of patients.
The nasal cavity should be prepared with cotton pledgets moistened in a solution with topical anesthetic with vasoconstrictor. In addition, local anesthetic is injected to block the infraorbital nerve.
IV sedation can be added for the comfort of the patient.
General anesthesia is an option according to the surgeon’s and/or patient’s preference.
2 Fracture reduction instruments topenlarge
Instruments commonly used for closed treatment of nasal fractures are:
- Asch septum-straightening forceps
- Walsham septum-straightening forceps
- Boies nasal fracture elevator
- Mayo hemostat with rubber tubing
- Killian nasal septum speculum
3 Reduction of nasal bones topenlarge
In laterally displaced fractures
Commonly laterally displaced fractures on one side are medially depressed on the other side. We will describe their treatment together.
Place an instrument (eg, Boies elevator) in the depressed side along the lateral wall of the nose to a point below the nasal frontal angle.
Place a finger along the lateral side of the nose above the depressed area.
Pearl: correct instrument placement
Prior to the endonasal placement of the elevator, it is placed against the outside of the nose to the level of the medial canthus. The index finger is then placed against the edge of the elevator and is used as a stop when the elevator is placed intranasally to ensure that it can not be advanced too far superiorly.
Carefully position the instrument under the depressed nasal bone.
In centrally depressed fractures
Sometimes the frontal processes of the maxillae are displaced laterally with the nasal bones impacted inside them.
Reduction requires elevation of the nasal bones anteriorly and repositioning of the frontal processes medially.
The elevator must not be inserted too far into the nasal cavity.
In this case the elevator is placed in the nose and lifts the nasal dorsal pyramid anteriorly, while simultaneously the thumb and index finger put medial pressure on the displaced frontal processes of the maxillae.
4 Closed reduction topenlarge
In some cases, Asch or Walsham forceps can be used to elevate the dorsum and disimpact the displaced septum.
Closed reduction requires indirect elevation of the nasal bones to restore the architecture of the nasal pyramid.
5 Reduction of the nasal septum topenlarge
Reduction of the nasal septum
The Asch or Walsham septum-straightening forceps are used to straighten the nasal septum.
Grasp the nasal septum with the blades of the instrument and gently manipulate the septum into proper alignment.
Centrally depressed fractures require posterior to anterior elevation which can often be achieved by reducing the nasal septum.
6 Splinting topenlarge
After reduction, adhesive strips are placed over the skin of the nasal dorsum and the nasal bones are splinted using an external splint that conforms to the patients nose. If the nasal bones are comminuted or loose, they should be supported with an intranasal packing, which should be placed prior to placing the external splint.
The nasal septum can be stabilized with splints or packs.
Removal of packings and splints
Hemostatic packs are removed after 24 hours. Packs that are supporting the nasal bones are left in place as long as the external splint is in place. (Various surgeons leave these in place from anywhere between 5-10 days).
The patient should be prescribed antibiotic treatment for as long as the nasal packs are in place.