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
Open reduction is generally performed under general anesthesia.
2 Choice of approach top
In case of severely comminuted or open fractures existing lacerations can be used. When associated with other facial fractures (eg, NOE, frontal sinus) the coronal approach can be used. Otherwise, depending on the surgeon's preference and the particular case an external rhinoplasty or an endonasal approach may be used.
3 Open reduction topenlarge
Reduction of the nasal bone
The blades of an instrument (eg, Lempert rongeur) are inserted on each side of the depressed nasal bone and used to mobilize and reduce the bone to its correct position.
Reduction of cartilages
The cartilaginous segments are exposed and reduced. Sometimes, segments of cartilage must be resected. If needed, a vomer osteotomy is performed to allow the septum to go back into its normal position.
Midline repositioning of quadrangular cartilage of the septum and the vomer
The septum is repositioned in its original midline position together with the quadrangular cartilage and vomer. As small suture may be placed from the anterior nasal spine to the anterior portion of the septum to maintain its reduction.
Severely comminuted fractures should not be treated via an open approach. In this case, the fractures are addressed via closed reduction and residual deformities are treated in a secondary procedure.
Overaggressive stripping of the periosteum may cause devitalization of the bone with subsequent necrosis. The use of miniplates or wires in comminuted fractures is not recommended because extrusion of the plate, wound dehiscence and unsightly appearance of the dorsal nasal skin over the plates or wires may occur.
In case of associated NOE, frontal sinus and/or Le Fort II, or Le Fort III fractures the use of microplates may be necessary to fix nasal bones and the frontal process of the maxilla.
Great care should be taken when considering placing plates anterior to the medial canthal ligament as these may be visible through the thin overlying skin.
Bone or cartilage grafting may be necessary in severely comminuted nasal bone fractures. When inserting the graft, the following points should be respected:
- The nasofrontal angle should be reconstructed in a normal relationship (105°-120)
- The collapsed septum should be suspended to the graft using non-resorbable sutures
- The graft should be long enough to re-suspend the lower lateral cartilages
Disarticulation of upper lateral cartilage
Treatment of disarticulation of the upper lateral cartilage is via lacerations or open approaches and is aimed to suturing the cartilages back to the nasal bone. Long term outcome is usually poor and often requires secondary procedures to correct the deformities.
Internal packing of the nose to support the upper lateral cartilage should be performed in an attempt to reestablish the preinjury relationship between the nasal bone and the upper lateral cartilage.
4 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.