What is Nasal Septal Fracture?
The nose bones are the most commonly broken bones in the face. This is due to their fragile nature and the nose’s prominent position on the face. Fractures of the nasal bone often come with fractures of the nasal septum, the partition in the middle of the nose, in between 42% to 96% of cases. These fractures can not only affect the look of the nose but also its ability to function properly, affecting breathing.
The structure of the nose is mainly made up of cartilage, bone, and skin. The nasal bones link to the frontal bone at the top and the sides of the nose. These nasal bones are usually thicker towards the area of the eyes.
In the nose’s interior, the nasal septum is made of bone at the back and cartilage at the front. The ethmoid bone and the vomer form the bony part of the septum at the back and join with the quadrangular cartilage at the front. This front part of the septum is supported by an important area in the middle third of the nose, just below the bridge of the nose. Here, the upper nose cartilages connect with the edges of the nasal bones and the top line of the septum cartilage, further stabilising the structure of the nose. The septum also attaches to the nose floor at the front and back.
What Causes Nasal Septal Fracture?
The nasal bones, located in the face, can break as a result of various injuries or traumas. The main reasons why nasal bones might fracture worldwide include fights, car crashes, accidents during sports, and falls. In North America, more nasal bone breaks happen due to car accidents than fights.
For children, the top causes are typically sports-related accidents or car crashes, depending on the source. Interestingly, sports that involve balls, like soccer, basketball, baseball, and rugby, have a higher occurrence of nasal bone breaks than combat sports.
Risk Factors and Frequency for Nasal Septal Fracture
Nasal bone and septal fractures, or breaks in the bone and cartilage of the nose, are more common in men and boys than in women and girls. This is often linked to a higher rate of physical conflicts among males. The highest number of these fractures occurs in people in their twenties and thirties.
In the United States, there has been a growing number of nasal bone and other facial fractures since 2000. Despite this increase, the number of these fractures being treated has stayed the same. This might suggest that more of these fractures are being managed without surgery or that there’s a trend towards less invasive treatment. It could also indicate that doctors are using CT scans more often to help decide on the best treatment option.
Signs and Symptoms of Nasal Septal Fracture
Priorities are established for those with facial trauma. The initial procedure includes checking breathing, heart rate, and possible disability. After dealing with urgent concerns, the cause of the trauma and a detailed physical examination may follow. Maxillofacial damage can range in severity, commonly through high-impact incidents, like car accidents, and often result in varied facial fractures. The trauma’s angle also plays a part in determining the possible internal damage.
It’s important to know a patient’s baseline facial appearance to identify any deviations caused by trauma. Difficulty breathing might point to nasal injuries. Moreover, prior nasal traumas or surgeries should be considered. The presence of symptoms such as telecanthus, double or lost vision, clear nasal discharge, misaligned teeth, weakness or numbness in the face might suggest much broader injuries.
The physical examination must include a thorough assessment of the whole head and neck region. In these cases, it’s recommended to examine:
- The skin
- Eye and ear
- Mouth and nasal cavities
A careful evaluation with a frontal lamp, nasal speculum, or rigid endoscope can provide valuable information about the nose’s shape and internal structure after the trauma. External nose injuries, exposed bone or cartilage, and visible deviations of the nasal skeleton should be noted. An increased distance between the inner corners of the eyes might indicate that a nose and eye socket bone fracture is present.
The nasal tip should be checked for support and the nose’s bridge for a saddle nose deformity, which may indicate a severe septal fracture or dislocation. Also, first rule out septal hematoma – a buildup of blood between layers of the nasal septum, which may appear as a soft red or blue discoloration. These need immediate draining to prevent abscesses and necrosis of the nasal cartilage, which can lead to a septal perforation and saddle nose deformity.
Significant dislocations of the septum, any intranasal wounds or disruptions of the nasal lining need to be documented. Clear nasal discharge might indicate a potential fluid leak from the brain. Every detail should be carefully considered in these cases to ensure proper treatment and recovery.
Testing for Nasal Septal Fracture
If you have a simple break in your nose, you typically don’t need any imaging tests. Traditional X-rays often aren’t helpful. However, if there’s a worry about more severe face injuries, a CT scan of your face without any injected contrast dye is the best way to check. This scan gives a clear picture of the bones in your face. Sometimes, if you have specific symptoms, your doctor might recommend imaging tests. While researchers have started to explore the use of ultrasound for diagnosing broken noses, so far, it’s not as good as a CT scan.
Usually, you don’t need lab tests for a simple nose fracture or for a blood clot in the nasal septum. However, if you have a nosebleed and lose a lot of blood or take blood-thinning medication, your doctor may want to check your complete blood count and how well your blood is clotting. If you have a persistent clear discharge from your nose, your healthcare provider may collect some and test it for beta-2-transferrin. This test can confirm or rule out if the fluid is cerebrospinal fluid, which might suggest a more serious issue.
Treatment Options for Nasal Septal Fracture
If you experience nose bleeding due to a nasal fracture, you can control it by applying pressure to the nostrils. For more severe nose bleeds, you might need treatments like cauterizing (burning) or stuffing the nose with gauze-like materials.
If the nose appearance hasn’t changed and you aren’t having trouble breathing through your nose, it’s recommended that you wait and see if it gets better on its own. To help with swelling, you should keep your head elevated and apply ice to the area. You should see a doctor for a check-up within 3 to 5 days because swelling could be hiding a crooked nose.
If your nose seems bent or you are having trouble breathing, you could have your nose gently moved back in place by a procedure called “closed reduction.” You may only need local anesthesia or mild sedation, but sometimes general anesthesia is better for ensuring your airway is protected and for your comfort. Some sources recommend having this done within 5 to 7 days, while others suggest waiting until all swelling has gone down, approximately 1 to 2 weeks after the injury. If you wait more than 2 weeks, the nose might not look as good because it’s already started healing in the wrong shape and place.
Occasionally the middle part of your nose, the nasal septum, can also be moved back into place using a similar procedure. If the septum can’t be straightened this way, your doctor may suggest a different procedure called a septoplasty. This could help improve your ability to breathe through the nose.
It’s usually recommended to wait 3 to 6 months after the injury before having any major nose surgery, as other damages to the cartilage and skin can further complicate the surgery and increase the possibility of infection. Future procedures can use CT scans to guide surgeons in reshaping the bones even a long time after the injury.
What else can Nasal Septal Fracture be?
When evaluating a broken nose, doctors also need to check for potential injuries to the surrounding facial bones, including injuries to:
- NOE Complex: This involves fracture of the nasal bones that extend towards the back into the ethmoid air cells, affecting one or both corners of the eye. Distinct signs of this condition include noticeable changes in the distance between the eyes. This type of fracture is also a characteristic of all LeFort type III midface fractures.
- Orbital Bone: Seeing swelling or bruising around the eyes could indicate a broken orbital bone. A fracture in the orbital floor, specifically, may lead to numbness of the cheek or difficulties in moving the eyes.
- Skull Base: Impacts with strong force can cause fractures in the base of the skull. Telltale signs of this include bruising around both eyes (known as “raccoon eyes”) and behind the ears (known as “Battle’s sign”). Patients with these fractures are at an increased risk of cerebrospinal fluid (CSF) leak and a spine fracture.
Therefore, it’s crucial for doctors to thoroughly examine these areas for a precise diagnosis.
What to expect with Nasal Septal Fracture
People usually recover well after having their broken nose bones fixed. However, the success of these operations can vary a lot. After the treatment, between 9% to 50% of patients still have some form of nasal deformity. On a positive note, treating other injuries to the nose, like fractures or twists in the nasal septum, at the same time can enhance the results.
If there’s remaining deformity or trouble in breathing through the nose after the initial procedure, a second surgery called septorhinoplasty can help. Patients who had a deformity or nasal restriction before breaking their nose or septum are more likely to need another operation later on.
Possible Complications When Diagnosed with Nasal Septal Fracture
After a surgery to fix broken nasal bones and a septal fracture, patients often still have some degree of nasal deformity. This can be seen in the form of a ‘saddle nose’ deformity, or a hole in the septum. These issues might happen post-surgery, after a septal hematoma (a swelling of clotted blood) formation, or as a result of a severe injury to the septum. Disturbances in the sense of smell (olfactory disturbances) are also relatively common, affecting up to one third of patients who experience a nasal bone fracture. This could be due to the sense of smell being affected during the surgery when the olfactory nervous tissue (located on the upper part of the nasal cavity) is manipulated.
Recovery from Nasal Septal Fracture
Nasal splints, both external and internal, should usually be taken out within a week. If the nose has been packed during treatment, it’s normal to provide patients with oral antibiotics to prevent a serious condition called toxic shock syndrome. Doctors typically advise against any intense physical activity, especially the kind that might cause additional harm to the nose. During this immediate healing period, nose hygiene using saltwater sprays is recommended to avoid recurrent nosebleeds. It’s also important to have regular follow-ups to check for any lingering issues with the shape or function of the nose, as a second surgery might be needed in such cases.
Preventing Nasal Septal Fracture
Before carrying out any procedures to fix nasal bone fractures, it’s very important to make sure patients understand the risks. There could be some leftover deformity or troubles breathing through the nose even after the procedure. It’s also crucial to let patients know that they must come back for regular check-ups. The sooner the procedure is done after the injury, the better. Additionally, teaching them about the use of seatbelts and wearing protective gear during sports may help avoid future nose injuries.
