Overview of Nasal Fracture Reduction
Nose fractures are the most common kind of facial break, making up 40% to 50% of all facial fractures. They are typically caused by fights, falls, sports injuries, and car accidents. These fractures can happen on their own or along with other injuries to the face’s soft tissue and bones. Men are twice as likely to get a nose fracture compared to women, likely because the nose sticks out from the face and is in the center, making it more prone to injury. Though nose fractures are the most common among all facial fractures, they can sometimes occur along with breaks in other parts of the face, like the cheekbone, eye socket, upper jaw, and the base of the skull. Doctors keep this in mind when examining a patient.
Anatomy and Physiology of Nasal Fracture Reduction
The nose is composed of a mix of bone and cartilage. The framework of the nose includes two nasal bones along with two maxillae, which support the front part of your face. The nasal tip is formed by lower lateral (or alar) cartilages. In the middle of the nose, there is a piece called the septum which is composed of both bone and cartilage. The septum supports the exterior of the nose. All of these pieces that form the nose are able to be broken. Besides this, the nose is also the organ responsible for our ability to smell.
Nosebleeds are a common result of injuries to the nose. The nose receives blood from both the internal and external carotid arteries. The internal carotid artery extends into an artery that supplies blood to the eyes, which then branches into two arteries that provide blood to the upper area of the septum of your nose. On the other hand, the arteries distributing blood from the external carotid artery include the facial and internal maxillary arteries. The facial artery further branches into the superior labial artery, and the sphenopalatine and greater palatine arteries.
When the nose is injured, it may lead to bleeding from a net of arteries located on the lower, front side of the septum. This network entails arteries from the nasal, maxillary, and facial blood supplies. This is an important area as more than 90% of patients with nosebleeds have bleeding from this area. Additionally, injuring the nasal bones might result in heavy and persistent bleeding, requiring medical attention to stop it. This, however, is very unusual. It’s also worth noting that a strong impact to the face that can break the nose may also damage the eye sockets, maxillary sinus, ethmoid sinus, and cribriform plate (a thin sieve-like structure between the olfactory bulb of the brain and the nasal passage).
Nasal trauma can be classified into six types, each corresponding to the severity of the injury. A fracture isolated to the nasal bone is typically due to lower impact or force trauma. If the nose is fractured with a higher force, additional fractures on the face may occur concurrently. Here are the types of nasal trauma:
- Type I: Limited to soft tissue damage
- Type IIa: Simple, one-sided non-shifted breakage
- Type IIb: Simple, two-sided non-shifted breakage
- Type III: Simple, shifted breakage
- Type IV: Closed shattered fracture
- Type V: Open shattered breakage or complicated fracture
Why do People Need Nasal Fracture Reduction
If you’ve hurt your nose, your doctor will ask you some questions to figure out what happened and if you’ve had any previous issues with your nose, such as past injuries or surgeries. They’ll check if your nose is blocked because of the injury. You might be given ice and pain relief to help reduce any swelling or discomfort initially. If your facial injury is severe, your doctor will make sure you can breathe okay by following established protocols.
Next, the doctor will perform a detailed examination to rule out any serious conditions that require immediate attention. The doctor will look for signs of swelling, bruising, nosebleeds, change in the shape of the nose, or issues in moving the eyes, which can suggest a fracture in the eye socket. Then, they might press down gently on your nose and check for any tenderness, unusual movement in your nasal bones, abnormal shapes, cracking sounds, unevenness in your bone structure, or numbness below your eye.
Your doctor will then examine the inside of your nose. If they find bruising and swelling on the divide in your nose (or nasal septum), it could indicate a septal hematoma – a swelling filled with blood, which should be drained immediately. Clear fluid from your nose may suggest leakage of cerebrospinal fluid (the fluid around your brain and spine), which could mean a fracture at the base of your skull. Unusual movement in your mid-face region or changes in how your teeth fit together may indicate a specific type of facial fracture, known as a Le Fort fracture.
In most cases, doctors don’t need to use an x-ray or a CT scan to diagnose a broken nose as they typically make this diagnosis through an examination. However, a CT scan may be needed if you have other head injuries, a possible fracture at the base of your skull, or multiple injuries on your face.
Small cuts on your nose are cleaned, and foreign objects are removed. Depending on the size, these cuts can be closed with medical-grade tape, glue, or fine stitches. For a broken nose, not all cases require treatment. If your nose looks normal, or if you’re not concerned about how it looks, you might not need any further treatment. However, your doctor may advise that the shape of your nose could affect how your glasses sit on your face. If swelling makes it hard to examine, your doctor will have you apply ice and keep your head elevated, and then will see you again 5 to 7 days later. Sometimes, a short course of oral steroids may help reduce severe swelling. If the bone fragments in your nose are not in their usual places, they should be put back in place within two weeks of the injury, as it would be difficult to move the healed nasal bones after this period.
Septal hematomas (the collections of blood beneath the skin of your nasal divide) usually cause pain and a blocked nose, and they appear as swollen, soft areas on the divide of your nose. If not drained, these hematomas could form an abscess, cause the cartilage to die, or even lead to a ‘saddle nose’ deformity. These hematomas may be drained with a syringe and needle, followed by regular check-ups to ensure no more blood builds up in your nose’s divide. In some cases, they might need to be removed in the operating room, with a small drain inserted or special stitches used to prevent the blood from building up again.
If a clear fluid is leaking from your nose after the injury, this could be a cerebrospinal fluid (CSF) leak. This happens when the top part of the bony partition in your nose (the cribriform plate of the ethmoid bone) breaks, as it is thin and easily perforated. You can confirm this diagnosis by testing the clear fluid for certain proteins. A high-resolution CT scan may help to show the exact pattern of the fracture in the skull base, if present.
When a Person Should Avoid Nasal Fracture Reduction
There are some circumstances when a doctor cannot perform a closed reduction procedure to fix a broken nose. These include:
– When the person’s nose and nasal septum (the wall inside our nose that separates our nostrils) are severely shattered into many pieces.
– When there are open fractures in the nasal septum. Open fractures are when the broken bone has punctured the skin.
– If a person comes to seek treatment 2 to 3 weeks or longer after the nose was injured. This is because the broken bones would have started healing incorrectly by this point.
– If the broken nose occurred along with other specific facial fractures, particularly naso-orbital-ethmoid or Le Fort fractures. These require an open reduction, which is a surgery where the doctor makes an incision to fix the broken bones instead of manipulating them from the outside.
Equipment used for Nasal Fracture Reduction
Fixing a broken nose is usually a simple procedure that doesn’t require a lot of equipment or many people to assist.
Here’s a list of what your doctor might use during your procedure:
- Topical decongestant: This is a medication like oxymetazoline, lidocaine with phenylephrine spray, that shrink the swollen tissues in your nose, providing relief from congestion.
- Local anesthetic: This is used to numb your nose so you won’t feel any pain during the procedure. This involves some small injections around the treatment area.
- Headlight: This is a small light mounted on a doctor’s forehead to light up the area they’re working on. It can help them see better during the procedure.
- Nasal speculum (Vienna, Cottle, Killian): A tool used to widen your nostrils so the doctor can see inside your nose better. These are types of speculums.
- Boies or Sayre elevator: These are tools used to gently lift and reposition bone or cartilage in the nose.
- Walsham or Asch forceps: These are types of surgical tweezers that doctors use to hold or move tissues during surgery.
- External splint: This is a rigid support placed outside your nose following the surgery to help hold things in place while your nose heals.
- If your doctor needs to make cuts in your bones (osteotomies), they will use a special surgical knife called a #15 blade, along with tools specifically designed for nasal bone cuts, and a small hammer-like tool, a mallet, to carefully reshape the bone.
Who is needed to perform Nasal Fracture Reduction?
In simple terms, fixing a broken nose without full anesthesia usually involves just a specialized doctor, like a surgeon or an expert in emergency medicine. Having a nurse or assistant on hand could be useful for providing equipment or reassuring the patient. If the patient needs to be fully asleep for the procedure – what we call general anesthesia – then a few more people come into play. This includes a circulating nurse and surgical technician who help keep everything running smoothly, an anesthesia provider who puts you to sleep, along with the surgeon.
Preparing for Nasal Fracture Reduction
Before a doctor tries to fix a broken nose, they will explain all the available options to the patient, including the possible risks and expected results. Many broken noses are left to heal naturally, but this may result in a permanent change in how the nose looks and issues with breathing through the nose. Usually, a doctor can attempt to set the broken nose back into place within two weeks after the injury. If the nose hasn’t been fixed by then, more involved procedures may be needed to correct the shape and function of the nose.
Something all patients must understand is that not everyone is satisfied with how their nose looks or works after it’s been fixed, which happens to up to one in five people. If a patient isn’t happy with the outcome, they can consider a type of nose surgery known as septorhinoplasty, which is typically done at least three to six months after the initial attempt to fix the nose.
Following the procedure to fix a broken nose, patients should be prepared for some discomfort, bleeding, swelling, bruising, and breathing difficulties.
How is Nasal Fracture Reduction performed
Choosing the Right Anesthetic
When a doctor is preparing to correct a broken nose, they need to consider the best type of anesthesia to use. Certain studies have compared the use of general anesthesia (where a patient is put to sleep) and local anesthesia (where only part of the body is numbed). In many cases, a mix of local and surface anesthesia, which is applied to the skin, is enough to make sure a patient doesn’t feel any pain. However, this doesn’t always block out all sensation, so it’s important to understand how well a patient can manage any minor discomfort.
This understanding becomes especially important with patients who have been drinking alcohol and might act unpredictably during the treatment. It’s generally not a good idea to perform this procedure on such patients. Similarly, because children can also be unpredictable and uncomfortable, it’s usually best to use general anesthesia on them. Most adults, however, can typically handle the procedure with local and surface anesthesia.
Using Local Anesthetic
When local and surface anesthetics are used, the procedure is generally well received by patients. The pain level is comparable to that experienced when general anesthesia is used. To do this, a surface numbing agent, such as 4% cocaine or 2% lidocaine, is applied using cotton pads placed inside the nose. The local anesthetic (usually 1% lidocaine with a small amount of epinephrine to prevent bleeding) is injected in and around the nose. Additional injections numb the infraorbital nerves (around the eyes), infratrochlear, and dorsal nasal nerves.
Correcting the Fracture
The simplest approach to fixing a broken nose has a 60%-90% success rate and is usually selected for simple and uncomplicated fractures. The idea is to apply pressure in the opposite direction of the fracture to move everything back into place. There are a few ways to do this; surgeons can either lift the depressed bone segments or use a special tool to push them from the inside. Sometimes, it might be necessary to increase the size of the fracture before reducing it, especially if the bones are overlapped. Any parts of the nasal septum (the wall separating the two sides of the nose) that have been dislocated should be repositioned. If more than 10 to 14 days have passed since the injury, the bones might have already started to set. In these cases, careful breaks (osteotomies) might be needed to move the bones, and may require an open approach.
After surgery, patients should wear a splint over the nose for a week to protect the bones from moving and to remind themselves and others to be careful. In most cases, there’s no need for an internal splint, but in some cases, like when the bones have been shattered or when the septum has been dislocated, one might be necessary.
Open Reduction
If a broken nose can’t be treated with the methods described above, it might be necessary to use an open surgery, known as an open septorhinoplasty. Sometimes, the injuries to the bones and cartilage are complex and need detailed manipulation, including grafting, or using additional tissue, osteotomies, and careful stitching. This helps to avoid ongoing difficulty with breathing or to prevent changes in how the nose looks. An open rhinoplasty can often handle these needs better, as it offers a clearer view and better maneuverability. It’s often best to wait 3 to 6 months after the initial injury to perform this procedure, giving time for swelling and inflammation to go down.
After Surgery
After the procedure, an external splint should be worn until the follow-up appointment, usually 1 to 2 weeks later. If splints were placed inside the nose to help with a fractured septum, these will be removed at the follow-up visit. Patients should be reminded that their nasal bones can still shift up to 2 weeks after surgery and will not be fully healed until 6 weeks after. To avoid any issues, it’s important to avoid contact sports, games involving flying objects (like playing catch or tennis), heavy lifting, strenuous exercise, and bending over for at least six weeks. Raising the head while sleeping and avoiding blowing the nose will help reduce swelling after the procedure.
Possible Complications of Nasal Fracture Reduction
While breaking your nose is usually not a serious issue, there can be certain complications. These could include:
* Changes in the appearance of your nose
* A pooling of blood besides the wall separating your nostrils, termed as a septal hematoma
* Collection of pus in the nasal septum, known as a septal abscess
* Lack of blood supply to the nose’s cartilage causing it to collapse and lead to a saddle nose deformity
* Trouble with nasal breathing, or nasal obstruction
* Fracture of the thin bone at the roof of the nose leading to leakage of cerebrospinal fluid (the fluid around your brain and spine), a condition called CSF rhinorrhoea
What Else Should I Know About Nasal Fracture Reduction?
Nasal bones, which are parts of the nose structure, are the bones most frequently broken in the body. In simple cases, a procedure called “closed reduction” can repair the damage and return your nose to its normal function and look. This procedure is done using local or general anesthesia, meaning you’re either numbed in the nose area or put fully asleep.
The timing of this procedure is important. If you leave your nose broken for more than 10 to 14 days, the bone pieces may settle in their new, incorrect positions, making it harder to correct. Also, if your nose is very swollen from the injury, it’s best to wait 3 to 5 days for the swelling to go down before the procedure.
In some cases, if the closed reduction procedure doesn’t work or the nose obstruction persists, an open surgery called “septorhinoplasty” may be needed. This surgery can fix any remaining nose deformities, or help clear any obstructions in the nose.
