Closed reduction

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.

Local 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
General anesthesia is an option according to the surgeon’s and/or patient’s preference.

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

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.

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.

Alternative technique
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.

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.

Nasal bones
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.

Nasal septum
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.

Keeping the patient’s head in a raised position both preoperatively and postoperatively may significantly improve edema and pain.

To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days following NOE fracture repair.

The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.

• No aspirin for 7 days (nonsteroidal antiinflammatory drugs (NSAIDs) use is controversial)
• Analgesia as necessary
• Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.)
• Nasal decongestant may be helpful for symptomatic improvement in some patients.
• Steroids, in cases of severe orbital trauma, may help with postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
• Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.

Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended to assess complex fracture reductions. In centers where intraoperative imaging is available postoperative imaging can be performed at a delayed time.

For nasal fractures, postoperative CT imaging is usually not necessary except in severely comminuted fractures.

Remove sutures from skin after approximately 5 days if nonresorbable sutures have been used.

Apply ice packs (may be effective in a short term to minimize edema).

Avoid sun exposure and tanning to skin incisions for several months.

Diet depends on the fracture pattern and patients condition but there are usually no limitations.

Clinical follow-up depends on the complexity of the surgery, and the patient’s postoperative course.

In all patients with NOE trauma, all the following should be periodically assessed:

• Globe position
• Double vision
• Other vision problems
• Nasal airway status

Other issues to consider are:

• Facial deformity (incl. asymmetry)
• Sensory nerve compromise
• Problems of scar formation
• Anosmia
• Epiphora and dacryocystitis

Implant removal is rarely required. It is possible that this may be requested by patients if the implant becomes palpable or visible. In some countries it will be more commonly requested. There have been cases where patients have complained of cold sensitivity in areas of plate placement. It is controversial whether this cold sensitivity is a result of the plate, a result of nerve injury from the original trauma, or from nerve injury due to trauma of the surgery. Issues of cold sensitivity generally improve or resolve with time without removal of the hardware.