Open 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.

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Open reduction is generally performed under general anesthesia.

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.

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.

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.

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

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.

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.