Fractures of the Nose
The nasal bones are the most frequently fractured facial bones because of their central location and protrusion. Depending on the mechanism of injury, fractures of the maxilla, orbit, or cribriform plate and injury to the nasolacrimal ducts may also occur.
Complications include cosmetic deformity and functional obstruction. Septal hematomas are subperichondrial blood collections that may lead to avascular or septic necrosis of the cartilage with resultant deformity (saddle nose). Cribriform plate fracture may cause a cerebrospinal fluid (CSF) leak, with increased risk of meningitis or brain abscess. Fortunately, this complication is rare.
Facial trauma resulting in epistaxis may indicate a nasal fracture. Other symptoms and signs include obvious or subtle nasal deformity, swelling, point tenderness, crepitus, and instability. Lacerations, ecchymosis (nasal and periorbital), septal deviation, and nasal obstruction may be present. Septal hematoma appears as a purplish bulge on the septum. CSF rhinorrhea appears as clear drainage but may be mixed with blood, making it difficult to identify.
Diagnosis is based on physical examination. Plain x-rays of an uncomplicated nasal fracture are not helpful because their sensitivity and specificity are poor. If other facial fractures or complications are suspected, CT of facial bones is done. Bedside glucose test strips do not accurately identify CSF rhinorrhea and are not recommended.
Immediate treatment includes symptomatic control with ice and analgesics. Septal hematomas must be immediately incised and drained to prevent infection and cartilage necrosis.
Reduction is needed only for fractures causing clinically visible deformity or nasal airway obstruction. The end-point of reduction is determined by clinical appearance or improved airway. Reduction is usually deferred for 3 to 5 days after injury to allow swelling to subside but should take place within 2 weeks of the injury, before bony callus formation. Nasal fractures in adults may be reduced after a local anesthetic is given; children require general anesthesia.
A blunt elevator is passed through the nares and placed under the depressed nasal bone, which is lifted anteriorly and laterally while pressure is applied to the other side of the nose to bring the nasal dorsum to the midline. The nose may be stabilized with internal packing (consisting of antibiotic-impregnated strip gauze, silicone elastomer sponges, or similar products) placed high within the nasal vestibule, as well as with external splinting. Internal packing is left in place for 4 to 7 days; external splinting is left for 7 to 14 days. Antibiotic prophylaxis effective against staphylococci is required for the duration of nasal packing to decrease the risk of toxic shock syndrome.
Cartilaginous injuries often do not require reduction. In the rare circumstance that a deformity persists after swelling subsides, a reduction and splinting after a local anesthetic is given are usually sufficient.
Septal fractures are difficult to hold in position and often require septal surgery later.
Cribriform plate fractures with CSF leak require hospital admission with bed rest, head elevation, and placement of a lumbar drain. Drain management and need for antibiotics vary by institution. If the CSF leak does not resolve, surgical repair of the skull base may be required.