Sharon Aronovich and Bernard J. Costello

Outline

Function of the Nose

The nose and perinasal tissues have functional and aesthetic roles. The aesthetic value of the nose is a key aspect of facial appearance and a very recognizable feature of the face. It is also the most exposed and prominent area of the face. The nasal form is directly related to its function. When treating nasal trauma, clinicians should aim at optimizing function as a primary objective in conjunction with the aesthetic goals. Nasal function is important for normal respiration, humidification, speech production, and sensations associated with smell and as an aesthetic facial feature.

Epidemiology

Nasal fractures are the most common facial fractures seen and occur at least twice as often in males as in females.1–6 The high frequency of nasal fractures can be attributed to its prominent location in the facial skeleton and the comparatively smaller amount of force needed to produce a fracture when compared with other facial bones. Athletic injuries, interpersonal altercations, falls, and motor vehicle accidents (MVAs) account for the greatest proportion of causes. In the children and adolescents, sports and falls are the major causes of isolated nasal bone fractures.^2–4,7,8 For example, a study of sports-related fractures in U.S. high schools has found a 10.1% rate of fractures with the highest rate in football, basketball, and soccer.⁴ The investigators found that when facial fractures occurred, nasal fractures were the most common injury and resulted in more than 3 weeks of time lost or medical disqualification from participation in sports, in addition to incurring substantial costs to the patient’s family and health care system.

Regional differences in the presentation of nasal fractures can be observed. In a retrospective study of Brazilian children aged 5 to 17 years, Cavalcanti and Melo have found that facial injuries were 3-fold more frequent in males aged 13 to 17 years; the most common causes of these injuries were falls and MVAs.³ Among facial injuries in that study, nasal fractures were also most common, 51.3%, followed by the zygomatic-orbital complex, 25.4%. In another retrospective study, Hwang et al have reviewed and analyzed the medical records of 236 patients with facial bone fractures caused by athletic activity who were treated at one institution between 1996 and 2007.⁹ The investigators noted that the age group with the highest frequency of these injuries was 11 to 20 years (40.3%), with a significant male predominance across all age groups (13.75 : 1). There were 128 isolated nasal fractures, with soccer accounting for 39%, followed by other sports, including martial arts.

Nasal injuries have been shown to be common in adults and children and may be associated with significant morbidity. Associated injuries of adjacent structures should be suspected based on common injury patterns. The age and the environment play a key role in determining the injury incidence and pattern.

Anatomy

The nasal bones are paired and joined at the midline; they articulate with the frontal bone superiorly and the frontal process of the maxillary bones laterally. Caudally, they interact with the upper quadrilateral cartilages. Basally, they articulate with the nasal septum, which is formed by the perpendicular process of the ethmoid and the vomer inferiorly (Fig. 20-1).

Nasal air passage may be affected by a variety of conditions. Anatomically the internal and external nasal valves must be patent, with the former having an angle of at least 10 to 15 degrees. A deviated nasal septum, nasal spurs, concha bullosa, nasal polyps, and inflammatory sinonasal disease represent examples of altered anatomy that potentially become sources of nasal obstruction and may contribute to nasal airflow obstruction (Fig. 20-2).

The neurosensory innervations of the nose are rich and complex (Fig. 20-3). The overlying nasal skin receives its innervation from the dorsal nasal and external nasal nerves, branches of the anterior ethmoidal and ophthalmic (to infratrocheal) nerves, respectively. Intranasally, the septum and lateral walls are innervated by branches of the sphenopalatine and anterior and posterior ethmoidal nerves. The nasal floor receives some fibers from the nasopalatine nerve and from the greater palatine nerve. The parasympathetic supply originates from the superior salivatory nucleus in the medulla, travels with the nervus intermedius and cranial nerve VII to the geniculate ganglion, and continues along the greater petrosal nerve and through the vidian canal to reach the pterygopalatine ganglion. The postganglionic fibers travel to the sinonasal mucosal, including the septum and turbinates.

Although concerns exist among clinicians about nasal tip edema or vascular insufficiency resulting from operative management of nasal injuries and the use of vasoconstrictors, this has not been substantiated by research studies. Lymphoscintigraphy, along with cadaver dissections and histologic studies, have revealed that the primary blood supply for the nasal tip arises from the lateral nasal branches of the facial artery (Fig. 20-4). Other arteries supplying the nasal tip include the columellar branch of the superior labial artery and the external nasal branch of the anterior ethmoid artery. Moreover, it was found that the major arterial, venous, and lymphatic vessels course at or superficial to the musculoaponeurotic layer of the nose. Therefore, open approaches must limit dissection deep to this musculoaponeurotic layer to maintain nasal tip blood supply and drainage conduits.¹⁰

Evaluation of Injury to the Nose

Treatment of Nasal Injuries

For most routine nasal fractures, operative management of nasal fractures requires consideration for the timing, anesthetic, setting in which treatment is rendered, and details of the operative approach.31–33 The recommended time frame to repair nasal fractures is within the first week after injury. It is acceptable to perform immediate treatment, but at times it may be helpful to allow swelling to decrease prior to definitive treatment. Some recommend delaying surgery because it is may sometimes be difficult to judge the adequacy of reduction in the presence of significant edema. However, surgeons must remember that the elastic cartilaginous framework may be difficult to reduce as fibrin organization and fibrosis ensues; thus, delayed repairs beyond 1 week may become increasingly more difficult to treat with closed reduction alone. Children have a tendency to heal the bony tissue more quickly, which may make it more difficult to achieve a detailed repositioning. Treatment within the first several days facilitates the healing process, limits patient disability, and decreases the patient’s time spent away from school, work, or other activities.³⁴

Local anesthesia or the use of sedation can be used, but it may put the patient at increased risk for bleeding in and around the airway. This can lead to laryngospasm in patients who are obtunded, particularly children. When the nasal complex is bleeding, it may complicate airway management and reduce the surgeon’s ability to reduce the fracture adequately under good conditions in a safe manner. We prefer to treat nasal and septal fractures with a brief general anesthetic in the operating room using an endotracheal tube or laryngeal mask ventilation device. Either airway option can be used for adults or children.

While the authors prefer general anesthesia for children during operative manipulation of nasal fractures. However, there are advocates for the choice of either local or general anesthesia, and some data to support that decision. Contributing factors may include patient cooperation, financial constraints, operator experience or comfort, and others.

Cook et al compared the manipulation and reduction of nasal fractures under local anesthesia (LA) and general anesthesia (GA). In this study, LA was administered with 0.5% bupivacaine blocking the infraorbital, infratrochlear, and external nasal nerves.³⁵ Patients in the LA group rated how painful the combined anesthesia administration and fracture manipulation had been on a scale from 1 to 5 at the 4-hour and 8-week time point after reduction. They also rated nasal airway patency and the surgeon rated the cosmetic result. After manipulation, the patency of nasal airways was comparable between the LA and GA groups. The local anesthesia group rated their median pain score as 3 out of 5. Pain was attributable to the infiltration of LA solution. When asked about their choice of anesthesia in case they would require nasal manipulation in the future, 24 of 25 patient in the LA group and 16 of 25 in the GA group indicated that they would opt for LA. There were no reported cases of perioperative airway compromise documented in these patients.

The same investigators also randomized two LA techniques among 50 consecutive adult patients with clinically displaced nasal fractures.³⁶ One group received blocks of the infraorbital, infratrochlear, and external nasal nerves by intranasal infiltration and the other group was given generalized infiltration of the nasal dorsum by an external route. All patients received intranasal cocaine. Postoperatively, patients recorded their overall discomfort level and subjective nasal airway patency. The surgeon also recorded the cosmetic result. They found the internal route to be significantly more painful (p < .001) and with no advantage to the patient with respect to postoperative ai/>