Key points
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Nasal bone fractures are the most common facial fractures in adult patients with trauma.
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The nasal complex comprises underlying nasal mucosa and turbinates, upper and lower cartilages, the cartilaginous and bony septum in the middle, and the paired nasal bones.
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The goals of management of nasal bony injuries are to prevent development of a posttraumatic nasal deformity, restoration of proper nasal air flow, prevention of cosmetic deformity, and maintaining of proper nasal complex topography and projection.
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Closed reduction of the nasal complex is still the most commonly performed maneuver for repair of the injured bony nose; however, the incidence of patients requiring a posttraumatic rhinoplasty following closed reduction can range between 9% and 62%.
Practitioners involved in the management of facial trauma are commonly involved in the treatment of patients with acute nasal injuries. Nasal bones are the most frequently fractured bones of the adult face. Because of its prominent location on the face, less force is required to fracture the nasal complex than any other facial bone. Because of the frequency of injury, as well as involvement of different components of the nose (bone, cartilage, mucosa, skin), appropriate management of the acutely injured nose is imperative in order to prevent adverse sequelae. Despite the seemingly simple approach to the management of nasal bone fractures, the incidence of unfavorable results is as high as 62%, which directly leads to the late management of nasal bone injuries.
The most common causal factors for blunt nasal trauma in the United States continue to be motor vehicle collision, interpersonal altercations, and sport-related injuries. Mechanism of injury is important in determining the nature of the deformity as well as history of previous nasal injury or surgery. This article reviews pertinent surgical anatomy, clinical and radiographic diagnostic tools, surgical management, and potential complications associated with nasal complex fractures.
Surgical anatomy
The nasal complex comprises underlying nasal mucosa and turbinates, upper and lower cartilages, the cartilaginous and bony septum in the middle, and the paired nasal bones. The superficial musculoaponeurotic system of the face comprises the overlying soft tissue envelope of the nose and includes all of the perinasal musculature and vascular supply ( Fig. 1 ). The paired nasal bones are located between the nasofrontal suture cephalically and the upper lateral cartilages caudally. They are laterally bordered by the frontal processes of the maxillary bones. It is important to remember that the nasal bones overlap the cephalic portion of the upper lateral cartilages by 3 to 4 mm ( Fig. 2 ). The nasal septum comprises cartilage (anteriorly) and the ethmoid and vomer bones (posteriorly). The quadrangular portion of the nose is the primary support mechanism of the nasal complex and is made of cartilage ( Fig. 3 ). The cartilage is thick posteriorly along the junction with the vomer and ethmoid bones as well as along the maxillary crest. The vascular supply to the nasal complex is through the internal and external carotid systems via branches of the facial, superior labial, angular, sphenopalatine, ethmoidal, and superior ophthalmic arteries. Innervation to the nasal complex is primarily through the second division (maxillary) of the trigeminal nerve.
Clinical and radiographic diagnostic tools
Examination of a patient with nasal trauma is no different than for any other acutely injured person. After all life-threatening and major organ injuries are addressed, a focused secondary evaluation of the maxillofacial region is performed. Imperative to the examination of the nose is obtaining a complete history. Mechanism of injury and timing of the event are important because they may assist in predicting a specific type of fracture or injury. For example, if the vector of force contacting the nose is directly perpendicular to the nasal dorsum, then it is predictable that the bony complex is typically fractured in a lateral (outward) direction. In contrast, if the force is directed laterally to the nose (a right-handed punch to the left side of the nose), the nasal complex then deviates away from the vector of force with one nasal bone being medially displaced, whereas the other is laterally displaced. Also, acknowledgment of any previous nasal trauma and presence of preexisting nasal deviation is important in determining whether a patient requires surgical intervention.
Examination of the nasal complex is done by performing a detailed internal and external evaluation of the nose. All patients with nasal complex trauma have epistaxis ( Fig. 4 ). Observation of the facial region may reveal clinical signs of underlying fractures such as periorbital ecchymosis, nasal swelling, nasal complex deviation, cerebrospinal fluid (CSF) rhinorrhea, and lack of nasal projection. Increased intercanthal distance should be noted. Difficulty smelling (anosmia) is a late finding following nasal complex trauma and usually occurs if the cribriform plate of the ethmoid bone is involved. Palpation of the nose may reveal mobility or crepitus indicating fracture. Internal examination with good lighting, nasal speculum, and suction is imperative to determine the presence of intranasal lacerations, septal deviations off the nasal crest of the maxilla, and the possibility of nasal septal hematoma. Septal hematoma must be drained in order to prevent late vascular complications associated with a devitalized cartilage predisposing to the development of a septal perforation. If a skull base fracture involving the cribriform plate of the ethmoid bone is suspected, a simple double halo test can be done at bedside to ascertain presence of CSF.
The standard of care for midface and upper face maxillofacial trauma currently radiography is computed tomography (CT) scan without contrast ( Fig. 5 ). Nasal bone injuries and septal deviations and fractures are clearly delineated via CT scan. Photographs of the acutely injured nose as well as premorbid photographs obtained from the patient or family are helpful for documentation purposes as well as for preoperative and postoperative comparison purposes.
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