Jebmh.com Original Research Article

NASAL BONE FRACTURE MANAGEMENT- OUR EXPERIENCE Abhilasha Sadhoo1, Manish Sharma2, Padam Singh3

1Fellow, Department of Head and Neck Oncology, KMIO, Bangalore. 2Senior Resident, Department of ENT and Head and Neck Surgery, Government Medical College, Jammu. 3Professor, Department of ENT and Head and Neck Surgery, Government Medical College, Jammu. ABSTRACT BACKGROUND Nasal bone fractures are distinctive due to their anatomical complexity area and associated psychological effects. An understanding of the epidemiology of these fractures is important to develop preventive measures, increase the efficiency and delivery of health services, improve the skills of healthcare providers and better distribute resources. The aim of the paper is to evaluate the approach towards management and outcomes of nasal bone fractures in tertiary care centre at Jammu. The aim of the study is to evaluate the approach towards management and outcomes of nasal bone fractures in tertiary care centre at Jammu.

MATERIALS AND METHODS Patients of maxillofacial injuries presenting to the hospital who had nasal bone fractures only were included in the study. The study period was from November 2009 to October 2010. Statistical Analysis- The data was tabulated and analysed in Microsoft Excel spreadsheet (version 2007). Setting- Shri Maharaja Gulab Singh Hospital, Government Medical College, Jammu. Design- Prospective cross-sectional study.

RESULTS In our study, majority cases were more common in urban areas and in males (80%). Younger age group (21-30) was most commonly affected. The fractures were most commonly associated with Road Traffic Accidents (RTAs) in 23 cases, assault in 7 cases and falls in 3 cases. Common clinical presentations were epistaxis, swelling and tenderness, nasal obstruction, external deformity and crepitus seen in all the cases of nasal fractures. Class II fractures were seen most commonly (51.42%) followed by class I fractures (42.85%). X-rays of the nasal bone demonstrated (88.57%) of the cases. Closed reduction was mode of treatment in 19 cases, 6 cases needed open reduction while 10 patients with undisplaced fractures were treated conservatively.

CONCLUSION Even though the current protocols in the management of nasal bone fracture are quite efficient a uniform protocol is still missing. Several techniques are used in individual fracture depending on the course of fracture, surgeon’s experience and patient’s preference. So, we conclude that long-term and multicentre collection of data about nasal trauma is important to develop standard protocols and consensus.

KEYWORDS Nasal Bone Fracture, Protocol. HOW TO CITE THIS ARTICLE: Sadhoo A, Sharma M, Singh P. Nasal bone fracture management- Our experience. J. Evid. Based Med. Healthc. 2017; 4(13), 717-722. DOI: 10.18410/jebmh/2017/139

BACKGROUND the patient’s facial physiognomy changes causing emotional The maxillofacial region is one of the most frequently injured shock even in cases of small facial injuries.4 areas of the body.1 Isolated fractures of the nasal pyramid Numerous factors are associated with a successful account for about 40 percent of all facial fractures.2 Younger postoperative cosmetic and functional result. They are age male patients are known to be at risk with alcohol intake and of the patient, time since injury, acute versus delayed vehicular accidents being modifying factors.3 Nasal bone intervention, anaesthesia used and approach (open vs. fractures do not cause an immediate risk to life, however, closed reduction).5 Historically, it was usual to await resolution of facial Financial or Other, Competing Interest: None. swelling before the assessment procedure began and Submission 09-12-2016, Peer Review 16-12-2016, patients waited for five to seven days before surgery was Acceptance 21-01-2017, Published 10-02-2017. considered. This policy avoided double insult of accidental Corresponding Author: Dr. Abhilasha Sadhoo, and surgical trauma. The treatment of facial fractures has #F-201, Ozone Evergreens Apartment, undergone a sea change since the earliest description almost Haralur Road, Bangalore - 560102. 5000 years ago. Maxillary injuries are separated into simple E-mail: [email protected] fractures that can be successfully treated and more complex DOI: 10.18410/jebmh/2017/139 fractures that lead to death. The goals of treatment of

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 13/Feb. 13, 2017 Page 717

Jebmh.com Original Research Article complex facial injuries include the restoration of bony form Common clinical presentations were epistaxis, swelling (dental occlusion) as well as facial form (appearance).6 and tenderness, nasal obstruction, external deformity and Controversy exists concerning the correct timing for repair crepitus seen in all the cases of nasal fractures. Ecchymosis required to achieve these goals.7 The timing of intervention was seen in 26 cases (74.2%) and telecanthus in 4 cases for any nasal injury also greatly influences the approach and (11.4%) (Figure 2). the outcome.5 Despite a multitude of options available in managing a case of nasal bone trauma, a uniform protocol in approach and treatment for nasal bone fracture is not present.8 The aim of our paper is to evaluate the current practices towards management of nasal bone fractures and their outcomes in a tertiary care centre at Jammu.

MATERIALS AND METHODS 35 patients with nasal bone fracture at the Department of Otorhinolaryngology, Shri Maharaja Gulab Singh Hospital Figure 2. Bar Chart Showing Different and Government Medical College, Jammu, for a period of Signs/Symptoms in Nasal Bone Fractures one year from November 2009 to October 2010 were included in the study. Patients who had history of any other Class II fractures were seen most commonly in 18 cases maxillofacial injury, life-threatening injury, which required (51.42%) followed by class I fractures found in 15 immediate attention were excluded from the study. All cases (42.85%). Only 2 cases of class III fractures were seen. were subjected to a detailed history and examination X-rays of the nasal bone could demonstrate 31 (88.57%) followed by x-ray nasal bones and computerised of the nasal fractures while remainder 4 cases (11.43%) tomography (if required). Cases were analysed with respect required computerised tomography of the face. to demography, cause of injury, presentation, type of Out of the 35 fractured cases, 33 (94.2%) presented fracture, management undertaken, anaesthesia used and within 24 hours of the trauma and 2 (5.75%) presented after outcomes. 7 days. 32 of the patients were treated within 2 weeks of RESULTS presentation and 2 cases of persistent septal deformity were Majority of the fractures occurred in urban areas (24 cases) operated within 3 weeks. Only 1 case of saddle nose was and the least from rural areas (11 cases). operated after 3 weeks because he presented after 7 days In our study, nasal bone fractures were more common of injury. in males, 28 cases (80%) compared to females, 7 cases Intervention was needed in 28 patients. Out of these, 10 (20%). patients were administered general anaesthesia, while 18 Nasal bone fracture was most commonly seen in the age patients were given local anaesthesia. range of 21-30 years (20 cases). Patients aged between 31- 10 patients had undisplaced nasal bone fractures treated 40 years were the second most vulnerable group (5 cases) conservatively with anti-inflammatory agents alone. 15 followed by those between 11-20 years (3 cases). Patients patients had class I fracture with only 6 requiring aged more than 60 years had the least incidence (2 cases) intervention in the form of closed reduction with (Figure 1). immobilisation by application of external nasal splint. 18 patients had class II fracture, one patient requiring no treatment, 13 needing closed reduction and 4 requiring open reduction and septal deformity correction. The 2 cases of class III fractures underwent open reduction and internal fixation (Figure 3).

Figure 1. Age Distribution of Nasal Bone Fracture

The fractures were most commonly associated with Road Traffic Accidents (RTAs) in 23 cases, assault in 7 cases and falls in 3 cases. Figure 3. Chart Showing the Modality of Treatment Used for Different Classes of Fracture

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 13/Feb. 13, 2017 Page 718

Jebmh.com Original Research Article

In the 6 patients of class I fracture treated with closed pyramid, nasal obstruction and tenderness over bridge of reduction, only one developed saddle nose deformity, nose and crepitus. The type and extent of fractures of postoperatively. Two patients of class II fracture treated by nasoethmoid complex determines the principal features closed reduction developed persistent septal deviation while found on clinical examination, usual features being frontal one patient treated by open reduction developed septal depression, nasal deformity and traumatic telecanthus. haematoma. Patients of class III had no postoperative Cerebrospinal Fluid (CSF), rhinorrhoea and diplopia maybe complications. present. Haemorrhage can be severe due to rupture of either anterior or posterior ethmoidal artery. He further DISCUSSION recommended that physical examination should incorporate An extensive bibliographical search revealed that very few both internal and external components. External studies were done on nasal bone fractures. Most of the examination must focus on obvious nasal defects, reported data was in conjunction with other maxillofacial malposition and other apparent soft tissue injuries including traumas that altered the approach to the patient lacerations, haemorrhage or oedema. Palpation of the nose markedly.3,8,9 Face because of its conspicuous position is the is critical with findings of crepitus, tenderness, depression, most frequently traumatised site of the body. Numbers of step-offs, nasal shortening or widening of the nasal base studies have been conducted from different countries about indicative of fracture. However, any injury without some the pattern of maxillofacial injuries, but the demographical degree of bleeding is unlikely to be a severe fracture. data are difficult to evaluate because of many variables.10 Intercanthal measurements are useful in ruling out In our study, 80% of the cases were males while 20% associated nasoorbitoethmoid fractures, especially in high- were females. Younger age group of 21-30 (20 cases) was velocity frontal or inferior injuries.15 The finding of significant most commonly affected. Males are known to be more prone rhinorrhoea should be evaluated for Cerebrospinal Fluid to nasal bone fractures.2 Latifi et al in their study on (CSF) leak by testing fluid levels of either glucose or β- maxillofacial fractures on 637 patients, males outnumbered transferrin, a suspicion of CSF leak necessitating a women (2.5:1), younger age group (20-30 years) was most neurosurgical consultation.5 prone and falls and RTA were the commonest aetiologies Maran classified nasal fractures into class I, II and III have also reported that males particularly in the younger age fractures. Class II fractures were seen most commonly in 18 group were more liable to sustain a nasal bone fracture.3 cases (51.42%) followed by class I fractures found in 15 The peak incidence was in the 15-30 years age group when (42.85%). Only 2 cases of class III fractures were seen. assaults, contact sports and adventurous leisure activities Class I fractures are the result of low-moderate degrees of were more common.2 force and hence the extent of deformity is usually not In our study, the fractures were most commonly marked. Class 2 fractures are the result of greater force and associated with RTAs accounting for 66% cases. Road traffic are often associated with significant cosmetic deformity. In accidents are now considered a public health hazard that is addition to fracturing, the nasal bones, the frontal process likely to escalate in severity owing to rapid rise in automobile of the maxilla and septal structures are also involved. Class users.10 This alarming trend has often been reported in 3 fractures are the most severe nasal injuries encountered numerous national as well as international journals. RTA has and usually result from high velocity trauma. They are also been reported to cause maxillofacial fractures including termed nasoorbitoethmoid fractures and often have nasal bone fractures in 60-70% cases in various studies associated fractures of the maxillae.2 similar to what we have observed. Physical assault (20% Out of the 35 fractured cases, 33 (94.2%) presented cases) and falls (8%) were the other aetiologies observed in within 24 hours of the trauma while only 2 (5.75%) our study. Interpersonal Violence (IPV) and assault has been presented after 7 days. 32 of the patients were treated reported in many studies to be the next leading cause of within two weeks of presentation, while two cases were maxillofacial fractures as was found in our study. Further, in operated within three weeks. Only one case was operated many nations, stringent laws have seen a reduction in after three weeks because he presented after 7 days of fractures due to RTA, but those due to IPV continue to injury. rise.11,12 We observed that earlier the patient presents after Examination of nasal trauma is often made in a sustaining maxillofacial trauma, the better the results a subjective manner. Therefore, a gold standard for the maxillofacial surgeon can offer. The reason for delay can be evaluation of the nasal trauma and its outcomes, a gold non-availability of proper medical facilities or patients may standard is missing.12,13 We observed that all cases consider the injury as trivial or the facial deformity is presented with epistaxis, swelling and tenderness, nasal camouflaged by the post injury swelling. According to obstruction, external deformity and crepitus. 26 (74.2%) Murray and Maran, timing of closed reduction of nasal cases had ecchymosis and 4 (11.4%) cases had telecanthus. fracture after sustaining trauma influences the final outcome Marco et al recommend that a history of epistaxis and nasal of operation. Rate of unsuccessful manipulation increases, deformity in a nasal trauma case must always arouse longer the gap between trauma and day of operation.15 suspicion of nasal bone fracture.14 Weing reports that it is desirable to provide definitive Maran observed that nasal fractures usually present with fracture treatment as soon as possible. He postulates that history of blow, epistaxis and external deformity of nasal an early reduction of fracture dislocation facilitates direct

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 13/Feb. 13, 2017 Page 719

Jebmh.com Original Research Article occlusal positioning and reconstruction of facial reduction of nasal bone fractures based on a patient’s configuration.6 preference and medical condition.22 Facial pain and oedema subside rapidly following early In our study, we observed that 10 patients (30%) had rigid internal fixation and repair. Although, a delay of two undisplaced nasal bone fractures treated conservatively with weeks in definitive repair could increase the difficulty in anti-inflammatory agents alone.15 Patients had class I obtaining adequate reduction of fracture dislocations, a fracture with only 6 requiring intervention in the form of period of 7-10 days prior to intervention to permit oedema closed reduction with immobilisation by application of to subside appears reasonable.6 external nasal splint.18 Patients had class II fracture with one X-rays of the nasal bone could demonstrate 31 (88.57%) patient requiring no treatment, 13 needing closed reduction of the nasal fractures while rest required computerised and 4 requiring open reduction and septal deformity tomography of the face 4 (11.43%). We believe that correction. 2 cases of class III fractures were managed by radiographic examination apart from its medicolegal aspects open reduction and internal fixation by transnasal wires. has not been found to be very helpful in the diagnosis of All class I and most class II fractures can be reduced nasal bone fractures, however, it is quite useful for with closed reduction techniques.2 For many class 2 documentation, litigation and for confirming the clinical fractures, closed reduction alone rarely achieves a diagnosis. satisfactory result as the final position of the nasal dorsum Mayell found that radiography in nasal fractures have reflects the deformity of the underlying septum.23 little value by because negative x-rays would not alter the Open reduction techniques may lead to improved results, management of a clinically fractured nose.16 Schultz despite the increased time and effort involved. Mayell et al observed that if the x-rays show displacement while nose found satisfactory results in only a third of cases reduced by looks straight, nose should be manipulated otherwise closed techniques, whereas Illum found 71-90 percent of cosmetic deformity ensues.17 Manson said that while patients had good results after closed techniques.16,24 roentgengraphic evaluation is indispensable in the Although, place of closed manipulation of nasal fractures evaluation of a patient with head and face injuries, it does has been questioned as regards the final outcome of not replace clinical examination, that is the most sensitive procedure (Mayell; Stell; Harrison), there have been indicator of facial injuries. Even though, the clinical advocates of closed reduction (Manglia; Schultz; evaluation may demonstrate obvious fracture and suggest a McCollough).16,17,25,26,27,28 According to Bowerman, standard type of management, a thorough roentgengraphic nasoethmoid injuries or class III fractures should be treated evaluation should be made. Because of the high incidence by open reduction. Weerda and Siegert observed that most of litigation arising from the injuries, it is of prime importance class III fractures should be treated with open reduction and to have a thorough documentation of all bone injuries even internal fixation.29 In the past, the reduced frontonasal if treatment is not required.18 Finkle et al observed that while complex would be supported by transnasal wires tied clinical examination was most accurate for nasal fractures, externally over either silicon or lead plates and the CT scan was most accurate for diagnosing fractures of the comminuted medial orbital wall left to reattach and lateral wall, orbital roof and floor and infraorbital rim for reorganise itself. The recent development of miniplate ethmoid and sphenoid sinus injuries.19 systems has had a huge impact on the management of these Recent trends are of using ultrasonography in the fractures. diagnosis of nasal bone fractures, especially in pregnant White observed that correction of nasal deformity is women and children and also in intraoperative evaluation of usually postponed for 3-5 days as swelling subsides. Nasal repositioning of the nasal bones. In cases of suspected fracture reduction is optimally performed within 2 weeks of complex facial bone trauma, a CT examination should be injury.30 McCollough et al observed that if nasal fractures are performed.20 seen prior to significant swelling, they can easily be reduced We observed that out of the 28 patients needing then only, but if these present when oedema has already set intervention, 10 were administered general anaesthesia, in or if there are open wounds, these should be meticulously while 18 were given local anaesthesia. Although, Schultz stitched and actual management of fracture may require found local anaesthesia quite satisfactory in 76% of his postponement for 5-7 days. They also reported that most of cases of facial fractures, Mayell carried out all the nasal the simple fractures of nose can be treated by closed fracture reductions under general anaesthesia. Local versus reduction by manipulation, but if by manipulation septum general anaesthetic as the preferred means for reduction of cannot be restored in central position, then one should nasal fracture is a contentious issue and the literature is proceed to open.28 divided over the influence on outcomes.16,17 Ridder et al Murray and Maran also said that time of reduction after found that there was no significant difference in overall sustaining fracture has relation with final outcome. In success rate between nasal fractures reduced with local and patients who were manipulated seven days after sustaining general anaesthesia.21 Al Morain observed that the incidence fracture, the rate of unsuccessful manipulation was 30% and of postoperative adverse effects and severity of those undergoing manipulation within 9-14 days, it was postoperative pain were similar between the two groups of 41%. There was a group in which manipulation was delayed general and local anaesthesia; therefore, concluded that to more than two weeks. Although, the failure rate was both anaesthetic techniques can be used during the smaller, viz., 22% yet according to them, this could not be

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 13/Feb. 13, 2017 Page 720

Jebmh.com Original Research Article relied upon as number of patients in this group was small. [3] Latifi H. Prevalence of different kinds of maxillofacial Class I fractures need simple manipulation and packing. In fractures and their associated factors are surveyed in case, Class II replacement of nasal bones maybe successful patients. Glob J Health Sci 2014;6(7):66-73. in >40% cases, there is redisplacement of the nasal bones [4] Aljinovic N. Maksilofacijalna traumatologija. Zagreb: due to overlapping of the fractured ends of the Klinicka bolnica Dubrava 1999. perpendicular plate of ethmoid and quadrilateral cartilage. [5] Kelley BP, Downey CR, Stal S. Evaluation and reduction The manipulation of the nasal bone here should be of nasal trauma. Semin Plast Surg 2010;24(4):339- accompanied by open reduction of the septal deformity. 347. Class III fractures require open reduction.23 [6] Wenig MR. Management of panfacial fractures. Harrison reviewed 40 cases in which close manipulation Otolaryngol Clin North Am 1991;24(1):93-101. was done and found that only 13 cases had a perfect result [7] Ashoor AJ, Alkhars FA. Nasal bone fracture. Saudi defined as a nose that is straight throughout its bony and Medical Journal 2000;21(5):471-474. cartilaginous bridge line with clear airways.26 [8] Yamamoto K, Matsusue Y, Horita S, et al. Clinical In the 6 patients of class I fracture treated with closed analysis of midfacial fractures. Mater Sociomed reduction, only 1 developed saddle nose deformity, 2014;26(1):21-25. postoperatively. Two patients of class II fracture treated by [9] Fornazieri MA, Yamaguti HY, Moreira JH, et al. Fracture closed reduction developed persistent septal deviation while of nasal bones: an epidemiologic analysis. Int Arch one patient treated by open reduction developed septal Otorhinolaryngol 2008;12(4):498-501. haematoma. Patients of class III had no postoperative [10] Subhashraj K, Ravindran C. Maxillofacial intervention complications. in trauma patients aged 60 years and older. Ind J Dent We observed that only one patient developed saddle Resear 2008;19(2):109-111. nose, which was due to late presentation and subsequently [11] Rallis G, Igoumenakis D, Krasadakis C, et al. Impact of late management. Residual deformity has been recorded in the economic recession on the etiology of maxillofacial 14-50 percent after closed reduction.31 Closed reduction is fractures in Greece. Oral Surg Oral Med Oral Pathol the treatment of choice in nasal bone fracture unless a Oral Radiol 2015;119(1):32-34. severe nasal septum fracture is observed.32 [12] Weihsin H, Thadani S, Agrawal M, et al. Causes and Illum reported that closed reduction is adequate for incidence of maxillofacial injuries in India: 12-year most fractured nasal bone, but if reduction is not retrospective study of 4437 patients in a tertiary maintained, then open reduction can be carried out months hospital in Gujarat. Br J Oral Maxillofac Surg later by traditional septorhinoplasty.24 In our study, we 2014;52(8):693-696. recorded a failure rate of 23% after closed reduction and all [13] Leong SCL, Abdelkader M, White PS. Changes in nasal of them were adult. Murray et al reported a failure rate after aesthetics following nasal bone manipulation. Journal closed reduction of up to 30-40% and attributed their failure of Laryngology and Otology 2008;122(1):38-41. to interlocking of fracture septal segment, which drag the [14] Fornazieri MA, Yamaguti HY, Moreira JH, et al. Fracture mobile fracture nasal bone segment toward their initial of nasal bones: an epidemiologic analysis. Intl Arch displaced position.23 Stucker et al pointed out the difficulties Otorhinolaryngol 2008;12(4):498-501. in determining when complete reduction has been achieved [15] Maran AGD. Fractured nose. In: Kerr AG, ed. Scott- after closed reduction in children.33 Brown’s otolaryngology. 5th edn. London: Butterworth 1988:212-221. CONCLUSION [16] Mayell MJ. Nasal fractures. Their occurrence, Even though, the current protocols in the management of management and some late results. J R Coll Surg Edinb nasal bone fracture are quite efficient, a uniform protocol is 1973;18(1):31-36. still missing. Several techniques are used in individual [17] Schultz RC. One thousand consecutive cases of major fracture depending on the course of fracture, surgeons facial injury. Rev Surg 1970;27(6):394-140. experience and patients’ preference. So, we conclude that [18] Manson NP. Facial injuries. In: McCarthy JG, James long-term and multicentre collection of data about nasal MW, Williams LJ, eds. Plastic s urgery. Vol. II. trauma is important to develop standard protocols and Philadelphia: WB Saunders Company 1990:867. consensus. [19] Finkle DR, Ringler SL, Luttenton CR, et al. Comparison of the diagnostic methods in maxillofacial trauma. Plast REFERENCES Reconstr Surg 1985;75(1):32-41. [1] Boffano P, Kommers SC, Roccia F, et al. Mandibular [20] Javadrashid R, Khatoonabad M, Shams N, et al. trauma treatment: a comparison of two protocols. Med Comparison of ultrasonography with computed Oral Patol Oral Cir Bucal 2015;20(2):e218-e223. tomography in the diagnosis of nasal bone fractures. [2] Holmes S, Gleeson M. Fractures of the facial skeleton. Dentomaxillofacial Radiology 2011;40(8):486-491. In: Gleeson M, Browning GG, Burton MJ, et al, eds. [21] Ridder GJ, Boedeker CC, Fradis M, et al. Technique and Scott-Brown‘s otorhinolaryngology, head and neck timing for closed reduction of isolated nasal fractures: surgery. 7th edn. London: Hodder Arnold 2008;2:1618. a retrospective study. Ear Nose Throat J 2002;81(1):49-54.

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 13/Feb. 13, 2017 Page 721

Jebmh.com Original Research Article

[22] Al-Moraissi EA, Ellis E. Local versus general anesthesia [28] McCollough EG, Gilber SE, Langsdon PR. Nasal for the management of nasal bone fractures: a fracture. Indian J Otolaryngol 1986;38(4)135-137. systematic review and meta-analysis. J Oral Maxillofac [29] Weerda H, Siergert R. Stable fixation of the nasal Surg 2014;73(4):606-615. complex. Facial Plas Surg 1990;7(3):185-188. [23] Murray JAM. Management of septal deviation with [30] White MJ, Johnson PC, Heckler FR. Management of nasal fractures. Facial Plastic Surgery 1989;6(2):88- maxillofacial and neck soft tissue injuries. Clinics in 93. Sports Med 1989;8:11-23. [24] Illum P. Long term results after treatment of nasal [31] Fernandes S. Nasal fractures: the taming of the fracture. J Laryngol Otoly 1986;100(3):273-277. shrewd. Laryngoscope 2004;114(3):587-592. [25] Stell PM. The fractured nose. Clinical Otolayngol [32] Han DS, Han YS, Park JH. A new approach to the 1980;5(6):362-363. treatment of nasal bone fracture: the clinical [26] Harrison DH. Nasal injuries: their pathogenesis and usefulness of closed reduction using a C-arm. J Plast treatment. British J Plastic Surg 1979;32(1):57-64. Reconstr Aesthet Surg 2011;64(7):937-943. [27] Maniglia AJ. Surgical correction of traumatized nose. [33] Stucker FJ, Ansel DG. A case against nasal packing. Otolaryngol Clin North Am 1983;16(3):609-621. Laryngoscope 1978;88(8 pt 1):1314-1317.

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 13/Feb. 13, 2017 Page 722