183 An Algorithm for the Initial Management of Nasal Trauma John F. Hoffmann, MD, FACS1 1 Department of Otolaryngology, University of Washington, Spokane, Address for correspondence John F. Hoffmann, MD, FACS, 217 W. Washington Cataldo, Spokane, Washington 99201 (e-mail: [email protected]). Facial Plast Surg 2015;31:183–193. Abstract Nasal fractures are the most common of all facial skeletal injuries. Untreated, these fractures frequently lead to functional and aesthetic problems. Careful history and physical assessment are critical to determine the extent of injury and to determine proper management. Critical aspects of assessment are discussed, as is the role of imaging in management. The unique aspects of pediatric nasal fractures and their management are reviewed. Fractures are classified based on the degree of injury and Keywords the involvement of the septum. A simple treatment algorithm is provided to help guide ► nasal fractures the selection of optimal treatment techniques. A review of instrumentation and ► septal trauma treatment techniques is provided. The goal of treatment is to restore the nose to its ► closed reduction preinjury shape and function and to minimize the need for secondary septorhinoplasty. Nasal fractures represent some of the most prevalent clinical Evaluation problems seen in a facial plastic surgery or otolaryngology practice. Fractures of the nose are the most frequent of all Unlike many facial fractures that rely on sophisticated radio- facial fractures and are reported to be the third most common graphic imaging for accurate diagnosis, isolated nasal fractures fracture of the human skeleton.1 Nasal trauma may lead to are principally diagnosed through history and especially through obvious or subtle changes in the nasal appearance and can carefulclinicalexamination.Thehistorywillprovidecluesasto lead to functional nasal airway obstruction as well. Almost the severity and location of the fractures. A lateral blow to the 40% of all facial fractures involve the nasal bones.2 These nose, as might occur when one is elbowed in a basketball game fractures run the gamut from simple, unilateral displaced or perhaps punched in an altercation, is likely to result in lateral fractures to severely comminuted bony trauma with associ- displacement of the nasal pyramid. A low-energy lateral strike ated septal deviation, dislocation, or fracture. It has been might result in isolated unilateral or bilateral fractures with mild reported that up to 90% of all nasal fractures may also have displacement of the dorsum (►Fig. 1). A higher-energy blow some degree of septal injury.3 might result in comminuted bilateral fractures such that the side The overall goal of treatment is to restore the nose to its that was struck is medialized—or depressed—while the contra- premorbid shape and function and to minimize the need for lateral bone is lateralized and made more prominent (►Fig. 2). subsequent surgery. Management of nasal fractures has re- The end result is significant movement of the nasal dorsum off mained controversial and challenging through the centuries. the midline. In these instances, displacement of the nasal Even Hippocrates expressed his frustration with the treatment of dorsum is highly suggestive of significantnasalseptaldislocation This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. nasal fractures more than 2,000 years ago.1 In response to this and fracture.4 Many of these patients will typically complain of challenge, several surgeons have advocated various treatment significant nasal airway obstruction as well. This is another strategies and treatment algorithms to guide clinicians through important clinical clue that suggests significant septal injury. the evaluation and treatment of a variety of nasal fractures from In contrast, a frontal blow in a fall will commonly fracture simple to complex. This article details the assessment of nasal the anterior aspect of the nasal bones, nasal tip, and septum trauma and provides a simple treatment algorithm based on (►Fig. 3). This may result in frontal depression of the nasal clinical evaluation and other published guidelines for the man- bones without lateral deviation. A more intense frontal blow agement of the most commonly seen types of nasal fractures. may lead to impaction of the nasal bones with loss of some Issue Theme Nasal Trauma; Guest Editor, Copyright © 2015 by Thieme Medical DOI http://dx.doi.org/ John L. Frodel, Jr., MD Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1555618. New York, NY 10001, USA. ISSN 0736-6825. Tel: +1(212) 584-4662. 184 An Algorithm for the Initial Management of Nasal Trauma Hoffmann Fig. 1 (A) A 15-year-old girl who sustained trauma while playing basketball. Nasal pyramid displaced to the right but patent nasal airway. (B)CT scan demonstrating displaced but minimal comminution and well-aligned septum. (C) Post closed reduction only. nasal height and splaying of the nasal bones laterally. Anterior trauma for clinical purposes alone. Surprisingly, more often trauma also frequently will cause fracture of the caudal than not, new patients referred with isolated nasal fractures septum and perhaps the anterior nasal spine (►Fig. 4). still present after they have had plain films taken elsewhere. It is important to inquire whether the patient has The indications for surgical intervention following nasal undergone septorhinoplasty surgery prior to the trauma. trauma are solely based on changes in the appearance or As septorhinoplasty may weaken nasal structures, this may function of the nose after injury, and plain film imaging will lead to greater instability and posttrauma deformities and rarely impact these decisions and may in fact be confusing. airway compromise.2 These patients are much more likely The only time that imaging is definitely indicated follow- to need secondary reconstruction after the initial manage- ing nasal trauma is when one suspects the presence of This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. ment of their fracture and they should be counseled associated facial injuries. A few clinical questions will quickly accordingly. identify most of those patients that may have additional facial Plain radiographic imaging offers little clinical benefitin fractures. Is there any facial numbness? If yes, that could isolated nasal trauma. In fact, sometimes plain film X-rays can suggest the presence of maxillary or orbital injury involving be confusing as they may suggest there is no fracture even the infraorbital nerve. Is there any double vision or change in when the nose is obviously displaced (►Fig. 5). Conversely, vision? If so, this would suggest orbital trauma. Has there plain X-rays may be read as significant fractures even when been any change in dental occlusion? If yes, then there may be there is no significant change in the nasal appearance or associated fractures of the maxilla or mandible. Is there airway. Plain films also are unable to distinguish between significant rhinorrhea? This might suggest a skull base or acute and old fractures. Even though there is little clinical frontal sinus injury with cerebrospinal fluid (CSF) leakage. A utility with plain radiographs, there may be a need for positive response to any of these inquiries would dictate the objective documentation of nasal fractures for legal purposes need for a high-resolution computed tomographic (CT) scan especially in cases of assault or liability claims.5 However, the of the face bones with axial, coronal, and sagittal views author never obtains plain films in cases of isolated nasal (►Fig. 6). Facial Plastic Surgery Vol. 31 No. 3/2015 An Algorithm for the Initial Management of Nasal Trauma Hoffmann 185 Fig. 2 (A) A 24-year-old man involved in altercation. Significant displacement of the dorsum to the left with associated septal dislocation and nasal airway restriction. (B) CT scan demonstrating significant comminution and septal displacement. (C) Post-op following closed reduction of nasal bone and septal fractures. Physical Examination Careful anterior rhinoscopy—and endoscopy as needed— should be performed to assess the septum and intranasal The goal of the physical examination in patients with nasal structures. One should carefully look for the presence of a trauma is to assess the extent and severity of the injury so that septal hematoma. A septal hematoma must be drained and one can determine the most appropriate management and managed as quickly as possible to avoid the development of counsel the patent accordingly. Nasal trauma commonly a septal abscess, which could lead to significant septal results in perinasal edema, ecchymosis, and deformity. The cartilage loss and subsequent nasal collapse. One should physical examination includes gentle palpation of the dorsum assessthealignmentoftheseptumandthedegreeofseptal This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. and tip. One should assess the degree of displacement of the dislocation and fracture. Significant septal deviation has bony pyramid and the extent of depression or lateralization of been shown in multiple studies to be a critical predictor of the nasal bones. Palpation of the nasal tip should assess failure of closed nasal fracture reduction and the need for – potential loss of caudal septal support. A saddle deformity revision surgery after closed reduction.6 8 The intranasal may indicate significant dislocation