When should a nasal fracture be treated?

The outer portion of the nasal structure consists of a bony pyramid-type projection in the upper part, and cartilaginous projection in the lower part including the tip. The lower half of the nose is therefore more flexible and can sustain minor blows without any significant deformity. The upper portion of the nose, consistent of the bony dome, is less flexible and external forces can cause fracture of the bone. If the nasal bones are fractured, these could be either non-displaced, displaced, or comminuted (shattered into smaller pieces). External examination of the nose can give us a clue as far as the general shape and deformity perceived by the examiner. If ecchymosis (black and blue) is seen or if there is crepitus (“rice crackle” sounds) externally, a nasal fracture is suspected. The most definite way to diagnose a nasal fracture is by doing a nasal x-rays and studying the bones directly.

Not every single case of nasal fracture needs to be medically addressed. A nondisplaced nasal fracture does not need any intervention and only needs time for the bones to heal themselves. A displaced nasal fracture might be observed if the degree of deformity is not severe. Alternatively, the bones might need to be realigned for proper healing.

Most simple displaced nasal fractures without any shattering of the bone can be fixed with what is called closed reduction. This is simply done by applying anesthetic to the area and popping the bone back in place with an instrument inside the nasal passages. Sedation is often administered to ease the anxiety over the procedure.

Typically, there are three windows of opportunity for reducing a displaced nasal fracture. If a patient is able to be seen by medical personnel within the first couple of hours and the diagnosis is made, the treatment can be given immediately. Unfortunately, by the time that many patients are seen in the emergency setting, several hours have passed, and the nasal areas have swollen to the point that proper assessment of the bones cannot be done externally, thus excluding a proper reduction of the nose in an immediate setting. A second idea is that although the patient might be seen in the emergency setting, they might choose to have the reduction done by a more skilled ear, nose, and throat doctor or a plastic surgeon for better outcome. The last concern for immediate closure is that the patient may not be able to give proper consent if they were intoxicated or otherwise have altered mental status.

The second window of opportunity for closed reduction of nasal fracture is typically between 1-2 weeks after the injury. By that time, most of the swelling has gone away, but the bones have not started to completely fuse. This time difference also allows the patient to better select the treating doctor for optimal outcome.

If a displaced nasal fracture is not reduced within the first couple of weeks, convention is that the bones have started to heal in the displaced configuration. Therefore, any reduction after that time would necessitate a more open approach to re-fracture the bones and then align them in a proper location. Many surgeons believe that we should then wait between 3-6 months for the normal healing of the bones to finalize, and only at that time to consider undertaking an open approach.

A comminuted nasal fracture probably is best dealt with open approach to begin with. Procedure should be done in the operating room under complete anesthesia. Depending on the degree of injury, various different reconstructive techniques might be necessary.

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