INTRODUCTION
The nose is the most common facial bone that is broken and is perhaps the most commonly broken bone in the human body. Because the nose is a prominent facial feature, a broken nose can dramatically alter one’s appearance. This Knol is designed to educate people about nasal fractures and the treatment options available to people who have suffered a fracture.BACKGROUND
What is the function of the nose? The nose has several purposes. The American Rhinologic Society is an organization that boasts a membership consisting of numerous physicians who have a solid professional interest in the nose and is a good source of information regarding various disease processes and functions of the nose: http://www.american-rhinologic.org/patientinfo.purposeofsinuses.phtml The nose is first and foremost an entry point for the air which we breathe. However, the nose is also tasked with processing this air before it enters the lungs. It is a very efficient humidifier which adds moisture to dry air. It is also a filtration apparatus: the nose produces about two liters of mucous per day. This mucous traps particulate matter and prevents particles from entering the lungs. Instead, the mucous is swallowed and impurities breathed in through the nose are shunted to the stomach and safely expelled by the gastrointestinal system. The nose is also a radiator which warms air, preventing frigid air from irritating the lungs. The nose is the seat of the sense of olfaction which adds to our enjoyment of food and is connected to the most ancient brain centers which govern emotion. Olfaction is a very important sense which impacts upon well being. A glimpse at the perfume and food and beverage industries highlights the importance of olfaction in our society. Nevertheless, olfaction is often at its root basis a safety factor that prevents the ingestion of spoiled food that would cause illness. Finally, the nose and sinuses add resonance to the voice.In order to accomplish these six functions, the nose is extremely well supplied with arterial blood. In fact, the blood supply to the nose is from both the external carotid system and the internal carotid system. The internal carotid system is a major blood supply to the brain. A large percentage of the blood circulated by the heart is sent to the carotid arterial system.
The nose has a complex structure that is made up of cartilage and bone. For the purposes of thinking about nasal fractures, it is useful to divide the nose into the septum, the upper third, the middle third, and the lower third.
The nasal septum is the midline wall of the nose that separates the left side from the right side. It is made up of several bones, including the maxillary crest of the maxilla, the vomer, and the perpendicular plate of the ethmoid bone. In addition, the front of the septum consists of a piece of cartilage called the quadrangular cartilage. Although the external carotid artery and the internal carotid artery system supply blood to the nasal septum, because the septum is a midline structure, if the vascular supply becomes attenuated it is possible for the septum to become starved for blood. If this happens, a part of the septum will die away and leave a hole in the septum which is called a septal perforation. Nevertheless, the septum usually has a lot of small blood vessels supplying it; especially near the nostril or entrance to the nose, which doctors call the caudal septum. The septum is made up of multiple structures articulating together and if the nose is struck or injured, these articulations can telescope and change the anatomy of the nose. When this happens, the septum will no longer be straight in the midline and this is referred to as a septal deviation.
The upper third of the nose is made up of the nasal bones. The nasal bones articulate with the frontal bone of the forehead and the maxillary bone of the middle portion of the face. These bones meet in the midline and create a sort of triangle or pyramid, with the nasal septum bisecting the triangle in the midline. At the lower end of the nasal bones, a cartilage structure is attached and is called the upper lateral cartilage. The angle of the upper lateral cartilage in its relation to the nasal septum is called the nasal valve because it is this area of the nose that allows air to flow properly and optimally. The nasal valve angle is optimally about 10 to 15 degrees. The angle of the nasal bone with the forehead is called the glabella. The prominence of the nasal bones is often part of the ethnic characteristics of a person’s nasal anatomy.
The middle third of the nose consists of the upper lateral cartilage and the top of the nasal septum which is mostly made up of the quadrangular cartilage. If the middle third of the nose is prominent, it might produce a convex characteristic, which makes the nose look large and “hooked.” The middle third of the nose has a critical role in air flow and therefore breathing.
The lower third of the nose consists of the lower lateral cartilages and the anterior or caudal septum. This is the portion of the nose that forms the nostril. Again, ethnic characteristics can be seen among different groups of people with regard to the anatomic structure of the lower third of the nose.
The inferior turbinates are on the outside wall of the nasal cavity and are the mucosal covering of the inferior turbinate bone. If one tries to look into the nostril, this is the lump that is seen on the outside wall of the nostril. If enlarged, the inferior turbinate may be confused with a polyp or tumor. The primary function of the inferior turbinate is to humidify air and warm air. It acts like a fin on a radiator designed to disperse heat. The inferior turbinate has venous lakes within it that allow it to function well. Whereas arteries carry blood in a high pressure system, the venous system is the one that returns blood to the heart after the oxygen has been removed. The venous system is a low pressure system.
NASAL FRACTURES
The nasal bone is the most commonly injured facial bone because of the prominent position that the nasal bone has on the face. The nose can be fractured during falls, fights, or sporting events. Falls will frequently produce a broken nasal septum first but a severe fall accompanied by loss of consciousness may produce enough force to break the nasal dorsum as well. A severe fall may be accompanied by a concussion or even a skull fracture. During fights, a punch with a fist directed at the face will often impact the nasal dorsum, fracturing the nasal bones and producing a collapse of the bone on one side. When viewed from the front, the nose may appear to be over to one side or deviated. Sports injury is a very common cause of nasal injury. Contact sports are a common cause but even non-contact sports like basketball, baseball, and bicycle riding can produce their share of nasal injuries. Protective gear such as helmets helps to reduce the incidence of facial fractures in general and nasal fractures in particular. Very frequently, nasal fractures will be immediately suspected at the scene because the injured person will have a profuse nose bleed from the trauma. Swelling of the nose and the beginnings of a black and blue skin discoloration known as ecchymosis will occur. Other facial fractures should be investigated as well.EMERGENCY MANAGEMENT
A person who has sustained a nasal fracture will usually stop their activity and sit down or lie down. Bleeding will frequently accompany the injury and the victim will search for something to stop the flow of blood, which can be quite dramatic. Holding initial pressure on the front of the nose to help stop the bleeding is instinctual. The use of ice on the nasal dorsum can be helpful to constrict blood vessels and stop bleeding. Ice also helps to reduces swelling. If bleeding does not stop with these measures, packing the nose can be effective. People will use many different things for packing material including Kleenex and cotton balls. Cotton dental rolls can be effective for this as well. A product called Telfa which is the white, gauze part of a Band-Aid is available in larger squares and rectangles which can be used for packing. In a pinch, a strip cut from a t-shirt and rolled into a two inch long by ½ inch diameter wick can be used to temporize severe bleeding. Also, for persistent bleeding, a topical decongestant spray like Afrin (oxymetazoline) or Neo-Synephrine (neosynephrine ½ % ) can be sprayed in the nose and this may also help to staunch the bleeding. If bleeding continues beyond these control measures, a doctor’s office visit is prudent. This Web site for physicians discusses advice on initial emergency management: http://www.aafp.org/afp/20041001/1315.htmlDoctors and emergency personnel often see patients who have sustained nasal fractures days or even weeks after the trauma. At first, patients seem to minimize the trauma and swelling occurs rapidly, which masks the appearance of deformity. As the swelling goes down, the patient notices in the mirror that the nose is different from the pre-injury state and this is what brings the patient to the doctor. It is very important, however, to ascertain that the injury is “only” a nasal fracture. If the victim complains of double vision, cheek numbness, teeth numbness, teeth not fitting together correctly, or has clear fluid discharge from the nose, immediate medical attention should be sought. Double vision could indicate an orbital floor fracture (eye socket floor fracture). Cheek numbness may indicate a zygomatic complex fracture or a maxillary fracture, and tooth numbness may indicate a jaw fracture. If teeth do not fit together correctly, some kind of jaw or tooth fracture would be likely. If clear fluid is draining from the nose, a cerebral-spinal fluid leak may be present which would indicate a skull base fracture or a nasoethmoid complex fracture. All of these conditions require more immediate attention. What will happen during a doctor’s visit? First, bleeding will be controlled and pain medication, if necessary will be prescribed. Other associated injuries will be assessed. For an isolated nasal fracture, the doctor may or may not order plain x-ray films to document the injury. These days, especially in emergency rooms, CT scans will be ordered to make sure that associated facial injuries are not also present. The doctor will also assess for the one complication of nasal fracture that can cause major long term consequences: septal hematoma. A septal hematoma occurs as a consequence of a nasal fracture that is complicated by a concomitant septal fracture. If blood accumulates under the nasal septal lining because of the septal trauma, a septal hematoma can occur. A septal hematoma is an emergency because the presence of blood under the nasal lining balloons up the septum and starves it from oxygen that is delivered to the septal cartilage from its lining. If a septal hematoma is not drained, loss of the septal cartilage is likely. If the septal cartilage is lost due to this process, severe nasal deformity will result and require sophisticated surgical reconstruction in an attempt to restore acceptable appearance. Therefore, a septal hematoma is the one true emergency that can result from a nasal fracture and the hematoma should be surgically drained as soon as possible.
Plain film x-rays are sometimes ordered:
SEQUELAE OF NASAL FRACTURES
So what’s the big deal if you sustain a nasal fracture? What can happen if you don’t fix a nasal fracture? Many people who have nasal fractures never seek care for them and many never have any substantial consequences of not reducing or correcting the fracture. Sometimes the physical appearance is minimally affected or so slightly perceptible as to mitigate the need to consider surgical correction. Other times, there is a noticeable appearance change, but the patient is unconcerned by it. A good example of this is the case of boxers. Many boxers will have broken noses. In fact, it is somewhat of an expectation to have a broken nose in active boxing. Often, the upper nasal dorsum will be pressed back into place by a trainer or coach. It would be foolhardy to seek surgical correction after every boxing match. Normally, after a boxing career has ended completely a consideration for surgical correction will be made. Nevertheless, some types of persistent problems can result from trauma. Nasal dorsum deviation can be a persistent consequence of trauma. Septal deviation and an inability to breathe through the nose can occur. A loss of nasal support with a collapse of the soft tissue covering of the nose can be a major problem after severe nasal trauma. Septal perforation can occur from associated nasal septal fractures. Infection can occur in the nose after trauma and if not treated expeditiously can lead to loss of cartilage support or even progression to other major infectious complications. A sequelae that I have seen is that patients sometimes will ignore a fracture at the time of the injury, but months or years later will realize that the consequences to their physical appearance that are quite noticeable and then will see correction at a time quite distant from the trauma. When this occurs, the options for surgical correction become more complicated and usually more extensive surgery is required because the nasal bones and cartilages have fused in a sub-optimal way.This nasal deviation caused by trauma was present for many years until the patient decided to seek treatment:
SURGICAL CORRECTION
After the fracture is assessed and stabilized and any appropriate imaging is obtained, the emergency department or primary care provider will likely make an appointment for the injured person to see a doctor who specialized in nasal surgery in about a week or so. Why so long? There are a few reasons to wait a little bit of time prior to seeking specialized care. One reason is that as swelling goes down, it is possible that evidence of the injury will disappear. In this case, no further treatment is required. On the other hand, as the swelling diminishes, people may be more concerned about their appearance and breathing and surgical correction becomes more desirable. So, “tincture of time” is important to allow the injury to resolve and to see the circumstances that remain. At about the one week mark, a visit to the surgeon will allow a detailed examination. This may include examination with an optical telescope to examine the inside of the nose and the nasal septum. The nose will be examined from the outside and the upper, middle, and lower third of the nose will be assessed. Imaging studies such as a CT scan of the facial bones may be ordered. Digital photographs using standardized nasal views will likely be obtained. A decision about the need for correction will then be made.Peri-traumatic surgical correction usually consists of what is known as a closed reduction of nasal fracture (CRNF). Closed reduction means that no incisions will be made and that the bones will be manipulated in place to try to improve things. CRNF can be done in the doctor’s office using local and topical anesthesia, but it also may be scheduled in a hospital or outpatient surgical center. CRNF consists of providing anesthesia using intravenous medication, or local injected medication and topical medication, or all three. With the patient sleeping and comfortable, instruments are used to move the nasal bones and septum into a straighter and more normal position. It is important for the swelling from the injury to be minimized so that the doctor can make a good judgment about where the bones should be moved to approximate the pre-injury appearance. A variety of intranasal material may be placed at the time of the surgery, including dissolvable material or packing material designed to be removed. A nasal cast is typically placed after the procedure. A CRNF will take about an hour to accomplish and the patient will typically go home the same day. Antibiotics may or may not be prescribed. Assessing the success of a CRNF should ultimately be done about 3 months after the procedure. It takes about 3 months for all swelling to diminish properly and for the patient to assess the ultimate results. CRNF is usually worth a try, but a substantial percentage of patients will still have problems related to the initial injury and require other procedures in the future. As a rule of thumb, I think about 2/3 of patients are satisfied after CRNF, but about 1/3 would like to consider further correction in the future.
What happens if after CRNF you are still unhappy with the appearance of your nose or your ability to breathe? At that point surgical correction would consist of one of several types of procedures. If breathing is the main issue, a type of nasal septal reconstruction surgery will typically be recommended. The purpose of this surgery is to straighten the septum and improve breathing. Physical appearance changes are not the main goal of this procedure, however. If the nose is still bothersome from an appearance standpoint, a rhinoplasty with or without septoplasty may be recommended. A rhinoplasty is a surgical procedure designed to change the outward appearance of the nose and also improve function in many cases. There are numerous types of rhinoplasty techniques and a detailed discussion of the various types is beyond the scope of this Knol, however some general principles are worth mentioning. In general, if the upper third of the nose is caved in or not straight, the nasal bones can be re-cut and re-positioned. The re-cutting of the nasal bones is done via osteotomies. If the middle third of the nose is also twisted or deviated, surgery directed at this area would concentrate on the upper lateral cartilages and also the upper portion of the septum in this area. The dorsum may also be surgically trimmed. The lower third of the nose or tip can also be approached surgically and maneuvers to straighten the front or caudal septum and perhaps to surgically re-position the lower lateral cartilages can be part of the reconstructive process. Sometimes, cartilage grafts are used in the reconstructive surgery. Even if a rhinoplasty is done, small revisions are sometimes necessary in up to about 10% of patients. The ultimate result is usually assessed at about 6 months to a year after surgery to allow for normal healing and the scarring process to settle down. However, 5-, 10-, and 20-year follow-up is necessary as the nose changes with time and aging and the results of surgery can change over long periods of time. The American Academy of Facial Plastic and Reconstructive Surgery has a Web site with good information about nasal reconstructive surgery: http://www.aafprs.org/patient/procedures/rhinoplasty.html
The Web site of the American Society of Plastic Surgery also has good consumer-oriented information pertaining to rhinoplasty: http://www.plasticsurgery.org/patients_consumers/procedures/Rhinoplasty.cfm
The American Academy of Otolaryngology-Head and Neck Surgery also has a Web site pertaining to nose surgery: http://www.entnet.org/healthinfo/nose/surgery_nose.cfm
CONCLUSION
Nasal fractures are very common. Initial management is aimed at halting the bleeding that invariably accompanies a nasal fracture. Emergent doctors visits are reserved for continued bleeding or if other fractures and more severe injuries are expected. If fracture reduction is contemplated, a visit to a doctor within 2 or 3 days is optimal. Surgical procedures are usually scheduled for about a week to 10 days after the injury. Sometimes, subsequent surgical procedures will be necessary even if the fracture is initially reduced nicely.REFERENCES
Textbooks:1: Spiegel JH and Sigmond BR, “Nasal Trauma”, Chapter 10 in Current Diagnosis and Treatment in Otolaryngology-Head and Neck Surgery, edited by Lalwani AK, Lange Medical Books/McGraw Hill, New York, 2004, p. 257- 264.
Articles:
1. Ridder GJ, Boedeker CC, Fradis M, Schipper J. Technique and timing for closed reduction of isolated nasal fractures: a retrospective study.Ear Nose Throat J. 2002 Jan;81(1):49-54. PMID: 11816391
2. Reilly MJ, Davison SP. Open vs closed approach to the nasal pyramid for fracture reduction.Arch Facial Plast Surg. 2007 Mar-Apr;9(2):82-6. PMID: 17372060
3. Hung T, Chang W, Vlantis AC, Tong MC, van Hasselt CA. Patient satisfaction after closed reduction of nasal fractures.Arch Facial Plast Surg. 2007 Jan-Feb;9(1):40-3. PMID: 17224487
4. Supriya M, Clement WA, Ahsan F, Cain AJ. Satisfaction with cosmesis following nasal manipulation: do previous fractures matter?J Laryngol Otol. 2006 Sep;120(9):749-52. PMID: 16939666