Diagnosis and management of nasal fractures

Diagnosis and Management of Nasal Fractures Tania P. Bartkiw, BScN, RN, Bruce R. Pynn, MSc, DDS, and Dale H. Brown, MD, FRCS(C)

Nasal fractures are very common in facial trauma but should not be considered minor injuries until they have been thoroughly assessed. Trauma care providers need to have an understanding of common mechanisms of injury, normal anatomy, and assessment techniques to make the diagnosis. Management of the injury will depend on whether the fracture is nondisplaced, displaced, open, or associated with a complication that necessitates a more aggressive approach. (INT J TRAUMA NURS 1995;1:11-8)

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asal fractures are fairly common, accounting for approximately 40% of all facial bone injuries. 1,2 Although often considered minor, a nasal bone fracture has the potential to be a serious injury if not recognized and treated early. Diagnosis is made almost totally from the clinical examination, and unless complications exist, the management is conservative. The primary goal of care is to return the patient to his or her appearance before the injury and to avoid undesirable sequelae. Attaining that goal depends on understanding the anatomy of the nose and h o w it is predisposed to injury.

and a cartilaginous lower half. The u p p e r b o n y portions articulate with the frontal and maxillary bones (Figure 1). The nose has a rich blood supply from the internal and e x t e r n a l carotid artery systems. This supply not only provides a connection be-

ACUTE CARE OF NASAL FRACTURES

t w e e n the nose and the cerebral blood supply but also contributes to significant blood loss if epistaxis is not controlled. The nerve supply is diverse and comes from multiple branches of the cranial nerves. Fractures are the result of a direct force applied to the midface (e.g., a motor vehicle crash, sports injury, or physical assault). The force can be lateral (side), sagittal (front), or inferior (below). Figure 2 shows examples of lateral and sagittal forces and h o w the severity of injury is influenced by the a m o u n t of force. Fractures can range from simple to complete disruption of the naso-orbital-ethmoid complex with extranasal soft tissue injuries. 3 Nasal fractures may occur

M echanism of

Injury

The nose is the most anterior projection of the face. It is m a d e up of a b o n y u p p e r half Tania P. Bartkiw is a clinical research nurse, Bruce R. Pynn is a resident in the Division of Oral and Maxillofacial Surgery, and Dale H. Brown is a staff otolaryngologist in the Department of Otolaryngology-Head and Neck Surgery at the Toronto Hospital, Toronto, Canada. For reprints write Bruce R. Pynn, MSc, DDS, The Toronto Hospital, Dental Department, 200 Elizabeth St., ESG-450, Toronto, Ontario M5G 2C4, Canada. Copyright 9 1995 by the Emergency Nurses Association.

1075-4210/95 $3.00 + 0 6511161620

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Although considered minor, a nasal bone fracture has the potential to be a serious

injury.

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1980:54.) alone or in combination with other head and face injuries. Lateral force injuries are the most c o m m o n type of nasal fractures (approximately 90%) and are usually associated with interpersonal violence. Victims of an assault tend to turn a w a y from an oncoming blow.

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Clinical History A clinical history helps identify factors that m a y affect the findings of a physical examination. Table 1 lists relevant questions to ask the patient or other reliable source if the patient is unable to provide information.

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Frontal plane 1

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Figure 2. A and B, Demonstration of increasing injury with increasing force to the nose. (From Mathog RH. Nasal fractures. In: Cummings CW, editor. Otolaryngology-head and neck surgery; vol 1. St. Louis: Mosby, 1986:626.) --_/

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Physical Examination

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Although fractures may not initially appear serious, midface trauma can produce airway problems, excessive blood loss, and neurologic compromise. A primary survey (i.e., initial assessment and interventions for life-threatening problems) should be done on admission, followed by a secondary survey (i.e., systematic head-to-toe physical assessment); with a focused examination of the face and nose. The primary survey is done to detect airway problems resulting from structural change, excessive edema, blood clots in the nose, or blood passing posteriorly d o w n the throat and accumulating in the hypopharynx. To check for obstruction, the patient should be instructed to breathe through one nostril while the other is occluded. If breathing is labored, oxygen should be started by mask. When possible, elevating the head of the bed 30 degrees can make it easier for the patient to breathe and has the added benefit of decreasing swelling in the nose or facial tissue. Epistaxis is common with a nasal fracture and tends to resolve on its own. If bleeding does persist, external pressure or nasal packing may be necessary. The packing is left in place for 15

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Figure 3. The normal and pathologic distances of the naso-orbital complex in traumatic telecanthus. (From Holt GR, Holt JE. Nasoethmoidcomplex injuries. Otolaryngol Clin North Am 1985;18:90.) JANUARY-MARCH 1995

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Table 1. Clinical evaluation of the patient with nasal fracture History Mechanism of injury Time since injury Areas of tenderness Significant symptoms since injury Altered level of consciousness Loss of ability to breathe through nostril(s) Decreased sense of smell (i.e., anosmia) Double vision, altered visual acuity, limited eye movement Altered dental occlusion or bite Altered sensory or motor function in facial area Present health, current medications (prescription or over-the-counter decongestants and antihistamines), ethanol or illegal substance use History of nasal injury or surgery Physical examination Primary survey Airway: patency of airway, ability to ventilate Bleeding: amount, source, evidence of CSF Consciousness Orientation, motor response, ability to arouse (i.e., Glasgow Coma Scale) Cervical spine tenderness Secondary survey Head-to-toe assessment to rule out other injuries and prioritize interventions Facial structures Eye: globe, lids, conjunctiva, visual acuity Cranial nerves Other structures Inspection: open wounds, loss of skin or other trauma; patterns of ecchymosis (periorbital or postauricular); facial deformity (flattening, widening, elongation); drainage (amount, source) Palpation: tenderness, subcutaneous crepitus present in recent fractures), edema; infraorbital ridge for step deformities (sign of orbital fracture) Nose External inspection: intercanthal distance (see Figure 3); front, oblique, lateral views of nose to detect deformities (depression, deviation of the tip, dorsum, or columella [see Figure 1]) Internal inspection (Note: best done after decongestant has been administered and clots carefully removed) Mucosa: tears, previous injury Nasal passages: patency, turbinate size Septum: displacement (up to 48% of people normally have a deviated septum12), septal hematoma (widened, distended, fluctuant mucosa, occluded nasal passage) Obtain ophthalmology and oral surgery consultations if needed Blood studies Prothrombin time Partial thromboplastin time Complete blood cell count

minutes, then removed for reevaluation. Vasoconstrictive topical anesthetics (cotton nasal packing soaked in a solution of 2% cocaine; a combination of 3% ephedrine and 1% tetracaine; or 4% lidocaine) can be applied to the nasal mucosa to stop blood loss. Topical anesthetics help control pain, decongest the nasal mucosa,

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and facilitate the internal examination of the nose. In difficult cases, it may be necessary to cauterize bleeding points with silver nitrate or repack the nose with petroleum jelly packing and leave it in place for up to 48 hours. If the bleeding continues despite the above measures, posterior epistaxis should be sus-

VOLUME 1, NUMBER 1

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Figure 4. Bone grafting of the nasal dorsum. Corticocancellous grafts may be harvested from either iliac crest or calvarium and used to augment the bony pyramid. Stabilization may be achieved by wires, mini-reconstruction plates, or lag screw technique. (From Arden RL, Mathog RH. Nasal fractures. In: Cummings CW, editor. Otolaryngology-head and neck surgery; vol 1. St. Louis: Mosby,

1993:749.) pected. A Foley catheter can be inserted through the bleeding nostril until the tip appears behind the uvula, and the balloon inflated to provide gentle traction while one or both nostrils are packed. The catheter is secured to the face to prevent moving and maintain traction. Commercially prepared products are available for posterior packing if preferred, as is a rolled gauze posterior pack. 4 The neurologic status is evaluated to determine whether an associated central nervous system injury has occurred. Cranial nerves that innervate the midface may be injured with a nasal fracture (e.g., injury to the maxilla can traumatize the second division of the trigeminal nerve). The cervical vertebral column, spinal cord, and spinal nerves are subject to injury with blows that cause h y p e r f l e x i o n - e x t e n s i o n or rotary motion to the h e a d or neck. If findings are questionable, spinal mobilization should be maintained until a more complete examination can be done with spinal radiographs. The secondary survey is used to rule out other injuries that m a y not be as obvious as facial trauma. If gastric or endotracheal intubation is n e e d e d , the oral route should be used to avoid additional injury to the nose or basilar skull

JANUARY-MARCH 1995

area. If the patient's condition permits, a displaced nasal fracture can be r e d u c e d while the patient is receiving general anesthesia for other procedures. The facial structures are e x a m i n e d in an orderly s e q u e n c e of inspection and palpation, beginning with the scalp and p r o c e e d i n g to the mandible and postauricular area. Table 1 lists the steps and significant findings, and Figure 3 illustrates a c h a n g e in naso-orbital distance. Because up to 20% of midface injuries m a y involve serious ocular injury, 5,6 the eye should be carefully assessed. The globe is inspected for position to determine w h e t h e r it is displaced (vertically, horizontally, or anteroposteriorly) and the sclera for subconjunctival hemorrhage. Visual acuity should be evaluated for acute changes that m a y be indicative of trauma to the eye or optic nerve. A laceration of the medial third of the lower eyelid should raise suspicion of injury to the nasolacrimal system. Drainage from the nose, ears, or tear ducts m a y contain cerebrospinal fluid (CSF). CSF escapes through a basilar skull fracture (cribriform plate of the ethmoid bone, sphenoid bone, or frontal sinus). Serosanguineous drainage that

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Table 2. Management of a patient with a nasal fracture Nondisplaced, uncomplicated fracture Apply ice, keep head of bed elevated to reduce edema Administer oral analgesics and nasal decongestant as needed Avoid manipulating fracture or reinjury Return for reevaluation as scheduled or as needed Displaced fracture Apply ice, keep head of bed elevated to reduce edema Reduce if injury less than 4-6 hours old 13,14 Use local anesthetic if patient is cooperative adult Use general anesthetic for children or uncooperative adult Use nasal packing to stabilize unstable fractures Use prophylactic antibiotics for duration of time nose is packed Delay reduction if edema too extensive to accurately assess fracture or obtain adequate reduction Instruct patient as for nondisplaced fracture Have patient return for scheduled reevaluation and reduction in approximately 1-2 weeks Open reduction Indications Complicated or extensive series of bone or soft tissue injuries of face or ethmonasal region a,s,9 Nasal instability Multiple trauma patient undergoing other surgical procedures with anesthesia Postoperative care Monitor patency of airway and ability to ventilate; renewed epistaxis; neurologic status and CSF leak in drainage Reduce edema with ice packs and elevation of head of bed Observe for infection locally and systemically; administer antibiotics as prescribed Change "snuffer" dressing under nose as needed; cleanse nostrils with normal saline solution or hydrogen peroxide-soaked swabs as needed Keep bandages and splints dry and intact Avoid resting eyeglasses on nose Limit activities that expose nose to further trauma (i.e., exercise, body-contact sports, swimming with nose submerged) Take pain medications as indicated Moisten lips with petroleum jelly if mouth breathing causes dry lips Consult dietitian if appetite becomes depressed with loss of sense of smell

contains CSF forms a characteristic "bull's eye" or "tram tracks" pattern (caused b y CSF separating from b l o o d cells). Ecchymosis m a y be a result of skin surface trauma or m a y be associated with injuries of deeper structures. Bilateral periorbital ecchymosis (referred to as "raccoon eyes") is commonly seen with a basilar skull fracture involving the anterior cranial fossa but is also highly suggestive of a nasal fracture. ~ P o s t a u r i c u l a r e c c h y m o s i s ( k n o w n as Battle's sign) m a y be seen with a fracture involving the base of the skull but m a y take up to 24 hourS to appear. A nasal examination should be d o n e with g o o d lighting, suction, and appropriate instruments. B e c a u s e the nose has a rich vascular

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and nerve supply, injured tissue will b e edematous, bleeding, and very tender. The patient can b e e x p e c t e d to b e apprehensive b e c a u s e of the pain, to have difficulty breathing, and to be c o n c e r n e d for his or her appearance. Measures to reduce e d e m a and v e n o u s congestion should b e started as soon as possible and will d e p e n d on the patient's overall condition. Ice can be applied to the nose, and measures discussed in the primary survey used to control epistaxis. W h e n the patient's condition is stable, the head of the b e d should b e elevated. If a significant blood loss is suspected, laboratory studies should b e obtained to rule out secondary causes of epistaxis and to assess the effects of blood loss.

VOLUME 1, NUMBER 1

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Figure 5. Stabilization of septonasal structures. A, Polyethylene splint. B, Splint maintained in position with mattress suture. C, Placement of nasal tampons; correct placement laterally to septal splint (inset). D, Application of external splint. (From Arden RL, Mathog RH. Nasal fractures. In: Cummings CW, editor. Otolaryngology-head and neck surgery; vol 1. St. Louis: Mosby, 1994:747.) Radiographic Assessment Unlike with other fractures, radiographs are not helpful in making a diagnosis of nasal fracture. As many as 50% of clinically o b v i o u s nasal fractures are difficult to confirm with radiographs, 7,s and the examiner can b e distracted b y suture lines, old fractures, or vascular patterns on routine facial films. A nasal fracture cannot b e excluded b y normal nasal films (i.e., a n t e r o p o s t e r i o r , lateral, a n d s u p e r o i n f e r i o r occlusal). The diagnosis is m a d e more on the clinical assessment. C o m p u t e d t o m o g r a p h y and three-dimensional reformatting are justified only if adjacent facial b o n e s are s u s p e c t e d to be involved.

DEFINITIVE CARE OF THE PATIENT WITH A NASAL FRACTURE Nasal fractures are m a n a g e d according to the type of fracture, w h e t h e r the fracture is displaced, w h e t h e r it has associated complications,

JANUARY-MARCH 1995

or whether additional injuries are present. Swelling makes it hard to assess the degree of deformity and the o u t c o m e of any attempts to reduce the fracture. Often it is appropriate to wait I to 2 w e e k s before attempting reduction. Table 2 provides a list of treatment options according to the type of fracture. A nondisplaced, uncomplicated nasal fracture is treated conservatively, on an outpatient basis. A displaced fracture will n e e d reduction to return normal function and appearance. If significant swelling is present, reduction will be delayed until e d e m a decreases. Outpatients are instructed to return often to monitor for complications, such as a septal hematoma or infection. A septal hematoma is a significant complication that d e v e l o p s from b l o o d accumulating b e n e a t h the perichondrium of the septum. It must b e treated early to avoid infection, septal abscess, necrosis of the cartilaginous nasal seprum, and possible saddle nose deformity (i.e., a depression also referred to as p u g nose).

A septal hematoma is a significant complication that develops from blood accumulating beneath the perichondrium of the septum. Small, u n c o m p l i c a t e d h e m a t o m a s can b e aspirated in an outpatient setting, if the patient can return for reevaluation and additional treatment if the h e m a t o m a should recur. A large h e m a t o m a should b e incised and drained, and treated with anterior nasal packing to prevent reaccumulation of blood. B e c a u s e of the potential for infection with nasal packing, the patient n e e d s to b e given empirical antibiotics until culture and sensitivity reports are received. O p e n reduction of a nasal fracture is indicated for cases involving extensive injury or for an unstable fracture. The surgeon will have better exposure to manipulate the fractured nasal b o n e s into an anatomically correct position and have access to repair other facial fractures. Wires and metallic reconstruction plates are used to

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stabilize bone fragments or to anchor bone grafts (Figure 4). O p e n reduction is preferred if the patient has associated fractures of the ethmonasal complex. 3,5,9 After surgery, the fracture site can be stabilized with antibiotic-soaked nasal packs and an external nasal splint (Figure 5). A small drainage catheter can be inserted along the floor of the nostril to equalize pressure in the nasopharynx, help prevent "fullness in the ears," and prevent blood accumulation in the nose. DISCHARGE CARE Patients with a nasal fracture are usually not admitted into hospital unless they have associated injuries or significant complications. If treated on an outpatient basis, patients should be instructed to return to the hospital or outpatient clinic after 2 days to have nasal packing removed to prevent paranasal or sinus infection. They should continue to take prophylactic antibiotics as long as the packing material is left in place. If an exterior splint is applied, it should be kept dry and intact for 7 to 10 days. 1° When eyeglasses are needed, they should be adapted to prevent resting on the nose. The constant weight of the glasses can cause settling and widening of a reduced fracture. 11A list of postoperative discharge instructions is included in Table 2. SUMMARY Although nasal fractures are the most comm o n type of facial b o n e injury, their diagnosis and proper care is not well understood. The clinical assessment and m a n a g e m e n t is individualized for the type and severity of injury. Pa-

tients should be instructed h o w to avoid further injury, w h e n to return for follow-up care, h o w to use medications, and what complications m a y be anticipated. A poorly m a n a g e d fracture could lead to i m p r o p e r healing, facial deformity, difficulty breathing or smelling, or chronic infection of the nose or sinuses.

REFERENCES 1. Zide MF. Nasal and nasoorbital ethmoid fractures. In: Peterson L, Indresano A, Marciani R, Roser S, editors. Principles of oral and maxillofacial surgery; vol 1. Philadelphia: JB Lippincott, 1992:547-73. 2. Sheperd JP, Shapland M, Pearce NX, Scully C. Pattern, severity and etiology of injuries in victims of assault. J R Soc Med 1990;83:75-8. 3. Arden RL, Mathog RH. Nasal fractures. In: Cummings CW, editor. Otolaryngology-head and neck surgery; vol I. St. Louis: Mesby, 1993:737-53. 4. Kitt S, Kaiser J. Emergency nursing: a physiologic and clinical perspective. Toronto: WB Saunders, 1990:110-24. 5. Pitcock JK, Bunsted RM. Nasal fractures. In: Fonseca RJ, Walker RV, editors, Oral and maxitlofacial trauma; vol 1. Toronto: WB Saunders, 1991:600-15. 6. Davidoff G, Jakubowski M, Thomas D, Alpert M. The spectrum of closed head injuries in facial trauma: incidence and impact, Ann Emerg Med 1988;17:6-9. 7. Clayton MI, Lesser THJ, The role of radiography in the management of nasal fractures. J Laryngol Oto11986;100:797-801. 8. Renner GJ. Management of nasal fractures. Otolaryngol Olin North Am 1991;24:195-213. 9. Verwoerd CD. Present day treatment of nasal fractures: closed versus open reduction. Facial Plastic Surgery 1992;8:220-3. 10. Howell E, Sherer C, Leyden A. Face and head trauma. In: Howell E, Widra L, Hill MG, editors. Comprehensive trauma nursing: theory and practices. Boston: Scott, Foresman, 1988:470-93. 11. Krekorian EA. Maxillofacial and mandibular injuries. In: Mattox KL, Moore EE, Feliciano DV, editors. Trauma. Norwalk, Connecticut: Appleton & Lange, 1988. 12. Ilium P. Long term results after treatment of nasal fractures. J Laryngol Otol 1986;100:273-6. 13. Pollock RA. Nasal trauma. Olin Plast Surg 1992; 19:133-47. 14. Cook JA, McRae RD, Irving RM, Dowie LN. A randomized comparison of manipulation of the fractured nose under local and general anaesthesia. Clin Otolaryngol 1990;15:343-6.

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