Nasal fractures, repair, and outcomes
Article by Behrooz Torkian, MD
Beverly Hills Facial Plastic Surgeon
Fractures of the nasal bones are the most common fractures in the face. In the body, nasal fractures rank third after fractures of the collar bone (clavicle) and wrist. In general, fractures of the nose occur after injury sustained from a lateral (from the side) blow to the nose. Some occur from a straight frontal force, and rarely, fractures occur from a force from below or above. Fractures of the nose may involve bone along the bridge or back of the septum (wall in between the two sides of the nose), the cartilage of the bridge and septum, and rarely the cartilage of the tip or sidewalls of the nose. Most fractures of the nose are sustained in young individuals, and many are sustained during participation in sports.
When a nasal fracture occurs there is generally a loud noise, bleeding, bruising, and a significant amount of swelling that occurs both on the outside and inside of the nose. Although fractures should be evaluated as soon as possible after the injury is sustained, the treatment may not always be possible in the immediate phases due to swelling. Evaluation of the injury includes direct examination of the bones by feeling the integrity and shape of the bones, and internal examination to evaluate the septum for deviation. X-rays and CT (CAT) scans may be helpful in some cases, but are generally not considered specific enough for minor or simple fractures.
Septal fractures can occasionally lead to an emergent complication called a septal hematoma, or a blood clot that forms in the tissues of the wall in between the two sides of the nose. If a septal hematoma is not recognized or treated in a timely fashion, the blood flow to the mucus membrane and cartilage of the septum may be compromised. This compromise in blood flow may lead to a perforation, or hole in the septum. Septal perforation is a fairly common complication of nasal trauma that may lead to severe crusting, noisy breathing, and occasionally to nasal deformities of the external appearance that are difficlut to correct. Thus, septal hematomas should be detected early and drained promptly to avoid these complications.
Treatment of simple nasal fractures may easily be conducted in an office setting or in an operating room when sedation or general anesthesia is required. In general, numbing medicines are injected and fractured bones and cartilages are moved into their proper positions to allow appropriate healing of these skeletal structures. A splint may be applied to the bridge, and occasionally to the septum. Packing may be necessary in the event of a septal hematoma or heavy bleeding. The bones generally are “set” and begin to stabilize by about 7-10 days in adults and 4-5 days in children.
During the first few hours after injury, the swelling that appears externally may prevent your doctor from being able to preciscely replace the bones in their pre-injury position for propper healing. Thus, if you see a doctor after 2-3 hours of the injury, he/she may defer the initial treatment of the fracture for 2-4 days in expectation of some decrease in swelling that would enable you to have the best possible overall result.
Delayed repair of nasal fractures that have remained untreated, or healed inappropriately currently accounts for approximately twenty percent of my practice. Many of these patients have sustained injury in their childhood that have later led to problems with breathing and external deformites. In these cases, surgical correction is required to repair changes in the structure of the nose inculding cartilage and bone. The repair of bony structural defects usually requires re-fracture of the bones and stabilization of the bones using a splint. The cartilagenous components including the septum, sidewalls, and bridge may require alterations in the connections of these cartilages to eachother, and to the bony components with internal stabilization using internal stitches. The goals of these operations include improvement of nasal airflow, and restoration of propper form of the nose. These often go hand-in-hand, and may partially be covered by insurance when appropriate.
Recovery is considered speedy and usually with only a few days of pain. Most patients are able to return to school or work within one week. Breathing slowly improves within one month as internal swelling improves. External appearance generally improves slowly over the course of one year. The greatest decrease in swelling is seen within the first 6 weeks, then slowly thereafter for the next 10 1/2 months.