illnesshacker: Medical information and health advice you can trust.

Nasal Septal Fractures – Causes, Symptoms, Treatment

Nasal Septal Fractures have been associated with nasal bone fractures in 42% to 96% of patients. Nasal bone and septal fractures have an impact not only on cosmetic appearance but also on functional nasal breathing as well.[rx][rx]

The structural support of the nose is comprised mainly of cartilage, bone, and skin. The paired nasal bones are attached to the frontal bone superiorly and the frontal process of the maxilla on either side laterally. They are attached to the nasofrontal and nasomaxillary suture lines, respectively. The nasal bones tend to be thicker above the level of the medial canthus.[rx]

The nasal septum is comprised posteriorly of bone and anteriorly of cartilage. The perpendicular plate of the ethmoid bone superiorly and the vomer inferiorly, make up the bony septum. These fuse with the quadrangular cartilage, which makes up the anterior portion of the nasal septum. The quadrangular cartilage provides support for the nasal dorsum from the keystone area to the supratip of the nose.[rx] This keystone area is a major structural support of the middle one-third of the nose. The upper lateral cartilages fuse to the cartilaginous septum, which is firmly attached to the perpendicular plate of the ethmoid bone. The final element of the keystone area is the attachment of the upper lateral cartilages to the nasal bony vault. The septum is attached to the nasal floor anteriorly at the nasal spine and posteriorly at the nasal crest of the maxilla and palatine bones.

Causes of Nasal Septal Fractures

Nasal bones are fractured with a variety of trauma to the maxillofacial skeleton.

The most common causes of nasal bone fractures globally are interpersonal violence, motor vehicle accidents, sporting accidents, and falls. In North America, traffic accidents account for more nasal bone fractures than interpersonal violence.[rx]
In children, the most common cause tends to be sporting accidents or motor vehicle accidents, depending on the source.[rx][rx] Interestingly, ball-related sports such as soccer, basketball, baseball, and rugby have a higher incidence of nasal bone fractures compared to fighting-related sports.[rx]

Symptoms Of Nasal Septal Fractures

Symptoms of a broken nose septum fracture include bruising, swelling, tenderness, pain, deformity, and/or bleeding of the nose and nasal region of the face.

Pain or tenderness, especially when touching your nose
Swelling of your nose and surrounding areas
Bleeding from your nose
Bruising around your nose or eyes
Bruising, swelling and tenderness around the nose
A deformed, twisted or crooked nose
Blockage of one or both nostrils
A deviated septum
A bruise-like discoloration under the eyes
Crooked or misshapen nose
Difficulty breathing through your nose
Discharge of mucus from your nose
Feeling that one or both of your nasal passages are blocked

You Might Also Like Fracture of Distal Radius - Causes, Symptoms, Treatment

Diagnosis of Nasal Septal Fractures

History and Physical

Patients who have undergone trauma to the maxillofacial region should first have a primary trauma survey performed, addressing Airway, Breathing, and Circulation, and Disability. After life-threatening issues have been addressed, a thorough history and secondary physical examination may be performed.

It is important first to delineate the mechanism of trauma to the maxillofacial region. Higher impact injuries, as seen in motor vehicle accidents, are prone to more severe injuries and may be associated with multiple facial fractures. The direction of impact may be important to understand the underlying fracture pattern better. Lateral blows tend to cause a fracture on the impacted side and out fracture on the opposite side, while impact directed straight onto the nasal dorsum tends to cause splaying out fractures of the bilateral nasal bones.[rx] It is also essential to get a sense of premorbid appearance. Patients should be asked if they notice an obvious deviation or deformity compared to before the injury. Difficulty breathing through either side of the nose should be explored, as this can signify injury to the nasal septum.[rx] The patient should also be questioned on any prior nasal trauma or surgeries. Symptoms that may indicate more extensive injuries include diplopia, loss of vision, clear rhinorrhea, malocclusion, facial weakness, or numbness.

Physical examination should include a thorough examination of the entire head and neck region to include skin, ocular examination, otoscopic exam, intraoral, and intranasal examination. A complete examination of the nasal dorsum and nasal cavity should be performed with the aid of a headlamp as well as a nasal speculum or rigid endoscope. The external noise should be closely evaluated for the presence of lacerations and exposed bone or cartilage. Any deviation of the bony nasal pyramid should be documented. Increased intercanthal distance suggests a nasoorbitoethmoid fracture.[rx] The nasal tip should be palpated to assess for adequate support, and the nasal dorsum should be evaluated for a saddle-nose deformity, which indicates significant septal fracture or dislocation.[rx] An intranasal examination should first rule out a septal hematoma, which is seen as a fluctuant red or blue discoloration along the nasal septum.[rx] This submucoperi chondrial collection of blood needs an urgent incision and drainage to prevent septal cartilaginous necrosis, which may occur within 24 hours. Over time, the resulting cartilage necrosis leads to septal perforation or saddle nose deformity.[rx] Significant dislocations of the septum should be noted, and any intranasal lacerations or mucosal disruptions should be noted as well. Care should be taken to inspect for clear rhinorrhea, which may suggest a cerebrospinal fluid (CSF) leak.[11]

You Might Also Like Distal Ulna Fracture; Causes, Diagnosis, Treatment

Evaluation

Imaging is generally not warranted for simple nasal bone fractures. Plain film X-rays are not typically useful. A computed tomography (CT) scan without intravenous contrast of the facial bones is the gold standard for evaluation of bony trauma of the maxillofacial area if there is a concern for more extensive facial injuries.[rx] Concerning symptoms, as previously noted, should prompt providers to order imaging. More recently, ultrasonography has been explored to help aid in the diagnosis of nasal bone fractures but proved inferior to CT.[rx]

Laboratory evaluation is generally not required in a simple nasal bone fracture or septal hematoma. A complete blood count and coagulation studies may be considered in patients with epistaxis who have lost a considerable amount of blood or who take anticoagulant medication. Patients with persistent clear rhinorrhea can have this collected and sent for beta-2-transferrin, which can be used to help confirm a CSF leak.

Treatment of Nasal Septal Fractures

Initial management should include control of epistaxis and closure of any lacerations of the external skin or internal nasal lining whenever possible. Epistaxis may be conservatively controlled with digital pressure, pushing the nasal alae against the septum. More serious epistaxis may require cauterization or nasal packing.

Observation without surgical intervention is recommended in patients who do not have an obvious cosmetic deformity or nasal obstruction. Conservative measures such as elevating the head and icing the area are recommended until local edema subsides. Patients should be closely followed within three to five days for reexamination, as nasal deviation can be unmasked with the resolution of edema.[rx]

Closed reduction of the nasal bone and septal fractures is generally recommended for fractures that cause nasal deviation or airway obstruction. It may be performed under local anesthetic or minimal sedation, but general anesthesia is most often preferred due to improved airway protection and overall patient comfort.[rx] Timing of closed reduction is varied in the literature, with some sources advocating early intervention within five to seven days, while others state that edema should completely resolve, and closed reduction should be performed within one to two weeks of injury.[rx][rx] After two weeks, patient satisfaction with cosmetic outcomes significantly decrease.[rx] Later intervention risks callus formation and difficulty reducing nasal bones into their premorbid location. In this case, an endonasal or percutaneous open reduction can be performed using osteotomies.[rx] In a typically closed reduction, a flat, broad instrument such as a Boies elevator is used endonasal to reduce fractures with a postoperative splint applied to the nasal dorsum.

You Might Also Like Elbow Joints Arthritis - Causes, Symptoms, Treatment

Closed reduction may also be performed on the nasal septum using a Boies elevator or Asch forceps. If adequate reduction of the nasal septum cannot be performed in a closed fashion, some have advocated for an open septoplasty in the acute setting, showing that patients have significant improvement in nasal obstruction postoperatively.[rx] Intranasal splints or packing may also be used to help keep the septum reduced, but this is typically not used unless a septoplasty has been performed. Septoplasty is avoided if there is significant mucosal disruption along the septum due to the risk of postoperative septal perforation.[rx]

An open septorhinoplasty is generally avoided in the acute setting as there are frequently nasal lacerations or cartilage disruptions. Further dissecting these cartilage structures can revascularize them in the acute setting, and any cartilage grafts may be more susceptible to infection and rejection. It is therefore often recommended septorhinoplasty be delayed 3 to 6 months post-injury.[rx]

References