Nasal Septal Fracture

Etiology

Nasal bone fractures can occur through various mechanisms. Globally, the most common causes are interpersonal violence, motor vehicle accidents, sporting events, and falls. In North America, motor vehicle accidents are responsible for more nasal bone fractures than interpersonal violence.[4] In children, the most common causes of nasal bone fractures are sporting or motor vehicle accidents, depending on the source.[4][5] Interestingly, ball-related sports such as soccer, basketball, baseball, and rugby have a higher incidence of nasal bone fractures compared to fighting sports such as wrestling and martial arts.[4]

Epidemiology

Nasal bone and septal fractures are significantly more common in males than females, reflecting the higher incidence of interpersonal violence among males and their increased tendency for risk-taking behavior. The incidence of nasal bone fractures peaks during the second and third decades of life.[6][7] 

In the United States, the rates of nasal bone and other facial fractures have steadily increased since 2000. However, repair rates have remained stable, which may indicate an increase in nonoperative fracture patterns, a trend toward more conservative management, and an increased use of computed tomography (CT) imaging to rule out fractures before proceeding with reduction.[7]

Pathophysiology

A frontal or lateral blow to the nose is the most common mechanism for fractures involving the nasal bones and nasal septum.[8] Fractures may be unilateral or bilateral and can present as nondisplaced, displaced, depressed, greenstick (incomplete), or comminuted.[9] Fractures may affect the nasal bones, lateral nasal cartilages, and septal cartilage. In severe, high-energy injuries, they can extend to the surrounding facial skeleton, leading to complex fractures such as Le Fort or naso-orbito-ethmoid complex fractures (see Image. External Nasal Skeleton). Please see StatPearls' companion resources, "Le Fort Fractures" and "Naso-Orbito-Ethmoid Fractures," for more information.

History and Physical

Patients with maxillofacial trauma should first undergo a primary trauma survey, evaluating the airway, breathing, circulation, neurological status, and environmental exposures. A comprehensive history and secondary physical examination should be conducted when life-threatening concerns have been addressed.

Determining the mechanism of trauma to the maxillofacial region is crucial. Higher-energy impacts, such as those from motor vehicle accidents, are more likely to result in severe injuries and multiple facial fractures. Understanding the direction of the impact can help identify the underlying fracture pattern. Lateral blows often cause inward displacement on the impacted side and outward displacement on the opposite side, whereas direct impacts to the nasal dorsum typically lead to splaying outfractures of both nasal bones.[10]

Understanding the patient's premorbid appearance is essential. Patients and their family members should be asked about any noticeable changes in the nose's appearance compared to before the injury. Difficulty breathing through either side of the nose should also be evaluated, as it may indicate intranasal edema or nasal septum injury.[11] The patient should also be questioned about any prior nasal trauma or surgeries, as these may impact the treatment plan and the discussion of treatment risks. Signs and symptoms suggesting more extensive injuries include telecanthus, diplopia, vision loss, clear rhinorrhea, malocclusion, facial weakness, and facial numbness.

The physical examination should comprehensively assess the entire head and neck region, including the skin, eyes, ears, and intraoral and intranasal areas. A detailed evaluation of the nasal dorsum and nasal cavity should be conducted using a headlamp and a nasal speculum or endoscope. The external nose should be inspected for lacerations or exposed bone and cartilage. Any mobility or deviation of the bony nasal pyramid must be documented. An increased intercanthal distance following trauma may suggest a naso-orbito-ethmoid fracture.[10] The nasal tip should be palpated to assess support, and the nasal dorsum should be examined for a saddle nose deformity, which may indicate a significant septal fracture or dislocation.[11]

An intranasal examination should prioritize ruling out a septal hematoma, which presents as a fluctuant red or blue discoloration along the nasal septum, typically evident within 24 to 72 hours post-injury (see Image. Nasal Septal Hematoma in a Child).[12] Strong clinical suspicion for septal hematoma is warranted when nasal obstruction persists despite the use of topical vasoconstrictors (eg, 0.05% oxymetazoline) and the evacuation of blood clots. Significant septal dislocations should be documented, along with any intranasal lacerations or mucosal disruptions. Clear rhinorrhea, with or without a halo sign, should be carefully noted as it may indicate a cerebrospinal fluid (CSF) leakage (see Image. Halo Sign Indicating Cerebrospinal Fluid Leakage).[11]

Evaluation

Imaging is generally not warranted for simple nasal bone fractures, which are diagnosed clinically. Plain film x-rays are rarely used today; instead, CT of the facial bones without intravenous contrast has become the gold standard for evaluating bony trauma in the maxillofacial region when there is concern for more extensive facial injuries (see Image. Nasal Septal Fracture on Computed Tomography Without Contrast).[11] Neurological symptoms may warrant magnetic resonance imaging (MRI) for further evaluation. The use of ultrasonography in diagnosing nasal bone fractures has recently been studied, but it has proven to be inferior to CT scanning.[13]

Laboratory evaluation is typically unnecessary for an isolated nasal fracture. However, a complete blood count and coagulation studies may be considered for patients with significant epistaxis, blood loss, or those on anticoagulant medications. For patients with persistent clear rhinorrhea, fluid may be collected and tested for β2-transferrin or β-trace protein to confirm or rule out the presence of a CSF leakage.

Treatment / Management

The initial management of nasal fractures focuses on controlling epistaxis and closing any cutaneous or mucosal lacerations whenever feasible. Epistaxis can often be managed conservatively by applying digital pressure to the nasal alae, compressing the anterior septum to occlude vessels within the Kiesselbach plexus, the most common site of nasal bleeding. More severe bleeding may require chemical or thermal cauterization or nasal packing (see Image. Supplies for Epistaxis Management). In cases of severe hemorrhage, endoscopic ligation of the sphenopalatine or ethmoid arteries, or angiographic embolization, may be necessary. Please see StatPearls' companion resource, "Epistaxis," for more information.

Observation without surgical intervention is recommended for patients with no apparent cosmetic deformity or nasal obstruction. Conservative measures, such as elevating the head and applying ice to the area, should be followed until local edema subsides. Patients should be reexamined within 3 to 5 days, as nasal deviation may become more evident as the edema resolves.[14]

Closed reduction of nasal bone and septal fractures is recommended for injuries that cause airway obstruction or a change in the appearance of the nose. Please see StatPearls' companion resource, "Nasal Fracture Reduction," for more information. Reduction can be performed under local anesthesia or with minimal sedation; however, general anesthesia is often preferred due to its advantages in airway protection and patient comfort. General anesthesia also provides a less stressful environment for the surgeon, allowing them to focus on achieving the best possible result without the added challenge of managing the patient's pain and anxiety.[10] 

If reduction is performed under local anesthesia, various nerve blocks can be used to facilitate the procedure. These include infraorbital (4-7 mm inferior to the infraorbital rim in the midpupillary line), dorsal nasal (6-10 mm lateral to the midline along the inferior margin of the nasal bone), and nasociliary (1 cm above the medial canthus and 1.5 cm deep, along the medial border of the orbit). Epinephrine injection should be avoided in this area to prevent retinal artery spasms.[15] These injections will anesthetize the lateral nasal wall and medial cheek; the nasal dorsum, tip, and ala; and the nasal radix, septum, and lateral nasal cavity wall mucosa, respectively. When combined with a topical anesthetic solution (1%-4% lidocaine or 4% cocaine) applied via cottonoid pledgets, there is no significant difference in patient-reported pain between local and general anesthesia.[16] 

The ideal timing for closed reduction is debated in the literature. Some authors advocate for early intervention within 5 to 7 days, while others recommend waiting until edema has completely resolved, typically 1 to 2 weeks after the injury.[10][11] However, patient satisfaction with cosmetic outcomes significantly decreases if the procedure is delayed beyond 2 weeks.[17] Delayed intervention carries the risk of callus formation and difficulty repositioning the nasal bones to their premorbid location, as the fractured segments may have already begun to heal. In such cases, an endonasal or percutaneous reduction can be performed, often involving osteotomies.[11] Using CT guidance to place osteotomies along healed fracture lines and facilitate precise reduction months to years after the injury has also been described as a valuable adjunct.[18] (B3)

In a typical closed reduction, a flat, broad instrument, such as a Boies or Sayre elevator, is introduced endonasally to lift and reposition the fractured bony segments. A postoperative splint is then applied to the nasal dorsum. Closed reduction of the nasal septum can also be performed using a Sayre or Boies elevator or with Asch forceps, which grasp the septum atraumatically and reposition it back into the midline (see Image. Instruments for Closed Reduction of Nasal Fractures). If adequate reduction of the nasal septum cannot be achieved through closed methods, some authors recommend operative septoplasty in the acute setting, noting significant improvement in nasal obstruction postoperatively.[19](B2)

Intranasal splints or packing may also help maintain septal alignment after reduction, although these are typically unnecessary unless a septoplasty has been performed. Septoplasty is generally avoided if there is significant mucosal disruption along the septum due to the increased risk of postoperative septal perforation.[19] If septoplasty is performed in the acute setting, it is typically done through a hemitransfixion incision in the membranous septum along the caudal margin of the quadrangular cartilage (see Image. Rhinoplasty Incisions). Placing the incision on the concave side of the septal fracture can facilitate mucoperichondrial flap elevation (see Image. Hemitransfixion Incision for Septoplasty). The flap is elevated to expose the fractures, and the deviated portions of bone and cartilage are removed, except when they are located within 10 to 15 mm of the dorsal or caudal margins of the quadrangular cartilage. When fractures extend into this region, known as the "L-strut," access and repair are most effectively performed via an open septorhinoplasty.(B2)

Open septorhinoplasty via marginal incisions is generally avoided in the acute setting due to the frequent presence of lacerations or cartilage disruptions from nasal trauma (see Image. Open Rhinoplasty Approach). Further dissection of these cartilages can lead to devascularization, making cartilage grafts more prone to infection, extrusion, or absorption. For these reasons, septorhinoplasty is typically recommended to be delayed for 3 to 6 months after the injury.[20]

Repair of septal cartilage fractures within the L-strut is typically achieved by placing cartilage grafts to splint the fractured segments, maintaining their alignment and stability. Spreader grafts are commonly positioned along the dorsal aspect of the L-strut, whereas septal batten or septal extension grafts may be used on the caudal portion of the L-strut (see Image. Spreader Grafting). Severely fractured septal cartilage, often resulting from multiple nasal traumas, may require extracorporeal septoplasty (see Image. Extracorporeal Septal Reconstruction Using Native Quadrangular Cartilage). In this procedure, the L-strut is reconstructed using dorsal and caudal grafts, such as extended spreader grafts and caudal strut grafts (see Image. Surgical Correction of Saddle Nose Deformity).

Differential Diagnosis

The differential diagnosis for nasal fractures should include bony injuries to the surrounding facial skeleton, as mentioned below.

Naso-Orbito-Ethmoid Complex Fracture

Nasal bone fractures may extend posteriorly into the ethmoid air cells and involve the medial canthus of one or both orbits. The hallmark of this condition is traumatic telecanthus (see Image. Naso-Orbito-Ethmoid Fracture). These fractures are also commonly observed in all Le Fort type III midface fractures.

Orbital Fracture

Periorbital edema or ecchymosis often suggests an orbital fracture. An orbital floor fracture may result in hypesthesia of the cheek due to injury to the infraorbital nerve or cause limitations in ocular movements from the entrapment of an extraocular muscle, typically the inferior rectus (see Image. Orbital Wall Fracture).

Skull Base Fracture

High-energy impacts can result in skull base fractures alongside fractures of the maxillofacial skeleton. Patients may exhibit characteristic bilateral periorbital ecchymosis, or "raccoon eyes," as well as postauricular ecchymosis, known as "Battle sign" (see Image. Skull Base Fractures). Patients with skull base fractures are at increased risk for developing CSF leaks and spinal fractures.

Prognosis

Patients typically recover well after nasal fracture reduction, although the success of surgical interventions can vary considerably. Persistent nasal deformity is reported in 9% to 50% of patients following closed reduction procedures.[14][20][21][22] Outcomes may improve with prompt management of nasal septal fractures or deviations at the time of injury.[2] Residual deformity or nasal obstruction can often be addressed later through septorhinoplasty. The likelihood of requiring revision surgery increases if nasal deformity or obstruction was present before the fracture occurred.[23] 

Many surgeons avoid performing open rhinoplasty on patients involved in high-risk activities for nasal fractures, such as combat sports. They typically choose to defer the surgery until the patient discontinues these activities, aiming to reduce the risk of repeated nasal injuries and optimize the final surgical outcome.

Complications

Residual nasal deformity often persists to varying degrees following the reduction of nasal bone and septal fractures. Saddle nose deformities and septal perforations can occur as complications of septoplasty, septal hematoma formation, or significant septal injury. Olfactory disturbances are relatively common, affecting up to one-third of patients with nasal bone fractures. These disturbances may result from intraoperative manipulation of the olfactory neuroepithelium, located on the superior aspect of the nasal septum and the superior or supreme turbinate.[24]

Management of Septal Hematoma

Subperichondrial hematomas of the nasal septum are most commonly caused by trauma, including iatrogenic injury during nasoseptal surgery, but they may occur spontaneously in patients with bleeding diatheses. Septal hematomas should be treated promptly after identification, as the collected blood can clot over time, making evacuation more difficult (see Image. Nasal Septal Hematoma).[25]

Prompt incision and drainage are essential to prevent abscess formation or septal cartilage necrosis. Cartilage necrosis can develop within a day due to ischemia from pressure on the cartilage, while abscesses may form within 72 hours, especially if mucosal disruptions allow nasal flora to access the hematoma, providing an ideal environment for bacterial growth. Over time, significant cartilage necrosis may result in septal perforation and saddle nose deformity.[12]

To evacuate a septal hematoma, appropriate anesthesia is administered, typically involving topical application of 1% to 4% lidocaine or 4% cocaine on cottonoid pledgets, with potential supplementation of local infiltration using 1% to 2% lidocaine with 1:100,000-200,000 epinephrine. Pediatric patients and adults who cannot cooperate with the procedure may require general anesthesia. A headlight and a nasal speculum (Vienna or Cottle) are typically used to visualize the hematoma, although a nasal endoscope may be an alternative. For smaller hematomas, aspiration with an 18- to 20-gauge hypodermic needle is often effective, especially if the hematoma is relatively fresh and has not yet consolidated. For larger or older hematomas, a horizontal incision is made along the most fluctuant portion of the hematoma, parallel to the floor of the nose.

Some surgeons may also excise a thin strip of mucoperichondrium to widen the incision and prevent premature closure, which could trap additional blood within the cavity if hemostasis is not achieved. The collected blood is expressed using a Freer elevator or similar instrument and then evacuated with a Frazier tip suction. A rubber band or thin Penrose drain is sutured into the wound for 3 to 5 days, and splints or quilting stitches are placed to eliminate dead space and prevent reaccumulation of the hematoma. If the hematoma is bilateral, incisions can be made on both sides of the septum, but they should be planned to avoid overlap, as this could create a full-thickness defect and increase the risk of developing a septal perforation.

Management of Septal Perforation

Perforations of the nasal septum range from asymptomatic microperforations, measuring less than a millimeter, to subtotal or total perforations that compromise critical support of the nasal dorsum, leading to significant aesthetic deficits (see Image. Nasal Septal Perforation). Please see StatPearls' companion resource, "Septal Perforation," for more information. Due to septal fractures, perforations are often small to medium in size, typically occurring as sequelae of hematomas and subsequent tissue necrosis.

Symptomatic perforations can lead to crusting, bleeding, a sensation of nasal obstruction, and whistling, with the latter being more common in smaller perforations. Perforations up to 1-1.5 cm in diameter are often closed using local advancement or rotation flaps, along with an interposition graft of cartilage, fascia, acellular dermis, or a polydioxanone sheet.[26][27][28] Larger perforations are often treated with obturation using a septal button prosthesis but may also be closed with regional or free flaps. Described options for flap closure include inferior turbinate flaps, pericranial flaps, facial artery musculomucosal flaps, and radial forearm free fascial flaps (see Image. Inferior Turbinate Flap Reconstruction for Nasal Septal Perforation).[29][30][31][32]

Management of Saddle Nose Deformity

The collapse of the quadrangular cartilage and loss of dorsal projection in the middle third of the nose results in a "saddle nose" deformity, characterized by a depression between the rhinion and the nasal tip (see Image. Saddle Nose Deformity).[33] This condition can affect both nasal breathing and contour. The reduction in dorsal projection causes the upper lateral cartilages to collapse inward, obstructing the airway at the internal nasal valves—the narrow area in the superior part of the nasal passages where the upper lateral cartilages meet the dorsal septum. Minor saddle deformities are typically treated with onlay grafting to restore normal dorsal contour. However, more severe saddle deformities, which are often associated with nasal obstruction, require reconstruction that includes resuspension of the upper lateral cartilages to their normal anatomical positions.

Rhinoplasty for a shallow saddle deformity may require nothing more than crushed or diced cartilage grafting, with or without fascia, vomer, or turbinate bone onlay, or can even be accomplished with dermal filler injections, such as hyaluronic acid.[34][33][35] However, saddle deformities extensive enough to cause nasal obstruction typically require repair of the L-strut via the extracorporeal septoplasty method described in the Treatment/Management section above. Patients who have undergone prior surgery or who have significant septal damage are unlikely to have enough residual quadrangular cartilage to fashion the necessary grafts. In these cases, costal cartilage is often used. However, some surgeons prefer using split calvarial bone, cantilevered off the nasal bones, to restore dorsal projection and resuspend the upper lateral cartilages, which also helps alleviate any concomitant nasal obstruction (see Images. Intraoperative View of Septal Reconstruction Using Costal Cartilage and Split Calvarial Bone Grafting).[36][37]