A nasal fracture is reduced either before the swelling develops or usually as soon as the swelling has subsided, preferably within 14 days from the injury.
As a rule, nasal fractures are treated in specialized care.
Late repairs of nasal fractures are very demanding.
Clinical examination
A cold pack placed on the nose immediately after the injury reduces oedema.
Palpation and inspection are the means required for examination of the patient.
The internal parts of the nose are inspected using a head lamp and a nasal speculum.
Suspect a fracture if the nose is swollen or dislocated, there is blood in the nostrils, or a crepitation is felt.
Nasal x-ray is unnecessary and does not affect the treatment.
The diagnosis is made difficult by
swelling
earlier fractures or distortions
old deviations of the nasal septum.
A physician with expertise in the treatment of nasal fractures can assess the need for treatment also over the phone or teleconsultation. If the shape of the nose and breathing through the nose after the injury are as they were before the injury, a possible fracture does not require treatment.
Treatment
Open fractures and injuries to the nasal septum should be immediately referred to specialized care for assessment. For other fractures it is advisable to suspend referral until the oedema has subsided. Only then is it possible to reliably assess the position of the nose.
Change in the patient's appearance that disturbs the patient him-/herself, or obstruction of nasal breathing are indications for treatment of a nasal fracture.
In growing children's fractures, deformities may become worse as the child grows, and hence even very mild deformities should be corrected.
Fractures are usually reduced under local anaesthesia. Severe fractures and fractures in children are reduced under general anaesthesia.
For local anaesthesia of the mucous membranes, the same anaesthetic can be used as for maxillary puncture Acute Maxillary Sinusitis. A piece of cotton wool soaked with the anaesthetic is inserted in the upper meatus, and another in the meatus between the inferior and medial conchae. Both gauzes should be placed as posteriorly as possible. The anaesthesia is completed by infiltration anaesthesia on the sides and back of the nose with 1% lidocaine-adrenaline.
A slightly curved elevator or a special instrument, the Walsham forceps, can be used for repositioning. The purpose of the repositioning is to detach the fragments from each other. This is usually best accomplished by pushing the nose in the direction of the dislocation. After the fragments have been mobilized with the elevator they can be lifted into place keeping the fingers on the nose to control the procedure.
Supporting tampons may be inserted inside the nose for a few days after repositioning if needed.
External fixation to the back of the nose by tape or glass fibre splint secures the position.
The splint is kept in place for a week.
It is advisable to avoid contact sports for about one month after a nasal fracture or, alternatively, to use a face or nose shield.
References
Renkonen S, Vehmanen S, Mäkitie A et al. Nasal bone fractures are successfully managed under local anaesthesia - experience on 483 patients. Clin Otolaryngol 2016;41(1):79-82. [PubMed]