Manipulation of Fractured Nasal Bones

 

Indication

Presence of laterally-deviated nasal bones following nasal trauma, causing change in cosmesis.

 

BACKGROUND

Please also see the page on nasal trauma. Ideally, this procedure should be performed within 7-14 days of injury (definitely within 21 days). This is because fracture-dislocations heal at about three weeks. Ask the patient how and where the nose is different following their injury. They should be encouraged to compare it mentally with how it looked before the injury (some have broken their noses before), rather than with a hypothetical ideal. Look at the nose from the base and from above to assess deviation.

Note that MUA nose is unlikely to improve nasal obstruction significantly (or even at all), since many patients with nasal obstruction also have septal deviation either caused or made worse by the injury, as well as swelling of the nasal mucosa. This will require re-assessment at a later date; the patient can either re-present via the GP of can be followed up in your general clinic.

 

Procedure

General anaesthesia is most common.  Depending on departmental practice, local anaesthesia can also be used, with reportedly similar results (1): 

  • Gently infiltrate the skin to block the infratrochlear and external branch of anterior ethmoidal nerves

  • Apply local anaesthetic spray or pledgets to nasal mucosa

The nasal bones are manipulated using digital pressure. The fracture-dislocation is distracted caudally (ie towards the chin) before pressure is applied gently to the bones to restore a more normal shape. Sometimes, a crack can be felt when the bones move back into place.

In theatre, Walsham's forceps or elevators may also be used to manipulate the bones. Small pieces of surgical tape/plasters may be applied onto the external nose.  Additionally, the surgeon may apply a thermoplastic or plaster of Paris nasal splint if they feel the nasal bones are unstable.

 

Complications

Pain

Bleeding  Rarely, bleeding may require control with nasal packing.  If septal haematoma develops then further management would be indicated.

Bruising and swelling This settles over in the days or weeks following the procedure.

Unsatisfactory cosmetic appearance  Nasal deformity may persist despite MUA.  Septorhinoplasty may be considered after an interval depending on various factors including local funding arrangements. 

 

Post-operative management

Patients are discharged on the same day.  No routine ENT follow up is required. Patients can take simple analgesia.

If tape/splints have been applied then these can generally be removed by the patient after 5-7 days. Patients should avoid contact sports for 6-8 weeks.

 

REFERENCES

(1) Khwaja S et al (2007). Nasal fracture reduction: local versus general anaesthesia. Rhinology 45 (1): 83-8.

 

Page last reviewed: 9 December 2019