MUA of Nasal Fracture

Full title: Manipulation under anaesthesia (MUA) of nasal fracture-dislocation

 

Indication

Presence of 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 with how it looked before the injury (some have broken their noses before), rather than with a hypothetical ideal. Look up the length of the nose from nasal tip to brow.

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 so the patient can either re-present via the GP of can be followed up in your general clinic.

If there is residual nasal obstruction without major external nasal deviation, a septoplasty may be considered. If both are present, then a septorhinoplasty may be warranted: check on the local funding position for septorhinoplasty for trauma. In many areas, septorhinoplasty is funded by the NHS where there has been i) trauma to the nose; ii) significant persistent nasal obstruction causing functional impairment; iii) demonstrable bony and cartilaginous deviation.

 

Procedure

Anaesthesia can be general (younger children; those unable to tolerate an attempt while awake) or local: 

  • 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 approach to anaesthesia is different in different units – many prefer one local anaesthetic attempt in clinic if the patient is agreeable; many others prefer to list directly for a general anaesthetic. The evidence suggests that both approaches have similar outcomes (1). 

As with everything, get someone to show you how. 

The nasal bones are manipulated using digital pressure. The fracture-dislocation is distracted caudally (ie towards the chin) before point pressure is applied gently to the lateral part of 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 is less common and settles over in the days or weeks following the procedure.

Unsatisfactory cosmetic appearance Nasal deformity may persist despite MUA either under general or local anaesthesia.  Septorhinoplasty may be considered after an interval. 

 

Post-operative management

Patients are discharged on the same day.  No routine ENT follow up is required. Patients can take simple analgesia (NB – it is cheaper for patients who pay for their prescription to obtain this from the supermarket).

If tape/splints have been applied then these can generally be removed 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: 3 March 2017