Surgeries for nasal fractures in children and adults

There are contraindications. Specialist consultation is required.

The correct position of bones and cartilage ensures the normal functioning of the upper respiratory tract. Repositioning of the nasal bones during a fracture is a procedure to restore displacement of the cartilage and bones of the nose resulting from trauma or congenital pathology.

Causes and symptoms

In the absence of adequate medical care, nasal deformations can lead to persistent impairment of nasal breathing and impaired sense of smell, so in this case, medical (manual or surgical) intervention should not be delayed.

Depending on the problems that brought the patient to the surgeon, there are:

plastic surgery of the nasal septum (performed in the presence of curvatures and deformations of the nasal septum);
plastic surgery of the back of the nose (correction of the curvature of the back, lowering, elimination of the hump).

Reasons to see a doctor are:

congenital pathologies of the structure of the nose.
consequences of injuries in the form of deformation of the nasal bridge or nasal septum.
open and closed nasal fractures, displaced fractures.

The main cause of a nasal fracture, in which the structure of the nose is disrupted, is trauma - sports, domestic, industrial, or as a result of an accident. The following symptoms indicate traumatic damage to the nasal bones:

burst blood vessels in the eyes;
nasal congestion;
severe pain symptom;
state of shock, temporary loss of consciousness.
bleeding from the nose (if the integrity of the mucous membrane has been compromised);
hemorrhage, including in the eyelid area (the so-called glasses symptom).
swelling in the nasal area, which in some cases can mask the deformity.
mucous discharge from the nose.
disturbance of breathing and smell.

A nasal fracture is also dangerous because it can be complicated by the formation of a hematoma of the nasal septum, when blood accumulates under the mucous membrane of the nasal septum. The consequences are narrowing of the nasal passages, breathing problems and severe pain, subsequently - suppuration of the hematoma and destruction or melting of the cartilage of the nasal septum.

Signs of a nasal fracture depending on the type of injury

In medicine, there are several types of damage in question:

Closed fracture of the nose without displacement. The only visible signs are extensive bruising and swelling of the upper part of the face. There is no change in the shape or location of the nose. Visually, there may be a depression of the nose, but the exact location of the fracture can only be determined by palpation. An x-ray is required to confirm the diagnosis. If the injury is severe, then damage to the mucous membrane of the nasal passages is possible and, as a result, bleeding.
Open fracture without displacement. The signs are the same as in the previous case, but the point of injury is determined visually - the skin is damaged, protruding bone fragments are clearly visible.
Displaced nasal fracture. A complex injury that can lead to respiratory failure, purulent tissue damage, problems with water and electrolyte balance, and trigeminal neuritis. You will definitely need to use the work of a plastic surgeon to perform rhinoplasty and restore your appearance.

Common signs of a nasal fracture:

hematomas around the eyes, on the bridge of the nose, can spread to the forehead;
swelling of the upper and central part of the face;
acute pain at the site of injury, aggravated by palpation;
difficult to stop bleeding from the nasal passages;
problems with nasal breathing.

If a comminuted fracture occurs, crepitus may be present - a crunch when touched, pathological mobility (the nose can literally be placed on its side).

The severity of a nasal fracture is determined only after the patient is examined by a doctor. For example, with the slow spread of hematomas and a gradual increase in edema, which are accompanied by increasing headaches, there is a risk of not only the injury in question, but also a fracture of the bones of the base of the skull. And in this case, immediate hospitalization and an extensive examination of the patient, including computed tomography, are required.

Treatment methods

Immediately after the injury (within 3-4 hours, before the development of soft tissue edema), manual reposition of the bones is performed - manual adjustment of bone fragments under local anesthesia (irrigation of the mucous membrane with lidocaine solution and injection of anesthetic). In case of lateral displacement of the bones, the shape of the nose is restored without the use of instruments. If the back of the nose is damaged, a so-called “elevator” is used, which is inserted into the nasal cavity to lift the sunken bone. Manual repositioning of the nasal bones is quite painful and does not always lead to the desired result. If more than 10 days have passed since the fracture, persistent impairment of respiratory and aesthetic function may occur. In this case, it is recommended to carry out reposition with the help of surgery, since a bone callus has already formed at the fracture site, leading to fusion of the bones. The operation is called rhinoseptoplasty, and if the correction affects only the septum, then septoplasty.

Clinical picture

Typical clinical signs that occur with fractures of the nasal bones are painful sensations that intensify with pressure.

If along with this the bones of the ethmoid labyrinth are damaged, subcutaneous emphysema appears in the area around the eyes. Another marker is nosebleeds, which develop as a consequence of rupture of the mucous membrane. Hemorrhage appears in the anterior chamber of the eye. Severe injuries are accompanied by displacement of the eyeball, which can cause deterioration or complete loss of vision.

Deformations may imply displacement of the back or even its complete collapse, the formation of a saddle shape.

Indications and contraindications

A traumatic nasal fracture requires immediate intervention. Rhinoseptoplasty is a major operation that is performed under general anesthesia, so there are contraindications for it:

general serious condition;
Diagnosed with blood clotting problems;
inflammatory processes in the facial area;
allergic reactions to anesthesia;
chronic diseases in the acute stage;
acute viral diseases;
herpes.

Diagnostics

Diagnosis of traumatic lesions is based on an analysis of the patient’s own complaints, visual deformations of this part of the face, anamnesis data and the clinical picture. Palpation, radiography, computed tomography in different planes, and nasal endoscopy are performed.

a — the nasal bones have shifted towards the processes of the upper jaw b — a fracture of the nasal septum, the bones are separated c — displacement, “flattening” of the external nose

Any such injury, in addition to consultation with an otolaryngologist, requires consultation with a neurosurgeon. This allows us to exclude brain damage, especially if we are talking about the patient’s serious condition, with loss of consciousness or other accompanying neurological symptoms.

Prices

Price (rub.)In installments* (rub.) Consultation with a surgeon for surgery (SPECIAL)0—Online doctor’s opinion on surgery (SPECIAL)0—Reposition of nasal bones from 7700—Reposition of nasal bones under ETIfrom 15000—

* You can read more about the conditions here - Treatment on credit or in installments

The cost is preliminary. The exact cost of the operation can only be determined by a surgeon during a free consultation.

Features of nose correction after a fracture

The CONSTANTA Clinic offers a broken nose correction service that solves two problems:

Returning bones to their correct position;
Restoring the functionality of impaired nasal breathing.

Before the operation, our specialists relieve the patient’s pain shock, swelling, and stop bleeding. The fracture site is numbed by irrigating the nasal cavity with an anesthetic compound and injecting it with a syringe. If there are a large number of fragments, after reposition, tampons with paraffin are inserted into the nasal cavity for proper fusion of bones.

Reduction if treated in a timely manner

A fresh injury does not require procedures in the operating room or general anesthesia. When a patient breaks his nose and promptly seeks medical help from our Clinic, a specialist in the ENT office can straighten it under local anesthesia. The doctor performs the adjustment from the outside with his fingers, acting inside the nose with a special instrument (an elevator or tweezers, the ends of which are protected by a fabric wrap and a rubber tube). After the necessary procedures and application of a protective bandage, the patient can immediately go home.

But even with timely medical help, non-surgical correction of a broken nose is not always possible. Indications for surgery are:

post-traumatic deformation of the outer part of the nose;
severe damage to the walls of the sinuses and soft tissues;
fracture, curvature of the nasal septum, requiring anesthesia and major surgery, including implantation;
extensive hematomas in the septal area, which must be drained to eliminate the risk of necrosis of cartilage tissue.

Correction of the nose for an old injury

If you did not have time to see a doctor in the first weeks after the injury, the fracture has already begun to heal, and healing often occurs at the wrong point. This is fraught with impaired free breathing and a number of aesthetic problems:

displacement of the nose to the side;
hump on the back;
a hole in the bridge of the nose.

Our Clinic successfully treats nasal fractures even years after the injury. The surgical operation in this case is a complex process performed under general anesthesia over several hours.

Stages of surgical correction of the nose after an old fracture

STAGE I	STAGE II	STAGE III
Osteotomy	Restoring the correct position of the bones	Aesthetic rhinoplasty
Through incisions in the skin, the surgeon gains access to the improperly fused bones of the nose and carefully breaks them	The doctor manually restores the normal position of the fragments using elevators	Nose surgery may include eliminating a hump or pit, narrowing the back, wings, tip of the nose, correcting the area of skin between the nostrils, etc.

Diagnosis of nasal bone fracture

In the process of diagnosing a fracture of the nasal bones, interviewing the patient is considered an important point, since the doctor needs to find out exactly how the patient received the injury. Then the specialist examines the nose and feels it. During palpation, a slight crunch may be felt, but the patient always feels pain. During the diagnosis process, an examination of the nasal cavity, called rhinoscopy . To ensure that the patient does not experience strong discomfort, he is usually given anesthesia . of lidocaine is often used for this . Another possible research method in this case is endoscopy. This procedure involves inserting into the nasal cavity a flexible thin tube equipped with a light and a video camera at the end.

Also, in the process of diagnosing a nasal fracture, radiography is sometimes used: an X-ray of the nasal bones is taken in a lateral projection.

Preparation for repositioning of the nasal bones

To establish the correct diagnosis, the doctor conducts an additional examination to determine the location of the nasal bones, the depth and area of damage to the skin and mucous membranes. This will help you choose treatment tactics and the severity of surgical intervention.

Additional research methods:

Rhinoscopy is an examination of the nasal mucosa. Detects the presence and location, depth and size of tears.
X-ray in frontal and lateral projections. Provides information about the location of bones and the degree of their displacement.
MRI and CT are prescribed in complex cases when radiography does not allow us to clarify all the details (for example, damaged cartilage remains invisible on X-ray film).
Endoscopy. A modern research method, when the doctor examines the mucous membrane of the nasal cavity using a special mini-camera mounted on a flexible carrier. Data from the camera is sent to the computer monitor. The image can be enlarged and literally every millimeter of the surface can be examined.

Based on the examination and additional examination data, the doctor establishes the correct diagnosis and determines the tactics for straightening the nose.

Why is self-medication dangerous?

People often underestimate the danger of a broken nose. First of all, men and especially if the fracture is without displacement or with a slight displacement that does not greatly spoil the appearance. Some, even more, try to “put their nose in place” on their own. Such actions are highly undesirable. They can worsen the situation and lead to complications:

Increased bleeding;
Greater displacement of fragments;
Improper fusion of bones and cartilage;
Ugly deformation of the nose;
Loss of central position of the nasal septum;
Difficulty nasal breathing;
Endless chronic rhinosinusitis.

Do not under any circumstances rely on chance and do not put off visiting the doctor! The sooner you contact, the faster, cheaper and more effective the treatment will be.

Diagnosis of damage to the bones of the external nose

Ultrasound scanner RS80

A benchmark for new standards!
Unparalleled clarity, resolution, ultra-fast data processing, and a comprehensive suite of advanced ultrasound technologies to solve the most challenging diagnostic problems.

Introduction

In otorhinolaryngology departments providing 24-hour emergency and urgent care, patients with nasal bone fractures (NBF) account for about 3% [1], while NBI are the most common injury to the facial skeleton and ENT organs [2]. Establishing an accurate diagnosis is necessary for expert assessment, issuing a reliable conclusion and determining treatment tactics.

In addition to clinical examination, to clarify the diagnosis, many medical institutions have a wide arsenal of diagnostic equipment (devices for radiography, computed tomography, MRI, ultrasound and endoscopic examination). A rationally selected diagnostic algorithm leads to a timely diagnosis of the patient, adequate and complete treatment measures, which ensures medical, social and economic efficiency.

The purpose of the study was to evaluate the informativeness of methods for diagnosing nasal bone fractures and to develop indications for ultrasound examination of patients with PCN.

Material and methods

131 patients with nasal bone fractures were clinically examined, all of them underwent radiography of the nasal bones, 20 of them underwent CT scanning. 100 ultrasound scans of the nasal bones were performed (20 healthy volunteers, 70 patients with PCN and 10 patients with persistent post-traumatic deformities of the nose). Radiographs of the nasal bones were taken in the lateral and direct occipitomental projections. CT scan of the nasal bones was carried out using a spiral computed tomograph in the axial and, in some cases, coronal projection with a step of 5 mm, followed by two-dimensional reconstruction. Ultrasound of the nasal bones was carried out taking into account the methods described in the literature [3, 4] on a modern ultrasound machine using a linear trapezoidal sensor with a working surface length of 40 mm and a frequency of 6-12 MHz with the patient lying on his back. The sensor was first installed longitudinally (parallel to the dorsum of the nose) and transversely on the dorsum of the nose, and then longitudinally and transversely on both slopes of the nose. To make the surface of the sensor and the nose congruent, a gel was applied to the skin of the nose.

Results and discussion

During a clinical study, when determining the crepitus of bone fragments, the mobility of the nasal pyramid, the appearance or increase in deformation of the external nose, the diagnosis of PCN was made only in 73 (55.3%) patients. However, in the presence of deformation of the external nose, without clinically detectable crepitus, mobility of bone fragments in 49 (37.12%) people, it was necessary to differentiate persistent post-traumatic deformation of the external nose from “fresh” PCN with deformation of the external nose. To clarify the diagnosis, instrumental additional examination was used. Using lateral radiographs of the nasal bones, it was possible to identify a fracture of the nasal bones in 125 (95.42%) of 131 patients. In 6 (4.58%) patients with clinical signs of PCN and deformation of the external nose, when one of the nasal slopes was retracted, no fracture was detected on lateral radiographs. The direct occipitomental view (Waters view) was used to assess lateral displacement of fragments or confirm evidence of a fracture not diagnosed on lateral radiographs. Thus, out of 8 patients, direct projection revealed a fracture in only 4 (50%), with significant displacement of the fragments. When the fragments were slightly displaced due to the overlap of bone structures, the displaced fracture could not be visualized. A CT scan of the nasal bones of 20 patients with PCN was analyzed; the presence of a fracture was confirmed in all of them.

Ultrasound was used as an alternative to the X-ray method. According to the literature, modern ultrasound devices make it possible to image the nasal bones, their fractures and displacements and are an alternative to x-ray research methods [5-8]. Ultrasound scanning occupies a leading position among radiation diagnostic methods, which is due to the simplicity, non-invasiveness and cost-effectiveness of sonography, the short duration of this study, and the absence of ionizing radiation [9].

Ultrasound examination of 20 patients without a history of nasal fractures revealed a normal ultrasound picture of the external nose (Fig. 1). The nasal bones were visualized as a continuous arcuate hyperechoic line, above which there was a hypoechoic zone interspersed with fatty tissue and a thin hyperechoic layer - the skin.

Rice. 1.

Ultrasound examination of the nose (normal and fractures).
1)
Nasal bones without signs of fracture (the arrow points to the nasal bones).
2)
Location of the sensor during the study (2a, 2c - in the photo, 2c - schematically).
3)
Fractures of the nasal bones (fracture sites are indicated by an arrow); a — the sensor is located longitudinally on the back of the nose; c — the sensor is located transversely on the back of the nose; c — the sensor is located transversely on the left slope of the nose.

During ultrasound scanning, the fracture sites were visualized, which looked like an anechoic strip, breaking the continuity of the hyperechoic line of the nasal bones; often the displacement of the fragments was visualized in the form of a step (Fig. 1). The image in the form of a snapshot was recorded on the monitor and stored in the computer memory; later it could be printed on paper. Difficulties arose during ultrasound examination of patients with PCN with damage to the skin of the nose, since this research method is contact, in contrast to radiography, which can be performed with an adhesive plaster or gauze bandage on the nose. In such cases, ultrasound was performed after primary surgical treatment of the nasal wound, or a latex cover filled with water or gel was put on the sensor. Among the 70 studied patients with nasal bone fractures, ultrasound was able to identify or confirm the presence of a fracture in 68 (97.14%).

For the differential diagnosis of PCN with persistent post-traumatic deformation of the external nose, 10 ultrasound scans of patients with improperly healed fractures were performed (Fig. 2). Ultrasound showed no clear anechoic fracture line, thickening of the bones and surrounding bones with tissue of reduced echogenicity were observed. As an illustration, we present one of our clinical observations.

Rice. 2.

Ultrasound of the nose: persistent post-traumatic deformities of the nose. The arrow points to the sites of healed fractures; the sensor is positioned transversely on the right slope of the nose.

Clinical observation

Patient B., 27 years old, was taken to the emergency department of the Ultrasonic Regional Clinical Hospital by an ambulance team after being beaten a few hours ago, but did not lose consciousness. The patient complained of pain in the nose and headache. The patient was examined by an otorhinolaryngologist and a neurosurgeon. It was established: pronounced swelling of the soft tissues of the external nose, more in the area of the right slope of the nose, the pyramid of the nose is located in the midline, motionless and painful on palpation, crepitus of bone fragments is not detected. Radiographs of the skull were taken in two projections, and radiographs of the nasal bones were taken in lateral projections. No information about the fracture was received. Due to the fact that traumatic brain injury (TBI) and PCN were not detected during examination and examination, the patient was diagnosed with “nasal contusion.” Further observation by an otorhinolaryngologist and neurologist at a local clinic is recommended.

The next day, the patient again sought help due to worsening headaches. A CT scan of the brain and facial skull was performed. A CT scan revealed a fracture of the nasal bones in the area of the right lateral slope of the nose (Fig. 3). The patient was hospitalized in the neurosurgical department with a diagnosis of “closed craniocerebral injury, concussion, fracture of the nasal bones.” An ultrasound scan of the nasal bones confirmed PCN and revealed a displacement—retraction of the nasal bones in the area of the right lateral slope. As the swelling of the soft tissues of the nose decreased, a slight deformation of the external nose began to be determined. The diagnosis was made: “closed fracture of the nasal bones with deformation of the external nose.”

Rice. 3.

Fracture of the nasal bones in the area of the right lateral slope of the nose (clinical observation): 1 - photograph, 2 - lateral radiograph, 3 - computed tomogram, 4 - echogram.

Based on the data obtained, an algorithm for examining patients with damage to the nose is proposed (Fig. 4).

Rice. 4.

Algorithm for examining a patient with a nasal injury.

conclusions

Most fractures of the nasal bones are detected using instrumental research methods; it is clinically possible to diagnose a fracture of the nasal bones in only 55.3% of patients.
Lateral radiography is advisable to use for screening examination of patients with nasal injuries.
Ultrasound of the nasal bones is a more accurate method for diagnosing fractures of the nasal bones in the area of the lateral slopes of the nose compared to radiography; it allows you to document the lateral displacement of the fragments.
CT is the most accurate research method and is indispensable for diagnosing combined skull fractures.

Literature

Semenov S.A. Features of the epidemiology of nasal bone fractures // Achievements of fundamental, clinical medicine and pharmacy: materials of the 65th scientific. sessions coll. University, Vitebsk, March 24-25, 2010 / Vit. state honey. University; editorial board: V.P. Deykalo [and others]. Vitebsk, 2010. pp. 65-67.
Boymuradov Sh.A. Frequency of occurrence of nasal bone fractures among facial injuries // Russian Otorhinolaryngology. 2006. N 4. P. 4-6.
Eremina N.V., Chernyshenko I.O., Rusetsky Yu.Yu. Diagnosis and treatment of nasal bone fractures using ultrasonography // Russian Otorhinolaryngology. 2007. N 4. P. 73-79.
Thiede O. Comparison of ultrasonography and conventional radiography in the diagnosis of nasal fractures // Arch. Otolaryngol. Head Neck Surg. 2005. V. 131 (5). P. 434-439.
Eremina N.V., Rusetsky Yu.Yu., Chernyshenko I.O. Diagnostic effectiveness of radiography for fractures of the nasal bones from the position of evidence-based medicine // Russian Otorhinolaryngology. 2004. N 3. P. 33-36.
Danter J. et al. Ultrasound imaging of nasal bone fractures with a 20-MHz ultrasound scanner // HNO. 1996. V. 44 (6). P. 324-328.
Friedrich RE, Heiland M., Bartel-Friedrich S. Potentials of ultrasound in the diagnosis of midfacial fractures // Clin Oral Investig. 2003. V. 7 (4). P. 226-229.
Zagolski O., Strek P. Ultrasonography of the nose and paranasal sinuses // Pol Merkur Lekarski. 2007. V. 22 (127). P. 32-35.
Chernyshenko I.O. Optimization of diagnosis and treatment of traumatic injuries to the bone structures of the nose: Abstract of thesis. diss. ...cand. honey. Sci. Samara, 2005.

Ultrasound scanner RS80

How long after a fracture is reduction carried out?

The success of the operation directly depends on how long ago the nasal injury occurred. The earlier the bones are repositioned, the greater the chance of restoring the sense of smell and free breathing, and avoiding the death of the mucous membrane and subsequent deformation of the nose. The timing of surgical intervention is determined taking into account the patient’s condition and the nature of the injury:

The first 2–5 hours after injury is the optimal time for surgical correction of a closed fracture. People often receive such an injury during active games (football, hockey, boxing), an unfortunate fall, an accident or a domestic fight. In the first 3 hours after a nasal injury, swelling is minimal, so the otolaryngologist can more accurately perform all manipulations to align bone fragments. Emergency reposition is performed in the absence of nosebleeds (internal or external).
The first week after injury - during this period, reposition is performed for patients with an open nasal fracture. During the postponed period, doctors suture the wound, eliminate severe swelling of the soft tissues and fight repeated bleeding, characteristic of an open injury to the bone structures of the nose. The fusion process has not yet begun, so the movable fragments can be easily moved into place.
1–2 weeks after a nasal fracture – surgery is postponed if the person simultaneously suffered a traumatic brain injury and is in serious condition. The process of bone tissue regeneration has already begun, but tight sutures at the fracture site have not yet formed.

3 weeks after a nasal injury or in case of chronic deformities (up to 1.5 months after the fracture) with the formation of a dense callus, a second fracture with subsequent reposition is required. Such operations are performed by plastic surgeons to eliminate aesthetic defects. It takes longer to recover. It is quite difficult to completely restore the sense of smell and breathing in such cases.

The extent of surgical intervention and the cost of repositioning the nasal bones depend on the complexity of the fracture. The financial costs are also affected by the qualifications of the operating doctor and the volume of diagnostic tests.

Possible consequences

If, when these symptoms appear, you do not consult a doctor and do not receive timely help, then the injury can lead to a number of consequences:

deformation of appearance due to improper fusion of bones;
deformation of the nasal septum. Leads to difficulty inhaling through the nose and the development of chronic diseases of the respiratory system. The problem can only be solved promptly;
deterioration of the sense of smell and other problems (asthmatic attacks, headaches, etc.).