Open And Close Reduction In Treatment Of Fracture Nasal Bones.

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1 Open And Close Reduction In Treatment Of Fracture Nasal Bones. Salem Hussian Ibraheem Al-Obiedi Department of Surgery, College of Medicine, University of Tikrit Abstract: To evaluate the functional (respiration) and cosmetic out comes for surgical procedures close and open reduction in treatment of sever nasal bones fractures with nasal obstruction due to nasal septal deviation. This study on 144 patients with isolated fracture nasal bones attained to E.N.T department in Tikrit Teaching Hospital. Iraq. During the period from Jan to Dec Undisplaced fractures were 16 patients (11.1%) no need for interference, 24 patients (16.7%) were simple fractures underwent manipulation under local anesthesia. The 104 patients (72.2%) with obvious external nasal deformities and nasal obstruction were selected, 72 patients underwent close reduction, 28 patients underwent open reduction (septoplasty, only five patients needs open bony reduction.), and 4 patients, (one have septal haematoma and three with septal abscess.) drainage was done with reduction of the fracture. All the operations were done under general anesthesia, with follow up for at least nine months. Patients underwent close reduction found that (75%) with good respiration, (58.4%) good alignment of the fracture, and 18 patients (25%) needs revision surgery. (12 septoplasty and 6 septorhinoplasty). While patients underwent open reduction, (92.9%) with good respiration, (78.6%) good alignment of the fracture, and two patients (7.1%) needs revision surgery (one septoplasty & one rhinoplasty). Keywords: Fracture nose, Nasal trauma, close reduction, open reduction, septoplasty, septorhinoplasty, Rhinoplasty. Introduction: The nose is the most prominent and fragile structure of the facial skeleton (1), so it commonly facial bone fracture about the half (2), and the third most common fracture bone after the clavicle and wrist (3). The commonest causes is personal assault in young adult male (4), other found that sporting activities was the commonest causes (5). The severity of the nasal fracture depends on the velocity and direction of the blow(4).approximately 80% the fracture will occur at the junction of the thick and thin portion of the nasal bone (5). The septal cartilage can be likened to the supporting pole of the tent, so it almost always moved out of its proper position when fracture to the nasal bones occurs(6), the fracture cartilage either Jarjavay's fracture runs horizontal direction parallel with the maxillary crest from maxillary spine to the vomer, results from trauma to the dorsum of the nose (7), Chevallet fracture, its vertical fracture occurs at the junction of thinner caudal and thicker cephalic portion, results from lateral trauma(6). The nasal bones are attached to the perpendicular plate of ethmoid so if there is any degree of deviation of the nasal bones visible, the perpendicular plate of the ethmoid must also be fractured(8). In the treatment of simple fracture of nasal pyramid without significant septal deformity may be reduced effectively under local or general anesthesia(9), but in sever trauma with extension of the fracture to the septum causing nasal obstruction, the nasal septal deformities and external fracture must be exposed and realigned during the same operation(open reduction) to promote uncomplicated healing, and to avoid functional and cosmetic sequel (10). The aim of this study is to compare between open and close reduction in treatment of fracture nose. Patients And Methods: This longitudinal clinical study was carried out in department of Oto-rhinolaryngology at Tikrit Teaching Hospital. Iraq. During the period from Jan to Dec They were 144 patients presented with isolated nasal fracture, evaluated by history

2 taken regarding type and duration of trauma, Results: nasal shape, and nasal obstruction prior There were 144 patients having trauma. Full E.N.T examinations were done fracture nasal bones presented to same auther stressing mainly on nasal examination. during seven years, male were108 The diagnosis was made clinically by patients(75%),male to female ratio was( localized tenderness, bony cripitus, and 3:1).The commonest age group affected was recent external deformity for displaced (11-20) year, then(21-30) year,(42.3%) fracture, confirmed by lateral plane X-Ray (29.1%)respectively(Table 1). Patients with for the nasal bone for medico-legal purposes. non-displaced fracture were 16 patients The patients with obvious external (11.1%), when no surgical interference deformities(deviated or saddle nose), with required, patients with mild external nasal nasal obstruction due to obstructed or deformities without significant septal impacted nasal septal deviation were deformities that causing nasal obstruction selected. Were as exclude patients with nondisplaced fracture or mild deformity with out reduction under local anesthesia were done were 24 patients (16.7%), simple close nasal obstruction, were reduced under local for them as out- patient procedure (Table 2). anesthesia as out patients basis by simple Three patients(2.9%) with septal abscess, and thumb pressure on the concave side or one patient (0.9%)with septal haematoma, disimpaction of unilateral simple depressed drainage and reduction of the fracture was nasal bone by one blade of Walsham's done. the patients with septal abscess ends forceps. with saddle nose, needs augmentation The selected patients were divided according rhinoplasty. to the treatment policy into: Patients with sever external nasal Group-1. Patients underwent simple close deformities and nasal obstruction at time of reduction using Walsham's forceps for bony reduction due to septal deviation were 100 reposition (disimpaction and elevation), and patients (69.4%), divided to two groups. Asch's forceps for the septal Group 1- Were 72 patients (50%), they deviation(elevation and straightening). underwent simple close reduction under Group-2. Patients underwent open general anesthesia. The mean time for reduction (septoplasty) through hemitrans interference was 8 days (2-16 days). fixation incision on the Side of dislocation, The follow up of the patients, exposure of deformed cartilage segments regarding the functional results, 54 patients then excision, scoring or suturing..maxillary (75%) were having good respiration, 18 crest and perpendicular plate of ethmoid patients(25%) were having nasal obstruction involvement, excised or fractured and due to septal deviation, 5 patients synechae reposition. and via intercartilagenous incision as well, 11patients (61%) with unilateral elevation of the skin and periostium, reduce nasal obstruction, and 7 patients(39%) were the mobile bony segment by Walsham's bilateral nasal obstruction. forceps. when firm fibrous healing reopen the Regarding cosmetic results, good fracture line by osteotome. alignment of the fracture (return to pretrauma All operations were done under shape) were 42 patients (58.4%), satisfactory general anesthesia, dealing with cosmetic results (The deformities were slight hypertrophied turbinate (SMD or partial and of little importance to the patient) were resection), bilateral septal stent was inserted 24 patients (33.3%), and 6 patients (8.3%) for open reduction to prevent synechiae, with obvious external nasal deformities removed after Seven days, with anterior nasal (Table 3), {3patients generalized deviation to packing to the vault of the nose for 48 hours, one side, 2 patients were C shape deviation, and plaster of Paris splint for dorsum of the one patient with supratip depression. nose for 10 days. Antibiotics cover for seven Revision surgery was indicated for days. Follow up of the patients for at least 18 patients (25%), {septoplasty for 11 nine months, for functional (nasal patients(61.1%), septorhinoplasty for 4 obstruction), and cosmetic out come, and patients(22.3%),and 3 patients(16.6%) revision (septoplasty, rhinoplasty, and refused surgery }(Table 4).The 15 patients septorhinoplasty) were done when indicated. underwent revision surgery, despite that

3 pretraumatic septal condition has not been cases were old partially healed fracture 29, documented, the operative finding were 34 days post injury, two cases were seven patients (46.7%) were C shape fracture pretraumatic deviated nose when medial and septal cartilage involving perpendicular plate lateral osteotomy was done, and one case was of ethmoid and vomer, then 4 patients impacted nasal bone under the frontal bone (26.6%) were inferior spur due to fracture/ with intact medial canthal ligament). dislocation of septal cartilage, 3 patients Following up found that 26 patients (20%) dislocation of septal cartilage from (92.9%) were having patent nasal respiration, maxillary crest with buckling of the septum, two patients (7.1%) gets unilateral nasal one patient (6.6%) vertical fracture of septal obstruction due to septal deviation. For cartilage, and all patients were having caudal cosmetic results, 22 patients (78.4%) with dislocation. good alignment, 5 patients (17.8%) with Groups 2 Patients that open reduction satisfactory results, and one case (3.6%) was done for them were 28 patients having supratip depression. Two patients (19.4%).The mean time for interference was (7.1%) revision surgery were indicated (one 13 days (5-34 days). Septoplasty was done septoplasty, and one septorhinoplasty was for septal deformities, only 5 patients (3.4%) child of 11 year so postponed the operation). open bony reduction were indicated (Two Table (1) : Age group of patients with fracture nose. Table (2) : Types of treatment. Age group Patients No. Fracture nose <10 years 20 (14%) year 61 (42.3%) year 42 (29.1%) year 14 (9.7%) >40 year 7 (4.9%) Total 144 (100%) Treatment. Number (%) Undisplaced fracture (no interference) 16 (11.1 %) Close reduction under local anesthesia. 24 (16.7 %) Close reduction under general anesthesia. 72 (50%) Open reduction under general anesthesia. 28 (19.4%) Drainage of septal haematoma and abscess 4 (2.8%) and reduction under GA Total 144 (100%) Table (3) : Results of treatment Group. No.0f patients. (1) Close simple 72 reduction (50%) (2)Open reduction 28 (19,4%) Functional results Good respiratio n 54 (75%) 26 (92.9%) Nasal obstruct -ion 18 (25%) 2 (7.1%) Cosmetic results Good 42 (58.4%) 22 (78.6%) Satisfactory * 24 (33.3%) 5 (17.8%) Poor 6 (8.3%) 1 (3.6%) Total *The deformities were slight and of little importance to the patient.

4 Table (4) : Number for revision surgery. Group No. of R e v i s i o n s u r g e r y patients Septo_plasty Septo_rhino_ plasty. Rhino_plasty Postponed the surgery Total (%) (1) Close simple reduction (2) Open reduction * 18 (25%) 28 1 O 0 1** 2 (7.1%) Total o 4 20 *Two patients needs septo rhinoplasty, and one septoplasty they refuse the operation. Discussion: An important dictum of nasal surgery is (As the septum goes- so goes the nose) (12), so that in fracture nasal bones failure to diagnose and effectively treat the associated septal fracture and dislocation almost always leads to poor therapeutic results. Cadaver nasal fracture experiments has shown that the bony septum is often involved as previously nasal trauma was thought to damage solely the anterior cartilaginous septum with sparing of the bony septum this may be the reason that reduction of the fracture nasal bones by simple reposition has been found to give poor functional and cosmetic results (13) (14).So septal fracture must be reduced or resected at the time of repair. otherwise the deviated septal fragments pull the nasal bones laterally (7).Generally the aesthetic out-come of closed reduction techniques are often less optimal(19 This clinical study found that (69.4%) of cases with fracture nasal bones having obvious external deformities with nasal obstruction due to obstructed or impacted nasal septal deviation they needs effective treatment. Patients with open reduction get (92.9%) good nasal respiration, (78.6%) with good alignment of the fracture and (7.1%) needs revision surgery. While patients underwent simple close reduction, despite of successful initial alignment of the nasal bones and septal deformities during the operation, (75%) were good nasal respiration, (58.4%) with good alignment, and (25%) needs revision surgery. Previous study was found that replacement of the nasal bones may be successful, but in over 40% of cases there will be redisplacement of the nasal bones due to overlapping of the fractured end of perpendicular plate of the ethmoid and quadrilateral cartilage, the tension in this overlap will drag the nasal bones back to their original fractured position(4). So it's essential to excise the overlapping fragment both bony and cartilaginous, and fixed the caudal end of the septal cartilage to the anterior nasal spine, and to the columellar tunnel by figure of eight suture before manipulation the nasal bones back, so that they heal in their correct position. Other found that 38% of all cases with isolated fracture of the bony nasal pyramid functionally and cosmetically satisfactory results and prefer open reduction (15). Many patients were waiting rhinoplasty which lead us to find (30-40 %) failure rate in nasal manipulative operation, and found that open reduction is preferred treatment for patients with deviated nose, especially patients with C-shape fracture of bony and cartilaginous septum (16). And open reduction is fundamental when lateral deviation of the nose (17).Francis & Herre found that when nasal pyramid deviation exceeding one half with width of the nasal bridge, extensive fracture dislocation of the bone and septum, fracture dislocation of caudal septum and open septal fracture were indications for open reduction. One study not support that high percentages of cases of nasal fracture have

5 been operated up on by open reduction 8. Thomson.CJ, et al. Extradural frontal (18,19). abscess complicating nasal septal In conclusion that open reduction for abscess in children.int.j.pediatrotolaryngol, treatment of patients with deviated or 1998.Oct 2; 45(2); 183- depressed nasal 6. fractures with nasal obstruction due to septal 9. Cook-JA, Manipulation of the deviation is the preferred method than simple fracture nose under LA.clinotolaryngol. close reduction, to restore satisfactory 1992 Aug; 17(4); 337- functional and ensure good cosmetic 40. outcome, and to minimize the need for 10. Jordan, L.W; The management of corrective surgery (weither septoplasty, acute injuries of the nasal septum. septorhinoplasty, or rhinoplasty). Laryngoscope.1967; 77, Chuknezi; AB, Nasal septal haematoma in Nigeria, J-laryngolotol.1992 May; 106(5); References: 1. Lanny Garth, et al. Nasal fractures. 12. David Brain, Reduction of fracture Craiy A. Foster et al. Surgery of nasal bones. Rob and Smith, facial bone fracture. Churchill Living operative surgery nose & throat. stone.1987; Butter worth. Fourth edition Muraoka-M et al. Twenty years of 16. statistics and observation of facial 13. Martinez-SA, Nasal fracture, what to bone fracture Acta- otolaryngol- do for successful outcome, Post suppl-stockh. 1998; 538: graduat-med.1987.dec. 82(8). 77,71-3. James F. Benson, Nasal trauma, 4. Bruce W.Jafek, ENT secrets, Jaypee 14. Murry-JA.et al.apathological brothers. India, 1996; classification of nasal injuries A.G.D Maran, The fracture nose, Sept. 17(5): Scott-Brown's otolaryngology. Ian 15. Eichhorn.T et al. Follow up patients smackay; Rhino logy, Butter worth with initial fracture of nasal pyramid; international edition, Fifth edition. Laryngol-rhinol-otol-stutty ; Mar. 62(3): Gilbert. JG, Treatment of post 16. Murry-JA et al. Open V close traumatic nasal deformity. N-Z- reduction of fracture nose. Archotolaryngol Dec. 110(12).797- Med.J Nov.25; 100(836): Charles W. Gross, Nasal fracture, 17. Farino-R. et al.traumatic nasal Gerald M otolaryngology 4. deformities. Aesthetic-plasticsurgery. 1983; 7(4): Hareper& Row, Philadelphia. 1987, 26 N. 18. Illum-P et al.role of fixation in the 7. Nasal and facial fracture: Loganturner's, Diseases of the nose throat oyolaryngol: 1983 Jun; (8): treatment of nasal fractures.clin- and ear. Edited by A.G.D maran, 19. Corry.J.et al.management of acute Tenth edition 1988; nasal fractures. American Family physician.oct.1,2004: P1315.