NASAL FRACTURES Andrew H. Murr, MD FACS Professor Chief of Service Department of Otolaryngology/ Head and Neck Surgery San Francisco General Hospital Roger Boles, M.D. Endowed Chair in Otolaryngology Education Department of Otolaryngology-Head and Neck Surgery University of California, San Francisco School of Medicine 1
The Nose Prominent facial feature Direct line of sight Can give an impression of one s personality Tough guy Self image Confidence in appearance Ethnic characteristic Airway! Epidemiology of Nasal Fracture Male 2X female Sports injury Assault Etoh 2 nd and 3 rd decade of lifepeak 2
Anatomy Upper third Bone Nasal Frontal Maxillary Anatomy Middle third Cartilage Upper lateral Sesamoid 3
Anatomy Lower third Cartilage Lower lateral Interdomal ligament Pitanguy Skin SSTE Anatomy Septum Vomer Palatine bones Maxilla Perpendicular plate of the ethmoid Quadrangular cartilage 4
Anatomy Nerve supply V1 Supratrochlear Infratrochlear V2 Infraorbital Blood supply Anterior ethmoid IMA Angular artery Valveless veins Fracture Patterns 5
History Time, date, associated factors MVA Restraints, airbags Assault Subpoena- photos Domestic violence 30 60% of women with facial trauma Substance abuse Withdrawal issues History Epistaxis Blood loss- H/H, T&C Airway obstruction Anosmia Clear rhinorrhea Numbness Incisors Occlusion Vision Past nasal surgical history 6
Physical Examination ABC s of trauma NEC, ZMC, Le Fort, Dentoalveolar, Mandible, Skull base! Dorsum Assymmetry/Mobility Nasaolabial angle 90-110 degrees Periorbital ecchymosis, edema Middle and lower third Septal Examination Equipment Suction, speculum, headlight, vasoconstrictor, anesthetic r/o Septal Hematoma Internal exam 30 degree Hopkins rod Flexible nasopharyngoscope Brown-Gruss analysis Upper, middle, and lower thirds 7
Studies Photographs Plain films Logan, Clin Radiol 49:192, 1994 CT scan Management Trauma ABC s Acute Management Bleeding/Clots Vasoconstrictors Afrin Cocaine (4%) Packing- telfa, merocel, vaseline gauze with antibiotic ointment and oral antibiotic coverage Hemostatic agents Avitene, gelfoam, topical thrombin, floseal 8
Management Immediate v. Delayed reduction Accurate reduction Patient expectations and psychology Timing of Delayed reduction 7-10 Days Algorithm Nasal Trauma Stabilize No deformity Deformity NOE CRNF ORIF High Satisfaction F/U Persisting Issues NSR v. Open Septorhinoplasty 9
Sequelae Persisting or noticeable nasal deformity Nasal obstruction Synechiae Septal perforation Sinusitis Epiphora Anesthesia General Conscious Sedation Local Topical Injected 10
CRNF Office v. O.R. Tools of the Trade Technical tips Gelfoam roll Asch forceps External splint Telfa Septoplasty Endoscopic Traditional Hemi-transfixion 11
NSR Severe septal deviation Dorsal deviation Septoplasty IC incisions Deglove UL separation +/- osteotomies Extremely severe septal deformity Septal perforation Severe dorsal deformity/grafting Tip work Open- grafting, tip work Septorhinoplasty 12
CHOOSING THE OPEN NSR CANDIDATE STEPS OF OPEN NSR 13
SSTE ELEVATION SSTE ELEVATION 14
SEPTAL CORRECTION DORSAL CORRECTION 15
ALLOPLASTIC GRAFTING MATERIAL MEDIAL OSTEOTOMY 16
LATERAL OSTEOTOMY LATERAL OSTEOTOMY 17
RESULT ON THE TABLE SPLINT/DRESSING 18
Satisfaction 80% of patients will be satisfied with CRNF 10% of patients will request revision after Rhinoplasty Taking care of nasal trauma skillfully can be the best entre into a cosmetic practice Satisfaction 19
Nasal Fractures Taking care of nasal fractures can be an entre to a cosmetic practice! Question #1 You intend to accomplish a closed reduction of nasal fracture under straight local anesthesia in your office. You should: A. Observe Universal Precautions B. Wear an Armani suit C. Instead, bring the patient to the operating room D. Instead, bring the patient to the surgi-center E. Never recommend a closed reduction for a nasal fracture. 20
Question #2 After a closed reduction of nasal fracture, the patient is unhappy about a persisting dorsal deviation. You should: A. Refer the patient to a psychiatrist B. Call your attorney to arrange your malpractice defense C. Recommend a nasoseptal reconstruction with osteotomies D. Recommend an open septorhinoplasty with cartilage grafting E. Arrange revision surgery and forego preoperative photography 21