What is the next step in managing minimally displaced bilateral nasal bone fractures with a possible nondisplaced fracture of the anterior process of the left maxilla (maxillary bone)?

From the Guidelines

For minimally displaced bilateral nasal bone fractures with a possible nondisplaced fracture of the anterior process of the left maxilla, the next step in management is closed reduction of the nasal fractures within 7-10 days of injury, as this approach is supported by recent evidence from 2022, which emphasizes the importance of proper diagnosis and treatment in managing facial trauma 1.

Management Approach

The procedure is typically performed under local anesthesia with sedation in an outpatient setting. Key considerations include:

• Evaluating the patient for nasal airway obstruction, septal deviation, and cosmetic deformity before proceeding with the reduction.
• Administering topical anesthetics (4% lidocaine with epinephrine-soaked pledgets) and local infiltration (1% lidocaine with 1:100,000 epinephrine) to the nasal area prior to reduction.
• Using instruments like Asch or Walsham forceps to manipulate the nasal bones back into proper alignment.
• Applying external nasal splinting for 7-10 days to maintain the corrected position after reduction.

Post-Procedure Care

• Advising the patient to avoid strenuous activity, nose blowing, and trauma to the nose for at least 2 weeks.
• Prescribing acetaminophen or NSAIDs as needed for pain management.

Conservative Management for Maxillary Fracture

The nondisplaced maxillary fracture can be managed conservatively with observation, as stable nondisplaced fractures typically heal well without intervention, according to the principles outlined in the management of facial trauma 1.

Rationale

This approach is recommended because minimally displaced nasal fractures can lead to both functional and cosmetic issues if not properly reduced, while stable nondisplaced maxillary fractures typically do not require surgical intervention, as supported by the recent guidelines on imaging of facial trauma following primary survey 1.

From the Research

Evaluation and Management

• The patient's condition involves minimally displaced bilateral nasal bone fractures and a possible nondisplaced fracture of the anterior process of the left maxilla, requiring careful evaluation and management 2, 3, 4.
• The goal of treatment is to restore the pretraumatic state and normal function, considering the degree of injury, presence of concomitant facial injuries, patient compliance, and training of the surgeon 3.

Treatment Options

• Manipulation under local anesthesia is an effective first-line treatment for simple nasal fractures, but associated septal injury may require other options 4.
• Closed reduction techniques are often used as first-line therapy for complex nasal fractures, but may result in disappointing treatment outcomes and require secondary surgical corrections 5.
• Open structure rhinoplasty and extracorporeal septal reconstruction can provide optimal anatomic fracture reduction and concomitant stabilization of the skeletal framework, resulting in unsurpassed contour restoration and lasting architectural stability of the nose 5.

Considerations

• Each patient's history must be recorded, including the cause of trauma, previous facial injuries, prior nasal deformity, or obstruction, to guide the choice of treatment 4.
• Careful physical examination is essential to determine the extent of the injury and choose the appropriate treatment approach 4.
• Adequate follow-up is necessary to monitor the patient's progress and address any potential complications 4.