What is the initial management for a deep nasal laceration showing cartilage with a likely mild fracture?

Management of Deep Nasal Laceration with Exposed Cartilage and Mild Fracture

For deep nasal lacerations with exposed cartilage and mild fracture, immediate surgical exploration, thorough wound irrigation, meticulous repair of the laceration with cartilage preservation, and appropriate antibiotic coverage is the recommended initial management approach. 1, 2

Initial Assessment and Imaging

• CT maxillofacial imaging is recommended for comprehensive evaluation of nasal trauma with deep lacerations showing cartilage, as it provides superior delineation of osseous and soft tissue structures and can detect subtle nondisplaced fractures 1
• Ultrasound may be considered as an adjunct for evaluating isolated nasal bone fractures with high sensitivity (90-100%) and specificity (98-100%), particularly for nondepressed fractures of the nasal bridge 1
• Plain radiographs have limited diagnostic value in nasal trauma with sensitivity ranging from 53-82% and generally do not alter management decisions 1

Immediate Wound Management

• Thorough wound irrigation with sterile saline to remove debris and reduce bacterial contamination 2
• Careful debridement of devitalized tissue while preserving as much viable cartilage as possible 3, 2
• Meticulous layered closure of the laceration, ensuring proper alignment of cartilage and soft tissue layers 2
• In cases of comminuted fractures with lacerations at fracture sites, consider open reduction through the laceration opening 4

Cartilage Preservation Techniques

• For exposed cartilage, ensure adequate soft tissue coverage to prevent desiccation and necrosis 3, 5
• If cartilage is fractured but viable, realign and stabilize with careful suturing techniques 5
• In cases of severe comminution where traditional fixation is difficult, fibrin glue may be used for internal fixation 4
• For infected cartilage grafts, consider through-and-through irrigation systems with culture-specific antibiotics rather than removing the cartilage 3

Fracture Management

• Mild nasal fractures with minimal displacement may be managed with closed reduction if necessary 6
• For fractures with significant displacement or comminution visible through the laceration, open reduction may be performed at the time of laceration repair 4, 6
• Preservation of periosteal and mucosal attachments is crucial to minimize destabilization of the nasal framework 7
• Camouflaging techniques using cartilage grafts may be considered for residual deformities after healing 1

Antibiotic Management

• Prophylactic antibiotics are recommended for deep nasal lacerations with exposed cartilage to prevent infection 1, 2
• If infection is suspected or present, obtain deep tissue cultures (minimum of five samples) for targeted antibiotic therapy 1
• Avoid swab cultures due to low sensitivity and high risk of contamination 1
• Antibiotics should be administered immediately after sampling in suspected infection 1

Complications to Monitor

• Septal hematoma formation, which requires immediate drainage to prevent cartilage necrosis and subsequent saddle nose deformity 5
• Wound infection, which can compromise the entire reconstruction and lead to cartilage resorption 3, 5
• Nasal airway obstruction due to septal deviation or mucosal edema 1
• Cosmetic deformities that may require secondary rhinoplasty after complete healing 1, 6

Follow-up Care

• Close monitoring for signs of infection or hematoma formation during the first week 5, 2
• Nasal saline irrigation to keep the nasal passages clean and prevent crusting 1
• Assessment of nasal airway patency and cosmetic appearance at follow-up visits 2, 6
• Consider delayed reconstruction for any residual functional or aesthetic concerns after complete healing (typically 3-6 months) 2, 6

Remember that early and appropriate management of nasal lacerations with exposed cartilage is crucial to prevent long-term functional and cosmetic sequelae. Failure to properly address these injuries can lead to significant morbidity including nasal airway obstruction, cosmetic deformities, and potential need for more extensive reconstructive procedures in the future 5, 2.