What is the treatment for trauma to the bony bridge of the nose?

Treatment for Trauma to the Bony Bridge of the Nose

For trauma to the bony nasal bridge, obtain CT imaging of the maxillofacial region for accurate diagnosis, then perform closed reduction within 3-5 days if displaced, while carefully assessing for septal hematoma and associated injuries that require immediate specialist referral. 1, 2

Initial Assessment and Imaging

Immediate Evaluation

• Assess for life-threatening complications first: Check for airway compromise from hemorrhage, soft-tissue edema, or loss of facial architecture 3
• Screen for associated injuries: Evaluate for intracranial injuries, other facial fractures (especially orbital, zygomaticomaxillary complex, and Le Fort patterns), and cervical spine injuries, as 68% of maxillofacial trauma patients have associated head injury 3
• Examine for septal hematoma: This requires immediate drainage to prevent cartilage necrosis and saddle nose deformity 2
• Check for cerebrospinal fluid rhinorrhea: Indicates skull base fracture requiring immediate specialist referral 2

Diagnostic Imaging

• CT maxillofacial imaging is the preferred modality for nasal bridge fractures, providing superior detection and characterization compared to plain radiographs 1, 4
• Plain radiographs have limited value with accuracy only 53-82% and rarely alter management decisions 1, 4
• Ultrasound may be considered as an alternative with high accuracy (sensitivity 90-100%, specificity 98-100%) particularly for isolated nasal bone fractures and can detect nondepressed nasal bridge fractures better than CT 1, 4

Treatment Algorithm

Step 1: Determine Timing of Intervention

• Perform closed reduction within 3-5 days after injury when swelling has resolved enough to assess alignment but before significant healing begins 5, 2
• Immediate reconstruction is ideal when medically possible to decrease long-term sequelae 6
• Wait until all swelling has resolved before definitive examination and treatment 5

Step 2: Assess Septal Involvement

• Septal correction must precede nasal bone realignment if septal deviation is present 1
• Position the septum into midline using transverse root osteotomy for complex fractures with septal deviation 1
• Place a strut between the medial crura for support and realignment when needed 1

Step 3: Perform Reduction

• Use the smallest manipulative force necessary to achieve reduction 1
• Preserve periosteal and mucosal attachments of the nasal bone to minimize destabilization of the osseous framework 1
• Avoid creating periosteal tunnels as these are detrimental to support 1
• Perform osteotomies while preserving periosteal and mucosal attachments when mobilization is required 1

Step 4: Address Complex or Comminuted Fractures

• Consider camouflaging techniques such as dorsal onlay grafts using septal cartilage to hide residual deviations when complete correction is impossible 1
• Avoid intermediate osteotomies as they risk visible irregularities or step-off deformities in areas with thin overlying skin 1

Critical Contraindications and Pitfalls

Absolute Indications for Immediate Specialist Referral

• Septal hematoma requiring immediate drainage 2
• Cerebrospinal fluid rhinorrhea indicating skull base fracture 2
• Malocclusion suggesting maxillary or mandibular involvement 2
• Extraocular movement defects indicating orbital involvement 2
• Naso-orbital-ethmoid fractures which can result in telescoping of the nose and require subspecialist management to prevent enophthalmos, telecanthus, lacrimal obstruction, and ptosis 3

Relative Contraindications

• Short nasal bones are a relative contraindication for osteotomies as they risk bony communication while yielding limited results 1

Post-Treatment Management

Follow-Up Care

• Arrange close follow-up within 3-5 days if immediate specialist referral is not indicated 2
• Continue postoperative follow-up for 6-12 months to ensure proper healing and satisfactory results 5
• Recommend nasal saline irrigation to keep nasal passages clean and prevent crusting 4

Monitor for Complications

• Nasal airway obstruction from septal deviation or mucosal edema 4
• Cosmetic deformities that may require secondary rhinoplasty after complete healing, which occurs in up to 50% of cases despite optimal acute management 7, 4
• Associated septal injuries can be responsible for postoperative nasal deformity and obstruction requiring additional correction 1

Pain and Infection Management

• Provide appropriate analgesia for pain control 2
• Prophylactic antibiotics are recommended for deep lacerations with exposed cartilage to prevent infection 4
• Perform minimal debridement when indicated in the primary care setting 2