Specialist Referral for Acute Bilateral Comminuted Nasal Bone Fracture
An acute bilateral comminuted nasal bone fracture should be referred to ENT (Otolaryngology), as they are the primary specialists who manage nasal bone fractures and perform the necessary closed or open reduction procedures, including corrective septorhinoplasty when indicated. 1
Primary Management Pathway
ENT specialists are the appropriate referral for isolated nasal bone fractures, including bilateral comminuted patterns, as they routinely perform:
- Closed reduction with or without septal correction 2
- Open reduction when necessary 1
- Concomitant corrective septorhinoplasty for acute fractures, which achieves superior aesthetic outcomes compared to delayed reconstruction 1
When Maxillofacial Surgery Becomes Necessary
Maxillofacial surgery referral is indicated when the nasal fracture extends beyond isolated nasal bones to involve:
Naso-orbital-ethmoid (NOE) complex fractures involving the medial orbital walls, nasal septum, and naso-frontal junction, which cause telescoping of the nose and require subspecialist management to prevent enophthalmos, telecanthus, lacrimal obstruction, and ptosis 3, 2
Le Fort II or III fractures where nasal bones are fractured as part of pyramidal midface injuries involving the orbital rims, maxillary sinuses, and pterygoid plates 3, 4
Zygomaticomaxillary complex fractures with nasal involvement requiring open reduction and internal fixation 5
Extensive orbital wall defects requiring reconstruction with titanium mesh or other biomaterials 6
Critical Assessment Points
Before making the referral, evaluate for associated injuries that change management:
Check for septal hematoma requiring urgent drainage to prevent septal necrosis 2
Assess for CSF leak suggesting cribriform plate involvement, which requires neurosurgical consultation 3
Evaluate intercanthal distance - widening suggests NOE fracture requiring maxillofacial surgery rather than ENT 4
Order CT maxillofacial imaging (not plain radiographs, which have only 53-82% accuracy) to characterize the fracture pattern and identify extension to adjacent structures 2
Screen for intracranial injury as 68% of maxillofacial trauma patients have associated head injury 5, 2
Timing Considerations
Fracture reduction should occur within 2 weeks for optimal outcomes:
- Septal correction must precede nasal bone realignment if septal deviation is present 2
- Early intervention prevents permanent deformity and functional impairment 5
Common Pitfall
The critical error is assuming all nasal fractures are simple ENT cases. Bilateral comminuted fractures have a 66.89% rate of coexistent frontal process of maxilla fractures and 16.51% rate of orbital wall fractures 7. If CT imaging reveals extension beyond isolated nasal bones into the NOE complex, orbits, or midface buttresses, maxillofacial surgery becomes the appropriate referral 3.