How to manage a patient with a nasal bone fracture and anterior wall of maxillary sinus fracture?

Management of Nasal Bone Fracture and Anterior Wall Maxillary Sinus Fracture

For isolated nasal bone fractures with anterior maxillary sinus wall involvement, ENT specialists should perform closed reduction with or without septal correction within 2 weeks, while anterior maxillary sinus wall fragments can be managed conservatively or with minimally invasive endoscopic techniques rather than open reduction and internal fixation. 1, 2

Initial Assessment and Imaging

Obtain CT maxillofacial without contrast as the gold standard imaging modality to characterize the fracture pattern and identify extension to adjacent structures, as plain radiographs have only 53-82% accuracy. 1 This imaging is critical because:

• 68% of maxillofacial trauma patients have associated intracranial injuries, requiring complementary CT head evaluation. 3, 1
• The imaging must identify whether this is truly an isolated injury or part of a more complex fracture pattern requiring subspecialist management. 1

Critical Red Flags Requiring Escalation

Before proceeding with routine ENT management, actively exclude these patterns that mandate maxillofacial surgery or neurosurgical referral:

• Naso-orbital-ethmoid (NOE) complex involvement (medial orbital walls, nasal septum, naso-frontal junction fractures) - these cause enophthalmos, telecanthus, lacrimal obstruction, and ptosis without proper treatment. 3, 1, 4
• Le Fort II or III patterns where nasal bones are fractured as part of pyramidal midface injuries involving orbital rims, maxillary sinuses, and pterygoid plates. 3, 1
• Zygomaticomaxillary complex fractures involving the zygomatic arch, inferior orbital rim, and both anterior and posterior maxillary sinus walls. 3
• CSF leak (clear rhinorrhea) suggesting cribriform plate involvement - requires neurosurgical consultation. 1, 4
• Extraocular movement restriction indicating orbital wall fracture with muscle entrapment. 4

Management Algorithm for Isolated Injuries

Nasal Bone Fracture Component

ENT specialists perform closed reduction with or without septal correction for isolated nasal bone fractures, including bilateral comminuted patterns. 1 Key technical points:

• Septal correction must precede nasal bone realignment if septal deviation is present. 1
• Fracture reduction should occur within 2 weeks for optimal outcomes to prevent permanent deformity and functional impairment. 1
• Before any reduction, urgently drain any septal hematoma to prevent septal necrosis. 1

Anterior Maxillary Sinus Wall Fracture Component

The surgical morbidity from open reduction and internal fixation (ORIF) of maxillary sinus wall fractures often surpasses the benefits, making minimally invasive approaches preferable. 2 Management options in order of invasiveness:

1. Conservative management for undisplaced or minimally displaced fractures - the maxillary sinus shows a clear tendency to spontaneously reventilate and drain after fracture. 5, 6

2. Transnasal endoscopic-assisted reduction (TERM) without internal fixation for displaced fragments:

   • Endoscopic inferior meatus antrostomy provides access to the maxillary sinus wall. 2
   • Counterforce is applied by pushing packed Vaseline-soaked gauze or using a zygomatic process approach via a Gillies incision. 2
   • Patient satisfaction with TERM is significantly greater than with ORIF (p = 0.031), and it avoids facial incisions. 2

3. Fibrin glue (Tisseel) fixation for comminuted anterior wall fragments when reduction is needed:

   • Bone fragments are maintained in their original places by fibrin clot layers. 7
   • Operation time is reduced, bleeding tendency decreases, and hemostatic reaction of fibrin provides stability. 7
   • No major side effects reported in 234 patients, with good postoperative CT findings. 7

4. ORIF via existing laceration or bicoronal approach reserved only for severe comminuted fractures where less invasive methods are inadequate. 5

Follow-Up Protocol

Patients with maxillary sinus wall fractures require rhinological follow-up examination including CT imaging approximately 3 months after surgery to detect complications. 6 Monitor for:

• Traumatic obstruction of the anterior ethmoid leading to secondary frontal sinus mucositis (occurred in 8 of 30 sides in one series). 6
• Maxillary sinus mucosal swelling or traumatic mucocele development (occurred in 12 of 30 maxillary sinuses). 6
• Paranasal sinusitis (affected 9 of 15 patients in follow-up). 6

If obstruction of the nasofrontal duct and/or maxillary sinus ostium is identified, endonasal endoscopic surgery is recommended for minimally invasive reconstruction of ventilation and drainage. 6

Common Pitfalls to Avoid

• Do not routinely debride every fractured ethmoidal cell system - the fractured ethmoidal cell system shows a clear tendency to spontaneously reventilate and drain. 6
• Do not miss associated posterior maxillary sinus wall fractures - these are part of zygomaticomaxillary complex fractures requiring different management. 3
• Do not delay reduction beyond 2 weeks - optimal outcomes require intervention within this window. 1
• Do not assume isolated injury without CT confirmation - clinical examination alone misses complex fracture patterns. 1