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Nasal fractures due to blunt trauma are a common occurrence. Fights, auto accidents, and sports accidents account for most fractures in an urban setting. Work, farm, sports, or leisure activity accidents account for most of these injuries in rural areas.1 Males aged 15 to 25 years old make up the majority of the population, with fights being their major etiology.2–5 These fractures are often missed on initial evaluation, especially when there are many more urgent trauma concerns. Perform closed or open reduction of these fractures within the first 2 weeks, when it is easiest to avoid the need for more elaborate operations later to correct the disfigurement and nasal airway obstruction. Perform the reduction in children within 3 to 7 days, as fracture fixation occurs faster than in adults.6

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The clinical indications of a nasal fracture include a history of epistaxis, new onset nasal blockage, or a change in nasal appearance. Determine whether the patient has a prior history of a nasal bone fracture, as repeat nasal bone fractures will be more difficult to reduce. An old photograph of the patient may aid this determination. One study revealed that 30 percent of injured noses had a preexisting nasal deformity.7 At least 48 percent of the general population has a nasal septal deviation.8 Physical examination may demonstrate skin lacerations, nasal tenderness and mobility, internal mucoperichondrial tears, ecchymosis, or a septal hematoma. A septal hematoma must be drained to avoid cartilage necrosis and a resulting saddle nose deformity. Refer to Chapter 147 regarding the complete details of nasal septal hematoma management.

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The mechanism of injury, force of impact, direction of impact, and the history of any prior nasal deformity must be ascertained from the patient in order to understand the potential magnitude of the fracture. Photographic documentation is crucial before one attempts any nasal manipulation. Obtain radiographs, Waters and lateral nasal, to support the physical findings of a nasal fracture (Figure 146-1). Many surgeons recommend radiographs as part of medical legal documentation, although all Otolaryngologists do not agree. Radiographs can have a high false-negative rate due to the lack of fine resolution or a high false-positive rate from the misinterpretation of the normal bony sutures.9,10

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Figure 146-1
Graphic Jump LocationGraphic Jump Location

Radiographs demonstrating a nasal fracture. A. Waters view of a deviated nasal septum and right nasal bone fracture. B. Lateral view of a fracture from a frontal and inferior force having driven the lower aspect of the nasal bones in.

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The direction of the force to fracture the nasal bone is variable. There are several lateral and frontal force injury classifications, but no consensus exists.5,11,12 One study demonstrated that 66 percent of nasal fractures were due to lateral ...

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