Anatomy

The nose is a fundamental structure in the facial skeleton, playing an important role in facial aesthetics and respiratory physiology. From an anatomical perspective, the external nose is divided into three parts: the upper third consists of a bony structure, while the lower two-thirds comprise cartilage. The bony upper section, known as the vault, includes paired nasal bones that connect superiorly with the frontal bone at the nasion. Inferiorly, these nasal bones join the paired upper lateral cartilages at the rhinion. This combination of nasal bones and upper lateral cartilages shapes and supports the nasal dorsum. In the lower portion, the paired lower lateral (also called alar cartilages) shape the nasal tip and provide structure to the external nasal valve (Fig. 1) (^{Greenlund et al., 2023}; ^{Trujillo & Lee, 2023}).

Figure 1 Anatomical depiction of the osteocartilaginous framework of the nose (^{Greenlund et al., 2023}). 

Fracture Classification

Currently, there is no universally standardized classification system for nasal bone fractures.

Nonetheless, Hwang et al. have suggested a system that divides these fractures into three primary categories: Type I: Simple without displacement; Type II: Simple with displacement; Type IIA: Unilateral; Type IIAs: Unilateral with septal fracture; Type IIB: Bilateral; Type IIBs: Bilateral with septal fracture; Type III: Comminuted (Fig. 2) (^{Hwang et al., 2006}).

Figure 2 Classification of nasal fractures proposed by Hwang et al. (^{Hwang et al., 2006}). 

Closed Nasal Reduction

When treating nasal fractures, functionality and aesthetics are critical considerations. Closed reduction is a minimally invasive procedure designed to reposition the fractured bones, enhancing the appearance and minimizing septal deviation (^{Trujillo & Lee, 2023}).

The main indications for closed reduction in a nasal fracture are primarily aesthetic deformities and changes in functionality. However, there are also several limitations and contraindications for this treatment, such as: excessive edema, which can lead to inadequate reduction; panfacial fractures, as the nasal fracture is often the last to be treated; naso-orbito-ethmoidal fractures, as the nasal fracture is part of a more complex injury requiring special considerations; cerebrospinal fluid leak, which requires neurosurgical evaluation and management (^{Kademani et al., 2017}).

The high prevalence of nasal fractures justifies the need for their management to also be the responsibility of the maxillofacial surgeon, an integral emergency team member responsible for the care of facial fractures.

To structure the research question guiding this work, the PICO model was used: (P) Adult patients with nasal bone fractures; (I) Closed reduction of the nasal fracture; (C) Other management options such as open reduction or conservative treatment; (O) Satisfactory aesthetic and functional results.

The research question was: “In adult patients with nasal bone fractures, is closed reduction effective in achieving satisfactory aesthetic and functional results, compared with other treatment options, such as open reduction or conservative treatment?” This paper aims to provide maxillofacial surgeons a comprehensive step-by-step guide to perform a closed nasal reduction by presenting a clinical case of a patient with a nasal fracture, accompanied by a brief literature review.

CASE REPORT

A 47-year-old male patient with no significant medical history presents to the emergency department following facial trauma due to an assault. Upon examination, the patient is conscious, lucid, and oriented to time and place. The evaluation reveals a nasal deformity with a right lateral deviation, left nasal compression, partial collapse of the left nostril, and reduced airflow through this side (Fig. 3).

Additionally, the patient reports difficulty breathing. Nasal speculum examination shows erythematous nasal mucosa, a nasal septum deviated to the right, and no septal hematoma. Waters’ view radiograph (Fig. 4) and nasal bone radiographs (Fig. 5) are requested to confirm the nasal fracture.

Since the evaluation of the patient was made early, and the fracture involved just the nasal bones and not the septum, a closed reduction in an outpatient setting with local anesthesia was planned. Treatment was deferred for 7 days.

Figure 3 Preoperative appearance: (A) bottom view, (B) top view. A right deviation and a left nasal depression stand out. 

Figure 4 (A). Waters’ radiograph shows the left HPN’s collapse. 

Figure 5 (A). Left HPN radiograph; (B) Right HPN radiograph. 

Surgical Technique for Closed Nasal Reduction Required Instruments

These are shown in order, from left to right, in Figure 6.

Figure 6: Instruments for the closed nasal reduction technique. 

Local Anesthesia:

The procedure should be carried out using local anesthesia. Initially, infiltrative anesthesia is administered to the infraorbital and infratrochlear nerves using 2% Lidocaine combined with 1:100,000 Epinephrine (Fig. 7). Then, bilateral nasal packing with gauze soaked in 2% Lidocaine + 1:100,000 Epinephrine is performed, and 10 minutes are allowed to elapse, providing adequate mucosal anesthesia and vasoconstriction for the procedure (Fig. 8) (^{López-Cedrún, 2019}).

Figure 7 Infiltrative anesthesia of the infraorbital and infratrochlear nerves. 

Figure 8 Bilateral nasal packing with gauze soaked in 2% lidocaine and vasoconstrictor to enhance anesthesia at the surgical site. 

Straightening of the Nasal Pyramid

The deviated nasal pyramid is manually straightened by pressing the thumb on the deviated side, applying counterpressure on the contralateral hemiface to stabilize the head (^{López-Cedrún, 2019}).

Measuring the instruments before insertion into the nasal cavities is essential, as the cribriform plate of the ethmoid bone, which connects the nasal cavity to the anterior cranial fossa, is situated in the upper region of the nasal cavity.

The measurement is taken from the base of the nose to the tip, subtracting 1 cm to obtain a safe measurement for instrument insertion, thereby reducing the risk of complications.

Reduction of Nasal Bone Depression: Lateral Rectification with Boies Elevator:

The Boies elevator or a similar blunt-edged instrument of comparable size is inserted into the nasal cavity, positioned against the inner surface of the depressed nasal bone, and outward pressure is applied until lateral realignment is accomplished (Fig. 9) (^{López- Cedrún, 2019}).

Figure 9 (A). Boies’ elevator measurement from the tip of the nose to the root of the nose. (B) Application of force laterally using the Boies elevator. 

Lateral Rectification with Asch Forceps:

The Asch forceps are introduced into the nostril on the affected side and closed, generating pressure on both the internal and external surfaces to rectify the lateral wall (Fig. 10).

Figure 10: Asch forceps in operation on the left nostril to reduce the left nasal bone. 

Evaluation and Treatment of the Nasal Septum:

The Walsham forceps are introduced, with each active part in each nostril, and closed to apply pressure on both internal walls of each nostril to rectify the septum’s shape (Fig. 11).

After performing reduction maneuvers, it is essential to verify both nostrils’ correct patency and rule out the presence of a septal hematoma.

Figure 11 Walsham forceps in operation for nasal septum rectification. 

Nasal Packing and External Splint:

Internal and external splinting is performed after completing the procedure and achieving fracture reduction (Fig. 12). Anterior packing with gauze is left in place to generate outward forces, maintaining the position of the cartilage and bones as an internal splint. Additionally, an external rigid splint, made of plaster bandage, is applied (Fig. 13), maintaining the reduction of the fragments and controlling the edema.

Figure 12 Post-reduction situation, highlighting the rectification of the nasal dorsum, from the nasion to the tip of the nose. The image is immediately post- reduction, so it is possible to see the inflammation and edema produced by the procedure. 

Figure 13 Fixation of internal and external splints using medical tape. 

Post-operative Care

Time of intervention

Opinions vary regarding the appropriate timing for intervention in isolated nasal bone fractures and their impact on outcomes. Many experts recommend early reduction for pediatric patients, typically within 7 days due to their faster healing rates, and within 10 days post-injury for adults (^{Wang et al., 2019}).

Trujillo et al. suggest an immediate closed reduction is feasible if the patient receives care within 3 to 6 hours of the injury, before significant swelling occurs. Beyond this period, it is generally advisable to postpone the procedure until the swelling subsides, which may take up to 14 days in adults.

However, authors like Yoon and Han have reported successful outcomes even when treatment was administered up to 41 days after the injury (^{Yoon & Han, 2016}).

Additionally, Koca et al. advised waiting 3-5 days for the swelling to subside following the initial diagnosis of a nasal fracture before deciding on the most suitable treatment approach, providing a window for evaluation and planning in the early phase of the injury (^{Firat Koca et al., 2022}).

Many experts recommend early reduction for pediatric patients, typically within 7 days due to their faster healing rates, and within 10 days post-injury for adults (^{Wang et al., 2019}). Trujillo et al. suggest an immediate closed reduction is feasible if the patient receives care within 3 to 6 hours of the injury, before significant swelling occurs.

Beyond this period, it is generally advisable to postpone the procedure until the swelling subsides, which may take up to 14 days in adults.

However, authors like Yoon and Han have reported successful outcomes even when treatment was administered up to 41 days after the injury (^{Yoon & Han, 2016}).

This approach underscores the importance of monitoring the patient’s condition and edema resolution before proceeding with intervention to ensure optimal outcomes.

Kang et al. emphasized the significance of early intervention for pediatric nasal fractures, noting that children’s faster bone healing process necessitates an earlier reduction compared to adults to ensure optimal surgical outcomes (^{Kang et al., 2021}).

In conclusion, when swelling is significant enough to hinder the intraoperative assessment of the underlying nasal bones, it is permissible to postpone closed nasal reduction for 7 to 10 days, or potentially longer, to allow the skin swelling to subside, with the preference being that this occurs prior to bony fusion.

Should bony fusion have already taken place, closed nasal reduction may necessitate a concurrent nasal osteotomy to reposition the displaced bone segment (^{Wang et al., 2019}).