[Nasal fractures--indications for open reposition].

BACKGROUND

Many septoplasties and septorhinoplasties are indicated due to previous traumatic etiologies, and the typical treatment of these septal and/or bone fractures has been closed reduction. Review of the literature reveals a success rate of only between 30-82%. One of the reasons for these poor outcomes is the influence of tension and pressure stress vectors due to hidden cartilage fractures behind intact septal mucosa. This is the main indication for open reduction of nasal trauma. The present study analyses the results of our experience with the open reduction of nasal fractures.

METHODS

In a six-year period between 1991 and 1996, a total of 34 open reductions were performed out of 155 nasal fractures. This series was analysed clinically and with the aid of computer tomograms. Postoperative follow-up involved a combination of clinical evaluation, nasal endoscopy, and photography. The indication for open reposition was based on analysis of force of impact and suspicion of cartilage damage. The goal of the procedures was to incise partial-thickness fractures to make them full-thickness, thereby relieving the inherent tension in the cartilage, and to mobilize impacted bone fragments with microosteotomies so they could be properly reduced. At the same time, any previously existing anatomical abnormalities with functional impact were also corrected.

RESULTS

The rate of patient satisfaction based on postoperative cosmesis and function was 88%. The group in which open reduction was most commonly indicated was the frontal impact cohort (n = 18.53% of open reductions). This was followed by the frontolateral impact cohort (n = 8.23%). In only one (1/155) open reduction was it not possible to find a cartilage fracture on exploration. Revision surgery was required in 2 cases due to nasal obstruction from synechiae between the septum and the anterior aspect of the inferior turbinate. Reoperation was necessary in a third patient due to airway obstruction from septal deviation. In a final case the patient was dissatisfied with the postoperative nasal appearance but declined revision surgery. Analysis of computer tomograms gave no additional information, though three-dimensional CT can aid in preoperative assessment of fragment position in those cases with severe edema and hematoma.

CONCLUSION

Due to the high rate of subjective and objective success in postoperative nasal function and appearance, we suggest that consideration be given to widening the current indications for open reduction of nasal fractures. It is important to maintain a high degree of suspicion and explore the septum for subclinical fractures and be aware of the pattern of damage that can be anticipated based on classification of impact as described herein. The importance of precise clinical evaluation by inspection, palpation, and endoscopy cannot be overemphasized, and may not be replaced by radiographic imaging.