J Oral Maxillofac 49:1299-1292.
Surg
1991
The Closed Reduction
of Nasal Fractures:
An Evaluation of Two Techniques RICHARD H. HAUG, DDS,* AND JOHN L. PRATHER,
DDSj-
Two techniques of closed reduction and fixation of nasal fractures are reported and the results compared. Both patients’ and surgeon’s postoperative evaluations of these techniques were favorable.
Nasal bone fractures are the most frequently encountered fractures in the face,le5 yet reports on this condition are virtually nonexistent in the oral and maxillofacial surgical literature. The purpose of this article is to provide a system of classification of nasal bone fractures (Table I), to present two methods of treatment, and to review the patients’ and surgeon’s perception of the results of these techniques .
METHOD OF TREATMENT FOR ISOLATED NASAL FRACTURES
After a successful induction of general anesthesia, the patient was orotracheally intubated and the region prepared with an antiseptic solution. One yard of !&in plain cotton gauze packing soaked in 4% cocaine was then layered in each nasal aperture. The packing was removed after 3 minutes. The entire nasal apparatus was then examined from posterior to anterior and superior to inferior with a long nasal speculum. The diagnosis was confirmed and correlated with the radiographs and preoperative clinical examination. An Asch forceps was then inserted into the nasal apertures with the dominant hand and the nasal bones were reduced in an anterior superior direction perpendicular to the ridge of the nasal bones (Fig 1A). The less dominant hand was used to mold the bones and soft tissues against the forceps in an anterior inferior direction. The Asch forceps was then used to realign the septum. Any additional reduction was performed with a Goldman elevator or Walsham forceps. Doyle Airway Splints (Xomed-Treace, Jacksonville, FL) were placed on either side of the septum and sutured to the nasal mucosa with 3-O silk (Fig 1B). Two to 3 yd of petrolatum-impregnated &in gauze was then layered from superior to inferior to support the fractured bones internally (Fig 1C). A Denver splint (Denver Splint Co, Englewood, CO) was then contoured to the patient’s soft-tissue anatomy. Benzoin, Suture Strips (Genetic Labs, St Paul, MN) and Velcro (Velcro USA, Manchester, NH) were placed and the Denver splint was secured (Fig 1D). On completion of the procedure, the nasal contours were reevaluated and patency of the airways was verified. On postoperative day 1, lateral and posterior-anterior radiographs of the nasal bones were obtained. On postoperative day 2, the Doyle Airway Splints and nasal packing were removed.
Materials and Methods Hospital charts and radiographs were collected for 10 patients with isolated nasal fractures managed under orotracheal intubation (Table 2) and 10 patients with additional injuries necessitating nasotracheal intubation and maxillomandibular tixation (MMF) (Table 3). The nasal fractures were classified according to the scheme described in Table 1. The patients were recalled for examination between 1 month and 1 year postoperatively. The surgeon rated the esthetic results of the treatment on a scale from 1 to 10 (1, the poorest result, and 10, the best result). The patients were also asked to evaluate the results using the same scale (Tables 2 and 3). Patients who required nasotracheal intubation also were asked whether they would have wanted to have a tracheostomy performed if they thought the surgical result could have been improved. The results were then collated and analyzed .
Received from the Division of Oral and Maxillofacial Surgery, MetroHealth Medical Center, Cleveland. * Assistant Professor of Surgery, Case Western Reserve University. t Chief Resident. Address correspondence to Dr Haug: Division of Oral and Maxillofacial Surgery, MetroHealth Medical Center, 3395 Scranton Rd, Cleveland, OH 44109. 0 1991 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391/91/4912-0005$3.00/0
1288
1289
HAUG AND PRATHER
Table 1.
Classification of Nasal Fractures
Type
Osseous Structures Affected Inferior one half of nasal bones Entirenasalbone separated at nasofrontal suture Nasal bonesand frontalprocess of maxilla Nasal bones, frontal process of maxilla, nasal spine of frontal bone, and ethmoid bone Includes a fractured septum
I II III IV
S modification
On postoperative moved.
day 10, the Denver splint was re-
METHOD OF TREATMENT FOR NASAL FRACTURES IN PATIENTS WITH NASOTRACHEAL INTUBATION AND MMF
Prior to nasotracheal intubation, 1 yd of M-in plain gauze packing soaked with 4% cocaine was layered in each nasal aperture, allowed to remain for 3 minutes, and then removed. General anesthesia was induced, the patient nasotracheally intubated, and the region prepared with an antiseptic solution. After thorough examination of the nasal apparatus, an Asch forceps was inserted into the nasal apertures with the dominant hand and the nasal bones were reduced as previously described (Fig 2A). Two trumpeted nasal airways were selected to match the diameter of the nasotracheal tube and reduced in length to extend only along the floor of the nose. One was placed in the aperture without the nasotracheal tube; the other was saved. Two yards of petrolatum-impregnated l&in gauze were then layered from superior to inferior to support the fractured bones internally. A Denver splint was applied. After satisfactory emergence of the patient from the anesthesia, the nasotracheal tube was removed and the other trumpeted nasal airway was Table 2. Patient CT MR JH RB JW MP DC FZ JC LM
placed (Fig 2B). Postoperative care was the same as for the patient treated under orotracheal anesthesia. Results
The isolated nasal fractures in this series were found almost exclusively in males (70%) in their third or fourth decade (70%). None of the fractures involved the ethmoid bone, but all involved the septum. The patients’ evaluations of the esthetic results between 1 and 12 months postoperatively were favorable (8.8 on a scale of 10). The surgeon’s opinion of the esthetic results was just as favorable (8.7). No patient requested additional corrective surgery. Nasal fractures in the group with other injuries requiring nasotracheal intubation were also found almost exclusively in males (90%), with a mean age of 27 years (range, 18 to 41 years). The associated injuries are described in Table 3. The patients’ opinions of the esthetic results between 1 and 12 months postoperatively were favorable (8.5 on a scale of lo), with three patients (30%) describing perfect results. The surgeon’s evaluations were equally favorable (8.6). All patients felt that the esthetic results were satisfactory and would not have wanted a tracheotomy. No patient requested additional corrective surgery. Discussion
Because of the prominence of the nose and its central location, it is the most frequent facial bone fractured.5 Illum estimated the incidence of nasal fractures in 1983 in Denmark to be 53.2/100,000 population.4 Lundin and coworkers in Gothenberg, Sweden, reported a 39% frequency of nasal fractures in 1,000 patients with maxillofacial trauma.3 A number of classifications of nasal fractures have been proposed, yet each falls short in some manner. Gillies and Kilner in 1929 developed a classification based on the direction of the impact on
Isolated Nasal Fractures Age (yr)
Sex
Type
Other Injuries
37 31 33 46 42 19 33 33 29 25
M F M M M M F M M F
IS 11s 111s 111s IS HIS 11s 11s 11s 11s
Right zygoma fracture Right zygoma fracture Right ankle fracture Right forearm fracture None Cornea1 abrasion None None None None
Patient’s Rating 9.5 9.0 8.5 9.0 6.5 8.5 8.0 9.5 10.0 9.0
Surgeon’s Rating 9.0 9.0 8.5 8.0 1.5 8.0 8.5 9.0 10.0 9.0
1290 Table 3.
Patient
CLOSED REDUCTION
Nasal Fracture With Nasotracheal lntubation and MMF Patient’s Rating
Age
Sex
Type
Other Injuries
KR
29
M
111s
JB
37
M
IVS
Right angle fracture Le Fort I fracture Right zygoma fracture Le Fort I fracture Right zygoma fracture Right condyle fracture Left symphysis fracture Le Fort I fracture Right zygoma fracture Left acetabular fracture Right ocular laceration Le Fort III fracture Frontal sinus fracture Right condyle fracture Left body fracture Le Fort II fracture Left parasymphysis fracture Right femur fracture Right knee fracture Left foot fracture Left condyle fracture Left parasymphysis fracture Le Fort II fracture Right zygoma fracture Le Fort I fracture Le Fort I fracture Right zygoma fracture
DR
TS
41
24
M
M
111s
111s
EB JW AV
18 23 18
M M M
111s IS IIS
FM
20
M
IVS
LQ
37 22
M F
11s IIS
cc
OF NASAL FRACTURES
the nose.6 The directions used for their classification were: 1) from the side; 2) from the front directly on the prominence of the bridge; 3) from below directed at the lower border of the septum; and 4) combinations. Although this attempt at classification was well intended, the system did not describe the bones affected and, therefore, could not direct treatment. Harrison in 1979 developed a system of classification that included displacement and bones affected.7 This system included four patterns of fracture: 1) lateral displacement without septal fracture; 2) lateral displacement with septal fracture; 3) fractures of the nasal cap; and 4) cornminuted fractures. This system failed to describe nasal fractures with ethmoidal or orbital components. Stranc and Robertson, also in 1979, developed a classification based on the direction of impact and the plane of the face injured.* Plane 1 injuries included the anterior nasal spine and tips of the nasal bones. Plane 2 injuries were deeper, but did not extend beyond the frontal process of the maxilla. Plane 3 injuries included the aforementioned planes, orbit, and central structures. This system falls short by generalizing the injuries and treatment of the regions affected. Murray and coinvestigators in 1986 attempted to classify fractures in cadavers in a way similar to Rene Le Fort.’ In this study, various weights were
Surgeon’s Rating
Results Worth No Tracheotomy?
6.0
7.5
Yes
10.0
9.0
Yes
7.0
7.0
Yes
10.0
9.5
Yes
8.5 9.0 8.0
8.5 9.0 9.0
Yes Yes Yes
10.0
9.0
Yes
7.0 9.0
8.0 9.0
Yes Yes
dropped on 50 cadavers and the nasal bones were then dissected. The seven classifications were: 1) simple nasal depression, fractures parallel to dorsum and nasomaxillary suture; 2) nasal bones intact, fracture lines parallel to dorsum; 3) nasal bones cornminuted, C-shaped septal fracture; 4) less nasal involvement but C-shaped septal fracture; 5) impacted nasal bones; 6) only cartilagenous septum fractured, no nasal fracture; and 7) only cartilagenous septum fractured from anterior nasal spine to the junction of the cartilagenous septum. This classification is excellent in describing the anatomic pathology; however, it requires dissection of soft tissue and cannot be based on a clinical examination and imaging. We believe the classification offered in Table 1 is simple, anatomically based, and can direct surgical therapy. The techniques described in this article offer a number of advantages over others in cost, technical ease, and design. The internal packing supports the nasal bones, reduces edema, and prevents hematoma formation during the first 48 hours. The Doyle Airway Splint used in the first technique supports the septum and prevents septal hematoma until a clot is formed. Because of the material properties of the Doyle Airway Splint, it is more easily removed from the posterior and medial regions of the nose than other materials. The trumpeted air-
m
CLOSED REDUCTION
FIGURE 2. Method of treatment for nasal fractures in oatients with nasotracheal fractures. B, Trumpeted airway in place.
ways used in the second technique provide the same septal support and prevention of hematoma that the Doyle Airway Splint provides. They also maintain a patent airway during the perioperative period and eliminate the need for a tracheotomy in patients requiring maxillomandibular fixation. Both techniques employ the Denver splint. This is easily manipulated and secured to the patient. It may be removed from the Velcro to be revised and recontoured. The splint is less unsightly than others. It is partially radiolucent and allows satisfactory postoperative radiographs. Because of its adherence to the underlying skin, it continues to support the nasal bones even when the packing is removed. Retrospective studies of the treatment of nasal fractures uniformly show less than perfect results. Harrison,’ in 1979, reviewed 40 patients treated for nasal fractures in Broxburn, England, thirteen of whom (30%) had perfect results, and the remainder had varying degrees of less than perfect results. Clark in 1983 reviewed 57 patients treated with both open and closed reduction of nasal fractures.” Of the 28 patients treated with closed reduction, only 6 (21%) had perfect results. He attributed the deviation from perfect to unreduced septal fractures. Illum in 1986 reviewed 106 patients with nasal fractures in Aarhaus, Denmark.4 The patients were divided into untreated (35%) and those treated with closed reduction (65%). At the end of 3 years, 90% of patients treated with closed reduction were satisfied with the results; yet 18% had some cosmetic complaint. Crowther and O’Donoghue in 1987, in
OF NASAL FRACTURES
intubation and MMF. A, Asch forceps reducing
Oxford, England, performed a retrospective study of patients treated with closed reduction of nasal fractures.” Of 80 respondents, 72 (85%) were satisfied with their nasal appearance, but 13 (15%) requested corrective surgery. The results of our study reflect those reported in other studies; yet, our patients were uniformly happy with their treatment (Tables 2 and 3). Four patients described perfect results, and no patient requested corrective surgery. We were thus able to treat patients satisfactorily in all instances without the need for tracheotomy. References 1. Altreuter RW: Nasal trauma. Emerg Med Clin North Am 5:293, 1987 2. Facer GW: Management of nasal injury. Postgrad Med 57:123, 1975 3. Lundin K, Ride11 A, Sandberg N, et al: One thousand maxillofacial and related fractures at the ENT clinic in Gothenburg. Acta Otol75:359, 1973 4. Illum P, Kristensen C, Jorgensen K, et al: Role of fixation in the treatment of nasal fractures. Clin Otol 8: 191, 1983 5. Martinez SA: Nasal fractures: What to do for a successful outcome. Postgrad Med 82:71, 1987 6. Gillies HD, Kilner TP: The treatment of the broken nose. Lancet 1:147, 1929 7. Harrison DH: Nasal iniuries: Their pathogenesis and treatment. Br J Plast Surg 32:57, 19798. Stranc MF. Robertson GA: A classification of iniuries of the nasal septum. Ann Plast Surg 2468, 1979 9. Murray JAM, Maran AGD, Busuttil A, et al: A pathologic classification of nasal fractures. Injury 7:338, 1986 10. Clark WD: Nasal and nasal septal fractures. Ear Nose Throat 62:25, 1983 11. Crowther JA, O’Donoghue GM: The broken nose: Does familiarity breed contempt? Ann R Coll Surg Edin 69:259, 1987
Surg
1991
The Closed Reduction
of Nasal Fractures:
An Evaluation of Two Techniques RICHARD H. HAUG, DDS,* AND JOHN L. PRATHER,
DDSj-
Two techniques of closed reduction and fixation of nasal fractures are reported and the results compared. Both patients’ and surgeon’s postoperative evaluations of these techniques were favorable.
Nasal bone fractures are the most frequently encountered fractures in the face,le5 yet reports on this condition are virtually nonexistent in the oral and maxillofacial surgical literature. The purpose of this article is to provide a system of classification of nasal bone fractures (Table I), to present two methods of treatment, and to review the patients’ and surgeon’s perception of the results of these techniques .
METHOD OF TREATMENT FOR ISOLATED NASAL FRACTURES
After a successful induction of general anesthesia, the patient was orotracheally intubated and the region prepared with an antiseptic solution. One yard of !&in plain cotton gauze packing soaked in 4% cocaine was then layered in each nasal aperture. The packing was removed after 3 minutes. The entire nasal apparatus was then examined from posterior to anterior and superior to inferior with a long nasal speculum. The diagnosis was confirmed and correlated with the radiographs and preoperative clinical examination. An Asch forceps was then inserted into the nasal apertures with the dominant hand and the nasal bones were reduced in an anterior superior direction perpendicular to the ridge of the nasal bones (Fig 1A). The less dominant hand was used to mold the bones and soft tissues against the forceps in an anterior inferior direction. The Asch forceps was then used to realign the septum. Any additional reduction was performed with a Goldman elevator or Walsham forceps. Doyle Airway Splints (Xomed-Treace, Jacksonville, FL) were placed on either side of the septum and sutured to the nasal mucosa with 3-O silk (Fig 1B). Two to 3 yd of petrolatum-impregnated &in gauze was then layered from superior to inferior to support the fractured bones internally (Fig 1C). A Denver splint (Denver Splint Co, Englewood, CO) was then contoured to the patient’s soft-tissue anatomy. Benzoin, Suture Strips (Genetic Labs, St Paul, MN) and Velcro (Velcro USA, Manchester, NH) were placed and the Denver splint was secured (Fig 1D). On completion of the procedure, the nasal contours were reevaluated and patency of the airways was verified. On postoperative day 1, lateral and posterior-anterior radiographs of the nasal bones were obtained. On postoperative day 2, the Doyle Airway Splints and nasal packing were removed.
Materials and Methods Hospital charts and radiographs were collected for 10 patients with isolated nasal fractures managed under orotracheal intubation (Table 2) and 10 patients with additional injuries necessitating nasotracheal intubation and maxillomandibular tixation (MMF) (Table 3). The nasal fractures were classified according to the scheme described in Table 1. The patients were recalled for examination between 1 month and 1 year postoperatively. The surgeon rated the esthetic results of the treatment on a scale from 1 to 10 (1, the poorest result, and 10, the best result). The patients were also asked to evaluate the results using the same scale (Tables 2 and 3). Patients who required nasotracheal intubation also were asked whether they would have wanted to have a tracheostomy performed if they thought the surgical result could have been improved. The results were then collated and analyzed .
Received from the Division of Oral and Maxillofacial Surgery, MetroHealth Medical Center, Cleveland. * Assistant Professor of Surgery, Case Western Reserve University. t Chief Resident. Address correspondence to Dr Haug: Division of Oral and Maxillofacial Surgery, MetroHealth Medical Center, 3395 Scranton Rd, Cleveland, OH 44109. 0 1991 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391/91/4912-0005$3.00/0
1288
1289
HAUG AND PRATHER
Table 1.
Classification of Nasal Fractures
Type
Osseous Structures Affected Inferior one half of nasal bones Entirenasalbone separated at nasofrontal suture Nasal bonesand frontalprocess of maxilla Nasal bones, frontal process of maxilla, nasal spine of frontal bone, and ethmoid bone Includes a fractured septum
I II III IV
S modification
On postoperative moved.
day 10, the Denver splint was re-
METHOD OF TREATMENT FOR NASAL FRACTURES IN PATIENTS WITH NASOTRACHEAL INTUBATION AND MMF
Prior to nasotracheal intubation, 1 yd of M-in plain gauze packing soaked with 4% cocaine was layered in each nasal aperture, allowed to remain for 3 minutes, and then removed. General anesthesia was induced, the patient nasotracheally intubated, and the region prepared with an antiseptic solution. After thorough examination of the nasal apparatus, an Asch forceps was inserted into the nasal apertures with the dominant hand and the nasal bones were reduced as previously described (Fig 2A). Two trumpeted nasal airways were selected to match the diameter of the nasotracheal tube and reduced in length to extend only along the floor of the nose. One was placed in the aperture without the nasotracheal tube; the other was saved. Two yards of petrolatum-impregnated l&in gauze were then layered from superior to inferior to support the fractured bones internally. A Denver splint was applied. After satisfactory emergence of the patient from the anesthesia, the nasotracheal tube was removed and the other trumpeted nasal airway was Table 2. Patient CT MR JH RB JW MP DC FZ JC LM
placed (Fig 2B). Postoperative care was the same as for the patient treated under orotracheal anesthesia. Results
The isolated nasal fractures in this series were found almost exclusively in males (70%) in their third or fourth decade (70%). None of the fractures involved the ethmoid bone, but all involved the septum. The patients’ evaluations of the esthetic results between 1 and 12 months postoperatively were favorable (8.8 on a scale of 10). The surgeon’s opinion of the esthetic results was just as favorable (8.7). No patient requested additional corrective surgery. Nasal fractures in the group with other injuries requiring nasotracheal intubation were also found almost exclusively in males (90%), with a mean age of 27 years (range, 18 to 41 years). The associated injuries are described in Table 3. The patients’ opinions of the esthetic results between 1 and 12 months postoperatively were favorable (8.5 on a scale of lo), with three patients (30%) describing perfect results. The surgeon’s evaluations were equally favorable (8.6). All patients felt that the esthetic results were satisfactory and would not have wanted a tracheotomy. No patient requested additional corrective surgery. Discussion
Because of the prominence of the nose and its central location, it is the most frequent facial bone fractured.5 Illum estimated the incidence of nasal fractures in 1983 in Denmark to be 53.2/100,000 population.4 Lundin and coworkers in Gothenberg, Sweden, reported a 39% frequency of nasal fractures in 1,000 patients with maxillofacial trauma.3 A number of classifications of nasal fractures have been proposed, yet each falls short in some manner. Gillies and Kilner in 1929 developed a classification based on the direction of the impact on
Isolated Nasal Fractures Age (yr)
Sex
Type
Other Injuries
37 31 33 46 42 19 33 33 29 25
M F M M M M F M M F
IS 11s 111s 111s IS HIS 11s 11s 11s 11s
Right zygoma fracture Right zygoma fracture Right ankle fracture Right forearm fracture None Cornea1 abrasion None None None None
Patient’s Rating 9.5 9.0 8.5 9.0 6.5 8.5 8.0 9.5 10.0 9.0
Surgeon’s Rating 9.0 9.0 8.5 8.0 1.5 8.0 8.5 9.0 10.0 9.0
1290 Table 3.
Patient
CLOSED REDUCTION
Nasal Fracture With Nasotracheal lntubation and MMF Patient’s Rating
Age
Sex
Type
Other Injuries
KR
29
M
111s
JB
37
M
IVS
Right angle fracture Le Fort I fracture Right zygoma fracture Le Fort I fracture Right zygoma fracture Right condyle fracture Left symphysis fracture Le Fort I fracture Right zygoma fracture Left acetabular fracture Right ocular laceration Le Fort III fracture Frontal sinus fracture Right condyle fracture Left body fracture Le Fort II fracture Left parasymphysis fracture Right femur fracture Right knee fracture Left foot fracture Left condyle fracture Left parasymphysis fracture Le Fort II fracture Right zygoma fracture Le Fort I fracture Le Fort I fracture Right zygoma fracture
DR
TS
41
24
M
M
111s
111s
EB JW AV
18 23 18
M M M
111s IS IIS
FM
20
M
IVS
LQ
37 22
M F
11s IIS
cc
OF NASAL FRACTURES
the nose.6 The directions used for their classification were: 1) from the side; 2) from the front directly on the prominence of the bridge; 3) from below directed at the lower border of the septum; and 4) combinations. Although this attempt at classification was well intended, the system did not describe the bones affected and, therefore, could not direct treatment. Harrison in 1979 developed a system of classification that included displacement and bones affected.7 This system included four patterns of fracture: 1) lateral displacement without septal fracture; 2) lateral displacement with septal fracture; 3) fractures of the nasal cap; and 4) cornminuted fractures. This system failed to describe nasal fractures with ethmoidal or orbital components. Stranc and Robertson, also in 1979, developed a classification based on the direction of impact and the plane of the face injured.* Plane 1 injuries included the anterior nasal spine and tips of the nasal bones. Plane 2 injuries were deeper, but did not extend beyond the frontal process of the maxilla. Plane 3 injuries included the aforementioned planes, orbit, and central structures. This system falls short by generalizing the injuries and treatment of the regions affected. Murray and coinvestigators in 1986 attempted to classify fractures in cadavers in a way similar to Rene Le Fort.’ In this study, various weights were
Surgeon’s Rating
Results Worth No Tracheotomy?
6.0
7.5
Yes
10.0
9.0
Yes
7.0
7.0
Yes
10.0
9.5
Yes
8.5 9.0 8.0
8.5 9.0 9.0
Yes Yes Yes
10.0
9.0
Yes
7.0 9.0
8.0 9.0
Yes Yes
dropped on 50 cadavers and the nasal bones were then dissected. The seven classifications were: 1) simple nasal depression, fractures parallel to dorsum and nasomaxillary suture; 2) nasal bones intact, fracture lines parallel to dorsum; 3) nasal bones cornminuted, C-shaped septal fracture; 4) less nasal involvement but C-shaped septal fracture; 5) impacted nasal bones; 6) only cartilagenous septum fractured, no nasal fracture; and 7) only cartilagenous septum fractured from anterior nasal spine to the junction of the cartilagenous septum. This classification is excellent in describing the anatomic pathology; however, it requires dissection of soft tissue and cannot be based on a clinical examination and imaging. We believe the classification offered in Table 1 is simple, anatomically based, and can direct surgical therapy. The techniques described in this article offer a number of advantages over others in cost, technical ease, and design. The internal packing supports the nasal bones, reduces edema, and prevents hematoma formation during the first 48 hours. The Doyle Airway Splint used in the first technique supports the septum and prevents septal hematoma until a clot is formed. Because of the material properties of the Doyle Airway Splint, it is more easily removed from the posterior and medial regions of the nose than other materials. The trumpeted air-
m
CLOSED REDUCTION
FIGURE 2. Method of treatment for nasal fractures in oatients with nasotracheal fractures. B, Trumpeted airway in place.
ways used in the second technique provide the same septal support and prevention of hematoma that the Doyle Airway Splint provides. They also maintain a patent airway during the perioperative period and eliminate the need for a tracheotomy in patients requiring maxillomandibular fixation. Both techniques employ the Denver splint. This is easily manipulated and secured to the patient. It may be removed from the Velcro to be revised and recontoured. The splint is less unsightly than others. It is partially radiolucent and allows satisfactory postoperative radiographs. Because of its adherence to the underlying skin, it continues to support the nasal bones even when the packing is removed. Retrospective studies of the treatment of nasal fractures uniformly show less than perfect results. Harrison,’ in 1979, reviewed 40 patients treated for nasal fractures in Broxburn, England, thirteen of whom (30%) had perfect results, and the remainder had varying degrees of less than perfect results. Clark in 1983 reviewed 57 patients treated with both open and closed reduction of nasal fractures.” Of the 28 patients treated with closed reduction, only 6 (21%) had perfect results. He attributed the deviation from perfect to unreduced septal fractures. Illum in 1986 reviewed 106 patients with nasal fractures in Aarhaus, Denmark.4 The patients were divided into untreated (35%) and those treated with closed reduction (65%). At the end of 3 years, 90% of patients treated with closed reduction were satisfied with the results; yet 18% had some cosmetic complaint. Crowther and O’Donoghue in 1987, in
OF NASAL FRACTURES
intubation and MMF. A, Asch forceps reducing
Oxford, England, performed a retrospective study of patients treated with closed reduction of nasal fractures.” Of 80 respondents, 72 (85%) were satisfied with their nasal appearance, but 13 (15%) requested corrective surgery. The results of our study reflect those reported in other studies; yet, our patients were uniformly happy with their treatment (Tables 2 and 3). Four patients described perfect results, and no patient requested corrective surgery. We were thus able to treat patients satisfactorily in all instances without the need for tracheotomy. References 1. Altreuter RW: Nasal trauma. Emerg Med Clin North Am 5:293, 1987 2. Facer GW: Management of nasal injury. Postgrad Med 57:123, 1975 3. Lundin K, Ride11 A, Sandberg N, et al: One thousand maxillofacial and related fractures at the ENT clinic in Gothenburg. Acta Otol75:359, 1973 4. Illum P, Kristensen C, Jorgensen K, et al: Role of fixation in the treatment of nasal fractures. Clin Otol 8: 191, 1983 5. Martinez SA: Nasal fractures: What to do for a successful outcome. Postgrad Med 82:71, 1987 6. Gillies HD, Kilner TP: The treatment of the broken nose. Lancet 1:147, 1929 7. Harrison DH: Nasal iniuries: Their pathogenesis and treatment. Br J Plast Surg 32:57, 19798. Stranc MF. Robertson GA: A classification of iniuries of the nasal septum. Ann Plast Surg 2468, 1979 9. Murray JAM, Maran AGD, Busuttil A, et al: A pathologic classification of nasal fractures. Injury 7:338, 1986 10. Clark WD: Nasal and nasal septal fractures. Ear Nose Throat 62:25, 1983 11. Crowther JA, O’Donoghue GM: The broken nose: Does familiarity breed contempt? Ann R Coll Surg Edin 69:259, 1987
