Efficacy of closed reduction of nasal fractures – a retrospective analysis with focus on factors affecting functional and aesthetic outcomes

Nasal bone fractures are the most common type of facial bone fractures . They are caused by different trauma mechanisms including traffic accidents, assault, external trauma from other objects or falls . Accurate initial treatment after diagnosis including closed reduction if indicated is essential to prevent deformity and functional impairment . Numerous guidelines have been described to refine and optimize acute nasal trauma management, but restoration of pretraumatic form and function remains a challenge . The need for secondary revision rhinoplasty for postreduction nasal deformity is said to range from 14 to 50 percent . Post-traumatic septo-rhinoplasty can be challenging and the result may not always be predictable, which makes optimizing the initial treatment key in decreasing the need for secondary surgery. While the nasal anatomy and closed reduction techniques of nasal fractures are well described , there is a paucity of data reporting on the need for revision rhinoplasty and potentially confounding factors. The objective of this study was an analysis of factors affecting the outcome and need for revision rhinoplasty in patients who underwent closed reduction for nasal bone fracture.

From 2010 to 2020, a total of 417 consecutive patients received a closed nasal reduction at our department after having suffered a nasal fracture. Medical files of the patients were reviewed retrospectively and analyzed for patient demographics, fracture characteristics, patient work up, surgical intervention and outcome. The fractures of patients who received a computed tomography as part of their diagnostic work up were staged according to the nasal fracture classification proposed by Rohrich and Adams . The areas targeted during revision rhinoplasty were assessed.

Between 2010 and 2020, closed nasal reduction was performed in 417 consecutive patients with nasal bone fractures (306 male and 111 female patients) (table 1). One illustrative case can be found in figures 1 to 4. Median patient age was 30 years (interquartile range [IQR]: 23-45 years). Overall, 371 (89 %) patients had a closed fracture while 46 (11 %) patients had open fractures. One third of all patients (139 patients, 33.3 %) suffered from an associated nasal septum fracture. A Septal deviation visible in the CCT and/or clinically was present in 135 patients (32.4%) and a dislocation of the septum was noted in 59 patients (14.1%). Concomitant facial fractures were seen in 56 patients (13.4%). At the time of initial presentation, a visible nasal deformity was noted in 415 (99.5%) patients. 190 (45.6%) complained of an additional subjective airway obstruction. 279 (66.9%) patients received a CCT. These fractures were staged according to Rohrich and Adams (table 2).

Most nasal fractures were sustained by an assault mechanism (147 patients, 35.3%).

285 patients (68.3%) received a computed tomography throughout their initial diagnostic workup. For 132 patients (31.7%), the diagnosis was based on x-rays.

46 patients (11%) had a history of at least one prior nasal fracture. In addition to closed reduction of the nasal bones, open septum surgery was performed on 7 patients (1.7%). Septal splints were placed in 42 patients (10%). All other patients received gauze tamponades only.

Closed reduction was performed in average 6 days posttraumatically (median, IQR 4-9). Gauze removal took place at 2 days postoperatively (median, IQR 2-3). The cast was removed after 7 days (median, IQR 7-8). If Doyle splints were placed, they were removed 14 days postoperative (median, IQR 8-14). 61 patients (14.6%) removed the gauze themselves before the scheduled appointment and 72 patients (17.3%) removed the cast themselves before the planned visit.

At the time of cast removal 52 patients (12.5%) complained of airway obstruction, that had not been present prior to the trauma. For 47 patients (11.3%) an indication for rhinoplasty surgery was documented after fracture healing. 32 of these patients underwent revision rhinoplasty at our institution. Average follow up time was 37 weeks. For patients requiring revision rhinoplasty, the end date for nasal fracture follow-up was defined as the date where the indication for rhinoplasty was made. Revision rhinoplasty was performed 398 (range 214-592) days after initial reduction. The indication for rhinoplasty was made to address persisting airway obstruction only in 10 cases and to address both airway obstruction and persisting cosmetic deformity in 18 cases. In 4 cases solely a cosmetic deformity needed to be addressed. In these case deformities were deemed as such when a visible deviation or hump was present that had not present prior to the trauma. In these cases patients were asked to demonstrate pre trauma photographs to get a better understanding of the posttraumatic deformity. Preoperatively an additional evaluation by an ENT surgeon was sought in 16 cases. The target areas addressed during revision rhinoplasty are documented in table 3. In the majority of patients the septum (87.5%) and the outer nose (81.3%) were addressed. In the postoperative regime gauze tamponades were removed after 24 hours in 12 patients, 3 patients had gauze removal after 2-5 days. 17 patients received foam cubes only. Septal splints were left in place for 5 - 7 days in 6 patients and for 10-14 days in 17 patients. Casts were removed after 5 - 7 days in 9 patients and after 10-14 days in 19 patients.

Patients who had suffered an additional septum fracture were more likely to undergo rhinoplasty (48.9% vs. 31.4%, p=0.02) The same was true for patients with septal deviation (51.1% vs. 30%, p= 0.006). Having suffered a previous nasal fracture made it more likely that there would be a need for open rhinoplasty after fracture healing (21.3% vs. 9.7%, p=0.01). Patients who complained of an airway obstruction at the time of cast removal were significantly more likely to require rhinoplasty surgery (34% vs. 9.7%, p<0.001).

No specific stage according to Rohrich and Adams was found to be a predictor for future need of revision rhinoplasty (table 2).

In multivariable logistic regression models evaluating the risk of the need for open rhinoplasty after fracture healing (see table 4) airway obstruction at the time of cast removal was an independent predictor of the need for open rhinoplasty after fracture healing (Odds ratio [OR]: 4.79, p=0.0004).

Closed treatment of nasal bone fractures has been described in detail for centuries . The restoration of form and function is the goal of closed nasal reduction . Even though this surgical intervention is considered a straightforward procedure, the incidence of post-reduction nasal deformity requiring open revision rhinoplasty is as high as 14 to 50 percent, according to Rohrich and Adams .

In our study, we analyzed which factors might be attributed to a higher risk of a residual post-reduction nasal deformity resulting in the need for revision rhinoplasty. Our analysis yielded several interesting findings.

First, median patient age was 30 years and most nasal fractures were sustained by an assault mechanism (147 patients, 35.3%). Other studies have quoted assault as a cause for nasal bone fractures with a percentage as high as 60% . Regarding age, other centers have reported similar data . Neither patient age nor trauma mechanism had an effect on the need for later revision rhinoplasty in our study. The majority of patients were male. This has been attributed to the higher incidence of interpersonal violence between males .

Second, 46 patients (11%) had a history of at least one prior nasal fracture. These patients were more likely to require revision rhinoplasty. Previous nasal injury and potentially pre-existing deformity could complicate closed reduction as the technique is based on visual examination .

Third, we saw that patients with an associated nasal septal fracture and a visible septal deviation were more likely to undergo revision rhinoplasty. A thorough assessment of the nasal septum is considered the most important step in determining aesthetic and functional outcomes in nasal fractures . Ash forceps are used for septal reduction and the septum is splinted post-reduction. 29.5% (41) of our patients with a septal fracture received silicon splints the remainder was treated with gauze packing only. However, visual inspection might not suffice to fully assess the post-reduction septal alignment and splinting techniques might be insufficient to maintain reduction resulting in a later need for revision rhinoplasty.

Fourth, in our cohort, 14.6% of patients removed the gauze packing prematurely or took off their cast prematurely in 17.3% of cases. This, however, did not have an impact on the likelihood of later revision rhinoplasty. Post-reduction external splinting by means of a nose cast or a thermoplastic dressing is generally considered necessary as a protection towards outside forces but reduction per se is not held by a cast thus premature removal seems to have no significant influence on overall outcomes.

However it needs to be considered that as Farber et al stated that one week after closed reduction, the nasal bones remain mobile. In fact some colleagues will manage any deviation or collapse with external manipulation of the nose with localized application of pressure until symmetry is reestablished. This approach is not performed in our department so its potentially beneficial effect towards avoiding the need for revision rhinoplasty could not be addressed.

Fifth, patients who complained of an airway obstruction at the time of cast removal were significantly more likely to end up requiring revision rhinoplasty surgery as described above. At our department, casts are generally removed seven days post-reduction and we typically wait 3 months post trauma before the indication for secondary rhinoplasty is made. Taking our findings concerning airway obstruction into consideration, it might be beneficial to discuss an increased risk for the need of secondary rhinoplasty with the patient already at the time of splint removal if airway obstruction is present. But of course airway obstruction at this point might also still be due to swelling.

There are several limitations to this study. It is a retrospective study and thus may be prone to observer bias. The conclusions will need to be supported by prospective data for greater impact. Additionally, as we are presenting consecutive cases, patients were operated on by different surgeons. These adhere to a department standard concerning the intra- and postoperative regime, but minor deviations based on personal preference might have been made. Additionally, it is possible that in some cases proper reduction might not have been achieved, consequently leading to residual airway obstruction or aesthetic deformity. This could of course not be identified in this retrospective analysis. And it has to be noted that the success of closed reduction was assessed clinically only. A CCT scan would have provided an objective assessment of the reduced nasal bones but would not have been justified in our opinion in this young (median patient age was 30 years (interquartile range [IQR]: 23-45 years)) patient cohort. A purely clinical assessment by definition is prone to observer bias. However, it is common practice for the reduction of isolated fractures of the nasal bone. Also objective measurements of nasal appearance and function especially in the form of a patient reported outcome measurement like e.g. the 10-Item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for these patients at the time of injury and at the final postoperative assessment are not available for this patient cohort, leading to a partly subjective assessment by the treating surgeon. A detailed assessment of the relative bony vs cartilaginous contributions to the nasal skeleton was not performed for this cohort. This might have been a factor that contributed to the need for revision and in itself could have been a significant contributor to closed reduction failure. Also, the pretraumatic nasal configuration of patients who ended up requiring revision rhinoplasty was not available thus minor, asymptomatic airway obstructions might have been present pretraumatic (with the patient not aware of them) and were only aggravated by the fracture. Lastly, some patients were lost to follow-up and may have undergone revision rhinoplasty elsewhere..

Even though closed reduction of nasal fractures is frequently considered a straightforward procedure, a significant number of these patients will require secondary revision rhinoplasty. Associated nasal septal fractures may present a risk factor for the need for secondary revision surgery. Subjective airway obstruction at the time of cast removal after closed reduction was found to be predictive of revision rhinoplasty later on. Prospective studies are required to support the findings of this investigation.

Approval to perform the study was given by the Cantonal Ethics Committee of Zurich, Switzerland (Ethical approval ID 2020-00349). All patients gave written consent for data evaluation. Patients of which photographs are shown gave written consent to show full face photographs.

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