The nasal pyramid is the most frequently fractured bone in the body. Fracture is suggested by crepitance or palpably mobile bony segments. Epistaxis and pain are common, as are soft-tissue hematomas (“black eye”). It is important to make certain that there is no palpable step-off of the infraorbital rim, which would indicate the presence of a zygomatic complex fracture. Radiologic confirmation may at times be helpful but is not necessary in uncomplicated nasal fractures. It is also important to assess for possible concomitant additional facial, spine, pulmonary, or intracranial injuries when the circumstances of injury are suggestive, as in the case of automobile and motorcycle accidents.
Treatment is aimed at maintaining long-term nasal airway patency and cosmesis. Closed reduction can be performed under local or general anesthesia; closed reduction under general anesthesia appears to afford better patient satisfaction and decreased need for subsequent revision septoplasty or rhinoplasty.
Intranasal examination should be performed in all cases to rule out septal hematoma, which appears as a widening of the anterior septum, visible just posterior to the columella. The septal cartilage receives its only nutrition from its closely adherent mucoperichondrium. An untreated subperichondrial hematoma will result in loss of the nasal cartilage with resultant saddle nose deformity. Septal hematomas may become infected, with S aureus most commonly, and should be drained with an incision in the inferior mucoperichondrium on both sides. The drained fluid should be sent for culture.
Packing for 2–5 days is often helpful to help prevent re-formation of the hematoma. Antibiotics with antistaphylococcal efficacy (eg, cephalexin, 500 mg four times daily, or clindamycin, 150 mg four times daily) should be given for 3–5 days or the duration of the packing to reduce the risk of toxic shock syndrome.