Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon
Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

Information is supplied only upon the condition that the viewer will make their own determination as to the suitability of the information for its purposes prior to use.  There will be no responsibility for information that is misused or misinterpreted and the information should not be used as a substitute for consultation with a health care professional.  It is not possible to answer questions regarding individual cases or to enter into individual correspondence.

Fractured Nose: Manipulation under Anaesthesia

Trauma to the nose can damage, and cause a change in the position of the nasal bones.  The damage to the bones, and attachments to upper and lower lateral cartilages, can produce a cosmetic deformity; it is also possible for the internal nasal septum (composed of cartilage and bone) to be damaged and angulated and this can be a significant cause of nasal obstruction.

It is important that a significant nasal injury examined as soon as possible to exclude the occurrence of a septal haematoma.  This is typically extremely painful and causes significant nasal blockage.  If this – relatively rare – complication is present it needs to be drained urgency (under general anaesthesia).  There also can be a risk of loss of nasal septal cartilage which can then produce a secondary “saddle” and a very serious cosmetic deformity.  This would, typically, be excluded by examination in an emergency department.

Otherwise, the ideal time for examination with regard to the position of the nasal bones is when the early swelling has settled.  Hence, referral from an emergency department or practitioner often requests ENT review at around 5 days; the ideal “window” of manipulation of the bones (with minimal swelling and whilst retaining maximum mobility of the fracture) requires the procedure of manipulation under anaesthesia to be performed ideally before 12 days and at least inside 14 days.  If this is not the case, and an indicator may be when the nose becomes “pain free”, then healing of the fracture occurs and it is much more difficult to mobilise, and correct, the cosmetic deformity.  Indeed, if there is severe impaction of the nasal bone at the primary injury or significant delay in treatment such that the fracture heals in a deviated position, subsequent septorhinoplasty may be required to correct the nasal position.  In the event of the deformity just relating to the bones, then the procedure would be a rhinoplasty; it is because the nasal septum is so often involved to a degree that a typical corrective procedure is a septorhinoplasty procedure.  This could be considered some months after the initial injury and that would require full healing of the fracture before the procedure to remodel and reshape the nose.

If manipulation can be performed before there has been significant healing of the fracture, then surprisingly good cosmetic results can be obtained by relatively simple manoeuvre.  There is usually only a small amount of addition, at worse, to any degree of swelling or bruising, and often no other sequelae.

There are possible complications from the procedure but the most significant difficult is of a failure to produce adequate improvement.  Indeed, the fracture may re-displace, such that a cosmetic deformity recurs and, in either of these situations, the only option may be to let the fracture then heal and consider a septorhinoplasty, as discussed above in the situation of either severe impaction causing complete immobility or delayed referral such that the fracture is also immobile.

There is a small risk of bleeding after the surgery and, just occasionally, insertion of a nasal dressing, or pack, can be required.  An external splint, and more rarely an internal support dressing, may be required if the fracture is unstable but frequently no internal or external splinter at all is required.  In the event of an external nasal splint being necessary this is typically removed after 7-10 days.

There may be a small amount of nasal discharge, ooze, after the procedure and contact sports should be avoided for six weeks.

The residual swelling and bruising is usually not worsened by the procedure but that related to the initial injury can easily take up to three weeks to settle.

Persistence of, or recurrence of, nasal deformity is a possibility.  It is, however, generally worth proceeding for an attempted manipulation of the nose as the procedure is relatively minor, involving only a brief general anaesthetic, and it is far better to try and achieve whatever correction is possible in the early stage prior to the situation being worsened by a displaced fracture healing.

In the event of failure to adequately improve the cosmetic appearance, a rhinoplasty or septorhinoplasty could be indicated.  A further problem which can occur relates to either to persisting deviation of the nasal septum or secondary growth of the nasal septum (following the injury where there has been damage to the mucoperiosteum which provides nutrition to the nasal cartilage) such that there is a development of nasal obstruction occurring 2-3 months after the injury.  Sometimes this can worsen and be very severe and, in this case, a subsequent septoplasty procedure may be required to correct, or at least optimise breathing through the nose.  Should there be any associated persisting deformity, then a septorhinoplasty procedure could be required.

Relatively rarely there can be other associated injuries with the nasal fracture, including fracture of the facial bones or even a CSF leakage.  A fracture of the nasal bones could be manifest by numbness of the area over the cheek; there could also be depression in the area of the zygoma and examination can usually indicate this.  It is now far less common to arrange x-rays for a fractured nose but this would certainly be necessary if there was any concern about associated other facial bony injury.  CSF leak, leakage of fluid from the brain, is a very rare complication and it can be manifest by persistent clear fluid leaking from the brain if there has been any damage of the anterior cranial fossa in the initial injury.  Sometimes this can be masked early on by the nasal bleeding and blockage occurring as a result of the initial injury.

The procedure of manipulation of anaesthesia of nasal bones is relatively brief; anaesthesia is generally light and discharge home the same day of the procedure is typical.  Absence of work of 1-2 days may be required, sometimes longer if there are other complications.