MANAGEMENT OF NASAL TRAUMA - INDICATIONS FOR OPEN REDUCTION

Background: Many septoplasties and septorhinoplasties are indicated du e 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 pressu re stress vectors due to hidden cartilage fractures behind intact sept al mucosa. This is the main indication for open reduction of nasal tra uma. The present study analyses the results of our experience with the open reduction of nasal fractures. Methods: In a six-year period betw een 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 combina tion of clinical evaluation, nasal endoscopy, and photography. The ind ication for open reposition was based on analysis of force of impact a nd suspicion of cartilage damage. The goal of the procedures was to in cise partial-thickness fractures to make them full-thickness, thereby relieving the inherent tension in the cartilage, and to mobilize impac ted bone fragments with microosteotomies so they could be properly red uced. At the same time, any previously existing anatomical abnormaliti es with functional impact were also corrected. Results: the rate of pa tient satisfaction based on postoperative cosmesis and function was 88 %. The group in which open reduction was most commonly indicated was t he frontal impact cohort (n=18.53% of open reductions). This was follo wed 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 exp loration. Revision surgery was required in 2 cases due to nasal obstru ction 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 patie nt was dissatisfied with the postoperative nasal appearance but declin ed revision surgery. Analysis of computer tomograms gave no additional information, though three-dimensional CT can aid in preoperative asse ssment of fragment position in those cases with severe edema and hemat oma. Conclusion: Due to the high rate of subjective and objective succ ess in postoperative nasal function and appearance, we suggest that co nsideration be given to widening the current indications for open redu ction of nasal fractures. It is important to maintain a high degree of suspicion and explore the septum for subclinical fractures and be awa re of the pattern of damage that can be anticipated based on classific ation of impact as described herein. The importance of precise clinica l evaluation by inspection, palpation, and endoscopy cannot be overemp hasized, and may not be replaced by radiographic imaging.