1. Definition

Fracture of the external nose refers to any break in the bony or cartilaginous framework of the nasal skeleton.
It is the most common facial fracture, accounting for over 50% of all facial trauma cases.
Because the nose is prominent, has minimal soft-tissue padding, and is structurally composed of delicate bones + flexible cartilage, even low-energy trauma can cause displacement.

2. Relevant Surgical Anatomy (Ultra-Expanded ENT Edition)

Understanding nasal skeletal anatomy is the foundation of fracture assessment and reduction.

2.1 Upper Third (Bony Pyramid)

Formed by paired nasal bones
Supported posteriorly by frontal process of maxilla
Joined superiorly to frontal bone (nasofrontal suture)
Thin → easily displaced
Fracture lines often extend into frontal process → causes deviation

Key Surgical Point:

A strong impact causes out-fracture laterally or in-fracture medially, creating internal valve narrowing.

2.2 Middle Third (Cartilaginous Vault)

Includes:

Upper lateral cartilages
Attached to septal cartilage (forming “keystone area”)
This region maintains airway patency; trauma here → internal valve collapse.

2.3 Lower Third (Tip Complex)

Lower lateral (alar) cartilages
Soft tissue + fibrofatty components

Tip injuries rarely cause true fractures but can cause distortion, asymmetry, and collapse when cartilage is torn or displaced.

2.4 Septum (Functional + Structural Pillar)

The septum is critical because:

It supports midline projection
It stabilizes both nasal bones
It defines symmetry

Septal fractures are often missed but more important than nasal bone fractures because they cause:

Persistent deviation
Chronic obstruction
External deformity
Saddle nose deformity (if septal cartilage necrosis occurs)

2.5 Nasal Mucosa and Soft Tissue

Highly vascular →

Swelling masks deformity
Infections spread quickly
Septal hematomas form easily

3. Mechanisms of Nasal Fracture (Deep ENT Breakdown)

3.1 Frontal Impact (Head-on Blow)

Examples:

Punch
Ball injury
Dashboard strike

Effects:

Bilateral displacement
Flattening of dorsum
Associated septal fracture
Internal valve collapse

3.2 Lateral Impact (Most Common)

Causes:

Hit from side
Elbow strike
Door impact

Effects:

One nasal bone depressed inward
Opposite bone displaced outward
Deviated septum
C-shaped external deformity

3.3 High-Energy Trauma

Examples:

Road traffic accidents
Falls from height
Assault with weapons

Effects:

Comminuted nasal bone fractures
Naso-orbital-ethmoid (NOE) fractures
Skull base involvement
CSF leak

3.4 Low-Energy Trauma

Examples:

Minor sports injuries
Children hitting furniture

Effects:

Green-stick fractures (common in children)
Minimal displacement
Swelling > deformity

4. Classification of Nasal Fractures (ENT Standard Systems)

4.1 Based on Displacement

A. Undisplaced fracture

Bone intact but cracked
No cosmetic deformity
No airway compromise

B. Displaced fracture

Shift in position of bony pyramid
Visible deviation
Requires reduction

4.2 Based on Laterality

Unilateral fracture
Bilateral fracture (more unstable)

4.3 Based on Complexity

Simple fracture

Single fracture line
No comminution

Comminuted fracture

Multiple bone fragments
Common in high-velocity injuries

4.4 Based on Associated Injuries

Nasal bone + septal fracture
Nasal bone + orbital rim fracture
NOE fracture
Skull base fracture

4.5 Pediatric Fractures (Special Category)

Children have:

Softer bones
Thicker periosteum
Higher elasticity

Thus:

Green-stick fractures common
Swelling disproportionate to injury
Septal injuries easily missed
Growth center can be damaged → long-term deformities

5. Clinical Features (Ultra-Expanded)

5.1 Symptoms

Nasal pain
Swelling
Epistaxis
Nasal obstruction
Difficulty breathing
Crunching sensation (crepitus)
Cosmetic deformity

5.2 Signs

External Signs:

Deviation of nasal dorsum
Widening or narrowing of nasal bridge
Flattening of nose
Bruising (periorbital ecchymosis)
Lacerations

Internal Signs:

Septal deviation
Septal hematoma (red, bulging, bilateral swelling)
Mucosal tears
Blood clots

5.3 Red Flag Symptoms

Suggesting more serious injury:

CSF rhinorrhea (clear watery discharge)
Diplopia
Loss of smell
Malocclusion (suggests midface fracture)
Telecanthus (NOE fracture)
Nasal airway collapse on inspiration

Red flags require immediate intervention and imaging.

6. Special Emergency: SEPTAL HEMATOMA

This is the most dangerous nasal trauma complication.

Why?

Blood collects under mucoperichondrium →

Cuts cartilage blood supply
Leads to cartilage necrosis → saddle nose deformity

Features:

Bilateral, soft, boggy swelling
Severe obstruction
Pain

Management:

Immediate drainage
Antibiotics
Nasal packing

Delay = guaranteed deformity.

7. Examination (Professional ENT Sequence)

7.1 External Inspection

Look from front
Look from above (bird’s-eye view)
Look from side (profile)
Look from base (alar symmetry)

7.2 Palpation

Gently feel nasal bones
Identify mobility
Identify crepitus
Assess displacement direction

7.3 Internal Examination

Use nasal speculum or endoscope:

Mucosal tears
Hematoma
Septal deviation
Obstruction sites

7.4 Eye & Orbit Examination

Because trauma often extends to orbital walls:

Check for:

Diplopia
Restricted gaze
Infraorbital nerve anesthesia
Telecanthus

7.5 Dental & Midface Examination

Check for:

Malocclusion
Maxillary mobility
Palatal fractures

8. When to Order Imaging? (ENT Decision Rules)

Most nasal fractures do not require imaging.

Imaging NOT needed when:

Isolated nasal trauma
Clear cosmetic deformity
Visible nasal bone fracture
Straightforward reduction planned

Imaging required when:

Suspected NOE fracture
Suspected skull base fracture
CSF rhinorrhea
Orbital involvement
Complex comminuted fractures
Associated midface trauma

Preferred imaging:
CT scan of nose, orbit, and facial bones.

9. Red Flag Injuries That Must NOT Be Missed

Septal hematoma
CSF rhinorrhea
Telecanthus (NOE fracture)
Diplopia or gaze restriction
Loss of smell (cribriform plate injury)
Facial numbness (infraorbital nerve injury)
Dental malocclusion

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

10. PRINCIPLES OF MANAGEMENT OF NASAL FRACTURES

Management aims to restore:

Function (airway patency)
Form (cosmetic symmetry)
Structural support (septal integrity)

Early swelling often hides the deformity, so timing matters.

10.1 Immediate Measures (Emergency Room Protocol)

A. Control Bleeding

Direct compression for 10–15 minutes
Ice packs to reduce swelling
Cautery only for clear bleeding sites

B. Assess Airway

Ensure unobstructed breathing
Look for severe septal deviation or hematoma

C. Rule Out SEPTAL HEMATOMA (Most Important Step)

A boggy, bilateral swelling must be drained at once.

D. Manage Soft Tissue Injuries

Clean lacerations
Close wounds in layers
Give antibiotics for exposed cartilage

E. Analgesics & Anti-inflammatory Agents

NSAIDs (unless bleeding risk)
Ice packs (20 min, 3–4 times/day)

F. Tetanus Prophylaxis

Always given in open injuries.

10.2 Definitive Treatment Overview

Two main approaches:

1. Closed Reduction

Most common
Performed when bones displaced
Best results within correct time window

2. Open Reduction

Complex fractures
Failed closed reduction
Severe comminution
Associated deformities

11. TIMING OF REDUCTION (CRITICAL ENT CONCEPT)

Adults:

Best time = 5–10 days after injury
Swelling subsides, bones still mobile

Children:

Best time = 3–5 days
Faster healing
Bones stabilize earlier

Waiting too long → callus formation → deformity becomes fixed.

12. CLOSED REDUCTION — STEP-BY-STEP ENT TECHNIQUE

Closed reduction is the gold standard for most nasal fractures.

12.1 Preparation

Local anesthesia with lidocaine + adrenaline
Topical vasoconstrictors
Mild sedation in anxious patients
Proper lighting and positioning

12.2 Instruments Needed

Asch forceps
Walsham forceps
Elevator (Freer)
Nasal speculum
Headlight

12.3 Manipulation Technique

A. Lateral Fracture (most common)

Insert Walsham forceps intranasally
Elevate depressed bone outward
Compress opposite side inward
Align dorsum symmetrically

B. Frontal Impact

Use upward pressure to restore nasal dorsum
Reposition both nasal bones together
Correct septal deviation if present

12.4 Internal Nasal Valve Assessment

After reduction, ensure airway patency.
If valve collapse present → consider spreader graft later.

12.5 Splinting

External nasal splint for 7–10 days
Internal packing if septal manipulation was done

13. OPEN REDUCTION — INDICATIONS & TECHNIQUE

Open reduction is required when:

Severely comminuted fractures
Old fractures (>14 days old)
Failed closed reduction
Open fractures with exposed bone
Fractures involving upper lateral cartilage & septum
Combined NOE fractures

13.1 Technique Overview

Incisions placed along natural creases
Elevate skin–soft tissue envelope
Restore bony pyramid using osteotomies
Reposition septal cartilage
Add structural grafts if needed
Close in layers
Apply splints

Open reduction = often combined with septorhinoplasty principles.

14. SPECIAL CATEGORY: SEPTAL FRACTURES (HIGH-YIELD)

Septal fractures are more important than nasal bone fractures.

Features:

Persistent deviation
Internal obstruction
Crepitus on palpation
Visible septal dislocation

Management:

1. Immediate care

Drain hematoma
Reposition septum manually
Internal splints may be used

2. Secondary correction

If persistent deviation remains → septoplasty after 3–6 months.

15. PEDIATRIC NASAL FRACTURES (ENT ULTRA-EXPANSION)

Children require special considerations:

15.1 Anatomical Differences

Bones → softer, pliable
Cartilage → proportionally larger
Perichondrium → thicker
Septum → critical growth center

15.2 Clinical Features

Swelling may appear dramatic; fractures subtle.

Signs:

Tenderness
Slight deviation
Green-stick fractures
Airway obstruction

15.3 Why Pediatric Fractures Need Greater Care

Damage to septum →

Growth disturbances
Internal + external deformity
Midface retrusion
Lifelong breathing issues

15.4 Best Management Approach

ENT evaluation within 48–72 hours
Closed reduction within 3–5 days
Avoid aggressive manipulation
Monitor for septal hematoma
Long-term follow-up to ensure normal growth

16. POST-OPERATIVE CARE AFTER REDUCTION

16.1 Medications

Antibiotics (if packing or lacerations present)
Analgesics
Decongestants (short course only)

16.2 Patient Instructions

No nose blowing for 10 days
Avoid pressure on nose
Sleep with head elevated
Avoid sports for 4–6 weeks
Keep splint dry

16.3 Follow-Up

After 1 week (splint removal)
After 1 month (airway + cosmetic assessment)
After 3 months (late deformity detection)

17. LATE COMPLICATIONS (WITH ENT SURGICAL PATHOPHYSIOLOGY)

Damage from nasal fractures may present weeks to months later.

17.1 Nasal Obstruction

Causes:

Septal deviation
Internal valve collapse
Synechiae
Turbinate hypertrophy

17.2 Cosmetic Deformities

A. Deviated Nose

Due to unilateral depression or septal shift.

B. Saddle Nose

Septal cartilage necrosis following hematoma → collapse of dorsum.

C. Open Roof Deformity

Poor reduction creates dorsal gap.

D. Inverted V Deformity

Upper lateral cartilages displaced.

17.3 Septal Perforation

Causes:

Mucoperichondrial tears
Infection
Hematoma complications

17.4 Anosmia (Loss of Smell)

Due to:

Cribriform plate fracture
Olfactory nerve injury

17.5 Chronic Rhinosinusitis

Disturbed airflow & drainage.

17.6 Persistent Pain & Numbness

Infraorbital nerve injury.

18. REVISION SURGERY AFTER NASAL FRACTURES (SECONDARY CORRECTION)

Revision surgery is required when the nasal fracture was:

Improperly reduced
Not reduced in time
Associated with septal injury
Complicated by cartilage necrosis
Caused long-term deformity or obstruction

Revision procedures are delayed until swelling resolves and tissues stabilize.

18.1 Timing of Revision

Performed 3–6 months post-injury
Allows fibrosis to mature
Ensures stable nasal anatomy

Immediate revision only if:

Septal hematoma-related cartilage necrosis
Infected cartilage
Severe airway compromise

18.2 Types of Deformities Requiring Revision

A. Deviated Nasal Dorsum

Cause:

Incompletely reduced fracture
Undetected septal displacement

Repair:

Osteotomies + repositioning
Septoplasty
Spreader grafts

B. Saddle Nose Deformity

Cause:

Septal cartilage necrosis
Hematoma not drained

Repair:

Costal cartilage graft for strong dorsal support
Rebuild L-strut
Onlay grafts
Columellar strut

C. Inverted V Deformity

Cause:

Upper lateral cartilages collapse inward

Repair:

Spreader grafts to widen internal valve

D. Tip Asymmetry

Cause:

Lower lateral cartilage disruption
Scar contracture

Repair:

Tip grafts
Columellar strut
Suture reorientation techniques

E. Open Roof Deformity

Cause:

Faulty reduction → dorsal gap

Repair:

Bilateral osteotomies + narrowing
Dorsal augmentation

19. SURGICAL PRINCIPLES FOR SECONDARY CORRECTION

19.1 Assessment Before Surgery

Surgeon must evaluate:

External deformity
Septal deviation
Nasal valve collapse
Airway patency
Skin thickness
Prior scarring

19.2 Structural Reconstruction Strategy

Restore septum
Rebuild dorsum
Correct nasal bones
Fix valve angles
Reconstruct tip

Sequence matters — structure before aesthetics.

19.3 Graft Choices in Revision

A. Septal Cartilage

Preferred but may be insufficient after trauma

B. Conchal Cartilage

Best for ala and valve

C. Costal Cartilage (ideal for saddle nose)

Strongest
Allows large dorsal augmentation
Used when septal cartilage is absent

20. ALGORITHMS FOR ENT TRAINEES (HIGH-YIELD)

20.1 Algorithm for Initial Nasal Fracture Management

Assess ABC
Inspect external deformity
Rule out septal hematoma
Evaluate for red flags (CSF leak, diplopia, NOE fracture)
Decide:
- If displaced → closed reduction
- If comminuted/complex → open reduction
Splint for 7–10 days
Follow up at 1 week, 1 month, 3 months
Consider revision after 3–6 months

20.2 Algorithm for Timing of Reduction

Day 0–3: swelling too high
Day 3–5: children reduction window
Day 5–10: adult reduction window
Day >14: bones set → open reduction required

20.3 Algorithm for Septal Hematoma Management

Diagnose clinically → bilateral soft swelling
Incise and drain
Insert small drain
Pack nasal cavity
Start antibiotics
Monitor for saddle nose deformity

20.4 Algorithm for Choosing Surgical Approach

Isolated nasal bone fracture → closed reduction
Nasal bone + septal fracture → closed + septal manipulation
Comminution → open reduction
Persistent deviation → septorhinoplasty
Airway collapse → spreader grafts

21. OSCE / LONG CASE MODEL ANSWER FOR NASAL FRACTURE

History Points

Mechanism of trauma
Time since injury
Presence of epistaxis
Nasal obstruction
Previous nasal injuries
Instant deformity vs delayed swelling
Discharge (clear → suspect CSF leak)
Vision symptoms

Examination Steps

1. Inspect

From front, side, top, and base
Look for deviation, swelling, lacerations

2. Palpate

Assess mobility of nasal bones
Feel for crepitus
Identify depression

3. Internal Examination

Mucosal tears
Septal deviation
Rule out septal hematoma

4. Check Eyes

Diplopia
Orbital wall fracture signs

5. Check Midface

Maxillary mobility
Malocclusion

Management Answer (Full Marks)

“I will control bleeding, reduce swelling, rule out septal hematoma, and schedule closed reduction within the appropriate time window.

If complex fracture → CT + open reduction.”

Examiners LOVE when candidates prioritize hematoma detection.

22. COMPLICATIONS OF NASAL FRACTURES — DETAILED ENT PATHOPHYSIOLOGY

22.1 Early Complications

A. Epistaxis

Due to mucosal tears
Managed with packing/cautery

B. Septal Hematoma

Cuts cartilage blood flow → necrosis
Most important emergency

C. Infection

Cellulitis
Chondritis

D. CSF Rhinorrhea

High-impact trauma
Cribriform plate fracture

22.2 Late Complications

A. Persistent Nasal Deviation

Due to incomplete reduction or septal malalignment.

B. Saddle Nose Deformity

Septal cartilage necrosis → collapse of dorsum.

C. Nasal Valve Collapse

Upper lateral cartilage displacement → inspiratory obstruction.

D. Septal Perforation

From mucosal injury, infection, or hematoma drainage.

E. Chronic Rhinosinusitis

Due to altered airflow and drainage.

F. Cosmetic Problems

Asymmetry
Wide dorsum
Open roof deformity

23. TEXTUAL DIAGRAMS FOR SEO & EXAM MEMORY

Diagram 1 — Nasal Fracture Displacement (described)

Imagine the nasal bones as two slanted plates forming a pyramid.

A lateral blow depresses one plate and pushes the opposite outward.
A frontal blow flattens the apex of the pyramid.

Diagram 2 — Septal Hematoma (described)

Picture the septum as a flat wall sandwiched between two mucosal layers.
Hematoma → a soft balloon-like swelling on BOTH sides.

Diagram 3 — Algorithm for Reduction Timing

Days 0–3 → swelling
Days 3–5 → pediatric window
Days 5–10 → adult window
After day 14 → bones fixed

24. HIGH-YIELD ENT MCQs (20 QUESTIONS)

MCQ 1

Most common facial fracture is:
A. Mandible
B. Zygoma
C. Nasal bone
D. Maxilla
Answer: C

MCQ 2

Most important emergency in nasal trauma:
A. Epistaxis
B. Septal hematoma
C. Swelling
D. Crepitus
Answer: B

MCQ 3

Best time to perform closed reduction in adults:
A. Day 1
B. Days 3–5
C. Days 5–10
D. >14 days
Answer: C

MCQ 4

A sign of septal hematoma:
A. Hard swelling
B. Fluctuant bilateral swelling
C. Localized nodule
D. Firm ridge
Answer: B

MCQ 5

Which imaging is best for complex nasal fractures?
A. MRI
B. X-ray
C. CT scan
D. Ultrasound
Answer: C

MCQ 6

Inverted V deformity occurs due to collapse of:
A. Lower lateral cartilage
B. Septal cartilage
C. Upper lateral cartilage
D. Nasal bones
Answer: C

MCQ 7

Most common mechanism of nasal fracture:
A. Lateral blow
B. Frontal blow
C. Vertical blow
D. Rotational trauma
Answer: A

MCQ 8

Septal cartilage necrosis leads to:
A. Saddle nose
B. Open roof
C. Inverted V
D. Deviated nose
Answer: A

MCQ 9

Which is a sign of NOE fracture?
A. Tip droop
B. Telecanthus
C. Nasal obstruction
D. Crepitus
Answer: B

MCQ 10

Closed reduction requires:
A. Incisions
B. Osteotomies
C. Manual repositioning
D. Grafting
Answer: C

MCQ 11

Most important structure for nasal projection:
A. Lower lateral cartilages
B. Nasal bones
C. Septum
D. Skin envelope
Answer: C

MCQ 12

Nasal valve collapse is worse on:
A. Expiration
B. Inspiration
C. Chewing
D. Speaking
Answer: B

MCQ 13

Treatment for saddle nose deformity:
A. Bilobed flap
B. Spreader graft
C. Costal cartilage graft
D. Direct closure
Answer: C

MCQ 14

Pediatric reduction timing is:
A. 0–3 days
B. 3–5 days
C. 5–7 days
D. 10–14 days
Answer: B

MCQ 15

Which indicates orbital injury?
A. Tip swelling
B. Ecchymosis
C. Diplopia
D. Crepitus
Answer: C

MCQ 16

Nasal bone fractures heal by:
A. Fibrous union
B. Bony union
C. Cartilage healing
D. Epithelial regeneration
Answer: B

MCQ 17

Which deformity results from poor reduction?
A. Wide dorsum
B. Steep dorsum
C. Long septum
D. Posterior tip
Answer: A

MCQ 18

Persistent obstruction after fracture likely due to:
A. Skin swelling
B. Septal deviation
C. Nasal bone mobility
D. Lacrimal obstruction
Answer: B

MCQ 19

A soft, fluctuant mass after trauma indicates:
A. Abscess
B. Hematoma
C. Fibrosis
D. Cyst
Answer: B

MCQ 20

Which is NOT an indication for open reduction?
A. Comminuted fracture
B. CSF leak
C. Mild unilateral displacement
D. Failed closed reduction
Answer: C