chap-3d fracture of nasal bone maxillofacial surgery.pptx

chap-3d fracture of nasal bone in craniomaxillofacial surgery

1. Management of Fracture of Nasal bones Moderator Dr. Tingirt H/ mariam ; consultant(OCMFS) Presenter; Dr. Alelign A.( ocmfs R2) 2024/5/29 1

2. L earning objectives Introduction Surgical Anatomy Clinical and Radiographic Diagnostic Tools Surgical Management Postoperative Care and Complications Take home message R eference outline 2024/5/29 2

3. At the end of the presentation we will able to describe surgical anatomy, clinical and radiographic diagnostic tools, surgical management, and potential complications associated with nasal complex fractures. learning objectives 2024/5/29 3

4. Common(40-50%) among facial bone fractures&3 rd most common. Common in young males b/c interpersonal violence Relatively little force(~25 pound) is required to fracture, like wise Most missed # which cause significant long term problems of deformity, obstruction, sinusitis … Most fractures result from laterally applied forces. Greater force is required to fracture the nose with a blow directed from the front as the nasal cartilages behave like shock absorbers . It is difficult to fully evaluate the deformity in primarily due to edema introduction 2024/5/29 4

5. The nose and perinasal tissues have functional and aesthetic roles When treating nasal trauma, clinicians should aim at optimizing function as a primary objective in conjunction with the aesthetic goals Cont … 2024/5/29 5

6. The nasal complex is composed of underlying nasal mucosa and turbinates , upper and lower cartilages, the cartilaginous and bony septum in the middle, and the paired nasal bones The two nasal cavities are the uppermost parts of the respiratory tract . The nasal septum is composed of cartilage (anteriorly) and the ethmoid and vomer bones (posteriorly Surgical anatomy 2024/5/29 6

7. Surface anatomy & skeletal framework of the external nose 2024/5/29 7

8. Skeletal frame work of the nasal cavity 2024/5/29 8

9. 2024/5/29 9 Cartilage component

10. The Roof & floor of Nasal Cavity 2024/5/29 10

11. The Medial Wall of Nasal Cavity -The Nasal Septum Divides the nasal cavity into right and left halves Osseous part consists of The perpendicular plate of the ethmoid bone (superior), The vomer (inferior) Cartilaginous part consists of The septal cartilage Septal process of alar cartilage 2024/5/29 11

12. The Lateral Walls of Nasal Cavity Formed by nasal, frontal process of maxilla, lacrimal, conchae and labyrinth of ethmoid, inferior nasal concha, perpendicular plate of palatine, medial pterygoid plate of sphenoid Marked by 3 projections: Superior concha Middle concha Inferior concha 2024/5/29 12

13. The blood supply to the nose arises from 3 major arteries: Ophthalmic Maxillary Facial VASCULAR SUPPLY OF THE NOSE 2024/5/29 13

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15. V1nasocilliary(ethmoid nerves, infratrochlear ) V2(infraorbital, nasopalatine, sphenop , Gpala 2024/5/29 15 Nerve supply

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17. The internal nasal valve primarily determines nasal resistance to airflow. Triangular, formed by the junction of the caudal upper lateral cartilages and nasal septum Inferiorly, it is bound by the nasal floor and posteriorly by the inferior turbinates‘ narrowest zone valve obstruction can be seen with post-traumatic weakness of the upper or lower lateral cartilage NASAL PATENCY AND AIRFLOW DYNAMICS 2024/5/29 17

18. May present with obstruction, changed appearance,.. prior nasal and/or septal trauma or surgery should be documented Recent pretraumatic photographs Mechanism of injury and timing of the event are important Observing the nasal dorsum from the frontal, worm’s eye, and bird’s eye views cottle test; elevation of nasolabial fold relieves nasal obstruction in case of fracture HISTORY AND PHYSICAL EXAMINATION 2024/5/29 18

19. Internal examination with good lighting, nasal speculum, and suction or endoscopy is imperative to determine the presence of intranasal lacerations, septal deviations off the nasal crest of the maxilla, nasal septal hematoma Rhinorrhoea, periorbital ecchymosis, diplopia, epiphora , telecanthus , anosmia, trismus, occlusion, …. Cont … 2024/5/29 19

20. present with some combination of deformity, tenderness, hemorrhage, edema, ecchymosis , Ttelecanthus , lack of nasal projection, instability, c repitation and anosmia However , these features may not be present or may be transient. Edema can mask underlying nasal deformity, crepitation, and instability. Further ivx Clinical features 2024/5/29 20

21. Rowe and Kiley(1968) ; according to the impact only Lateral nasal injuries Anterior nasal injuries Cont … 2024/5/29 21

22. 2024/5/29 22

23. provide simple classification based on clinical finding 1 laterally displaced 2 posteriorly depressed 3 disarticulation of upper lateral cartilage 4 anterior nasal spine fracture 5 involvement of nasal septum AO (Arbeitsgeminschaft osteosynthese) classification 2024/5/29 23

24. isolated nasal injuries with no loss of consciousness and a clear history of the mechanism can be diagnosed and treated without the need for exposing the patient to radiation. Lateral nasal xray RADIOGRAPHIC EXAMINATION 2024/5/29 24

25. The goals of management of nasal bone# to prevent development of a posttraumatic nasal deformity, restoration of proper nasal airflow , prevention of cosmetic deformity, maintenance of proper nasal complex topography and projection Restoration of the sense of smell Surgical Management 2024/5/29 25

26. Management of a nasal bone fracture Dependent upon multiple factors including : Age of the patient , Time since injury , Necessity for acute versus delayed reduction , Choice of anesthesia Approach (open vs. closed reduction ) Cartilage have memory and may spring back to pre surgical state 2024/5/29 26

27. Main indications Non-displaced fractures without nasal deformities or airway obstruction. Further indications Nondisplaced fractures of the nasal bone, nasal septum and anterior nasal spine No clinically relevant nasal deformities on physical examination No clinical evidence of airway obstruction The patient should be followed until all the swelling is resolved to ensure that a deformity has not been missed. Closed reduction 2024/5/29 27

28. Less invasive Simpler Accuracy of reduction can not be directly evaluated 15 % to 50% of those having closed reduction of a nasal fracture will ultimately undergo revision rhinoplasty 2024/5/29 28 Cont …

29. LA administered with blocking bilateral infraorbital, infratrochlear , and external nasal nerves intranasally to block the branches to ( the septum, internal mucosa, and subciliary ) anterior ethmoidal, sphenopalatine, nasopalatine nerves care must be taken not to distort the overlying dorsal nasal soft tissues GA can be used based on surgeon preference Choice of anesthesia 2024/5/29 29

30. 1-cm nasal tape 2-mm osteotome Appropriate sutures Ash forceps Boer elevator Doyle internal splint Freer elevator Local anesthetic with vasoconstrictor Mallet Nasal speculum Needle holder Periosteal elevator Scalpel blades (#11 and #15) Thermoplastic external splint Walsham forceps Armamentarium 2024/5/29 30

31. correct instrument ( Boies nasal fracture elevator) placement Prior to the endonasal placement of the elevator, it is placed against the outside of the nose to the level of the medial canthus . The index finger is then placed against the edge of the elevator and is used as a stop when the elevator is placed intranasally to ensure that it can not be advanced too far superiorly . 2024/5/29 31 Reduction

32. The Asch or Walsham septum-straightening forceps are used to straighten the nasal septum . Grasp the nasal septum with the blades of the instrument and gently manipulate the septum into proper alignment . Centrally depressed fractures require posterior to anterior elevation which can often be achieved by reducing the nasal septum 2024/5/29 32 Reduction of the nasal septum

33. Commonly laterally displaced fractures on one side are medially depressed on the other side . Place an instrument ( eg , Boies elevator) in the depressed side along the lateral wall of the nose to a point below the nasal frontal angle . Place a finger along the lateral side of the nose above the depressed area . 2024/5/29 33 In laterally displaced fractures

34. The reduction must be maintained via intranasal packings Finally, an external nasal splint may be applied Cont … 2024/5/29 34

35. Hemostatic packs are removed after 24 hours . Packs that are supporting the nasal bones are left in place as long as the external splint is in place . ( Various surgeons leave these in place from anywhere between 3-10 days ). Septal splint 1 week or longer 2024/5/29 35 Removal of packings and splints

36.  Excessive swelling and edema : Panfacial fractures Naso - orbito -ethmoid (NOE) fracture Cerebrospinal fluid (CSF) leakage Limitations and Contraindications 2024/5/29 36

37. Fixation Micro plates Resorbable plates Septoplasty Rhinoplasty Main indications Persistent septal deformity leading to external nasal deformity and/or airway obstruction. septorhinoplasty once the fracture has healed (6 months posttrauma ) 2024/5/29 37 Open Reduction & Internal Fixation

38. Severe fracture of the nasal bones and septum Associated orbital wall or ethmoid bone fractures Nasal pyramid deviation that exceeds one half the width of the nasal bridge Caudal septum fracture dislocation Open septal fractures Fractures examined 3 weeks or longer after the injury occurred Poor outcome after primary management 2024/5/29 38 Further indications

39. Comminuted fractures Severely comminuted fractures should not be treated via an open approach. In this case, the fractures are addressed via closed reduction and residual deformities are treated in a secondary procedure . Overaggressive stripping of the periosteum may cause devitalization of the bone with subsequent necrosis. The use of miniplates or wires in comminuted fractures is not recommended because extrusion of the plate, wound dehiscence and unsightly appearance of the dorsal nasal skin over the plates or wires may occur. 2024/5/29 39

40. Intercartilaginous incision Inverted Y incision Subciliary incision Upper labial vestibular incision hemitransfixion incision Existing laceration H shaped incision not popular again In case of severely comminuted or open fractures  existing lacerations  can be used. When associated with other facial fractures ( eg , NOE, frontal sinus) the  coronal approach  can be used. Otherwise, depending on the surgeon's preference and the particular case an  external rhinoplasty  or an  endonasal approach  may be used. 2024/5/29 40 Surgical Approach

41. Bone or cartilage grafting may be necessary in severely comminuted nasal bone fractures. When inserting the graft, the following points should be respected The nasofrontal angle should be reconstructed in a normal relationship (105°-120) The collapsed septum should be suspended to the graft using non- resorbable sutures The graft should be long enough to re-suspend the lower lateral cartilages 2024/5/29 41 Grafting

42. Treatment of disarticulation of the upper lateral cartilage is via lacerations or open approaches and is aimed to suturing the cartilages back to the nasal bone . Long term outcome is usually poor and often requires secondary procedures to correct the deformities. Internal packing of the nose to support the upper lateral cartilage should be performed in an attempt to reestablish the preinjury relationship between the nasal bone and the upper lateral cartilage Disarticulation of upper lateral cartilage 2024/5/29 42

43. Postoperative positioning: Keeping the patient’s head in a raised position both preoperatively and postoperatively may significantly improve edema and pain . Nose-blowing: To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days following NOE fracture repair . Avoid exertion for 4-6 wks Ice packs 2024/5/29 43 Post operative care

44. Medication Analgesia as necessary Antibiotics. Nasal decongestant may be helpful for symptomatic improvement . Steroids , in cases of severe orbital trauma, may help with postoperative oedema . Ophthalmic ointment should follow local and approved protocol 2024/5/29 44

45. Septal hematomas : This is a common and serious complication of nasal trauma resulted from collections of blood in subperichondrial space which pressure on the underlying cartilage Resulting in irreversible necrosis of the septum , A saddle deformity, perforation, columellar retraction Complications of a septal hematoma include local infection, meningitis and/or brain abscess, nasal airway obstruction, and septal perforation. Rarely, the latter can lead to a loss of dorsal nasal support and a saddle nose deformity 2024/5/29 45 complications

46. The main symptom is severe nasal obstruction On examination the septum appears swollen and boggy The swollen area should be palpated with a cotton-tipped applicator . If a hematoma is present it should be compressible . The presence of a significant septal hematoma requires immediate drainage . 2024/5/29 46 Cont …

47. Septal hematomas must be drained immediately upon their being found . Cotton pledgets soaked in 2% lignocaine are used for topical anesthesia . A scalpel incision must be made to allow drainage . A small Penrose-type drain is placed to prevent re-accumulation . Finally , nasal packing is placed . The patient should be started on oral antibiotics 2024/5/29 47 Septal hematomas: Drainage procedure

48. Epistaxis Anterior epistaxis typically arises from Kiesselbach’s plexus Posterior nasal epistaxis arise from woodruff plexus located posterior to the middle turbinate or at the posterior superior aspect of the nasal cavity chemical cautery with silver nitrate, local hemostatic agents, and anterior or posterior nasal packing, such as 14 -inch gauze, sponge , or commercially produced packing material. Posterior nasal packing with cotton balls tied together and introduced transorally into the nasopharynx. Balloons and inflatable catheters can also be rapidly applied in case of airway compromise, Endoscopic cauterization, arterial embolization 2024/5/29 48

49. Skilled management of nasal and septal fractures requires a thorough understanding of facial anatomy, causes of injuries, function and aesthetics of the nose, modern operative techniques, timing for reconstruction , setting and anesthesia choices, and possible complications. Take home message 2024/5/29 49

50. R aymond J Fonseca, o ral & ma xillofacial tra uma 4 th ed , Elsevier Peterson's principle of oral & maxillofacial surgery 4 th ed , Elsevier R eference 2024/5/29 50