A recent article in Emergency Medicine Australasia by a group of ENT clinicians looks at manipulation of nasal fractures under local anaesthetic in the emergency department. The authors have created an online video tutorial to show you how to do it step by step.
Nasal fractures are a common presentation to the emergency department — especially on weekends, as the majority occur during contact sports or the usual Friday and Saturday night alcohol-induced wrestle-manias…
Nasal fractures account for 40% of fractures resulting from facial trauma. Displaced nasal fractures can be of great cosmetic concern for the patient, although displacement may not be visualised early depending on the amount of swelling present.
Assessment of Nasal Fractures
A detailed history and examination should include:
- Assessment of airway, breathing, circulation and disability (remember its a head injury)
- Mechanism of injury and amount of blood loss
- Time since injury — nasal fractures are best reduced immediately or 2 weeks post injury once the initial swelling has subsided.
- Examine the nasal bone, and inside nasal cavity and septum (don’t miss a septal hematoma), also look at surrounding orbits, facial bones and cervical spine.
- Examine the eyes carefully to assess eye movements and visual acuity, as well well other signs of trauma such as hyphema and subconjunctival hemorrhage.
- Document findings carefully, especially if the injury is the result of an assault. Consider the possibility of domestic violence.
Complications of Nasal Fractures
- Septal haematoma (incision and drainage is needed to prevent septal necrosis)
- Cerebrospinal fluid rhinorrhea (due to fracture of the cribriform plate)
- Malocclusion and deformity of nose, with obstruction of the nasal passages
- Extraocular movement defects (muscular trapping by orbital rim fractures)
Emergency Department Management
- Ensure airway is patent, and overall stability of patient before focusing on nasal fracture.
- Epistaxis is common but fracture displacement and pain can make applying pressure difficult. Packing may be required.
- Lacerations should be irrigated and sutured, ADT should be updated.
- Antibiotic prophylaxis for CSF rhinorrhea is controversial.
- Displaced fractures are usually managed by either immediate manual manipulation following the injury or once swelling has subsided at about 2 weeks after injury. Manipulation is typically performed under general anaesthetic in theatre, however (as described by the authors in the video below) manipulation may be performed under local anesthesia decreasing the risk and inconvience to the patient from a general anaesthetic, reducing hospital stays, bed occupancy and overall cost.
- A recent Best Bets review suggests that manipulation under local anaesthesia is acceptable to the patient in terms of pain, cosmetic and functional outcome.
Method for manipulation of local anaesthesia
The method described by Repanos et.al (2010):
- Spray two puffs of lignocaine + phenylephrine (co-phenylcaine forte) to each nostril and apply one cotton wool ball soaked in this to each nostril.
- Alcohol wipe the nasal skin up to the eyebrows and laterally to mid-orbit (infra-orbital foramen).
- Inject 1ml of 1% lignocaine with 1:80 000 adrenaline half way between the medial canthus and the glabella on each side down to the periosteum. This anaethetizes the nasocillary nerve and acts as a haematoma block. This nerve block is crucial for the effectiveness of local anesthesia for nasal fracture reduction. Take care needs to avoid injecting into the angular vein.
- If necessary, disempact and elevate the nasal bones (e.g. using a Boies’ elevator and Walsham’s forceps).
- Perform closed reduction by exerting external digital pressure.
- Ensure the patient has appropriate follow up arranged. If the fracture appears unstable use plaster of paris to make a support splint.
Local Anaesthetic Nasal Fracture Reduction
- Kucik, C. Clenney, T. & Phelan, J. (2004). Management of Acute Nasal Fractures. American Family Physician. 70(7), 1315-1320. PMID: 15508543
- Powell, O. & Doshi, D. (2007). Should nasal fractures be manipulated under local anaesthesia? Best Bets review.
- Repanos, C. et.al. (2010). Manipulation of nasal fractures with local anaesthetic: A ‘How to do it’ with online video tutorial. Emergency Medicine Australasia. 22, 236-239. DOI: 10.1111/j.1742-6723.2010.01289.x
- Repanos, C. Carswall, A. Chadha, N. (2010). Manipulation of nasal fractures under local anaesthetic: a convenient method for the Emergency Department and ENT clinic. Emergency Medicine Journal. 27, 473-474.PMID: 20466835