Introduction
Nasal bone fractures are the most frequently occurring facial bone fractures; however,
in recent years, opportunities to experience cases of nasal bone fractures in daily
practice at the department of otolaryngology clinics are decreasing as these cases
are treated more often in the department of plastic surgery. This is because nasal
bone fractures often involve changes in appearance and skin damage, and considering
the cosmetic aspect, consultations with the department of plastic surgery have increased.
However, it is important that otolaryngologists understand the current status as specialists
treating nasal diseases concerning our daily clinical practice.
Here, we report a clinical investigation of cases of nasal bone fracture experienced
in our department.
Material and Methods
The subjects included 299 cases of fresh nasal fractures diagnosed by computed tomography
(CT) scans in the Department of Otorhinolaryngology at Himeji St Mary's Hospital during
the 10-year period between January 2008 and December 2017.
The examination items included sex and age, causes of bone fractures, fracture causes
by age and sex, causes of sports-related fractures, causes of traffic accident-related
fractures, frequency by classification of fracture types, directions of external force
in case of assault, coexistence of other facial bone fractures, and whether or not
surgical treatment was performed and the procedure types.
Discussion
The hospital is located in the northeastern part of the regional core city, and the
age composition of the said medical zone shows an aging trend; however, there are
no other distinctive regional characteristics, including the educational environment.
In addition, our hospital also serves as an emergency medical care facility in the
area, and because there is no department of plastic surgery, all nasal bone fracture
cases are treated in our department. Therefore, the cases investigated in this study
are considered to represent the actual state of nasal bone fractures in this medical
service area.
The most common age at the time of nasal bone fracture was the teenage years and the
patients aged 10 to 20 years comprised more than 70% of cases.[1]
[2]
[3]
[4]
[5] Males are more common, with the ratio of males to females of approximately 4:1.[2]
[3]
[4] Similar results were obtained in our study, probably because there are many opportunities
for injury among young men.[3]
Most reports indicate that sports are the most common causes of bone fractures.[5]
[6]
[7]
[8] The causes of fractures by age showed that sports are the most common cause among
those in their teenage years,[2]
[4] and in the 20s, the number of cases of traffic accidents and violence/fights increases.
It has been reported that the proportion of falls increases with age;[4] moreover, the proportion of patients aged ≥70 years was high in fall cases in our
study. As Japan is becoming a super-aging society, the number of cases of falls by
elderly persons is expected to increase.
Of the sports-related causes, baseball was the most common cause, followed by other
ball sports such as soccer, softball, and basketball.[3]
[5]
[6]
[7] In this study, direct external force was most commonly caused by hard baseball among
male high school students and softball among female junior high school students. However,
injuries occurring during playing soccer, basketball, volleyball, and rugby were most
commonly due to contacts with the parts such as head, elbow, and knee. Among the sports-related
cases, there were many cases of injuries caused during extracurricular activities
at school, and it is desirable that in the future, guidance for club activities is
provided with prime focus on safety.
Regarding traffic accidents, the number of bicycle accidents has become the most frequent
cause, reflecting the increase in popularity of bicycles in recent years.[8] Of our cases, bicycle-related cases were the most common, comprising more than half
of all cases. In recent years, there have been cases of expensive claims for damages
due to bicycles, and therefore, those who ride bicycles should comply with the traffic
rules such as not riding a bicycle after consuming alcohol or riding without a light.
In addition, as there were cases of falls into gutters, careful bike riding with a
special caution to gutters is needed on roads with side grooves.
According to the frequencies by classification of fracture types, there are several
reports that displacement types comprise approximately 70% of cases and depressed
types are approximately 30%.[3]
[9]
[10] Among our cases, similar results were obtained; however, the reason for the large
number of cases of displacement types is that there were many cases of external force
applied laterally to the nasal bone and lateral force is more likely to cause nasal
bone fracture than anterior or inferior external force.[3]
[11] Furthermore, when there is a fracture in the upper part, the applied external force
should be strong, which frequently causes a comminuted fracture.[9]
Although there are reports that blows with the fist tend to cause deviation to the
right due to the fact that many people are right handed and use the right fist to
punch,[3]
[12] it has also been reported that deviation to the left was more common.[4] Even in our cases, left-side deviation was slightly more common than right-side
deviation. The reason why deviation to the right side is not necessarily more common
is that straight punch is most common although right-handedness is more common, and
the injured side is determined by the timing when the person being hit attempts to
divert the face.
It has been reported that coexisting nasal septum fractures were observed in 3.4 to
38.7% cases[2]
[4]
[5]
[13] in Japanese studies and 10 to 96.2% cases[14]
[15]
[16] in studies abroad. Among our cases, CT imaging confirmed coexisting nasal septum
fractures in 44.2% of cases. Thus, confirming the presence or absence of complicated
nasal septum fractures in nasal bone fractures is also important for treatment described
later.
It is indicated that the coexisting facial bone fractures other than nasal septum
fractures range from 5 to 15.7%;[1]
[4]
[5]
[15]
[17] blow-out fractures were most frequent, followed by cheekbone and maxillary bone
fractures.[4]
[5]
[18] It appears that this is because the orbital wall and the cheekbone/maxilla are anatomically
adjacent to the nasal bone.[5] Among our cases, 11.7% cases involved coexisting facial bone fractures. As causes
for complicated facial bone fractures, sports, which is a common cause of facial fractures
among younger patients, was rare, and falls in elderly patients were highly frequent
causes. This was because elderly persons tend to fall due to the decline in the sense
of balance, and because their bone density is decreased, even weak external force
is likely to cause other facial bone fractures.
The rate of surgical intervention for nasal bone fractures varies from 35.8 to 96.2%.[2]
[3]
[4]
[8]
[10]
[17] Indications for nasal bone fracture reduction are said to include cosmetic issues
due to deformation of the external nose and functional disorders such as nasal obstruction
due to deformity in the nose.[19]
[20]
Regarding the method of anesthesia, reports are split on general anesthesia being
mainly used[4]
[7] and local anesthesia being mainly used.[13] The advantage of general anesthesia is that there is no pain during reduction, making
it possible to perform complete reduction.[4]
[7] It has also been reported that surgery under general anesthesia is more satisfying
than local anesthesia in terms of nose appearance and function in patients, and as
a result, the frequency of revision surgeries can be lowered.[21] However, the advantage of local anesthesia is that it can be easily and quickly
performed even in an outpatient clinic and the patient can confirm the status of reduction
during the procedure.[13] In our department, in general, we select general anesthesia to eliminate the patient's
suffering caused by pain, and to perform satisfactory reduction without hesitation.
Noninvasive reduction of nasal bone fracture is primarily performed,[7]
[22] whereas invasive reduction of nasal septum fracture is mainly performed. When nasal
septum deviation due to septum fractures accompanying the nasal bone fracture is left
untreated, the deviation worsens over a long period of time, resulting in nasal obstruction
and deviation of appearance also occurs; this tendency is particularly notable in
pediatric patients.[4]
[23] DeFatta et al[24] reported that 60% of the cases of conservative reduction of the nasal bone and nasal
septum fractures exhibited deformity of the nasal septum, whereas only 12.5% of the
cases where the nasal bone was treated by a conservative reduction and open surgery
was performed for the nasal septum showed deformity of the nasal septum. Based on
these reports, it is recommended that nasal septum fracture reduction is performed
for nasal septum deviation due to nasal septum fracture accompanying nasal bone fracture.[4]
[25] We are also proactively performing open reductions for nasal septum fractures under
rigid endoscopy, by which highly accurate reduction can be performed as it allows
the surgeon to confirm the fracture site and the condition in detail with favorable
mobility of the fracture site.
Kang and Han[22] reported that postoperative complications occurred in 8.61% of cases; deviation
was the most common, followed by saddle nose, broad nose, swelling, nasal congestion,
and transient hyposmia. Another study reported that the most common complication was
postoperative pain.[18] Many patient satisfaction surveys have reported that 70 to 80% of the patients were
satisfied;[1]
[4]
[26]
[27]
[28]
[29] however, satisfaction tended to be low in severe cases with nasal septum fracture.[28] Hwang et al[15] reported that it should be explained to the patient that nasal deformity and deviation
and obstruction of the nasal septum are postoperatively observed in 10% of the cases
of nasal bone fractures. However, there are reports that the shape of the external
nose after fracture reduction was improved only with follow-up observation in approximately
60% of cases at 1 month postoperatively[29] and in approximately 50% at 3 months postoperatively.[30] Although there were no cases in our study that required revision surgery owing to
nasal obstruction or deformity of the external nose, follow-up observation may be
necessary for at least 3 months postoperatively for the symptoms to become fixed and
to determine the necessity of postoperative revision surgery.
