Management of Acute Bilateral Comminuted Nasal Bone Fractures

Primary Management Pathway

ENT specialists perform closed reduction with or without septal correction for isolated nasal bone fractures, including bilateral comminuted patterns, as they routinely manage nasal bone fractures and perform necessary procedures 1

Maxillofacial surgery referral is indicated for naso-orbital-ethmoid (NOE) complex fractures involving the medial orbital walls, nasal septum, and naso-frontal junction, which require subspecialist management to prevent complications such as enophthalmos, telecanthus, lacrimal obstruction, and ptosis 1, 2
Le Fort II or III fractures, where nasal bones are fractured as part of pyramidal midface injuries involving the orbital rims, maxillary sinuses, and pterygoid plates, require maxillofacial surgery referral 2, 3
Zygomaticomaxillary complex fractures with nasal involvement require open reduction and internal fixation, and thus, a maxillofacial surgery referral 4

Before referral, evaluate for associated injuries such as septal hematoma, which requires urgent drainage to prevent septal necrosis 1
Assess for CSF leak, suggesting cribriform plate involvement, which requires neurosurgical consultation 5
Order CT maxillofacial imaging to characterize the fracture pattern and identify extension to adjacent structures, as plain radiographs have only 53-82% accuracy 1
Screen for intracranial injury, as 68% of maxillofacial trauma patients have associated head injury 1, 4

Fracture reduction should occur within 2 weeks for optimal outcomes, and septal correction must precede nasal bone realignment if septal deviation is present 1
Early intervention prevents permanent deformity and functional impairment 4