The nasal bone is the most common site of facial fractures due to its protruding position in the middle of the face and its composition of relatively weak bone. Among nasal bone fracture cases, the incidence of accompanying septal fracture, known as nasoseptal fracture, is reportedly 42.0%–96.2% [1,2]. Fractures of the nasal bone and septum are affect one’s cosmetic appearance and nasal airway function. As an untreated septal fracture can cause deviation of the nasal alignment and narrowing of the nasal passages, it is important to also correct an accompanying septal fracture. In septal fracture reduction, direct observation of the fracture site is necessary. Many studies support that open septoplasty shows favorable outcomes [1,3,4]. However, it features a long learning curve, requires extended operation time, and carries the risk of postoperative scarring. To overcome these limitations, we used endoscopic open reduction of the septal fracture with classical closed reduction of the nasal bone fracture. Here we present our experience.

A 69-year-old man visited our outpatient department with bilateral nasal stuffiness after hitting his nose on the street after a fall 2 days prior. He experienced epistaxis at the moment of the trauma. No depression of the nasal dorsum was observed upon general inspection (Fig. 1A, B). An endoscopic examination revealed a convex protrusion on the left side of the septum suggestive of a nasal septum fracture as well as mucosal tearing of the right side of the nasal septum. A nasal bone fracture and dislocation of the osteochondral junction with retraction of the cartilaginous septum to the left side were identified on computed tomography (CT) (Fig. 2).

Figure 1. Extraphoto. Both (A) frontal view and (B) lateral view taken before operation, multiple abrasions on face, but there was no significant nasal dorsum depression. Both (C) frontal view and (D) lateral view taken 14 weeks after operation, there was no significant difference from before surgery, but the profile of nose looked firmer and clearer.

Figure 2. Pre-operative computed tomography scan. (A) Axial view and (B) coronal view shows nasal septum deviation to right and septal cartilage disposition to left nasal cavity due to traumatic septal fracture.

Endoscopic septoplasty and closed reduction of the nasal bone fracture were planned. A hemitransfixion incision to the left side of the nasal septum was performed as in conventional septoplasty. After a meticulous dissection of the submucoperichondral and submucoperiosteal plane on the left side of the septum under endoscopic assistance, the right side of the septum was approached in the same manner through the existing incision site to gain mobility of the fractured cartilaginous septum. Considering the mucosal tearing on the right side of the septum (Fig. 3A), preserving the mucosa on the left side of the septum was important. The fracture site was examined and reduction was performed under endoscopic assistance through the elevated mucosa (Fig. 3B, C). As the overlapping area between the cartilaginous and bony septum was present, it was removed and the edge of the bony septum trimmed. Once mobility was regained, the fractured cartilaginous septum was easily reduced in the opposite direction of the external force (Fig. 3C). An anchoring suture was placed to fix the cartilaginous septum in the reduced position. Upon correction of the septal fracture, the nostrils and mucosal tearing appeared realigned (Fig. 3D). Next, conventional closed reduction of the nasal bone fracture was performed using a Boies elevator. The incision site was sutured with Vicryl 5–0, and silastic sheets were applied to both sides of nasal septum to promote mucosal recovery.

Figure 3. Intraoperative findings. Cartilaginous and bony septum were separated from one side to the other with the attached mucous membrane. (A) Mucosal tearing on the right side of the septum (asterisk). (B) After the mucosal dissection, separated cartilaginous and bony septum directly shown. Disrupted osteochondral junction and cartilaginous septum dislocated to the left (arrow) was observed. (C) Fractured cartilaginous septum was pulled to the opposite direction of the applied external force. (D) After reduction, shift of the right nostril was corrected and mucosal tearing was well aligned.

The silastic sheets were removed at 15 days postoperative, and the mucosa recovered thoroughly. Photographs taken at 4 months postoperative showed an improved contour of the nasal dorsum compared to the preoperative appearance (Fig. 1C, D). The septum remained at midline without distortion during 4 months of outpatient follow-up.

Nasal bone and septal fractures are important; if not corrected properly, they can require secondary operation such as septorhinoplasty due to complications such as postoperative nasal deformity and nasal obstruction [1,5]. Through study of the pathogenesis of nasal fracture, Murray et al. [6] found that, if the fractured nasal bone displacement exceeds the width of the nasal bridge, a C-shape fracture on the bony and cartilaginous septum may occur; thus, they suggested open reduction of the nasal bone fracture.

A meticulous examination and history taking are needed to diagnose nasal bone fracture with septal fracture. Mucosal tearing, septal deviation, crepitus, epistaxis, and intranasal bleeding on physical examination may present a high requirement for septoplasty [1]. CT is useful for identifying a fracture site, but it is not a definite diagnostic modality due to discrepancies with the actual fracture.

In recent studies, early open reduction with submucosal septal resection, reconstruction, or repositioning of the nasal bone fracture with septal fracture has shown improved long-term cosmetic and functional outcomes compared to closed reduction [1,4]. However, open septoplasty features a long learning curve, requires extended operation time, and carries the risk of postoperative scarring. It also features poor visualization of the posterior septum, where more severe fractures may occur. External forces applied at the time of trauma divide fracture mechanisms into three categories: tension, compression, and shear force. The osetochondral junction of the nasal septum is the known stress concentration area when external forces are applied to the nose. Therefore, shear force applied to the cartilaginous and bony septum disrupts the osteochondral junction and displaces the cartilaginous septum (Fig. 4). In this case, we predicted that the shear force applied laterally to the left side of the nasal bone caused the septal fracture.

Figure 4. Reconstruction of the fracture situation. (A) Bony septum and septal cartilage separated by shearing force. External force (arrow) is transmitted to the nose at the impact moment. (B) Shearing force potentiated separation. (C) Complete cartilage and bony septum separation.

Endoscopic septoplasty involves a short learning curve because the use of nasal endoscopy has become popularized and video connection enables easy training [7]. Moreover, this approach takes less time and features a shorter recovery than the open approach and has no risk of postoperative scarring. Furthermore, this approach enables direct visualization of the posterior septum and fracture site, thereby allowing direct manipulation of the fracture site. For these reasons, its surgical outcomes are favorable compared to those of open septoplasty [7]. However, reduction using this approach might be ineffective in cases of extensive and complex fracture. Thus, closed reduction of the nasal bone fracture and endoscopic septoplasty for nasoseptal fracture is preferable in cases in which there are relatively few bone fragments and obtaining satisfactory results by traditional closed reduction is difficult.

Therefore, we suggest that reduction could be achieved through closed reduction of the nasal bone fracture and endoscopic septoplasty for septal fracture instead of open septoplasty in selected cases.

The authors have nothing to disclose.