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Saturday, October 20, 2012

Broken Owen Wilsons. .errr. .uh. .Noses

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Probably the most famous crooked nose I know belongs to Owen Wilson. He wasn’t born that way. He broke it twice. Once in a fight with another kid at school and once playing football with buddies.

Adam Foote was a great hockey player who spent much of his time with the Colorado Avalanche and has quite the crooked nose also from multiple fractures.

The reason I bring up these two noses is because they are some of the more famous extremes of the results of unreduced nasal fractures of which I’m aware. It’s quite easy to find a smorgasbord of other examples both worse and more tame with a simple search of Google Images.

So here are some key things to know about nasal fractures.

Nasal fractures are common, but it’s important to recognize that they may represent more significant trauma. It’s always a good idea to have a nasal fracture evaluated unless you’re certain it’s the nose alone that is involved and not other bones. For example, it’s not uncommon for the orbit (bones around the eye) to be fractured at the same time if enough force is applied. This can cause some significant vision problems if unrecognized and untreated.

Bones in the face heal differently than any other bones in the body. When you break your arm, the fracture heals with new bone, making a solid connection that is often stronger than the original bone. Bones of the face (except for the mandible or jawbone) heal by what’s called fibrous union which means that the bones do not fuse with new bone, instead a nasal bone that breaks is always broken. It heals with thick scar tissue (collagen) which holds the bones together. This is nearly as strong as the original bone and actually provides some “give” for repeat trauma to the area

Not healing with new bone has a few implications. First, you can always feel the fracture. The skin over the nose is very thin and even if the bones are lined up perfectly, you usually can feel the fracture line even if there is no Owen Wilson evidence of it. Second, when a nose breaks, it heals in the position to which it’s fractured. If it’s knocked to the side, it will heal to the side like the guys above. If it breaks but remains normal in appearance, it will heal without any significant deformity.

However, because of fibrous union, scar tissue remodels for a full year following a fracture. Therefore, as the scar tissue heals and contracts, it can pull the bones into or out of alignment slightly. That’s why even with plastic surgery, the cosmetic appearance of the nose 1 month after surgery is not exactly the same as it is 1 year later. Look at celebrity nose jobs and the media will often report that they have had 2 in the last year, whereas remodeling actually caused the slight changes over that time

When the nose is deviated out of position from a fracture, healing will cause the fibrous union process to start almost immediately. Sometimes there is quite a bit of swelling that makes the degree of deviation difficult to assess. One trick is to have the patient stand under a bright light. There should be a light reflection that runs down the bridge of their nose. If the reflection is crooked, the nose is probably crooked and if the light reflection is straight, the nose is probably straight and swelling is just making it look crooked. This is not an absolute rule, but holds true most of the time. In the pictures that follow, the light reflection has a gentle “c-shaped” curve to it on the left (pre-procedure photo) and it is straight on the right side after correction. The picture is taken from a plastic surgery site that you can visit by clicking on the picture itself. (This patient also had some tip work done to the nose–there was more than simple straightening involved.)
The way the nose breaks it very consistent with most fractures. Most tend to be from trauma directed from one side or the other, such as occurs when someone is punched. It is not as common to have direct trauma straight on, but this occurs with air bag deployment sometimes. The following is my poor man’s attempt to diagram how most fractures create a deformed appearance. If you consider looking at the nose like you’re looking up the nostrils, it very much resembles a pyramid. The outer struts are the bones and the midline strut is the septum or the wall that divides the two sides of the nose. There are 2 ways that the bones can fracture 1 & 2, with 2 being the most common I see. In 1, the entire pyramid is deviated to the L (pretend your looking up someone’s nostrils) and the R strut has been pushed a little down (depressed) compared to the L side. The septum is also slightly deviated. In 2, the R nasal bone fractures in the middle and is also depressed with the L bone elevated and shifted as well.
To fix this, we simply elevate the bone on the R (from inside the nose and lifting upward) while pushing from the L toward the R on the outside of the nose to reduce the fracture(s), or in other words, line up the bones back in the midline. There are no cuts or incisions needed if this is done in a timely fashion.

One major thing I think should be clarified is when to have the nose evaluated. There is a common misconception that you shouldn’t see the ENT for at least a week to give the nose some time for the swelling to go down and have a better idea if any residual cosmetic deformity is present. Since fibrous union starts to develop immediately, it becomes so strong that by 2 weeks out it is nearly possible to rearrange the bones without re-fracturing the nose. In my experience, this is actually quite difficult in some patients even a week out although most of the time it’s not terribly hard to reduce these fractures if done in the first 10 days following the trauma. Therefore, I like to see patients on the day of the fracture if possible, before swelling begins, or 3-5 days after the trauma. By that time, most of the major swelling has decreased enough that I can see if there’s a need for reduction. If for whatever reason 14 or more days pass without a reduction, because of the remodeling that occurs for 12 months afterward, it is better to hold on any rhinoplasty (formal cosmetic surgery to repair the nose) for a full year. In some situations, it may be appropriate to repair sooner, like at 6 months, but this can only be determined by your surgeon.

Just because the nose is broken, doesn’t mean surgery is needed. If the bones are non-displaced and no cosmetic deformity exists, there is nothing to do. Or if the cosmetic appearance doesn’t bother the patient like with Owen Wilson or Adam Foote, there is nothing that needs to be done.

Assuming no fractures occur outside of the nose itself, there are three emergencies of which to be aware. First, is obviously bleeding (epistaxis). Second, is an open fracture (where bone is exposed due to a laceration in the skin. Third, is a septal hematoma. Sometimes blood will collect between the lining of the nose and the nasal septum. This blood can cause permanent damage to the nasal septum not unlike a boxer or wrestler with a cauliflower ear. The cartilage can die from this and cause holes in the septum (septal peforations) or severe nasal obstruction due to a deviated septum. The first two problems should be readily apparent, but the 3rd may not be noticed unless you have a doctor look on the inside of the nose. So here are the take home points:

Once a nose is broken it will always be broken, but it’s important to try to fix it in the first 10 days if possible for the best chance of a good cosmetic outcome without the need for invasive surgery later on.

Nasal fractures can be associated with more significant fractures of the face, particularly the bones around the eye

If you are concerned about a nasal fracture, call the ENT office as soon as you know about it–if someone tells you to wait for a week before doing so, don’t. Call. We can tell you how soon you should come in.

Most fractures can be repaired without significant difficulty and without complications, but there are emergencies that may occur and need to be addressed to prevent serious complications

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