|Year : 2021 | Volume
| Issue : 11 | Page : 1674-1681
Etiology, pattern, and treatment of nose fractures: A 10-year cross-sectional cohort retrospective study
M Juncar1, PA Tent1, RI Juncar1, A Harangus2, M Rivis3
1 Department of Oral and Maxillo-Facial Surgery, University of Oradea, Cluj-Napoca, Romania
2 Department of Functional Genomics, Biomedicine and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
3 Department of Dental Medicine, Discipline of Oral Surgery, 2nd “Victor Babeş” University of Medicine and Pharmacy, Timisoara, Romania
|Date of Submission||28-Jan-2021|
|Date of Acceptance||06-Apr-2021|
|Date of Web Publication||15-Nov-2021|
Dr. P A Tent
Department of Oral and Maxillo-Facial Surgery, University of Oradea, Str. Pia?a 1 Decembrie, No. 10, 410073
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Determining the etiology, epidemiology, pattern, and treatment of nasal bone fractures and the associated soft tissue injuries in a population will be beneficial for the prevention, rapid and correct diagnosis, and adequate management of this pathology in order to minimize postoperative complications. Patients and Methods: This study retrospectively evaluated the patients admitted and treated for nasal bone fractures in a university clinic of oral and maxillofacial surgery in Romania over a 10-year period. Following statistical analysis, evaluation and correlation of the monitored variables, a P value < 0.05 was considered statistically significant. Results: Nasal bone fractures had the highest incidence among men (88.30%), aged 20–29 years (33.33%), with no education (33.33%), interpersonal violence being the main cause in this category of patients (P = 0.004; P = 0.005; P = 0.005). In urban environment (55.9%), nasal bone fractures through aggression and road traffic accidents were predominant, while in rural areas (44.10%), those caused by domestic accidents and animal attacks prevailed (P = 0.551). Nondisplaced (81.10%), closed (85.60%) and involving the nasal septum fractures (51.35%) were preponderant. Hematoma was the most frequent associated soft tissue injury (86.49%), its incidence being increased in the case of displaced (P = 1.000) and open fractures (P = 0.692). The most frequent treatment method was close nasal reduction (CNR) + closed septoplasty (51.35%). The most frequent complication was malunion (7.2%), secondary to CNR without septoplasty (P = 0.037). Conclusions: The main etiology of nasal bone fractures was interpersonal violence, which mainly affected men, aged 20–39 years, with a low level of education, living in urban areas. Implementing laws to fight interpersonal aggression and increase the education level of the population would lead to a considerable reduction in the incidence of this pathology. Patients treated by CNR + closed septoplasty and ORIF had the best postoperative evolution. Immediate septoplasty in the case of associated septal fractures significantly decreased the rate of postoperative complications.
Keywords: Clinical features, etiology, nasal bones, nose fractures, nose trauma, treatment
|How to cite this article:|
Juncar M, Tent P A, Juncar R I, Harangus A, Rivis M. Etiology, pattern, and treatment of nose fractures: A 10-year cross-sectional cohort retrospective study. Niger J Clin Pract 2021;24:1674-81
|How to cite this URL:|
Juncar M, Tent P A, Juncar R I, Harangus A, Rivis M. Etiology, pattern, and treatment of nose fractures: A 10-year cross-sectional cohort retrospective study. Niger J Clin Pract [serial online] 2021 [cited 2021 Nov 28];24:1674-81. Available from: https://www.njcponline.com/text.asp?2021/24/11/1674/330468
| Introduction|| |
The symmetry and suppleness of the nose have been considered characteristics of facial beauty and aesthetic appearance since ancient times. Through their prominence in the facial skeleton, nasal bones are more exposed to trauma, the incidence of fractures at this level being high. The etiology and epidemiology of nasal bone fractures differ significantly depending on the geographic area, living environment, and the social, cultural, educational, and economic context of the analyzed population. Given these discrepancies, periodic epidemiological studies are required in order to implement necessary means for preventing this pathology, redistributing financial resources in health care and ensuring high-quality public health.,,
The complexity of the cases varies depending on the etiology of the trauma, kinetic energy of the wounding agent, pattern of the fracture lines, involvement of the nasal septum, the number and trajectory of the associated fracture lines, and the presence of concomitant soft tissue injuries. Knowing the interrelation between the fracture pattern and the overlying soft tissue injuries is extremely important for establishing clinical diagnosis, triage, and complementary imaging investigation, which must lead to a proper treatment approach.,, The treatment of nasal bone fractures varies depending on the fracture pattern, involvement of the nasal septum, age, or the associated pathology of the patients, including both closed nasal reduction (CNR) and open reduction and internal fixation (ORIF), associated or not with septoplasty. Although nasal bone reduction often seems easy, the rates of postoperative complications (14–62%) and patient dissatisfaction (29%) are significantly high.,, Secondary septoplasty or rhinoseptoplasty has an increased incidence in these cases, reintervention rates between 14% and 50% being reported.,,, Given the literature contradictions related to the causes, clinical picture, and therapeutic success of nasal bone fractures, this study aimed to determine the etiology, epidemiology, and the pattern of nasal bone fractures in order to identify the main categories of affected patients. Another aim of the study was the statistical correlation between the fracture pattern and the type of associated overlying soft tissue injuries, in order to identify their interrelationship and provide rapid and correct clinical diagnosis. Also, we wanted to evaluate the main therapeutic methods and their effectiveness depending on the rate and type of postoperative complications. The results of this study will be used for implementing legislative norms in order to prevent nasal bone fractures, as well as in training the medical personnel for adequate management of this pathology.
| Subjects and Methods|| |
A 10-year retrospective evaluation of patients with nasal bone fractures from a university clinic of oral and maxillofacial surgery in Romania was performed.
The study was approved by the Ethics Committee of Oradea University, Romania (Irb No. 35768/19.01.2018). All patients included in this study signed an informed consent to the use of their medical data for scientific research. In the case of minor patients, the informed consent was signed by their parents. This study was approved by the Territorial Ethics Commission and was therefore performed in accordance with the ethical standards laid down in the 2008 Declaration of Helsinki and its later amendments.
The study inclusion criteria were at least one fracture line in the nasal bones, isolated nasal bones or associated with a naso-orbital-ethmoid (NOE) complex fracture, acute trauma episode history, up to 72 hours' time since the trauma, the presence of computed tomography (CT) confirming the clinical diagnosis of fracture and evidencing its location and characteristics, treatment performed in the study host institution, follow-up at least 8 weeks postoperatively.
Exclusion criteria were patient without fracture lines in the nasal bones, absence of CT imaging, treatment performed based on clinical or plain radiographic criteria and not based on CT, time since trauma more than 72 hours, associated facial bone fractures other than NOE complex, treatment performed in another service, absence of one or more variables monitored in this study from the medical records, absence of patient follow-up for at least 8 weeks postoperatively.
The data were extracted from the patients' medical records, the following variables divided into subgroups being monitored: patients' sex, age (by life decades), patients' living environment, level of education (no education—patients who did not complete the first grade of the primary cycle, the primary cycle—the highest level completed, the middle school cycle, high school, university education), type of traumatic etiology, degree of bone displacement, relationship of the fracture focus with the external environment, presence and type of associated soft tissue injuries, type of treatment, incidence, and type of postoperative complications. We mention that in this study, the following were considered as associated soft tissue injuries: hematoma, laceration, and excoriation. Posttraumatic edema was not considered to be an associated soft tissue injury in this study. It is part of the pathophysiology of trauma, accompanying in the majority of the cases any type of facial fracture or contusion. Therefore, its exclusion as a parameter in the statistical analysis of this study was considered, its relevance being insignificant in this context.
In order to prevent bias, the patients' medical records were double-checked by both the first author who collected the data and one member of the statistical department.
We achieved the size of this study due to the 10-year period over which the data were collected.
The data were centralized in electronic format using Microsoft Excel software. Descriptive statistics of the assessed cases was performed with a percent accuracy of two decimals. Statistical analysis was carried out with MedCalc Statistical Software version 17.2 (MedCalc Software bvba, Ostend, Belgium; 53 https://www.medcalc.org; 2017). Continuous data were expressed as mean and standard deviation, while nominal data were expressed as frequency and percentage. The comparisons of the frequencies of a nominal variable between the categories of another nominal variable were performed using the Chi-square test. The comparison of a continuous nominal variable between two groups was performed via the t-test for independent variables. A P value <0.05 was considered statistically significant.
This study was performed according to STROBE guidelines.
| Results|| |
Following evaluation of the medical records, 280 patients with trauma in the nasal region were identified in the studied time period. Of these, 169 patients were excluded from the study based on the following criteria: 43 patients had missing data regarding their living environment, 34 patients had missing data referring to their level of education, 40 patients had nasal bone fractures associated with other fractures than NOE complex fracture, 21 patients refused to be treated in our clinic, and 31 patients missed the postoperative follow-up of at least 8 weeks. The study inclusion criteria were met by 111 patients.
The majority of the patients with nasal bone fractures belonged to the 20–29-year age group, n = 37 (33.33%), followed by those aged 30–39 years, n = 24 (21.62%), 40–49 years, n = 17 (15.32%), 10–19 years, n = 12 (10.81%), 50–59 years, n = 9 (7.21%), 0–9 years, n = 5 (4.50%), 60–69 years, n = 5 (4.50%), and 70–79 years, n = 3 (2.70%).
Male patients were more affected, n = 98 (88.30%), compared to the female sex, n = 13 (11.70%). The M:F ratio = 7.54.
Regarding the living environment, patients from urban areas were more affected, n = 62 (55.90%), those living in rural areas representing a smaller proportion, n = 49 (44.10%).
Most of the patients with nasal bone fractures had no studies, n = 42 (36.90%), being followed by patients with high school education, n = 23 (20.70%), middle school education, n = 22 (19.80%), university education, n = 15 (11.70%), and primary cycle education, n = 9 (7.2%).
The most frequent cause of nasal bone fractures was interpersonal violence (IPV), n = 48 (43.24%), followed by road traffic accidents (RTA), n = 22 (19.82%), trauma by falling, n = 14 (12.61%), domestic accidents, n = 9 (8.11%), animal attacks, n = 8 (7.21%), sports injuries, n = 7 (6.31%), and work accidents, n = 3 (2.70%).
The majority of the patients had fractures with bone fragment displacement, n = 90 (81.10%), patients with nondisplaced fractures representing a small proportion, n = 21 (18.90%). Closed nasal bone fractures were predominant, n = 95 (85.60%), while there was a reduced number of open fractures, n = 16 (14.40%). Fifty-seven (51.35%) patients had both nasal bone and nasal septum fractures, 28 (25.22%) patients had nasal bone fractures only, 21 (18.90%) patients had nondisplaced nasal bone fractures and unfractured nasal septum, and 5 (4.53%) patients presented NOE complex fractures.
The most frequent associated soft tissue injury was hematoma, which was found in 96 (86.49%) patients, being followed by excoriation, n = 76 (68.48%), and laceration, n = 61 (54.95%).
The most common type of treatment used was CNR with closed septoplasty n = 57 (51.35%), conservative treatment n = 21 (18.90%), followed by CNR only n = 28 (25.23%) and ORIF n = 5 (4.51%). ORIF treatment was strictly performed in patients with NOE fractures. Of all patients, eight (7.2%) patients developed postoperative complications, seven patients developed malunion with secondary nasal asymmetry, and one patient developed nasal obstruction secondary to a septal fracture malunion. Six patients refused surgical reintervention. Rhinoplasty was performed in one patient with nasal asymmetry and septorhinoplasty was performed in the case of the patient with nasal obstruction. Two patients evolved without postoperative complications.
The traumatic etiology of the nasal bone fractures was correlated with the age group [Table 1]. Patients aged between 20 and 49 years more frequently had nasal bone fractures caused by IPV, patients aged 10–19 years more frequently suffered fractures in RTAs, and those aged over 49 years presented fractures of various other causes. These results were statistically significant.
|Table 1: Distribution of the types of traumatic etiology depending on age|
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[Table 2] shows the correlation of traumatic etiology with patients' sex, living environment, and level of education.
The correlation of the incidence of associated soft tissue injuries with the degree of bone displacement and the relationship with the external environment of the nasal fractures [Table 3] shows an increased incidence of all soft tissue injuries in the case of displaced and open fractures. [Table 4] evidences a high rate of postoperative complications associated with CNR treatment without septoplasty. Also, in this study, the rate of postoperative complications was directly proportional to the degree of displacement of the fractured bone fragments [Table 5].
|Table 2: Distribution of the types of traumatic etiology depending on sex, environment of origin, and level of education|
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|Table 3: Distribution of the types of associated soft tissue injuries depending on the bone displacement and the relationship with the external environment of the fracture site|
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|Table 4: Distribution of postoperative complications depending on the treatment method|
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|Table 5: Distribution of postoperative complications depending on the bone displacement and the relationship with the external environment of the fracture site|
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| Discussion|| |
In this study, the most affected age group was the 20–29-year age group, a result similar to those of other authors.,, In contrast, some authors indicate the highest incidence of nasal bone fractures in the 30–39-year decade,,,, while others report it to occur in the 10–19-year age group. Between 20–39 years of age, individuals are more active socially, professionally, and in sports, being considerably more exposed to trauma.,,,,
Most of the patients in the current study were men. This result is supported by other authors.,,,,,,,,
Nasal bone fractures were predominant in the urban environment, similarly to the results of other authors.,, This result is not surprising given the increased population density in urban areas, the differences between social classes and the discrepancies between people's level of education., These aspects are also emphasized by our results, most of the nasal bone fractures through IPV being predominant among individuals without education or with a low level of education. These results are supported by the studies of other authors who indicate a reduced incidence of IPV among subjects with university education., The absence of a qualification or higher education predisposes to unemployment, insufficient financial resources, and, especially, difficulties in accessing health care services., All this can lead to frustration, depression, predisposing to interpersonal conflicts., Nevertheless, in our study, IPV was the main etiological factor of nasal bone fractures in rural areas as well. This is unusual, being rarely found in the literature.,,, Although the highest incidence of IPV in this study was found among patients without education or with a low level of education, this was the main etiological factor in all the other categories, even among patients with university education. This result is in contradiction with the literature findings, signaling a major public health problem.
The main etiological factor of nasal bone fractures in this study was IPV, similarly to the reports of other authors.,,,, Contrary to our results, some authors report RTAs to be the main etiology,,, while others indicate fall,,, or sports injuries., These discrepancies vary from one region to another; for example, Hwang et al., in their review, report an increase of IPV in the case of nasal bone fractures in Asia, South America, and Europe, while in the USA nasal bone fractures caused by RTAs are predominant. In our study, IPV mainly affected the 20–49-year age group, the results being statistically significant. Byun et al. even indicate an increased incidence of IPV in school children and teenagers, the so-called school violence, raising a red flag regarding the difficulty of preventing this behavior. However, in our population, this behavior is currently controlled, IPV in the under 20-year age group having a low incidence. RTAs were the second cause of nasal bone fractures in this study, this etiology being found particularly among women. The low number of nasal bone fractures due to falls in this study can be explained by the small number of children and patients aged over 70 included, categories recognized for their risk to suffer injuries through this etiology. Nasal bone fractures caused by animal attacks, domestic or work accidents had a low incidence in this study and were mainly found in rural areas. This is in accordance with the literature.,,,,
In this study, displaced nasal bone fractures were predominant.,, In contrast, other authors indicate a high incidence of nondisplaced fractures., In our study, closed fractures were preponderant, the result being in line with the literature.,,,
This study and the results of other authors show the fact that the incidence and severity of associated soft tissue injuries are higher in the case of open and displaced fractures.,, In our study, the most frequent associated soft tissue injury was hematoma; in contrast, other authors indicate laceration as the most frequent injury.,,, Laceration in this study had a low incidence. The presence of nasal soft tissue laceration is more frequently associated with open, displaced, and comminuted fractures associated with nasal septum fractures and displacements.,,, Under these circumstances, the increased incidence of hematoma in our study can be an indicator of reduced severity of nasal trauma among our population. Knowing the interrelation between associated injuries and underlying fractures can help and guide the clinician in establishing a rapid clinical diagnosis. However, imaging investigations are required.,,,,,,, The current golden standard for the evaluation of nasal bone fractures is CT.,,,, Hwang et al. demonstrated in their systematic review the fact that CT examination currently has the highest specificity, sensitivity, and accuracy compared to ultrasonography and plain radiography.
The most frequent type of treatment used in our study was CNR with closed repositioning of the nasal septum, similarly to the findings of other authors., These results can be explained by a high incidence of associated septal fractures in our population. Other authors indicate a high incidence of CNR only in their results. In contrast, Davis and Chu recommend in their study open septorhinoplasty with ORIF in the case of all nasal bone fractures. These recommendations result from the significant rate of postoperative complications reported in the literature following CNR and from an increased incidence of up to 37–62% of open secondary reinterventions.,,,,,,,,, They state that nasal septum fractures or nasal bone fractures with concomitant septal deviation are impossible to reduce adequately by closed methods. Despite these radical statements, the complication rate in our study was low—eight (7.2%) patients. This shows that timely and adequate reduction of nasal bone fractures and realignment of the nasal septum to the median line ensures a stable healing, without major complications over time, even by closed methods. Hwang et al. and James et al. in their exhaustive reviews found no statistical differences between the incidence of complications secondary to CNR compared to ORIF. However, primary repositioning of the nasal septum is mandatory to prevent secondary nasal obstruction.,, This is also shown by our results. In our study, the rate of complications was directly proportional to the degree of displacement of the fractured fragments, without being dependent on the relationship with the external environment. These results are supported by other authors.,, In contrast, Yi et al. report a close connection between open fractures and the occurrence of postoperative complications. Nasal bone fractures were rarely treated by ORIF in this study, only when they were part of an NOE complex fracture. A similar approach was reported by other authors., The most frequent complication in this study was malunion, a result similar to those of other authors.,,, Corrective open septorhinoplasty is required in these cases in order to permeabilize the nasal fossae and restore facial symmetry. [8,16-18,28] This approach was also used in this study, patients having a favorable evolution. In nondisplaced fractures, conservative treatment with follow-up of up to 8 weeks is recommended., The fact that in our study no complications were reported after conservative treatment shows that the indications of this method were entirely respected.
The aim of this study was attained: the etiology, epidemiology, the clinical features, and the optimal treatment methods of nasal bone fractures were determined.
We can conclude that the most frequent cause of nasal bone fractures was IPV, the risk group including male patients from urban areas, aged 20–39 years, with a low level of education. Fighting IPV and educating the population would lead to a significant decrease of nasal bone fractures. The majority of the nasal bone fractures were displaced, closed, with the involvement of the nasal septum. The most frequent treatment method was CNR + closed septoplasty. The greatest number of postoperative complications occurred secondarily to CNR without septoplasty, the most frequent being malunion. Addressing septal nasal fractures immediately is mandatory regardless of the therapeutic method chosen to minimize the development of postoperative complications.
However, this study has a number of limitations. The most important of these is its retrospective nature; data may have been registered erroneously or incompletely in the medical records. To eliminate this possibility, we only selected complete records, but in this way, many cases were lost. Also, the results obtained following a retrospective study do not have the same impact as those obtained following a randomized controlled trial. Such a study will be required in the future to validate the results obtained. Regarding etiology, data may have been intentionally reported falsely by patients in order to avoid certain legal aspects. This frequently occurs in the case of IPV.
All authors had equal contribution in writing this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]