Management of nasal fractures has evolved substantially in recent decades. Whereas closed reduction of nasal fractures was frequently attempted in the past, then followed up by secondary open reduction when inadequate correction was noted, now most experienced rhinologists and otolaryngologists will be prepared to do a definitive open reduction of nasal and septal fractures as the primary correction with much more reliable functional results. The spectrum of injuries to the nose and septum have responded much better to early open correction and prevented late obstructive and crooked pyramid sequelae. This is the philosophy best taught in current training and is becoming an improved standard of care.

In the treatment of the displaced nose, closed reduction has traditionally been considered adequate management. Within the specialty of rhinology, however, closed reduction is acceptable in only the most minimally traumatized nose and nasal septum. There should be no hesitation in performing an open reduction of nasal and septal fractures if the closed reduction attempt is inadequate for straightening the nasal pyramid and restoring the intranasal respiration.

Timing of the repair is an inpatient consideration. Closed reductions may be successful in the first 10 days after trauma, but beyond that time, open reduction may be required to provide adequate alignment and repair of both nasal pyramid and septal structures because of potential healing in displaced positions.

Preoperative management of the typical patient with a nasal and septal fracture waiting for edema to resolve, prior to operative procedure, requires administering a prophylactic antibiotic, usually an oral cephalosporin, to diminish the risk of intranasal infections, especially if there have been mucosal tears. Analgesics may also be given to diminish discomfort in the acute postinjury phase.

Anesthesia for the nasal/septal reduction procedure, in the outpatient operating suite, can be selected as either IV analgesic or, for younger patients or challenging adults, general endotracheal anesthesia. In both situations, delicate and complete local anesthesia with a topical decongestant and infiltrated dilute Xylocaine with epinephrine solution is effective for vasoconstriction during the anatomic correction.

The cephalosporin antibiotics are administered IV at the time of the procedure and continued postoperatively orally, especially if light postoperative splinting or packing support is necessary.

In patients with confirmed septal dislocation and nasal fracture with displacement, the septum should first be explored surgically and realigned during the same procedure as the nasal pyramid so that reconstitution can be controlled in the operating room environment in order to promote good healing, alignment, and nasal respiration and to prevent bony malunion in a crooked position.

If present, a septal hematoma should be drained expeditiously to avoid sequelae such as absorption of septal cartilage with a resultant saddle nose deformity.