When is the Optimal Time to Reduce Pediatric Nasal Bone Fractures?

by By Sheng Zhou, MD, Marta Kulich, MD, Christopher Pool, MD, Javan Nation, MD, Shelby Leuin, MD, Jeffrey A. Koempel, MD, MBA, and Vijay A. Patel, MD •

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summary below includes the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.com.

BACKGROUND

Nasal bone fractures are the most common subsite of pediatric maxillofacial trauma (J Craniofac Surg. 2008;19:339–349), which affects older children and often results from physical altercations, falls, motor vehicle accidents, and sports-related injuries (J Craniofac Surg. 2012;23:1364–1366). The timing of operative repair has been well characterized in adults, but definitive practice guidelines for fracture reduction are lacking for children. Historically, nasal fractures have been reduced within seven days as pediatric patients are thought to undergo rapid osseous healing. Delayed nasal fracture reduction, however, allows soft tissue edema to abate, potentially aiding intraoperative result assessment. This comprehensive review aims to serve as a primer in understanding the current evidence surrounding optimal timing for pediatric nasal fracture repair.

Independent searches of the PubMed, MEDLINE, and Cochrane databases were performed on December 11, 2022, by the first and senior authors to identify articles that specifically described the timing of pediatric nasal fracture repair using the Boolean method and relevant search term combinations. Articles were sorted by best match without limitations on article type, text availability, or publication date. To identify additional articles, the reference lists of selected articles were individually searched as well as citing articles. This yielded a total of 213 unique hits, of which 26 articles were directly analyzed for further review. Excluded articles included studies with facial fractures other than nasal bone fractures and nontraumatic pediatric rhinology. The remaining articles were assessed to determine which studies described the direct impact of timing on postoperative outcomes following nasal fracture reduction, of which four studies were included for final analysis.

BEST PRACTICE

The available literature demonstrates that nasal fracture reduction within 14 days of injury may have comparable aesthetic results with operative intervention closer to the date of initial injury. Clinicians should be cognizant of relevant timelines when counseling children and families regarding available treatment options for nasal fracture injuries. Future prospective data collection and multi-institutional collaborations are necessary to better understand the long-term cosmetic and functional sequelae of pediatric nasal bone reduction and whether age plays a definitive role in treatment outcomes.

Although there is no evidence that one specific value determines surgical candidacy or precisely predicts postoperative pulmonary compromise, this assessment will inform the perioperative risk factors to aid in a shared treatment decision-making process. Ultimately, multi-institutional prospective studies are needed to better understand the role of preoperative testing in evaluating candidacy and pulmonary- related outcomes in patients undergoing open or endoscopic partial laryngeal surgery.