 Introduction: Nasal bone fracture occurs due to its vulnerable position and reduced biomechanical resistance to traumas. If not timely treated, it can result in permanent functional and esthetic damage. Methods: A retrospective and cross-sectional study conducted on 91 patients above 17 years of age with nasal bone fractures in the Department of Otorhinolaryngology and Head and Neck surgery of a tertiary care hospital in Kavre. Results: Road traffic accident was the most common cause of fracture (45.1%) followed by fall (36.3%), violence (13.2%), sports-related accidents (4.4%) and occupational accidents (1.1%). Class I fracture was seen in 70 (76.9%), Class II in 17 (18.7%), and Class III in 4 (4.4%). A closed reduction procedure was performed in 74 (81.30%) of the cases, closed reduction with septoplasty was done in 10 (11%), closed reduction with augmentation rhinoplasty was performed for 3 (3.3%), closed reduction with inferior turbinoplasty was required in 3 (3.3%) whereas closed reduction with debridement was done in 1(1.1%). Conclusion: Nasal bone fracture is a complex clinical issue which needs to be addressed early. Violence prevention programs along with drinking and driving campaigns need to be more strengthened to decrease the alarmingly high frequency of nasal bone fracture in the current scenario

Abha Kiran KC

Ashish Dhakal

Krishna Sundar Shrestha

Manish Neupane

Monika Pokharel

Pradeep Rajbhandari

Subindra Karki

Journal of Lumbini Medical College

&nbsp;Introduction: Nasal bone fracture occurs due to its vulnerable position and reduced biomechanical resistance to traumas. If not timely treated, it can result in permanent functional and esthetic damage. Methods: A retrospective and cross-sectional study conducted on 91 patients above 17 years of age with nasal bone fractures in the Department of Otorhinolaryngology and Head and Neck surgery of a tertiary care hospital in Kavre. Results: Road traffic accident was the most common cause of fracture (45.1%) followed by fall (36.3%), violence (13.2%), sports-related accidents (4.4%) and occupational accidents (1.1%). Class I fracture was seen in 70 (76.9%), Class II in 17 (18.7%), and Class III in 4 (4.4%). A closed reduction procedure was performed in 74 (81.30%) of the cases, closed reduction with septoplasty was done in 10 (11%), closed reduction with augmentation rhinoplasty was performed for 3 (3.3%), closed reduction with inferior turbinoplasty was required in 3 (3.3%) whereas closed reduction with debridement was done in 1(1.1%). Conclusion: Nasal bone fracture is a complex clinical issue which needs to be addressed early. Violence prevention programs along with drinking and driving campaigns need to be more strengthened to decrease the alarmingly high frequency of nasal bone fracture in the current scenario

Pokharel, Monika

Karki, Subindra

Dhakal, Ashish

KC, Abha Kiran

Shrestha, Krishna Sundar

Rajbhandari, Pradeep

Neupane, Manish

Journal of Lumbini Medical College (JLMC)

J. Lumbini. Med. Coll. Vol 9, No 1, Jan-June 2021Pokharel M, et al. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepaljlmc.edu.np___________________________________________________________________________________Submitted: 24 March, 2021Accepted: 03 June, 2021Published: 20 June, 2021a- Associate Professor, Department of Otorhinolaryngology and HNSb- Associate Professor, Department of Radiodiagnosis and Imagingc- Assistant Professor, Department of Otorhinolaryngology and HNSd- Lecturer, Department of Otorhinolaryngology and HNSe- Medical Officer, Department of Otorhinolaryngology and HNSf- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel, Kavre, Nepal.Corresponding Author:Monika Pokharele-mail: monikapokharel2020@gmail.comORCID: https://orcid.org/0000-0002-9298-5534_______________________________________________________ ABSTRACT:Introduction: Nasal bone fracture occurs due to its vulnerable position and reduced biomechanical resistance to traumas. If not timely treated, it can result in permanent functional and esthetic damage. Methods: A retrospective and cross-sectional study conducted in 91 patients above 17 years of age with nasal bone fractures in the Department of Otorhinolaryngology and Head and Neck surgery of a tertiary care hospital in Kavre. Results: Road traffic accident was the most common cause of fracture (45.1%) followed by fall (36.3%), violence (13.2%), sports related accidents (4.4%) and occupational accidents (1.1%). Class I fracture was seen in 70 (76.9%), Class II in 17 (18.7%) and Class III in 4 (4.4%). A closed reduction procedure was performed in 74 (81.30%) of the cases, closed reduction with septoplasty was done in 10 (11%), closed reduction with augmentation rhinoplasty was performed for 3 (3.3%), closed reduction with inferior turbinoplasty was required in 3 (3.3%) whereas closed reduction with debridement was done in 1(1.1%). Conclusion: Nasal bone fracture is a complex clinical issue which needs to be addressed early. Violence prevention programs along with drinking and driving campaigns need to be more strengthened to decrease the alarmingly high frequency of nasal bone fracture in the current scenario.Keywords: Closed reduction; Complication; Nasal bone fractureOriginal Research Articlehttps://doi.org/10.22502/jlmc.v9i1.426Monika Pokharel,a,f Subindra Karki,b,f Ashish Dhakal,c,f Abha Kiran KC,d,f Krishna Sundar Shrestha,d,f Pradeep Rajbhandari,d,f Manish Neupane e,fA Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of NepalHow to cite this article:Pokharel M, Karki S, Dhakal A, KC AK, Shrestha KS, Rajbhandari P, Neupane M. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepal. Journal of Lumbini Medical College. 2021;9(1):5 pages. DOI: https://doi.org/10.22502/jlmc.v9i1.426. Epub: June 20, 2021.Licensed under CC BY 4.0 International License which permits use, distribution and reproduction in any medium, provided the original work is properly cited.INTRODUCTION: The nasal bone is commonly fractured due to its vulnerable position and reduced biomechanical resistance to traumas, fracturing even as a result of the action of wounding agents that develop low intensity kinetic energy.[1] Nasal bone fracture is the most common facial fracture, accounting for approximately 40% of all facial fractures.[2]If not properly and timely treated, nasal bone fractures can result in permanent functional and esthetic damage, lead to complications in the upper airway,[3] and necessitate septoplasty or augmentation rhinoplasty. It can also affect social activities and may result in economic and psychological problems.[4] There is paucity of data relating to nasal bone fractures in our region. Hence, the aim of this study is to analyze the socio-demographic factors, etiology and patterns of nasal bone fractures. Understanding about the patterns, etiology and complications can help the health planners and policy makers to specifically address the burden of nasal bone fractures. J. Lumbini. Med. Coll. Vol 9, No 1, Jan-June 2021Pokharel M, et al. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepaljlmc.edu.npMETHODS: This was a retrospective, cross-sectional study conducted in the Department of Otorhinolaryngology and Head & Neck Surgery at the Kathmandu University Dhulikhel Hospital between January 2010 to January 2020. The study population consisted of 91 adult patients more than 17 years with nasal bone fractures. Patients were excluded if they were < =17 years, were pregnant or had undisplaced fractures which did not require correction. Patients who had Le Fort fractures, zygomaticomaxillary complex fractures, dentoalveolar fractures or mandibular fractures, previous facial fractures or aesthetic surgeries were also excluded. Similarly, patients with acute rhinosinusitis, malignancy of the nose and paranasal sinuses, soft tissue injuries were also not enrolled. The age, gender, etiology, associated injuries, type of fracture and treatment offered, alcohol intoxication, time elapsed after fracture until surgery, presenting symptoms, drug abuse were recorded. Etiologies of fractures were grouped into road traffic collisions, fall, violence, sports accidents and occupational accidents. A detailed clinical data proforma was filled up.  In addition, assessment was done by using plain radiographs of the nasal bone in lateral view. In 48 patients, computed tomography scan of the nose, paranasal sinuses and the facial skeleton were taken for effective preoperative evaluations and to confirm the clinical diagnosis.  From the axial scan, a three dimensional reconstruction was performed using the Syngo via software using a volume and surface rendering technique in Siemens somatom perspective 128 slice Computed tomography scanner. Nasal fractures were classified according to the Harrison’s classification system into three categories depending on the degree of damage as Class 1, Class 2 and Class 3 fractures. Depressed fracture of nasal bone where very little force is sufficient to cause a fracture was defined as Class 1- Chevallet fracture. Fracture causing significant amount of cosmetic deformity in which not only the nasal bones were fractured, but the underlying frontonasal process of maxilla was also fractured and the fracture line involved the nasal septum was defined as Class 2.Then orbitoethmoid fractures caused by high velocity trauma causing the most severe nasal injuries were defined as Class 3 fractures.[5]In the current study, open reduction under general anesthesia was performed for more accurate nasal bone reduction and intraoperative pain reduction. All patients except for the type I group underwent closed reduction with external nasal splinting under general anesthesia. Intravenous antibiotics were prescribed and antiseptic impregnated ribbon gauze packing was done for two days. External nasal splint was applied to all patients for a total of 10 days. Statistical analysis was performed using the IBM SPSS software (version 22.0; IBM Corp., Armonk, NY, USA).  Ethical approval was granted by Kathmandu University School of Medical Sciences Institutional Review Committee (No.-139/20)RESULTS: Of the 91 patients, 65 (71.4%)were males and 26 (28.6%)were females. The mean age of patients was 30.1±11.2 years (range:18-73 years). Table 1 shows the socio-demographic characteristics of the patients.Table 1. Sociodemographic characteristics of the study population (N=91). Variables Frequency (%)Sex Male 65 (71.4)Female 26 (28.6)Alcohol intake at presentationYes 43(47.3)No 48(52.7)  Road traffic accident was the most common cause of fracture (45.1%) followed by fall (36.3%),violence (13.2%), sports related accidents (4.4%) and occupational accidents (1.1%) as shown in Table 2. Our findings showed that physical assault was the most common cause of nasal bone fracture among people in their twenties, with its frequency decreasing with increase in age. Similarly, we also observed a striking decrease in the frequency of sports-related fractures among patients aged 40 years and above. In the age group analysis, the most J. Lumbini. Med. Coll. Vol 9, No 1, Jan-June 2021Pokharel M, et al. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepaljlmc.edu.npcommon age group involved was 21-30 years. Class I fracture was seen in 70 (76.9%), Class II in 17 (18.7%) and class III in 4 (4.4%). Altogether 43 (47.3%) of patients who presented with fractures were under the influence of alcohol as shown in Table 2. Sixty four (70.3%) patients presented in <3 days, 18 (19.8%) presented within 3 days to 1 week, 2 (2.2%) in more than 1 week to 2 weeks,  2 (2.2%) in  >2 weeks to 3 weeks and 5 (5.5%) presented in >3 weeks. A closed reduction procedure was performed in 74 (81.3%) of the cases, closed reduction with septoplasty was done in 10 (11%), closed reduction with augmentation rhinoplasty was performed for 3 (3.3%), closed reduction with inferior turbinoplasty was required in 3 (3.3%) whereas closed reduction with debridement was done in 1(1.1%). The various complications that occurred in our patients are depicted in Table 3. Table 3. Complications occurring in patients with nasal bone fractures.Complication Class 1 Class 2 Class 3 TotalHump nose 6 10 1 17 (18.7%)Saddle nose 1 0 4 5 (5.4%)Nasal widening8 1 1 10 (10.9%)Deviated nasal septum13 3 0 16 (17.5%)Hyposmia 12 2 1 15 (16.5%)Pain 44 12 2 58 (63.7%)Scar formation18 15 3 36 (39.6%)DISCUSSION: The objective of this study was to analyze the socio-demographic factors, etiology and patterns of nasal bone fractures. In the present study, there was male preponderance in all age groups. This may be attributable to the fact that males are more exposed to activities such as drinking, driving, and physical assault which entail a high risk of fracture as compared to females. Also, more social freedom given to men as compared to women may be a contributory factor for the same especially in a conservative country like ours. Our findings are comparable to previous studies.[6,7] We found that patients in their twenties showed the highest incidence of fracture, with the frequency gradually decreasing with increase in age. This result is also consistent with the findings of a previous study.[7] People in the age group of 20–29 years are often exposed to trauma because of their high levels of physical and social activities thus resulting in increase in their chances of being exposed to trauma and hence nasal bone fracture. However, our findings are different from another study which has reported an increasing rate of fractures in the elderly.[8] Our findings showed that physical assault was the most common cause of nasal bone fracture among people in their twenties, with its frequency decreasing with increase in age. Similarly, we also observed a striking decrease in the frequency of sports-related fractures among patients aged 40 years and above. This may be explained due to the fact that younger aged individuals are more involved in physical and interpersonal activity under the influence of alcohol.  Surveys of facial injuries have shown that the etiology of fractures varies from one country to another and also within the same country depending on the prevailing socioeconomic, cultural and environmental factors.[9,10] In our study, road traffic accident was the most common cause of fracture followed by fall and violence. Sports related accidents and occupational accidents constituted a minority.This is in accordance with other studies.Table 2. Relationship between etiology of fracture and alcohol consumption during the time of occurrence of fracture.Alcohol intake                                                 Etiology TotalRoad traffic collisionFall Violence Sports related traumaOccupational traumaYes 32 (74.4%) 4 (9.3%) 7 (16.3%) 0 (0%) 0 (0%) 43(47.3%)No 9 (18.8%) 29 (60.4%) 5 (10.4%) 4 (8.3%) 1 (2.1%) 48 (52.7%)Total 41 (45.1%) 33 (36.3%) 12 13.2%) 4 (4.4%) 1 (1.1%) 91 (100%)J. Lumbini. Med. Coll. Vol 9, No 1, Jan-June 2021Pokharel M, et al. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepaljlmc.edu.np[11,12,13] However, some other authors have reported the most common cause of facial fracture as assault or fall.[8,14,15] There may be many factors associated with increase in the rate of road traffic accidents in Nepal like violation of the traffic rules, unsuitable road conditions, use of alcohol or other intoxicating agents. Also, people in the villages climb mountains and trees to get leaves to feed their livestock which may be the reason for fall. Other than these reasons, the violence between people is also common in many societies due to consumption of alcohol and drugs.Our study also has some limitations.Since it is a single centered study,our findings cannot be generalized. Another potential limitation is the retrospective nature of study. Moreover, this study excluded patients with a nasal bone fracture who received conservative treatment and were not admitted to the hospital. Also, those who belonged to pediatric age groups were excluded which explains the moderate sample size in our study.CONCLUSION: Nasal bone fracture is a complex clinical issue which needs to be addressed early. Reduction and alignment of nasal bone fracture should be carried out within 2-3 weeks time. Acute saddling may require early surgical intervention in order to restore the septal height for good aesthetic purpose. Our findings suggest that violence prevention programs along with drinking and driving campaigns need to be more strengthened to decrease the alarmingly high frequency of nasal bone fracture in the current scenario.ACKNOWLEDGEMENT:Dr. Laxmi Khadka.CONFLICT OF INTEREST: The authors declare that no competing interests existSOURCE OF FUNDS: No fund was requestedREFERENCES:1. Hyman DA, Saha S, Nayar HS, Doyle JF, Agarwal SK, ChaietSR. Patterns of Facial Fractures and Protective Device Use in Motor Vehicle Collisions From 2007 to 2012. JAMA Facial Plast Surg. 2016;18(6):455-61.PMID: 27441732 DOI: https://doi.org/10.1001/jamafacial.2016.07332. Kucik CJ, Clenney T, Phelan J. Management of acute nasal fractures. AmFam Physician. 2004;70(7):1315-20. PMID: 155085433. Hashim H, Iqbal S. Motorcycle accident is the main cause of maxillofacial injuries in the Penang Mainland, Malaysia. Dent Traumatol. 2011;27(1):19-22. PMID: 21244625 DOI: https://doi.org/10.1111/j.1600-9657.2010.00958.x4. Miloro M, Ghali GE, Larsen PE, Waite PD. Peterson’s Principles of Oral and Maxillofacial Surgery. vol. 1. 2nd ed. Hamilton: BC Decker Inc; 2004. Available from: 5. Harrison DH. Nasal injuries: their pathogenesis and treatment. Br J Plast Surg. 1979;32(1):57-64. PMID: 427309 DOI: https://doi.org/10.1016/0007-1226(79)90063-86. Maliska MC, Lima Júnior SM, Gil JN. Analysis of 185 maxillofacial fractures in the state of Santa Catarina, Brazil.Braz Oral Res. 2009;23(3):268-74. PMID: 19893961 DOI: https://doi.org/10.1590/s1806-832420090003000087. Kang BH, Kang HS, Han JJ, Jung S, Park HJ, Oh HK, et al. A retrospective clinical investigation for the effectiveness of closed reduction on nasal bone fracture.MaxillofacPlastReconstr Surg. 2019;41(1):53. PMID: 3182489 DOI:https://doi.org/10.1186/s40902-019-0236-y8. Jeon EG, Jung DY, Lee JS, Seol GJ, Choi SY, Paeng JY et al. Maxillofacial Trauma Trends at a Tertiary Care Hospital: A Retrospective Study. MaxillofacPlastReconstr Surg. 2014;36(6):253-8. PMID: 27489843 DOI: https://doi.org/10.14402/jkamprs.2014.36.6.2539. Hogg NJ, Stewart TC, Armstrong JE, Girotti MJ. Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma. 2000;49(3):425-32. PMID: 11003318 DOI: https://doi.org/10.1097/00005373-200009000-0000710. Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer J. Lumbini. Med. Coll. Vol 9, No 1, Jan-June 2021Pokharel M, et al. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepaljlmc.edu.npH. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillafac Surg. 2003;31(1):51-61. PMID: 12553928 DOI: https://doi.org/10.1016/s1010-5182(02)00168-311. Morris C, Bebeau NP, Brockhoff H, Tandon R, Tiwana P. Mandibular fractures: an analysis of the epidemiology and patterns of injury in 4,143 fractures. J Oral Maxillofac Surg. 2015;73(5):951.e1-951.e12. PMID: 25883009 DOI: https://doi.org/10.1016/j.joms.2015.01.00112. vanBeek GJ, Merkx CA. Changes in the pattern of fractures of the maxillofacial skeleton. IntJ Oral Maxillofac Surg. 1999;28(6):424-8. PMID: 10609743 DOI: https://doi.org/10.1034/j.1399-0020.1999.280605.x13. Ugboko VI, Odusanya SA, Fagade OO. Maxillofacial fractures in a semi-urban Nigerian teaching hospital. A review of 442 cases.IntJ Oral Maxillofac Surg. 1998;27(4):286-9. PMID: 9698176 DOI: https://doi.org/10.1016/s0901-5027(05)80616-214. Brook IM, Wood N. Aetiology and incidence of facial fractures in adults. Int J Oral Surg. 1983;12(5):293-8.PMID: 6420354 DOI: https://doi.org/10.1016/s0300-9785(83)80016-715. Ellis E, el-Attar A, Moos KF. An analysis of 2,067 cases of zygomatico-orbital fracture. J Oral MaxillofacSurg. 1985;43(6):417- 28.PMID: 3858478 DOI: https://doi.org/10.1016/s0278-2391(85)80049-5

English

A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepal

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J. Lumbini. Med. Coll. Vol 9, No 1, Jan-June 2021
Pokharel M, et al. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepal
jlmc.edu.np
___________________________________________________________________________________
Submitted: 24 March, 2021
Accepted: 03 June, 2021
Published: 20 June, 2021
a- Associate Professor, Department of Otorhinolaryngology and HNS
b- Associate Professor, Department of Radiodiagnosis and Imaging
c- Assistant Professor, Department of Otorhinolaryngology and HNS
d- Lecturer, Department of Otorhinolaryngology and HNS
e- Medical Officer, Department of Otorhinolaryngology and HNS
f- Kathmandu University School of Medical Sciences, Dhulikhel 
Hospital, Dhulikhel, Kavre, Nepal.
Corresponding Author:
Monika Pokharel
e-mail: monikapokharel2020@gmail.com
ORCID: https://orcid.org/0000-0002-9298-5534_______________________________________________________ 
ABSTRACT:
Introduction: Nasal bone fracture occurs due to its vulnerable position and reduced biomechanical resistance 
to traumas. If not timely treated, it can result in permanent functional and esthetic damage. Methods: A 
retrospective and cross-sectional study conducted in 91 patients above 17 years of age with nasal bone 
fractures in the Department of Otorhinolaryngology and Head and Neck surgery of a tertiary care hospital 
in Kavre. Results: Road traffic accident was the most common cause of fracture (45.1%) followed by 
fall (36.3%), violence (13.2%), sports related accidents (4.4%) and occupational accidents (1.1%). Class 
I fracture was seen in 70 (76.9%), Class II in 17 (18.7%) and Class III in 4 (4.4%). A closed reduction 
procedure was performed in 74 (81.30%) of the cases, closed reduction with septoplasty was done in 10 
(11%), closed reduction with augmentation rhinoplasty was performed for 3 (3.3%), closed reduction with 
inferior turbinoplasty was required in 3 (3.3%) whereas closed reduction with debridement was done in 
1(1.1%). Conclusion: Nasal bone fracture is a complex clinical issue which needs to be addressed early. 
Violence prevention programs along with drinking and driving campaigns need to be more strengthened to 
decrease the alarmingly high frequency of nasal bone fracture in the current scenario.
Keywords: Closed reduction; Complication; Nasal bone fracture
Original Research Articlehttps://doi.org/10.22502/jlmc.v9i1.426
Monika Pokharel,a,f Subindra Karki,b,f Ashish Dhakal,c,f Abha Kiran KC,d,f 
Krishna Sundar Shrestha,d,f Pradeep Rajbhandari,d,f Manish Neupane e,f
A Ten-year Retrospective Study of Nasal Bone 
Fractures at a Tertiary Care Hospital of Nepal
How to cite this article:
Pokharel M, Karki S, Dhakal A, KC AK, Shrestha KS, Rajbhandari P, 
Neupane M. A Ten-year Retrospective Study of Nasal Bone Fractures 
at a Tertiary Care Hospital of Nepal. Journal of Lumbini Medical 
College. 2021;9(1):5 pages. DOI: https://doi.org/10.22502/jlmc.
v9i1.426. Epub: June 20, 2021.
Licensed under CC BY 4.0 International License 
which permits use, distribution and reproduction in any 
medium, provided the original work is properly cited.
INTRODUCTION:
 The nasal bone is commonly fractured due to 
its vulnerable position and reduced biomechanical 
resistance to traumas, fracturing even as a result 
of the action of wounding agents that develop low 
intensity kinetic energy.[1] Nasal bone fracture is 
the most common facial fracture, accounting for 
approximately 40% of all facial fractures.[2]
If not properly and timely treated, nasal bone 
fractures can result in permanent functional and 
esthetic damage, lead to complications in the 
upper airway,[3] and necessitate septoplasty 
or augmentation rhinoplasty. It can also affect 
social activities and may result in economic and 
psychological problems.[4] There is paucity of 
data relating to nasal bone fractures in our region. 
Hence, the aim of this study is to analyze the socio-
demographic factors, etiology and patterns of nasal 
bone fractures. Understanding about the patterns, 
etiology and complications can help the health 
planners and policy makers to specifically address 
the burden of nasal bone fractures. 
J. Lumbini. Med. Coll. Vol 9, No 1, Jan-June 2021
Pokharel M, et al. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepal
jlmc.edu.np
METHODS:
 This was a retrospective, cross-sectional study 
conducted in the Department of Otorhinolaryngology 
and Head & Neck Surgery at the Kathmandu 
University Dhulikhel Hospital between January 2010 
to January 2020. The study population consisted of 
91 adult patients more than 17 years with nasal bone 
fractures. Patients were excluded if they were < =17 
years, were pregnant or had undisplaced fractures 
which did not require correction. Patients who had 
Le Fort fractures, zygomaticomaxillary complex 
fractures, dentoalveolar fractures or mandibular 
fractures, previous facial fractures or aesthetic 
surgeries were also excluded. Similarly, patients 
with acute rhinosinusitis, malignancy of the nose 
and paranasal sinuses, soft tissue injuries were also 
not enrolled.
 The age, gender, etiology, associated 
injuries, type of fracture and treatment offered, 
alcohol intoxication, time elapsed after fracture until 
surgery, presenting symptoms, drug abuse were 
recorded. Etiologies of fractures were grouped into 
road traffic collisions, fall, violence, sports accidents 
and occupational accidents. A detailed clinical data 
proforma was filled up. 
 In addition, assessment was done by using 
plain radiographs of the nasal bone in lateral view. In 
48 patients, computed tomography scan of the nose, 
paranasal sinuses and the facial skeleton were taken 
for effective preoperative evaluations and to confirm 
the clinical diagnosis. 
 From the axial scan, a three dimensional 
reconstruction was performed using the Syngo via 
software using a volume and surface rendering 
technique in Siemens somatom perspective 128 slice 
Computed tomography scanner.
 Nasal fractures were classified according 
to the Harrison’s classification system into three 
categories depending on the degree of damage as 
Class 1, Class 2 and Class 3 fractures. Depressed 
fracture of nasal bone where very little force is 
sufficient to cause a fracture was defined as Class 
1- Chevallet fracture. Fracture causing significant 
amount of cosmetic deformity in which not only 
the nasal bones were fractured, but the underlying 
frontonasal process of maxilla was also fractured 
and the fracture line involved the nasal septum was 
defined as Class 2.Then orbitoethmoid fractures 
caused by high velocity trauma causing the most 
severe nasal injuries were defined as Class 3 
fractures.[5]
In the current study, open reduction under 
general anesthesia was performed for more accurate 
nasal bone reduction and intraoperative pain 
reduction. All patients except for the type I group 
underwent closed reduction with external nasal 
splinting under general anesthesia. Intravenous 
antibiotics were prescribed and antiseptic 
impregnated ribbon gauze packing was done for two 
days. External nasal splint was applied to all patients 
for a total of 10 days.
 Statistical analysis was performed using 
the IBM SPSS software (version 22.0; IBM Corp., 
Armonk, NY, USA). 
 Ethical approval was granted by Kathmandu 
University School of Medical Sciences Institutional 
Review Committee (No.-139/20)
RESULTS:
 Of the 91 patients, 65 (71.4%)were males and 
26 (28.6%)were females. The mean age of patients 
was 30.1±11.2 years (range:18-73 years). Table 1 
shows the socio-demographic characteristics of the 
patients.
Table 1. Sociodemographic characteristics of the 
study population (N=91). 
Variables Frequency (%)
Sex Male 65 (71.4)
Female 26 (28.6)
Alcohol intake at 
presentation
Yes 43(47.3)
No 48(52.7)
  Road traffic accident was the most common 
cause of fracture (45.1%) followed by fall 
(36.3%),violence (13.2%), sports related accidents 
(4.4%) and occupational accidents (1.1%) as shown 
in Table 2.
 Our findings showed that physical assault 
was the most common cause of nasal bone fracture 
among people in their twenties, with its frequency 
decreasing with increase in age. Similarly, we also 
observed a striking decrease in the frequency of 
sports-related fractures among patients aged 40 
years and above. In the age group analysis, the most 
J. Lumbini. Med. Coll. Vol 9, No 1, Jan-June 2021
Pokharel M, et al. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepal
jlmc.edu.np
common age group involved was 21-30 years. Class 
I fracture was seen in 70 (76.9%), Class II in 17 
(18.7%) and class III in 4 (4.4%). Altogether 43 
(47.3%) of patients who presented with fractures 
were under the influence of alcohol as shown in 
Table 2. Sixty four (70.3%) patients presented in <3 
days, 18 (19.8%) presented within 3 days to 1 week, 
2 (2.2%) in more than 1 week to 2 weeks,  2 (2.2%) 
in  >2 weeks to 3 weeks and 5 (5.5%) presented in >3 
weeks. A closed reduction procedure was performed 
in 74 (81.3%) of the cases, closed reduction with 
septoplasty was done in 10 (11%), closed reduction 
with augmentation rhinoplasty was performed for 3 
(3.3%), closed reduction with inferior turbinoplasty 
was required in 3 (3.3%) whereas closed reduction 
with debridement was done in 1(1.1%). The various 
complications that occurred in our patients are 
depicted in Table 3. 
Table 3. Complications occurring in patients with 
nasal bone fractures.
Complication Class 1 Class 2 Class 3 Total
Hump nose 6 10 1 17 
(18.7%)
Saddle nose 1 0 4 5 
(5.4%)
Nasal 
widening
8 1 1 10 
(10.9%)
Deviated 
nasal septum
13 3 0 16 
(17.5%)
Hyposmia 12 2 1 15 
(16.5%)
Pain 44 12 2 58 
(63.7%)
Scar 
formation
18 15 3 36 
(39.6%)
DISCUSSION:
 The objective of this study was to analyze 
the socio-demographic factors, etiology and patterns 
of nasal bone fractures. In the present study, there 
was male preponderance in all age groups. This 
may be attributable to the fact that males are more 
exposed to activities such as drinking, driving, 
and physical assault which entail a high risk of 
fracture as compared to females. Also, more social 
freedom given to men as compared to women may 
be a contributory factor for the same especially in 
a conservative country like ours. Our findings are 
comparable to previous studies.[6,7]
 We found that patients in their twenties 
showed the highest incidence of fracture, with the 
frequency gradually decreasing with increase in age. 
This result is also consistent with the findings of a 
previous study.[7]
 People in the age group of 20–29 years are 
often exposed to trauma because of their high levels 
of physical and social activities thus resulting in 
increase in their chances of being exposed to trauma 
and hence nasal bone fracture. However, our findings 
are different from another study which has reported 
an increasing rate of fractures in the elderly.[8]
 Our findings showed that physical assault 
was the most common cause of nasal bone fracture 
among people in their twenties, with its frequency 
decreasing with increase in age. Similarly, we also 
observed a striking decrease in the frequency of 
sports-related fractures among patients aged 40 
years and above. This may be explained due to the 
fact that younger aged individuals are more involved 
in physical and interpersonal activity under the 
influence of alcohol. 
 Surveys of facial injuries have shown that 
the etiology of fractures varies from one country to 
another and also within the same country depending 
on the prevailing socioeconomic, cultural and 
environmental factors.[9,10] In our study, road 
traffic accident was the most common cause of 
fracture followed by fall and violence. Sports related 
accidents and occupational accidents constituted a 
minority.This is in accordance with other studies.
Table 2. Relationship between etiology of fracture and alcohol consumption during the time of occurrence 
of fracture.
Alcohol intake                                                 Etiology Total
Road traffic 
collision
Fall Violence Sports related 
trauma
Occupational 
trauma
Yes 32 (74.4%) 4 (9.3%) 7 (16.3%) 0 (0%) 0 (0%) 43(47.3%)
No 9 (18.8%) 29 (60.4%) 5 (10.4%) 4 (8.3%) 1 (2.1%) 48 (52.7%)
Total 41 (45.1%) 33 (36.3%) 12 13.2%) 4 (4.4%) 1 (1.1%) 91 (100%)
J. Lumbini. Med. Coll. Vol 9, No 1, Jan-June 2021
Pokharel M, et al. A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepal
jlmc.edu.np
[11,12,13] However, some other authors have 
reported the most common cause of facial fracture as 
assault or fall.[8,14,15] There may be many factors 
associated with increase in the rate of road traffic 
accidents in Nepal like violation of the traffic rules, 
unsuitable road conditions, use of alcohol or other 
intoxicating agents. Also, people in the villages 
climb mountains and trees to get leaves to feed their 
livestock which may be the reason for fall. Other 
than these reasons, the violence between people is 
also common in many societies due to consumption 
of alcohol and drugs.
Our study also has some limitations.Since 
it is a single centered study,our findings cannot 
be generalized. Another potential limitation is 
the retrospective nature of study. Moreover, this 
study excluded patients with a nasal bone fracture 
who received conservative treatment and were not 
admitted to the hospital. Also, those who belonged to 
pediatric age groups were excluded which explains 
the moderate sample size in our study.
CONCLUSION:
 Nasal bone fracture is a complex clinical issue 
which needs to be addressed early. Reduction and 
alignment of nasal bone fracture should be carried 
out within 2-3 weeks time. Acute saddling may 
require early surgical intervention in order to restore 
the septal height for good aesthetic purpose. Our 
findings suggest that violence prevention programs 
along with drinking and driving campaigns need 
to be more strengthened to decrease the alarmingly 
high frequency of nasal bone fracture in the current 
scenario.
ACKNOWLEDGEMENT:
Dr. Laxmi Khadka.
CONFLICT OF INTEREST: The authors declare 
that no competing interests exist
SOURCE OF FUNDS: No fund was requested
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A Ten-year Retrospective Study of Nasal Bone Fractures at a Tertiary Care Hospital of Nepal

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