Fractured nose reduction
A broken (fractured) nose is the most common facial fracture. A blow to the nose can push the nasal bones — and often the septum — out of position, leaving the nose looking bent or flattened and frequently causing blockage on one or both sides.
An external reduction (also called a closed reduction or manipulation of the nasal bones) is a procedure to move the broken bones back towards their original position before they set. No cuts are made on the outside of the nose.
Part 1 — Before Your Surgery
Why Timing Matters
Swelling after an injury can hide the true shape of the nose. It usually takes about five to seven days for enough swelling to settle to judge whether the nose is genuinely displaced and whether surgery is needed.
The broken bones begin to knit within two to three weeks. Once they have set, they can no longer be moved by external reduction. The only option then is a formal septorhinoplasty, usually performed at least six months after the injury.
Assessment Before Surgery
- External examination of the nose and internal examination using a small telescope (nasal endoscopy). Photographs are taken.
- X-rays are generally not helpful and are not routinely needed. A CT scan is only required if there is concern about other facial fractures or an injury to the eye socket. You do not need to organise either of these prior to seeing Dr Roth.
- A photograph of yourself from before the injury is very useful — please bring one if you have one.
- Dr Roth will check for a septal haematoma (a collection of blood under the lining of the septum). This is uncommon but needs to be drained urgently, as it can permanently damage the cartilage.
Preparing for Your Operation
You will be given fasting instructions by the hospital. Please follow these exactly — your surgery will be cancelled if you have eaten or had anything to drink within the fasting period.
Where possible, avoid the following for two weeks before surgery: smoking, aspirin, ibuprofen, Nurofen, Naprosyn, Naprogesic, excessive alcohol, vitamin E, fish oil, garlic tablets, ginkgo biloba, ginseng, and horseradish. Because a fractured nose must be treated quickly there may not be two clear weeks available — please tell Dr Roth what you have taken rather than delaying your surgery.
Tell Dr Roth if you take a blood thinner such as warfarin, apixaban (Eliquis), rivaroxaban (Xarelto), or clopidogrel (Plavix, Iscover). Do not stop these medications yourself.
- You will need somebody to collect you from hospital, take you home, and stay with you for the first night.
- Please purchase your medications before the day of surgery, not afterwards.
What the Operation Involves
What This Operation Can and Cannot Achieve
The aim is to restore your nose as close as possible to the way it looked and worked before the injury. This is not a cosmetic rhinoplasty, and Medicare and health funds do not cover cosmetic changes as part of this procedure. Any bend or asymmetry that was present before the injury will still be there afterwards.
Even after a technically good reduction, some residual bend, asymmetry, or blocked breathing remains in a proportion of patients. Roughly one in five to one in three people go on to consider a formal septorhinoplasty at a later stage. A fracture that mainly involves the cartilage of the nose, rather than the bone, often cannot be fully corrected by external reduction alone.
Risks and Complications
Serious complications are uncommon. The following are worth being aware of.
The most common issue, and may lead to a later septorhinoplasty. Recurrence of the bend as swelling settles over the following weeks, or if the nose is knocked again before the bones have set, is also possible.
Common for the first few days and usually minor. Heavier bleeding occasionally requires a return to hospital.
Most often from a deviated septum that cannot be fully straightened during a closed reduction.
A collection of blood beneath the lining of the septum. Presents as sudden worsening blockage in the days after injury or surgery and requires urgent drainage.
Uncommon, and usually treated with antibiotics.
Numbness of the tip of the nose or the upper front teeth. Usually temporary and settles over weeks to months.
Skin irritation or a pressure mark from the external splint and tape. Settles once the splint is removed.
Including nausea and a sore throat from the breathing tube. Uncommonly, deep vein thrombosis, chest infection, or heart and lung complications.
Alternatives to Surgery
- Doing nothing — accepting the current shape of the nose and any blockage. A reasonable choice if the change is minor.
- Formal septorhinoplasty — performed at least six months after the injury. The necessary option if you present too late for a closed reduction, or if the deformity is largely cartilaginous.
Part 2 — After Your Surgery
Surgery of the nose is generally very safe. It is important to remember that significant healing is occurring inside your nose where you cannot see it, and this takes a number of weeks to settle.
Leaving Hospital
You will need somebody to collect you from the hospital and take you home. Most patients go home the same day; some may require an overnight stay.
Medications
A saline spray such as FESS keeps the inside of the nose moist and softens crusts and dried blood. Use three sprays in each nostril several times a day.
A large-volume rinse (NeilMed Sinus Rinse or Flo Sinus Rinse) may be started after the first few days if the nose is very crusty. Always use gently — high volume, not high pressure. Use boiled water that has been allowed to cool, or sterile water. Keep rinse bottles dry after use, store them with the lid off, and clean them regularly.
Most patients need only simple pain relief. Take two 500mg paracetamol (Panadol) tablets four times a day, regularly rather than waiting for pain to build up.
Ibuprofen may be added if you have no reason to avoid it. Do not take ibuprofen together with meloxicam or celecoxib. A stronger tablet such as oxycodone may occasionally be prescribed for the first day or two — paracetamol can be taken in addition to this.
Antibiotics are only used routinely when internal splints or packing have been left inside your nose. Always complete the full course.
Optional — does not speed recovery. Improves breathing while the tissues are swollen and reduces oozing of blood. May be used every six hours but must be stopped after three days.
Your External Splint
- The splint stays on for approximately one week and is removed at your first post-operative appointment. Please do not remove it yourself.
- Keep the splint dry. You may shower, but keep your face and nose out of the water.
- If the splint starts to lift — which often happens if you become hot and sweaty — place some micropore tape over the top to re-attach it to the cheek skin, and let the rooms know.
- The shape of the external splint tells you nothing about the shape of the nose underneath. Please do not judge your result from it.
- If internal splints were placed, you may notice your ears popping or bubbling when you swallow. This settles once they are removed at approximately one week.
Bleeding
Expect some oozing and spotting of blood for the first few days. Older blood in the nose has a brown colour — this is normal. If brisk continuous bleeding occurs, follow these steps:
Swelling and Bruising
- Bruising around the eyes is common — usually at its worst two to three days after surgery and largely faded by two weeks.
- Swelling of the nose settles over several weeks. The final shape may take some months to declare itself — please be patient before judging your result.
- Expect your nose to feel congested, as though you have a cold. This is normal swelling of the air passages.
- Keep your head elevated at all times and sleep propped up on three or four pillows for the first week. Avoid leaning over.
- Use ice packs on the cheeks and under the eyes for the first 48 hours. Do not apply pressure to the nose itself.
At Home — Activity and Care
- Most patients need about one week off work. Allow longer if your work is physical.
- Do not blow your nose for one week. After that, gentle nose blowing is permitted.
- If you need to sneeze, open your mouth widely to release most of the force.
- Avoid straining, heavy lifting, straining on the toilet, and physical exertion.
- Avoid things that make you flushed — hot and spicy meals, large meals, alcohol, and steaming hot showers — as these can start the nose bleeding.
- Do not rub or pick your nose.
- Do not smoke — it slows wound healing.
- Avoid exercise and any aerobic activity for two weeks.
- Avoid swimming for two weeks.
- Avoid contact sport and any activity that risks a knock to the nose for six weeks. The bones are not fully set before then and can easily be displaced again. A face guard or helmet is sensible when you return.
- Avoid the sun and accidental knocks for eight weeks.
- Avoid resting glasses on the bridge of your nose for four weeks after the splint is removed. Tape them to your forehead or use a nose support device such as the one at www.nosecomfort.com.
- There is no danger in flying, but it is best to wait seven days so you are not travelling at the point when a nosebleed is most likely.
Pain
This procedure is usually not particularly painful, though this varies. Discomfort may be felt in the ears, face, or teeth, and some patients have a sore throat from the breathing tube. Most pain settles after two to three days. Pressure from dried blood or mucus in the nose can be uncomfortable — saline spray helps to clear this and improves both pain and breathing. Pain is best managed with regular pain medication rather than allowing it to build up.
Follow-up
- One week — external splint and any internal splints are removed. Follow-up is essential.
- Six weeks — final shape and breathing are assessed once the swelling has settled.
- You can drive yourself to these visits and do not need to take pain relief beforehand.
Contact Dr Roth at once if you experience any of the following
- A fever of more than 38.5°C
- Bleeding that will not settle with the measures above
- Severe or increasing pain, or a nose that becomes rapidly and completely blocked in the first few days — this can indicate a septal haematoma, which needs urgent treatment
- Increasing redness of the skin over the nose
- A clear watery discharge from the nose that will not stop
- Any concern about your recovery
If it is out of business hours and you need urgent care, please attend your nearest emergency department or GP. If your surgery was performed at Wyvern Private Hospital or North Shore Private Hospital, you may also contact the ward nursing staff, who are available 24 hours a day. Note that these hospitals do not have an emergency department, have no medical staff on site overnight, and cannot provide assistance in the case of emergencies once you have left the hospital.
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
View full profile
