Endoscopic-assisted nasal bone reduction for nasal bone fracture as a practical outpatient approach: A retrospective case series

Abstract

Objective

This study aimed to evaluate the clinical efficacy and safety of endoscope-assisted nasal bone reduction performed in the outpatient clinic and determine whether this technique offers advantages over conventional closed reduction methods.

Methods

We conducted a retrospective review of 64 patients who underwent endoscope-assisted nasal bone reduction between May 2022 and December 2024 at a tertiary university hospital. Patient demographics, injury characteristics, surgical details, and postoperative outcomes were analyzed. Outcomes were assessed via clinical examination, facial computed tomography, and patient-reported satisfaction scores at 3 months postoperatively.

Results

All procedures were successfully performed under local anesthesia without the need for general anesthesia or conversion to open surgery. Direct endoscopic visualization allowed real-time confirmation of fracture reduction. At 3 months, 87.5% of the patients had achieved favorable nasal symmetry, and >80% reported “excellent” satisfaction. The revision rate was 14.1%, and the incidence of saddle nose deformity was 1.6%. No significant complications such as infection, persistent bleeding, or major deformities were observed.

Conclusions

Endoscope-assisted nasal bone reduction provides advantages over traditional closed reduction in terms of enhanced accuracy, improved patient satisfaction, and feasibility of early intervention in the outpatient setting.

Introduction

Nasal bone fractures represent the most common type of facial fractures, accounting for approximately 40% of all facial injuries, largely due to the prominent anatomical location of the nose. ¹ Closed reduction under local or general anesthesia remains the mainstay of treatment for acute nasal bone fractures. ² However, the conventional closed reduction technique—typically performed blindly using instruments such as Boies elevators and Freer elevators—has several critical limitations that often result in suboptimal treatment outcomes.^3–5

Objectively, a significant proportion of patients undergoing closed reduction experience residual deformity, nasal asymmetry, or persistent step-off deformities.^6,7 Subjectively, patient dissatisfaction with the cosmetic outcome is common, with reported satisfaction rates ranging from 62% to 91%. ² From the surgeon’s perspective, the procedural success rate is notably lower, ranging between 21% and 65%, largely due to the inherent limitations of performing the reduction in a blind manner—relying solely on tactile feedback without visual confirmation.^6,7 This lack of direct visualization often leads to uncertainty regarding the adequacy of fracture alignment, reducing the surgeon’s confidence during the procedure and ultimately diminishing surgical satisfaction. Furthermore, several studies have reported that up to 50% of patients who undergo closed reduction eventually pursue secondary rhinoplasty due to unsatisfactory aesthetic or functional results. ⁸

The timing of nasal bone reduction (NBR) is another pivotal factor in determining outcomes. Conventionally, it is recommended to delay the procedure until post-traumatic swelling has subsided—typically within 1–2 weeks—based on the assumption that reduced swelling allows for more accurate assessment and manipulation.^8,9 However, paradoxically, such delays may be detrimental. As time progresses, the onset of fibrotic tissue formation, malunion, and loss of fracture mobility significantly reduce the ability to achieve proper anatomical realignment. This paradox presents a particular challenge in conventional closed reduction techniques, which rely solely on external inspection and tactile feedback to assess the adequacy of fracture alignment. In the acute phase, when soft tissue swelling is maximal, these methods become unreliable—especially in anatomically difficult areas such as the base of the pyriform aperture. In the absence of visual confirmation, the surgeon must depend entirely on tactile feedback through edematous tissue, increasing the risk of undercorrection and residual deformity and contributing to surgical uncertainty and variable outcomes.^4,10 In addition, nasal bone fractures frequently extend to involve the frontal process of the maxilla, a structure that forms the lateral nasal wall and internal nasal valve region; in such cases, precise visualization and targeted reduction of these deep, anatomically constrained areas is critical for restoring both contour and airway support. ¹¹

To address these limitations—including the lack of visual confirmation, reliance on subjective tactile cues, and challenges posed by soft tissue swelling—we have introduced an endoscope-assisted NBR technique at our institution. Endoscopic guidance allows direct visualization of the fracture site, minimizes tissue trauma, and facilitates earlier, more precise intervention in the outpatient clinic.

The present study aimed to evaluate the clinical efficacy and safety of endoscope-assisted NBR performed in the outpatient clinic of a tertiary university hospital. We intended to determine whether this technique can improve patient satisfaction, reduce complications, and offer clinical advantages in early-stage nasal bone fracture management.

Materials and methods

This study was a retrospective case series conducted at Chungbuk National University Hospital between May 2022 and December 2024. The medical records of patients who underwent endoscope-assisted NBR were reviewed. The reporting of this retrospective observational case series conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. ¹² The study was approved by the Institutional Review Board of Chungbuk National University Hospital (No. 2025-04-025), and the requirement for individual informed consent was waived due to the retrospective study design. All patient data were deidentified prior to analysis. The study was conducted in accordance with the Declaration of Helsinki (1975), as revised in 2024.

Patients with isolated nasal bone fractures (International Classification of Diseases, 10th Revision (ICD-10) code S02.2), confirmed via physical examination and facial computed tomography (CT), were included. All consecutive patients were selected based on clinical and radiographic findings consistent with acute nasal bone fracture. Exclusion criteria included comminuted fractures involving the nasal septum and cases requiring open surgical approaches. For outcome analyses, patients without documented external appearance assessment findings at follow-up were not included in the cosmetic appearance analysis (n = 5).

Patient information was retrospectively reviewed from electronic medical records. Demographic data, including age and sex, were recorded. Clinical timelines were analyzed by measuring the interval between the initial trauma, first outpatient department visit, and day of NBR. Intraoperative details such as the use of nasal packing (none or absorbable materials) and the degree of bleeding were documented. Postoperative outcomes were assessed based on endoscope examination and facial CT scans performed 3 months after the procedure. Patient-reported outcomes were evaluated using a 4-point satisfaction scale (excellent, good, fair, and poor). Any postoperative complications, including asymmetry, saddle nose deformity, and the need for revision, were also recorded.

The procedure was consistently performed in an outpatient setting under local anesthesia. Endoscope-assisted NBR was performed using a 0° or 30° rigid nasal endoscope. After decongestion of the nasal mucosa using a cotton pledget soaked in a lidocaine (2%)–epinephrine (1:100,000) mixture, the undersurface of the nasal bone was visualized through the nasal cavity. The endoscope was inserted along the nasal floor and gently tilted upward to examine the fracture site, especially around the rhinion and pyriform aperture. After fracture alignment was visualized directly, instruments such as Boies and Freer elevators were used under endoscopic guidance to reposition the nasal bones. Reduction was confirmed visually in real time via endoscopy. The adequacy of reduction was judged by the elimination of step deformities and symmetry of nasal dorsum as visualized through the endoscope and externally. Palpation and visual inspection were used in combination. Nasal packing was used only if minor bleeding occurred post-reduction, and absorbable materials (e.g. Nasopore) were favored. External nasal splints were applied selectively based on the fracture type and post-reduction stability.

Postoperative evaluation included both clinical examination and radiological imaging (facial CT) at 3 months following the procedure. Subjective patient satisfaction was assessed during follow-up visits using a 4-point scale (excellent, good, fair, poor). The presence of postoperative complications, including bleeding, asymmetry, saddle nose deformities, and the need for revision, were also documented (Figure 1).

Figure 1.

A 66-year-old male patient with nasal bone fracture. (a) Axial computed tomography showing nasal bone fracture with inward depression near the rhinion area. (b) Preoperative nasal endoscopic view demonstrating depressed nasal bony vault in the right nasal cavity (arrow). (c) Nasal bone reduction performed using a Freer elevator (asterisk) positioned at the most depressed site under endoscopic guidance. (d) Immediate post-reduction endoscopic view showing well-corrected fracture alignment without mucosal injury or bleeding. (e) Nasal endoscopic view at 3 months postoperatively showing complete healing of the nasal bone fracture.

Results

In total, 64 patients underwent endoscope-assisted NBR during the study period. The cohort included 53 men and 11 women, with a mean age of 29.6 years (range, 13–79 years). Causes of nasal bone fractures included physical assault in 21 cases, falls in 21 cases, sports injuries in 13 cases, and traffic accidents in 9 cases. The mean interval from trauma to the first outpatient department visit was 2.8 days, and the mean interval from trauma to NBR was 4.8 days (Table 1). All procedures were performed within 2 weeks following the injury.

Table 1.

Demographic and clinical characteristics.

Variable	Value
Age	29.6 ± 16.9 years (13–79 years)
Sex (male:female)	53:11
Cause of injury
Physical assault	21 (32.8%)
Falls	21 (32.8%)
Sports injuries	13 (20.3%)
Traffic accidents	9 (14.1%)
Time from trauma to reduction (days)	4.8 ± 4.0

Data are presented as mean ± standard deviation unless otherwise specified.

Endoscope-assisted NBR was successfully completed under local anesthesia in all patients without the need for general anesthesia or conversion to an open surgical approach. During the procedures, endoscopic visualization allowed direct inspection of the fracture sites, particularly around the rhinion and base of the pyriform aperture. Step-off deformities were clearly identified and corrected under real-time endoscopic guidance. The adequacy of reduction was judged intraoperatively via both visual confirmation and external palpation, ensuring anatomical alignment of the nasal dorsum.

Intraoperative bleeding was absent in 58 cases (90.6%) and minor and self-limiting in 6 cases (9.4%), with no instances of moderate or severe bleeding. Nasal packing was not required for 46 patients (71.9%), while 18 patients (28.1%) received absorbable packing materials such as Nasopore.

At 3 months postoperatively, clinical examination and facial CT were performed for outcome assessment. External aesthetic outcomes were favorable in most cases. In total, 56 patients (87.5%) had achieved symmetrical nasal appearance on follow-up. Only a few patients exhibited minor deviations, such as minor asymmetry (3.1%) and saddle nose deformity (1.6%). Among the patients who underwent follow-up facial CT (n = 22), 86.4% showed excellent bony alignment, with only a few cases rated as “good” (9.1%) or “fair” (4.5%). Similarly, endoscopic follow-up assessments (n = 30) revealed excellent mucosal and structural results in 96.7% of the patients, confirming the adequacy of fracture realignment under direct visualization (Table 2).

Table 2.

Clinical outcomes following endoscope-assisted nasal bone reduction.

Outcome	Value
External appearance, n (%)
Symmetric	56 (87.5)
Minor asymmetry	2 (3.1)
Saddle nose	1 (1.6)
Facial computed tomography result (n = 22), n (%)
Excellent	19 (86.4)
Good	2 (9.1)
Fair	1 (4.5)
Endoscopy result (n = 30), n (%)
Excellent	29 (96.7)
Good	1 (3.3)
Revision surgery required, n (%)	9 (14.1)

Patient-reported satisfaction was evaluated using a 4-point scale at the 3-month follow-up. In total, 52 patients (81.3%) rated their outcome as “excellent,” 6 (9.4%) as “good,” and 6 (9.4%) as “fair.” No patient rated their outcome as “poor” (Figure 2).

Figure 2.

A 6-year-old male patient with nasal bone fracture. (a) Preoperative axial computed tomography showing right nasal bone fracture with mild displacement and severe subcutaneous swelling. (b) Facial photograph 1 week after trauma showing persistent swelling at the right nasal sidewall; asymmetry of the bony pyramid is not identifiable. (c) Nasal endoscopic views: step deformity at the right pyriform aperture (left), intraoperative reduction using a Freer elevator (asterisk) (middle), and resolution of the step deformity after reduction (right). (d) Axial computed tomography at 3 months postoperatively showing well-corrected nasal bone alignment. (e) Postoperative external nasal appearance demonstrating well-maintained symmetry.

Revision surgery was required in 14.1% of the patients. These included a variety of secondary procedures such as septorhinoplasty and augmentation rhinoplasty, mostly performed for aesthetic refinement rather than due to failure of primary reduction.

Discussion

In the present study, endoscope-assisted NBR was successfully performed in 64 patients with nasal bone fractures. All procedures were completed under local anesthesia in the outpatient clinic without the need for general anesthesia or conversion to an open surgical approach. Direct endoscopic visualization allowed precise assessment and correction of fracture alignment. Most patients achieved favorable external nasal symmetry at 3 months postoperatively, with minimal postoperative complications. Radiologic and endoscopic follow-up assessments confirmed excellent anatomical realignment in most cases, and >80% of the patients reported “excellent” satisfaction with their surgical outcomes. Revision surgery was required for only 14.1% of the patients.

The management of nasal bone fractures traditionally relies on closed reduction techniques performed under local or general anesthesia. ² Although closed reduction remains the standard of care, it is inherently limited by the lack of direct visualization, relying primarily on tactile feedback and external inspection.^6,7 These constraints often lead to uncertainty in the adequacy of fracture alignment, increasing the risk of residual deformities and patient dissatisfaction, eventually requiring secondary procedures. ¹³

In response to these limitations, endoscope-assisted NBR was introduced to enhance the accuracy and predictability of fracture realignment. By providing direct visualization of the fracture sites, this technique allows real-time confirmation of reduction, ensuring more precise correction of step-off deformities and minimizing mucosal trauma. In our experience, the endoscopic approach addresses several shortcomings of conventional blind techniques.

A key advantage of the endoscopic technique is its ability to allow reduction under direct vision, eliminating the guesswork associated with traditional blind methods. This direct visualization enables more precise correction of step-off deformities and ensures proper anatomical alignment, minimizing the risks of overcorrection, undercorrection, and postoperative asymmetry. Surgeons were able to accurately assess the reduction in real time, which not only improved the objective outcomes but also significantly increased the surgeons’ confidence during the procedure.

Another important advantage of the endoscope-assisted approach is that it allows early intervention without the need to wait for the resolution of post-traumatic edema and swelling. In conventional blind reduction, significant swelling often obscures external landmarks, requiring the surgeon to wait for several days to achieve optimal conditions for manipulation. ¹⁴ However, with endoscopic guidance, fractures can be accurately assessed and reduced even in the acute swollen phase. The addition of topical vasoconstrictors and anesthetics further improves visualization and minimizes discomfort, especially in pediatric and anxious patients. This permits early treatment, typically within a few days of trauma, under local anesthesia in the outpatient clinic. Early intervention prevents the onset of fibrotic healing, malunion, and fracture immobilization, thereby improving both anatomical and cosmetic outcomes. This early, minimally invasive intervention also improves patient comfort and reduces the anxiety associated with delayed treatment.

Based on the two key advantages described above—direct visualization and feasibility of early intervention—our method demonstrated a notably lower revision rate than traditional methods. Conventional closed reduction techniques have reported revision rates between 15% and 50%, while the revision rate in our study was only 14.1%.^13,15 In addition, the incidence of saddle nose deformity was very low (1.6%). The minimal need for nasal packing further underscores the tissue-sparing and patient-comfort benefits of the endoscope-assisted approach.

Although this study primarily reports short-term cosmetic and anatomical outcomes, it did not systematically capture validated functional metrics such as pre- and post-procedural Nasal Obstruction Symptom Evaluation (NOSE) scores. Because this was a retrospective series of acute injuries managed in the outpatient clinic, standardized nasal airway assessments were not consistently documented across all patients. Nevertheless, intraoperative endoscopic guidance allowed direct visualization and immediate correction of inward displacement of the lateral nasal wall and internal nasal valve region in selected cases, suggesting a functional benefit beyond cosmetic realignment. Prospective studies with standardized functional outcome measures, including validated nasal obstruction scores, are warranted to further evaluate this aspect.

Despite these promising findings, this study has certain limitations. First, its retrospective nature inherently introduces potential biases related to patient selection and data collection. Second, although all 64 eligible patients underwent endoscope-assisted NBR, not all patients completed every follow-up assessment. This incomplete and modality-specific follow-up may have introduced selection bias and limited the objectivity and generalizability of the cosmetic and anatomical outcome assessments. Third, the follow-up period was limited to 3 months, and longer-term outcomes were not assessed. Future prospective studies with larger cohorts and standardized long-term follow-up are needed to validate these findings.

Conclusion

Endoscope-assisted NBR appears to offer significant advantages over traditional closed reduction, including enhanced accuracy and improved patient satisfaction. It offers a high degree of anatomical and aesthetic success with minimal morbidity and is well-suited for the outpatient setting. Given its feasibility in the outpatient setting and minimal morbidity, endoscopic-assisted NBR may become a preferred standard for selective nasal bone fractures, particularly in the early post-traumatic period.