Blog

Closed Nasal Reduction and ENT Instrument Care: A Surgeons Guide

Would you like to know more about the surgical techniques for closed nasal reduction or details on sterilization and maintenance for these ENT instruments?

Nasal bone fractures are among the most common facial injuries encountered in clinical practice, representing approximately 40% of all facial fractures. The nose's prominent and exposed position on the face makes it particularly vulnerable to trauma, whether from motor vehicle collisions, sports injuries, or interpersonal violence. For surgeons managing these injuries, closed nasal reduction remains a cornerstone procedure, offering a minimally invasive approach to restoring both form and function.

But successful outcomes depend on two equally critical factors: mastering the surgical technique and properly maintaining the specialized instruments that make it possible. This article explores both dimensions, providing a comprehensive guide to closed nasal reduction alongside essential sterilization and maintenance protocols for ENT instruments.

Part One: The Art of Closed Nasal Reduction

Why Closed Reduction Matters

Given the nose's integral role in both facial aesthetics and respiratory function, managing nasal fractures effectively is fundamental to ensuring optimal outcomes. Closed reduction—a technique that realigns fractured nasal bones without external incisions—offers several advantages over open surgical approaches. It minimizes scarring, reduces operative time, and allows for faster recovery while still achieving satisfactory aesthetic and functional outcomes when performed correctly.

The procedure is particularly suitable for simple, non-comminuted fractures where the bone segments have not yet fused. Research demonstrates that with proper technique and postoperative management, closed reduction can achieve success rates exceeding 90%.

Timing: The Critical Window

One of the most important considerations in closed nasal reduction is timing. The procedure is best performed during the "acute" window, typically within 7 to 14 days of injury, before bony fusion occurs.

Key timing considerations:

• Early intervention (within 7-10 days): Allows for optimal mobilization of fractured bone segments before callus formation.
• Delayed reduction: When significant swelling obscures the underlying nasal architecture, it may be permissible to postpone the procedure for 7 to 10 days (or longer) to allow edema to subside, provided bony fusion has not yet occurred.
• Established fusion: If bony fusion has already taken place, closed reduction may require concurrent nasal osteotomy to mobilize the displaced bone segment, requiring referral to otolaryngology or maxillofacial surgery.

Step-by-Step Surgical Technique

The closed nasal reduction procedure follows a systematic approach, beginning with patient preparation and extending through postoperative care.

Step 1: Patient Evaluation and Preparation

Before proceeding with reduction, the surgeon must assess the fracture pattern and determine whether closed reduction is appropriate. Simple, non-comminuted fractures with minimal displacement are ideal candidates. Preoperative imaging, typically a CT scan, helps characterize the fracture pattern and guide intervention.

The patient is positioned supine with the head elevated to minimize bleeding. Local or general anesthesia may be used depending on the fracture complexity and patient factors. Topical vasoconstrictors are often applied to reduce intranasal bleeding and improve visualization.

Step 2: Instrument Selection

The choice of instruments significantly influences procedural success. The AO Foundation Surgery Reference specifically identifies Asch septum-straightening forceps and Walsham septum-straightening forceps as the primary instruments for closed treatment of nasal fractures.

Walsham Forceps (1847–1903): Developed by William Johnson Walsham, these forceps were designed for forcibly straightening the deflected septum. Walsham, drawing on his experience in orthopedics, advocated for relocation of the deflected septum followed by a protracted period of postoperative splinting. His textbook describes the procedure, noting that "Great force is required, and care must be taken, by properly padding the forceps, not to injure the soft parts”.

Asch Forceps: These forceps, named after Morris Joseph Asch, have a slightly different design. Asch initially denounced purely manipulative methods as ineffective, advocating instead for "destroying the resiliency of the septum" before realignment. The Adams compressing forceps (now commonly called Asch forceps) were used to align the fragments prior to splinting.

Step 3: Reduction Technique

The AO Foundation Surgery Reference describes the core reduction technique:

1. Septal Straightening: Asch or Walsham septum-straightening forceps are used to straighten the nasal septum. The septum is grasped with the blades of the instrument and gently manipulated into proper alignment.
2. Bone Elevation: For centrally depressed fractures, posterior-to-anterior elevation is required, which can often be achieved by reducing the nasal septum. Asch or Walsham forceps can be used to elevate the dorsum and disimpact the displaced septum.
3. Indirect Elevation: The procedure requires indirect elevation of the nasal bones to restore the architecture of the nasal pyramid.

The surgeon applies controlled force to mobilize the fractured segments and restore the normal nasal contour. This may require working from both inside and outside the nose, depending on the fracture pattern.

Step 4: Postoperative Care

Proper postoperative management is essential to maintain the reduction achieved during surgery. The following protocols are recommended:

• Head Position: Maintaining the patient's head in a raised position both preoperatively and postoperatively may significantly reduce edema and pain.
• Nasal Splinting: Internal splints (such as Doyle splints) and external splints help maintain alignment during healing. For septoplasty cases, internal silastic splints are commonly used.
• Nose Blowing: Should be avoided for at least ten days following fracture repair to prevent orbital emphysema.
• Medication: Antibiotic ointment may be applied over splints or packing to retard infection. Oral antibiotics should be given as long as nasal packing remains in place.
• Ice Packs: Effective for short-term edema control.

Step 5: Clinical Follow-up

Regular postoperative assessment is essential to identify and address any developing deformities. The AO Foundation Surgery Reference recommends periodic evaluation of:

• Nasal airway status
• External nasal deformity
• Excess compression from splints
• Facial asymmetry
• Sensory nerve compromise
• Scar formation
• Anosmia
• Epiphora and dacryocystitis

Success Rates and Outcomes

A study from Washington University School of Medicine evaluated a protocol for nasal fracture management aimed at reducing secondary deformities. Among 90 patients who underwent closed nasal reduction, postoperative deformity was reported in 15.6% of patients. However, 64.3% of those were managed successfully with external manipulation alone, avoiding secondary surgery. The overall success rate, including postoperative manipulation when necessary, was 94.5%.

The study concluded that using a structured protocol for treating nasal fractures resulted in a low rate of postreduction deformity and a small percentage of patients requiring revision surgery.

Part Two: Instrument Sterilization and Maintenance for ENT Practice

The Reusable vs. Single-Use Debate

ENT uses more instruments than many other surgical specialties in the outpatient setting. There has been a trend toward using single-use individually packaged medical instruments—a 2024 survey at the ENT UK Spring Meeting found that 46% of ENT surgeons reported using single-use instruments exclusively, 43% used a combination, and only 11% used reusable instruments exclusively.

However, mounting evidence supports the use of reusable instruments from both economic and environmental perspectives:

• A life cycle analysis comparing reusable to single-use scissors found an 80% lower ecological impact for reusable instruments, aside from increased water use due to autoclaving.
• Repairing reusable instruments rather than disposing of them can further reduce carbon footprint by 20%.

Reprocessing Guidelines

The ENT UK guidelines provide clear recommendations for reprocessing outpatient ENT metal instruments:

1. Use reusable metal instruments whenever possible.
2. Prepare and reprocess instruments in tray sets rather than individually.
3. Instruments that are commonly used should remain on communal instrument trays.
4. Only rarely used instruments should be packaged separately.

An important distinction is that almost all ENT outpatient instruments only need to undergo high-level disinfection rather than full sterilization, because they do not breach skin or mucosa during use. This means they can be kept in trays throughout their processing, improving efficiency and reducing energy consumption.

Case Study: Nasendoscope Disinfection

Flexible nasendoscopes present unique cleaning challenges that have been well-studied. An audit at a UK hospital demonstrated the importance of following established guidelines and how simple interventions can dramatically improve compliance.

The challenge: A 2005 audit found poor awareness of ENT UK disinfection guidelines. Key findings included:

• Only 5 of 10 clinics cleaned nasendoscopes before use (if needed)
• Only 1 of 10 clinics checked the expiry date of disinfection solution
• No clinics transported dirty scopes in proper bags
• No clinics followed proper rinsing and drying protocols

The solution: After an intervention involving staff training and placement of instructional posters in all clinical settings:

 

Parameter	First Cycle	Second Cycle	Improvement
Transport dirty scope in bag	0%	53%	P < 0.001
Tap water and foam clean	0%	100%	P < 0.001
Rinse and dry with alcohol swab	0%	97%	P < 0.001
Place in clean bag/back on stand	0%	97%	P < 0.001
Expiry date check	10%	100%	P < 0.001

The audit concluded that "it is vital to ensure that ENT ward and out-patient nasendoscopes are disinfected according to current guidelines in order to avoid potential contamination and the risk of dissemination of infection, including prion disease”. Simple measures like instructional posters and staff training proved to be "simple, cheap and effective to institute”.

Advanced Instrument Cleaning

Recent research has also examined optimal cleaning methods for tubular instruments. A 2026 study found that depressurized boiling cleaning machines significantly improved cleaning outcomes compared to spray washing machines. Using electronic endoscopic inspection, the depressurized boiling method achieved a 99.43% cleaning qualified rate versus 82.18% for the spray method. The authors concluded that these advanced methods "can effectively improve the quality of cleaning and detection of tubular instruments and ensure the medical safety”.

The Connection: Instruments and Outcomes

The relationship between instrument quality and surgical outcomes cannot be overstated. Instruments with histories dating back over a century—like the Walsham and Asch forceps—remain in daily use today precisely because their designs remain effective for their intended purposes. But these instruments can only perform at their best if properly maintained.

ENT UK guidance emphasizes that "repair of reusable metal instruments (rather than disposal) can further reduce carbon by 20%”, highlighting the importance of ongoing instrument maintenance. This extends beyond environmental considerations—well-maintained instruments with sharp cutting edges and properly functioning joints perform better and reduce the risk of surgical complications.

Conclusion

Closed nasal reduction remains a widely used and effective procedure for managing nasal bone fractures, particularly when performed early after injury. As the AO Foundation Surgery Reference states, the procedure is an "elementary skill" that maxillofacial and ENT surgeons should master given the prevalence of nasal fractures in emergency settings.

The instruments essential to this procedure—particularly the Asch and Walsham septum-straightening forceps—have withstood the test of time, with origins dating back to the late 19th century. Their continued relevance speaks to the enduring power of thoughtful instrument design.

However, the success of any surgical procedure depends not just on instrument selection and technique, but on proper instrument care. The ENT UK guidance provides a clear framework: use reusable instruments, process them efficiently in trays, and ensure proper high-level disinfection for outpatient tools. Simple educational interventions can dramatically improve compliance with cleaning protocols.

For surgeons seeking optimal patient outcomes, the message is clear: master the technique, select the right instruments, and care for them properly. The combination of surgical skill and instrument stewardship ensures the best possible results for patients with nasal fractures.

#ClosedNasalReduction #NasalFracture #ENTSurgery #Septoplasty #AschForceps #WalshamForceps #ENTInstruments #SurgicalTechniques #InstrumentSterilization #InfectionPrevention #PatientSafety #FacialTrauma #SurgicalOutcomes #MoxieEnterprises #MedicalDevices #Healthcare #SurgicalInstruments #NasalReduction #TraumaSurgery #ENT #Otolaryngology #Maxillofacial #PlasticSurgery #SurgicalEducation #MedicalTraining #InstrumentMaintenance #Sterilization #MedicalTechnology #ENTUK #AOFoundation