Trauma to the nose

Feb 7, 2009

Injuries to the nose are commonly sustained in fights, sport­ing injuries and road traffic accidents. A blunt injury of moderate force may lead to springing of the nasal septal cartilage with separation of the overlying mucoperichondrium. Bleeding into this potential space will cause a septal haematoma which may be unilateral or bilateral. The haema­toma will give rise to nasal obstruction and can be easily overlooked in the presence of extensive facial injuries. It is, however, an important diagnosis not to miss because untreated, a septal haematoma will progress to abscess forma­tion and ultimately result in necrosis of the septal cartilage. Robbed of this support the tip of the nose will collapse. A septal haematoma should be treated by incision and evacuation of the blood clot. The insertion of a small silicone drain and packing of the nasal fossa will prevent reaccu­mulation and encourage the mucoperichondrium to readhere to the septal cartilage. A broad spectrum prophylactic antibiotic should be prescribed.
A more violent blunt injury to the nose can fracture the nasal bones. This may be a simple crack of the nasal bones without displacement, but greater force may result in deviation of the bony nasal complex laterally (Fig. 39.7) or depression of the bony pyramid if the blow is directly from the front. Greater impacts from this direction may cause a comminuted fracture and widening of the nasal bones or involve the lacrimal bones causing a nasoethmoidal fracture. Lateral injuries with displacement of the nasal bones may also be associated with a C-shaped fracture of the septal cartilage and the anterior portion of the perpendicular plate of the ethmoid (Jarjavay fracture). Nasal bone fractures can extend into the lacrimal bone tearing the anterior ethmoidal artery to produce catastrophic haemorrhage. This may be delayed, occurring only as the soft-tissue swelling subsides and the torn artery opens up.
Violent trauma to the frontal area of the nose can result in a fracture of the frontal and ethmoid sinuses extending into the anterior cranial fossa. Dural tears and brain injuries are then at risk from ascending infection through the fracture line from the nose or sinuses which may progress to meningitis or a brain abscess.
Cerebrospinal fluid (CSF) rhinorrhoea is a certain sign of a dural tear. There may be associated surgical emphysema, proptosis with or without loss of vision or frontal pneumoencephalocele. Anosmia occurs in 75 per cent of patients with these injuries, and cranial nerves II—VI may be injured. A clear discharge from the nose may be confirmed to be CSF by a simple stix test demonstrating the presence of glucose, which is not present in nasal mucus. Such injuries are man­aged by neurosurgical exploration to remove bone fragments, repair the skull base and close the dura. Late complications of this injury include CSF fistula, recurrent late meningitis, brain abscess, osteomyelitis and the formation of mucopyoceles.

Management of fractured nasal bones
Fractured nasal bones are often accompanied by extensive overlying soft-tissue swelling and bruising which may hinder the assessment of the underlying bony deformity. Reviewing the patient 4—5days later will give time for the soft-tissue swelling to subside and make subsequent assessment of any deformity much easier. If a fracture to the nasal bones has caused a significant degree of nasal deformity then this should be corrected by manipulation of the nasal bones under general anaesthesia. This must he carried out within 10 days of the injury while the bony fragments are still mobile. The deviated nasal bones are repositioned to restore the correct alignment of the nose or, in the case of a depressed fracture, the fragments are elevated and supported if necessary with anterior nasal packing. Often a satisfactory result can be obtained by simple manipulation, but should this fail then a rhinoplasty procedure (see later) may be necessary at a later date to obtain further improvement in the appearance of the nose. Any blow to the nose may cause displacement or fracture of the cartilaginous septum giving rise to post-traumatic nasal obstruction. Unlike the nasal bones, the nasal septum cannot be manipulated back into position and requires a formal septoplasty to restore the anatomy and the patency of the nasal airways (see later).

Nasal trauma — summary
•Do not overlook a septal haematoma
•Displaced nasal bone fractures should be reduced within 10 days of injury
•Severe epistaxis suggests lacrimal bone fracture and anterior ethmoid artery injury
•CSF rhinorrhoea indicates fracture involving frontal or ethmoid sinuses with a dural tear

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