Trauma
to the nose
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—5
days 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