Nasal Trauma

Basic Anatomy
Principals of evaluation
History
Physical Examination
Complications that require immediate intervention include
Look for important associated injuries
Imaging
Further management and follow-up

The nose is one of the most commonly injured structures of the face. Although nasal injuries are often simple, serious complications and associated injuries must be considered to avoid poor patient outcomes.

Basic Anatomy

The nose is given shape by a combination of bone and cartilage. The exterior surface is covered by tough skin with many sebaceous glands. The interior surface is covered by a highly vascular mucosa.

It is important to note that the nose is in close proximity with many important structures:

Important Structures Close to the Nose

• The orbits and their content, incl. the eyes
• The lacrimal apparatus
• Para-nasal sinuses
• Mid-facial bones
• The mouth and its contents, incl. teeth
• Cranium and brain

Principals of Evaluation

When evaluating a patient with nasal trauma, there are four critical questions to be answered:

The four critical questions:

• Any complications that require immediate intervention?
• Any associated injuries?
• Does the patient need follow up to evaluate the need for reduction or cosmetic correction?
• What advice should my patient receive?

History

Remember to specifically ask about the mechanism of injury, previous nasal injury or surgery, allergies and medications (especially anticoagulants like aspirin or warfarin) and associated non-nasal complaints, like neck pain.

Physical Examination

Remember to evaluate the entire patient. That means using a structured approach to identify physiological instability (like ATLS^©) followed by a thorough head-to-toe evaluation to look for associated injuries and finally a detailed examination of the nose itself.

Evaluating for associated injuries will be covered in the next section.

To examine the nose, position the patient comfortably and ensure good lighting. Begin by evaluating the exterior, noting any deformity, lacerations crepitus or bruising.

To facilitate the interior examination of the nose, gently remove any clot and then apply a decongestant (i.e. oxymetazoline) and a local anaesthetic spray (i.e. lignocaine). Thoroughly inspect the nares and nasal canals for bleeding, mucosal tears, exposed bone or a septal hematoma. Using a nasal speculum and head lamp can be very useful if available.

Complications That Require Immediate Intervention include:

• Airway obstruction or compromise
• Hemodynamic compromise from severe epistaxis
• Uncontrolled epistaxis
• Open fractures
• Septal hematoma
• Important associated injuries (see later)

Airway compromise and haemorrhagic shock should be managed according to the principals of trauma resuscitation (like ATLS^©).

Ongoing epistaxis should be managed initially with direct external pressure. Further management should follow a step-wise approach such as the one outlined elsewhere in this section’s chapter on epistaxis.

Open fractures should be irrigated with copious amounts of sterile water. If possible the skin should be approximated over the fracture. A sterile dressing should then be applied, antibiotics given and the patient referred to an ENT surgeon. Remember: mucosal tears associated with fractures should be considered open even if the overlying skin is intact.

A septal hematoma is a collection of blood between the mucosa or perichondrium of the septum and the septal cartilage. As the hematoma expands and strips the perichondruim from the cartilage, blood supply to the septum is disrupted. If left untreated, the septum will necrose and collapse with disastrous consequences for the patient. A septal hematoma usually appears as a red, purple or white raised area as shown here.

All septal hematomas should be treated at once. Treatment involves anaesthesia, followed by incision using a scalpel and haemostat, drainage of the hematoma using low pressure suction, a syringe or gentle manual evacuation and insertion of sterile gauze to prevent re-accumulation of blood (the latter is optional).

If the above treatment is not possible due to a lack of skill or equipment, aspirate as much of the hematoma as possible using a large bore needle and pack the nose as for epistaxis.

Regardless of what management modality was used, the patient should be discussed with an ENT surgeon for urgent review.

Look For Important Associated Injuries

Important injuries that should be actively sought and excluded include

• Injury to the orbits and eyes
• Mid-facial fractures
• Injuries to the maxilla, mandible or teeth
• Intracranial injuries
• Cervical spine injuries

The close proximity of the orbits to the nose means that injuries of these structures are not uncommon. Examine the eyes and orbits carefully. Specifically document visual acuity and look for injuries to the globe. Evaluate the movements of the eye. Limitations of movement may indicate an orbital fracture with entrapment of the extra ocular muscles of the eye. Other findings that may indicate orbital fractures include crepitus, a palpable bony step or fracture and subcutaneous emphysema. All these patients should be referred to an ENT or ophthalmic surgeon.

High energy trauma to the nose and mid-face may result in facial fractures, fractures of the maxilla and mandible and injuries to teeth. Palpate the mid-face and confirm its stability. Evaluate the mouth, specifically noting loose teeth and malocclusion. If any injuries are identified, the patient should be referred to an oral or maxillofacial surgeon.

Important indicators of intracranial injuries include an altered level of consciousness, focal neurological abnormalities, seizures and CSF rhinorrhoea. All patients with suspected neurological injuries should be referred to a neurosurgeon.

Always consider cervical spine injuries in patients with trauma above the clavicles. Examine the neck and maintain a low threshold to image the spine.

Imaging

Plain film X-rays are not helpful in the evaluation of simple nasal injuries, even if you suspect a nasal bone fracture. X-rays and more advanced imaging should instead be reserved for patients with complicated and associated injuries, such as orbital or mid-facial fractures, CNS injuries or cervical spine injuries.

Tailor the investigation to the injury. In general, CT scanning provides superior images and information when facial injuries are suspected. If not available, discuss the patient with an ENT or maxillofacial surgeon.

Further Management and Follow-Up

If all the above complications have been considered and excluded, the injury can be considered to be uncomplicated.

Uncomplicated nasal injuries do not require intervention in the acute phase. Cosmetic evaluation and reduction of fractures should only be attempted once facial swelling has subsided.

Patients should be provided with analgesia and arrangement for evaluation of the nose in 5 to 10 days should be made. Remember to educate the patient about basic home management of epistaxis.

At the follow up evaluation, carefully evaluate for nasal deformity, septal deviation, nasal occlusion, recurrent epistaxis and associated injuries missed during the initial visit. If any such complications are identified, refer the patient to an ENT surgeon.