Nasal Trauma

Traumatic injuries to the nose are extremely common and usually of little long-term significance. In some patients, however, trauma can result in significant cosmetic and functional problems. In severe cases, nasal trauma can result in severe bleeding and cerebrospinal fluid (CSF) leakage and can even be life threatening.

Evaluation of a patient who has sustained nasal trauma requires a thorough history. The mechanism of injury must be understood. If the injury was recent, the patient must be examined for signs of cervical, mandibular, maxillary, orbital, or intracranial injury. Bleeding can be quite severe after isolated nasal trauma but usually stops spontaneously or with only digital pressure.

Initial evaluation includes assessment of the gross appearance of the face, with special attention to the possibility of other facial fractures (orbital, zygomatic, mandibular). Obvious deformity of the nose should be noted, although marked edema obscures this in some cases. Radiographs may be ordered, but their utility is variable because nondisplaced fractures usually require no treatment, and displaced nasal fractures are usually obvious on examination.

Intranasal examination is done to rule out the presence of a septal hematoma or CSF leakage. A septal hematoma results when bleeding occurs between the septal perichon-drium and the underlying cartilage. The hematoma can be unilateral or bilateral. It results in a widened septum with nasal obstruction. Successful treatment requires prompt diagnosis followed by incision and drainage and packing to prevent reaccumulation. If untreated, and especially if bilateral, the hematoma leads to ischemic necrosis of the cartilage or can result in abscess formation. This can ultimately result in loss of enough septal cartilage to cause external nasal collapse, called saddle nose deformity. Because it is extremely difficult to repair, avoiding saddle nose deformity is paramount.

Severe bleeding after nasal trauma can result from a vascular injury of the ethmoidal, the sphenopalatine, or rarely the carotid arteries. ENT consultation should be obtained if severe bleeding persists. CSF leakage is diagnosed when clear drainage is seen dripping from one or both sides of the nose. Leakage can increase in a more dependent position. Nasal CSF leakage requires urgent ENT and neurosurgical consultation. It often resolves spontaneously but can lead to life-threatening problems such as pneumocepha-lus (air within the cranial vault), meningitis, and brain abscess.

Isolated nasal deformity after nasal trauma results from displacement of the nasal bones, the external nasal cartilages, or the septum. The nasal bones can often be repositioned with excellent results by performing a closed reduction. This is done under local or general anesthesia, usually after the initial edema has subsided and before the bones have set (7-10 days after injury). Sometimes an open reduction, which involves refracturing the nasal bones, is required. If the septum is greatly deviated, it can be repaired at the same time. If significant nasal deformity persists, a formal rhinoplasty, which more precisely addresses all aspects of the external nose, can be done later. In children with nasal fractures, closed reduction is usually recommended sooner than for adults because their fractures heal more quickly. Repair should be done within 7 days of the injury, if possible. Open reduction is generally not recommended in children because of concern for affecting future nasal growth. If necessary, rhinoplasty is delayed until nasal growth is complete, which is shortly after puberty.

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