Journal of the International Society of Head and Neck Trauma (ISHANT)

Invited review Assessment of nasal trauma

Dr SUMIT SHARMA. MBBS (ENT-Honors) (KGMC-Lko), M.S. (KGMC-Lko),

Assistant Professor, Department of E.N.T.,

Mayo Institute of Medical Sciences, Barabanki, India [email protected]

Received July 2016. Accepted following peer review September 2016. Published September 2016

JISHANT 2016:7 Introduction

The assessment of nasal injuries accidents, sports injuries and during requires a delicate balance of history physical confrontation. Because of this taking and clinical examination. they are twice as more common in males Management of these injuries must take than in females. The nose is the most into consideration both functional and prominent feature of the face and has cosmetic aspects. Although not an little protection or support. exhaustive review of the literature this Nasal bones are very brittle and can paper discusses key aspects of be broken easily with trivial impacts. assessment with observations from my Low impact forces of 30G can be own experience. sufficient to result in fracture, compared Pathophysiology to the supraorbital rim which requires a force of 200G on impact (2). The ease Nasal bone fractures are the with which the nose is broken may help commonest facial fracture and make up absorb the energy of impact and offer to 39% of all maxillofacial injuries some protection to the brain. Thus it has (1).These types of fractures are mainly been suggested this acts as a protective seen in road traffic mechanism (3). Journal of the International Society of Head and Neck Trauma (ISHANT)

From the structural point of view the side of the point of impact. This is the nasal bones are divided into two halves most common mechanism in adults. by the intercanthal line - into a stronger Clinical features upper portion and a weaker lower portion. Most nasal bone injuries occur Nasal fractures are not life- in the lower segment (3). Injuries to the threatening injuries and therefore it is upper portion therefore represent higher important to ensure that the patient is energy impact and should raise concerns stable and more serious injuries are regarding extended or deeper injuries. It managed first. has also been observed that younger Fractures of the nasal bones are patients tend to have fracture-dislocation compound fractures – almost always. of larger segments, whereas older Breaches of the skin or mucosa is patients (with brittle and less elastic present in the vast majority of cases. bone) tend to have comminuted Hence epistaxis is the rule in most fractures. The nasal septum (septal patients. This may have ceased by the cartilage) supports the lower two third of time patient, reaches you. Be very the nasal framework. It is an elastic careful when you examine such cases as structure and can absorb and recoil bleeding may restart. If the patient minor nasal impacts, preventing attends 3-4 days after injury then the fractures. The turbinates support the wound may be infected and antibiotics lateral nasal wall (frontal process of the may be needed. Otherwise antibiotics lateral nasal wall) in lateral impact are usually not needed. injuries. Usually the history is very suggestive Two basic types of impact injuries are of a fracture - the patient receives a blow seen in nasal trauma to the nose. The main clinical features 1) Frontal impact injuries – where the include: impact of injury is from the front / head- 1. Bleeding. If present ask the patient on trauma. Here, the fractured segments to apply gentle finger pressure until it are displaced inwards and are splayed. has settled. Patients often develop saddle nose deformity 2 Swelling of nose - this appears within a few hours and may obscure 2) Side impact injuries. Here the details of examination (notably the fractured segments are displaced to the intercanthal distance). Swelling opposite Journal of the International Society of Head and Neck Trauma (ISHANT) increases 4-6 hours after the injury for serious injury. In more severe cases there the first 3-5 days (4), then it subsides. may also be orbital symptoms, canthal displacement and watery nasal discharge 3. Blood staining (bruising) around (CSF Rhinorrhoea). The one or both eyes - Periorbital nasoorbitalethmoidal (NOE) complex is ecchymosis. It is worth remembering a very delicate and complex structure; it that a well defined ‘Black eye” indicates is composed of four bony regions – the presence of a fracture somewhere cranium, orbits, nose and maxilla and (not always the nose). This should four cavities – cranium, orbits, nasal and prompt careful examination and further maxilla. This central crossroad location imaging. and collapsible nature due to the deeper 4. Pain. ethmoidal sinuses makes it very vulnerable to direct impacts. Symptoms 5. Nasal deformity. The nose may be of NOE fractures include significant depressed from the front or the side, or facial oedema which develops early. the whole of the nasal pyramid deviated Ophthalmic / orbital symptoms include to one side. It is important to consider diplopia, telecanthus, enophthalmos, and exclude any previous deformity. epiphora and a shortened palpebral 6. Nasal obstruction due to swelling, fissure, which results from orbit wall or septal injury or haematoma. Septal medal canthal tendon displacement. haematoma requires rapid evacuation to Nasal symptoms include collapse prevent septal necrosis and subsequent (retrusion) of the nasal bridge, anosmia collapse (caused by damage to the olfactory nerve as it passes through the cribiform 7. Lacerations of the skin over the plate), and nasal congestion, secondary nose with exposure of nasal bones and to swelling, septal haematoma or bony / cartilage may also occur. Rarely is tissue cartilaginous deformity (5). The two main loss significant. Consider the need for sites from which CSF leakages occur are antibiotics and tetanus immunisation. the cribriform fossa and the roof of the 8. In more severe cases there may be ethmoids. These must both be ocular / orbital symptoms and a watery investigated in suspected cases of CSF nasal discharge - suggestive of CSF rhinorrhoea. leakage Examination When examining the nose it is Some authors suggest examination important to determine whether it is just should start distally and move a ‘simple’ nasal fracture, or a more Journal of the International Society of Head and Neck Trauma (ISHANT) proximally, dividing the nasal 2 Septal haematoma / mucosal tears examination into upper, middle, and 3 Vision and diplopia lower thirds (4). However the precise sequence is not critical so long as all the 4 Sit the patient forward and look for steps are completed. CSF leaks

The key issues to consider when 5 Measure the Intercanthal distance examining a patient include: (ICD)

1. Rapid and confident exclusion of If swelling is present then assessment more extensive injuries (most notably of the injury becomes very difficult. The NOE / Anterior cranial fossa (ACF) / look of the patient often says it all – Orbital walls / ocular injuries). Then fracture of the nasal bones is a clinical note the following diagnosis. A comprehensive diagnosis with documentation should include the 2. Deviation, depression, step details of location, extent and deformities displacement of the fractures as far as 3. Mobility, crepitus, specific areas of possible. These can be obtained by the point tenderness combination of physical examination and radiographic imaging when 4. Areas of swelling, bruising and skin necessary. Pre-traumatic photographs lacerations can provide additional details, 5. Septal fracture/haematoma/ particularly if the patient is known to abscess/perforation have a pre-traumatic abnormality of the nose / deviated nasal septum. 6. Mucosal lacerations With questionably injured noses a 7. Infra orbital numbness – due to good method of eliciting the fracture injury to the infra orbital nerve. If this is crepitus is by using the 3 fingers of your present then the injury is more than a dominant hand – the Index finger is simple nasal fracture. placed on the dorsum, with the thumb 8. Rhinorrhoea - determine whether and the middle fingers on the sides. Then patient has had epistaxis alone or is gently move the nose from one side to combined with watery discharge (CSF). the other (after informing the patient this may cause mild discomfort). Any A simple checklist therefore includes fracture present produces crepitus which 1 Deformity can be easily felt and occasionally heard. Crepitus, tenderness, depression, step- Journal of the International Society of Head and Neck Trauma (ISHANT) offs, nasal shortening, or widening of the Transferrin are the most reliable. This is nasal base are indicative of fracture. present mostly in CSF with a little However any injury without some amount in eye fluid. It is not present in degree of bleeding is unlikely to be a blood , saliva, or nasal secretions. severe fracture (6). Types of fractures In severely displaced, depressed or In clinical practice the following deformed cases examination does not types of fracture may be evident: need to elicit crepitus and movement. However it is still important to assess the A. Fractures confined to the nose other elements in the checklist. If the 1. Fractures involving only the Nasal patient has a significant watery bones – here only the dorsum of nose is rhinorhoea he / she should be assumed to deformed. Depending upon the have a cerebrospinal fluid (CSF) leak. displacement of the distal segment it can From a practical viewpoint any be either depressed (more common) or suspected CSF leak requires a elevated (less common). This can neurosurgical opinion or advice. happen in both frontal and lateral impact CSF is confirmed by either injuries. Often no significant haematoma performing a bedside test for the Halo is seen around the eyelids sign, or by testing fluid levels for either 2. Unilateral fractures involving the glucose or β- transferrin. The “halo” or nasal bones and frontal process of “double-ring” sign uses the principle of maxilla – here in addition to the previous chromatography: different components findings the lateral wall of nose is of a fluid mixture will separate as they depressed to the side opposite to the site travel through a material. Although the of impact. The disfigurement here is value of this sign has been debated, more significant than the first case. This studies have shown that the sign is usually happens in side impact injuries. consistently positive when CSF There is often mild haematoma in the concentrations are 30%–90% of the eyelids of the involved side. bloody discharge. However, this sign is not specific for CSF alone: mixtures of 3. Bilateral fractures involving the blood with saline and tears also nasal bones and frontal process of produced halos. It is therefore not 100% maxilla. This is usually seen following reliable. Filter paper, paper towels, frontal impacts with increasing coffee filters and linen can all be used to disfigurement than previously. Most of show a ring (7). Laboratory test for B- the entire nose appears depressed. There Journal of the International Society of Head and Neck Trauma (ISHANT) is usually haematoma in the eyelids on C. Fractures of the septum both the sides. Septal fractures can occur with any of B. Fractures extending beyond the the above fractures. The septal fracture nose associated with isolated fractures of the nasal bone is of three types– 4. Bilateral fractures involving the nasal bones, ethmoids and frontal i) Chevrolet fracture. This is a vertical process of maxilla. The entire nose is fracture of nasal septum which occurs depressed and sunken inside. when the direction of blow on the nose Telecanthus may be seen in these cases. is from below upwards (8, 9) There is usually haematoma in the ii) Jarjaway fractures are a horizontal eyelids on both the sides. These injuries fracture of nasal septum. These occur are often associated with other facial when the direction of blow on the nose injuries including the orbits. is from the front (10). 5. Fractures involving the orbits along iii) A third type is a crushed septum with nasal bones and the ethmoids. when the impact force is significantly (Nasoorbitalethmoidal – NOE fractures). more and from the front. The septum is These are more severe injuries and often crushed and highly comminuted. ocular function may be affected, depending upon the severity of ocular It is important to note that septal injuries. 1 & 4 (NOE fractures) are fractures can occur in the absence of commonly classified according to the nasal bone fractures. This usually attachment of the medial canthus to the happens in frontal and below-upwards bone (Markowitz classification) impact injuries.

6. Fractures involving the anterior One of the consistent signs in septal cranial fosse along with orbits, nasal fracture is a mucosal tear. This must be bones and the ethmoids. These are the looked for in all cases during most severe types of fractures and examination. If not identified there is a besides nasal disfigurement patients also chance of missing a nasal septal fracture. have watery nasal discharge (CSF). Fortunately the likelihood of infection is These should be considered as head very low but failure to manage the injuries and referred accordingly. The septum correctly will result in residual nasal fractures are a lower priority at this deformity. Deviation may not always be time. seen in septal fractures because of the Journal of the International Society of Head and Neck Trauma (ISHANT) elastic recoil, hence its absence should A five point grading system has been not rule out a fracture. developed to help describe the extent of lateral deviation of the nasal pyramid: Due to the intimate associations of the bony and cartilaginous portions of the Grade 0: bones perfectly straight – nose and the septum it is unusual to see undisplaced fractures. fractures to either structure without Grade 1: bones deviated less than half damage to the other. Septal fractures of the width of the bridge of the nose tend to release interlocked stresses. There are forces locked within the Grade 2: bones deviated half to one matrix of the cartilage existing in a state full width of the bridge of the nose of balance, the outer layers being in a Grade 3: bones deviated greater than state of tension, the inner layers being one full width of the bridge of the nose largely maintained in a state of compression. These forces have been Grade 4: bones almost touching the termed "interlocked stresses” (11). During cheek the process of healing by fibrosis this This grading system is helpful in may result in septal twisting into various preoperative assessment of injury, configurations (C-shaped, S-shaped), or deciding whether to do closed or open spurs. Septal fractures also are reduction and comparing postoperative frequently associated with "telescoping" results. of the fractured edges causing a retruded appearance of the cartilaginous portions The role of radiological evaluation of the nose and a depressed dorsum. The need for X-rays of the nose is It is therefore important to always controversial and whilst some clinicians assess the septum carefully. If not done will request imaging, others will not. In so many patients develop nasal the UK for example, X-rays of suspected obstruction or sinusitis later. isolated nasal fractures are almost never requested. Other classifications of nasal bone fractures are described. However if imaging is considered necessary, the three basic radiological 1) Stranc Robertson classification investigations reported are Plain 2) Harrison’s classification radiography, CT and ultrasonology (12)

3) Murray’s classification. A. Arguments for obtaining plain films include: Extent of deformity Journal of the International Society of Head and Neck Trauma (ISHANT)

1. It is a good tool for documentation For those countries where imaging is of injury when CT not available routinely required the following information may be useful. 2. Universally available unlike CT. 1) Usually we take a lateral skull X- 3. Economical – the cost of X-ray is ray for nasal bones which usually shows only 5-6% as compared to CT scan the fracture clearly. The only problem 4. It may be helpful in undisplaced with this view is that it does not show fractures where clinically nasal structure any fractures of frontal process of appears normal and we may not require maxilla because the two sides overlap. In a CT scan. fact no plain X-ray view clearly shows the fracture in the frontal process of B. Arguments against plain films maxilla. Therefore there are limitations incude: with plain films in visualizing nasal 1. It does not give any addition fractures. Since X-ray provides limited information for management above information CT scan may be considered. clinical examination. True lateral x-rays 2) CT is of value in high energy taken under less than ideal injuries, not only to determine the extent circumstances are usually non- of the nasal fracture but also to exclude contributory. Furthermore, plain film deeper and hidden fractures to the skull images frequently fail to give base and orbits. sufficiently detailed information as to the nature and extent of any CT scan of paranasal sinus with 2mm neighbouring injuries (such as skull base sections (both axial and coronal) is fractures, orbital wall injuries, pterygoid required. This will clearly show all the plate fractures and sagittal fractures of fractures including the ethmoids, orbits the maxilla and condylar process of the and skull base. mandible). So they are of limited use The main advantages of CT scan 2. According to Sharp (12) X-rays of include: nasal bone fails to reveal fractures in a) High accuracy in evaluating both nearly 50% of the patients. bony and soft tissue injuries. 3. The amount of radiation exposure b) More sensitive than plain film in is very high – hence must be avoided. fracture detection Therefore it is best to refer to local c) Easier to perform. guidelines, depending on where you live. Journal of the International Society of Head and Neck Trauma (ISHANT)

d) Radiation dose far below threshold advantages of ultrasound is that it is easy dose for cataract formation. and quick to perform, inexpensive, portable and non-invasive. In one study The main disadvantages of CT scan is the precision of ultrasonography and CT that it is not universally available at all scan of the nasal bone were similar. centers and is expensive. Whilst it can However, the sensitivity and specificity theoretically be used in pregnancy, many of ultrasonography has not been tested in specialists prefer to avoid for a relatively the diagnosis of nasal bone fractures (14). minor injury (relative contradiction)

Computed tomography is very helpful in diagnosing septal fractures although it Learning points can not predict severity accurately. Its role in planning management is therefore 1 Nasal bone injuries are a common limited (13). sequel to road traffic accidents, sports, or direct confrontation; they are the 3) Ultra sonography: In some commonest nasal facial fractures. countries ultrasound is increasingly being recognised as a tool for 2 Early diagnosis and treatment are key investigating nasal fractures. It has the to a successful management. clear advantage of being non invasive 3 These injuries can be deceptive - and has zero radiation hazards. always consider deeper and more serious Ultrasound using 10 MHz probe gives a injuries. clear view of the nasal bone area thereby facilitating easy identification of 4 CT scan is the best modality in fractures. Many images can be taken evaluating these injuries. The role of without any technical problems. It is also plain film radiography is controversial cost effective. Unlike X-ray it can tell us and at best very limited. about the presence of ethmoidal and 5 If properly assessed and managed orbital fractures although the anatomy results are often very good. can not be used to plan surgery. Other Journal of the International Society of Head and Neck Trauma (ISHANT)

References

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2. Al Haitham Al Shetawi, John Geibel. Initial Evaluation and Management of Maxillofacial Injuries. http://emedicine.medscape.com/article/434875-overview

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8. https://en.wikipedia.org/wiki/Chevallet_fracture.

9. Scott brown's otorhinolaryngology. Head and neck surgery volume 2 (2 ed.) April 25, 2008 by CRC Press ISBN 9780340808931 - CAT# K18471

10. Bailey & Love's Short Practice of Surgery 25th Edition

11. Fry, H. Nasal skeletal trauma and the interlocked stresses of the nasal septal cartilage. British Journal of Plastic Surgery Volume 20, 1967, Pages 146-158

12. Sharp JF, Denholm S. Routine x-rays in nasal trauma: the influence of audit of clinical practice. J Royal Soc Med 87:153-154, 1994

13. Rhee SC, Kim YK, Cha JH, Kang SR, Park HS. Septal fracture in simple nasal bone fracture. Plast Reconstr Surg. 2004 Jan;113(1):45-52.

14. Javadrashid R, Khatoonabad M, Shams N, Esmaeili F and Jabbari Journal of the International Society of Head and Neck Trauma (ISHANT)

Khamnei H. Comparison of ultrasonography with computed tomography in the diagnosis of nasal bone fractures. Dentomaxillofac Radiol. 2011 Dec; 40(8): 486–491.

Accepted August 2016

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