Traumatic Nasal Injuries in General Practice

CLINICAL

Traumatic nasal injuries in general practice

Joo H Koh, Osama Bhatti, Abbas Mahmood, Nicholas Agar

Background he nose is the most prominent and external carotid arteries. Venous feature projecting from the face and drainage occurs anteriorly via the facial Traumatic nasal injuries are common T is prone to injury arising from facial vein and posteriorly via the pharyngeal in all age groups of the community. trauma. Injury can occur in all age groups and pterygoid plexus. These pathways Significant nasal trauma can cause nasal and from a variety of causes, which may lack internal valves, creating the risk of fractures and a range of complicating be either blunt or penetrating. The majority retrograde intracranial infection.1 injuries. of injuries result in either bruising alone Uncomplicated nasal Objectives or a simple nasal fracture. Nasal fractures should be referred to ear, nose and throat injuries This article provides general (ENT) or maxillofacial services for prompt Nasal bones are the most commonly practitioners (GPs) with a succinct reduction (ideally one to two weeks from fractured facial bones.2 The mainstay of overview of pathology arising from injury). assessment is a thorough history and nasal trauma, and a framework on Complicated injuries include suspected physical examination. Important aspects the assessment and management of facial fractures, full thickness lacerations, of history include injury mechanism, if common nasal injuries. septal haematoma, septal abscess and there was immediate deformity (prior to cerebrospinal fluid (CSF) leak. It is critical soft tissue swelling), and new-onset nasal Discussion that these are recognised early and obstruction. It is also important to note During assessment of traumatic nasal managed appropriately in primary care. any previous nasal injury or pre-existing injuries, it is essential to exclude a deformity. septal haematoma, which requires Anatomy Physical examination involves assessing urgent drainage. Undisplaced nasal The nose can be subdivided into thirds. the degree of bony deformity by fractures without functional symptoms The upper third is made up of the paired inspection and palpation, and excluding can be managed conservatively. nasal bones, which are attached to Displaced fractures should be referred the frontal bones superiorly, forming for reduction. There is a window of two a pyramid-shaped bony vault. The weeks before the displaced nasal bones perpendicular plate of the ethmoid fuses start uniting. Investigations are rarely with the nasal bones on the inner aspect, indicated for traumatic nasal injuries. providing additional support. The middle Blood tests, including full blood count third is composed of the quadrilateral and coagulation screening, may be cartilage of the septum in the midline and indicated in severe epistaxis. X-rays the upper lateral cartilages laterally. The are not helpful for the assessment of lower third contains fibrofatty soft tissues traumatic nasal injuries. Computed of the nasal tip, supported by the lower tomography (CT) scans are only indicated if there is a suspected orbital, lateral (alar) cartilages (Figure 1). maxillary, frontal or zygomatic fractures. The nerve supply is from the ophthalmic and maxillary divisions of the Figure 1. Anatomical illustration of nasal bones trigeminal nerve. Blood supply to the and cartilages nose has contributions from the internal

650 AFP VOL.45, NO.9, SEPTEMBER 2016 © The Royal Australian College of General Practitioners 2016 TRAUMATIC NASAL INJURIES CLINICAL

features of a complicated nasal injury.2 time frame for reduction is three to five persistent bleeding may have associated Soft tissue oedema arises within hours days after the injury, and early referral nasoethmoid orbital fracture. In these of injury and may significantly affect to an ENT service is needed.6 In very circumstances, proper technique prevents assessment. frail patients, or patients with advanced intracranial placement of a nasal pack. Plain X-ray investigations are frequently dementia who have nasal fractures with To facilitate nasal packing, there is a inaccurate and generally do not contribute only minor cosmetic change, it is prudent range of commercial products available, to the assessment of nasal injuries. False to discuss the option of leaving the fracture with Merocel and Rapid Rhinos commonly positive results can occur from previous to unite, albeit with slight deformity used in Australia. Merocel (Medtronic, injuries, prominent vascular markings or remaining. This is often more appropriate to Minneapolis) is a nasal tampon that suture lines, whereas cartilaginous injuries avoid further discomfort and potential harm expands with saline and is efficient for can cause a false negative result.3 from anaesthetic agents. anterior packing.10 Rapid Rhino (AthroCare, Austin) is a balloon device available in Cartilage deformity Complications of nasal sizes suitable for anterior and posterior If the nasal bones are midline but a injury packing.10 Rapid Rhinos are soaked in cartilaginous septal deformity exists, Lacerations sterile water before insertion into the these injuries are non-reducible acutely as Traumatic lacerations of the nose are nasal cavity. Once inserted, the attached the tissues spring back to their deformed common. Debride and irrigate the wound balloon can be inflated with air to increase state. It is appropriate to exclude a septal well before closure.7 Most skin lacerations the volume and pressure of packing. Rapid haematoma. If there is persisting nasal without involvement of cartilage or Rhinos are found to be more comfortable obstruction after one month of the injury, mucosa can be repaired with 6-0 non- than Merocel.10 patients can be referred to ENT outpatient absorbable monofilament sutures. Place If commercial nasal packing is not services for consideration of elective sutures with small bites as nasal skin has available, anterior nasal packing can still be septoplasty. little redundancy and poor flexibility.8 Refer achieved with layered insertion of ribbon deeper lacerations involving cartilage or gauze soaked in petroleum jelly (Vaseline). Uncomplicated nasal fracture mucosa to ENT or plastics services on Alternatively, intranasal insertion of cotton Nasal fractures are generally managed the same day. Selected lacerations that pledgets soaked in tranexamic acid has with closed reduction under local or are clean and have well-opposed edges been shown to be effective treatment for general anaesthesia. The choice of may be closed with tissue adhesives, anterior epistaxis.11 In suspected posterior anaesthesia does not affect the success particularly in children.7 Determine and epistaxis, a Foley catheter is advanced into rate.4 Whenever possible, patients update tetanus immunisation status. the posterior oropharynx, then inflated. with suspected nasal fractures should The anterior nasal cavity can then be be referred to an ENT service. Closed Epistaxis packed with Vaseline gauze. This packing reduction should be performed once Epistaxis is common with nasal injuries method can be secured in place with a oedema resolves, ideally within 10–14 days caused by trauma to the nasal mucosa and clamp over the gauze.10 of the injury. vessels. To administer first aid, the nose All patients with nasal packing In remote areas that do not have timely should be held firmly with the thumb and should be placed on oral antibiotics access to ENT services, appropriately forefinger, closing the nostrils. The head is (eg amoxicillin, cephalexin) to prevent skilled general practitioners (GPs) may tilted forwards and the patient instructed toxic shock syndrome.10 These patients perform closed reduction under local to spit rather than swallow the blood. should be referred promptly to ENT anaesthesia in a compliant adult patient. A Continue pressure for 10–20 minutes.9 services for admission as there is a risk local anaesthetic, such as lignocaine with If available, vasoconstrictors such as of inadvertently dislodging the nasal pack adrenaline, is effective when administered cophenlycaine may slow or stop bleeding. into the oropharynx. The nasal packs are into the root of the nose and lateral aspect Patients with haemodynamic instability or left in situ for three to five days to facilitate of the bones.4 Severe injuries with gross persistent bleeding (particularly patients mucosal healing.10 external deformities or compound nasal taking anticoagulant agents) should be fractures require early surgical intervention referred to the emergency department. Septal haematoma and abscess and should be referred to the emergency Nasal packing may be required to Nasal septal haematomas occur as a department immediately.2 stabilise a patient for transfer. It is significant complication of nasal trauma Paediatric patients have incomplete essential to ensure these are placed in 2% of nasal injuries.12 Blood vessels ossification of nasal bones and a greater horizontally along the floor of the in the overlying mucoperichondrium proportion of nasal cartilage; hence, they nose. Nasal packing should not be supply the septal cartilage, which can be are prone to greenstick injuries.5 The ideal directed superiorly as patients with injured resulting in formation of septal

haematoma. If left undrained, a septal Septal abscesses are a delayed haematoma can develop into a septal complication of nasal trauma. It is abscess or lead to ischaemic necrosis of common to have progressive worsening the septal cartilage in a delayed manner bilateral nasal obstruction with increasing and subsequent saddle nose deformity.12,13 pain, headache and malaise. There may Septal abscesses can result in meningitis, be fevers and purulent nasal discharge. intracranial abscesses and cavernous Examination findings are similar to septal sinus thrombosis because of the valveless haematomas. Assessment should include venous drainage pathways creating an vital signs and neurological examination.13 intracranial entry point.13 Nasal septal haematomas and abscesses Figure 2. Clinical photograph showing septal On examination, nasal septal require intravenous (IV) antibiotics and haematoma in a paediatric patient haematomas show bilateral septal urgent drainage, and the patient should be swelling obstructing the nasal airway, referred to the emergency department. which is boggy on palpation with a blunt Cerebrospinal fluid rhinorrhoea instrument (Figure 2). This is in contrast to can result from fracture and associated a cartilaginous deformity (convex in one The presence of thin, clear rhinorrhoea dural tear of the cribriform plate in the nostril, concave in other) with a firmness after nasal trauma should be considered anterior skull base.9 The time frame for to palpation. CSF leak until proven otherwise. This presentation can range from two days to

Table 1. Clinical features and assessment of facial fractures associated with traumatic nasal injuries15,16

Fracture type Assessment essentials Key assessment findings Key points/management

Mandibular fracture • Palpate mandible • Trismus • Second most frequent fractured facial bone • Inspect mandible dentition • Malocclusion • Angle and body most common fracture site • Assess mouth occlusion • Chin numbness (mental • Refer for CT facial bones and maxillofacial nerve injury) services (within 24 hours)

Zygomaticomaxillary • Palpate zygoma and maxilla • Mid-face numbness • Fractures may involve lateral orbital wall, complex fracture • Intraoral and intranasal examination • Malar depression zygomatic arch, anterior or lateral maxillary sinus • Visual acuity and range of eye • Enopthalmus wall, or orbital floor movement • Trismus • Refer for CT facial bones and maxillofacial services (within 24 hours) • Mid-face sensation • Malocclusion • Ophthalmology review for visual symptoms or orbital injury

Frontal fracture • Palpate frontal bar • Forehead lacerations • Prone to injury due to anatomic position • Assess forehead sensation • Forehead numbness • CT facial bones and sinuses • Visual acuity • Epistaxis • Be wary of intracranial complications • Assess for CSF leak • Rhinorrhoea • Delayed complications include CSF leak and frontal sinusitis

Orbital fracture • Palpate orbital rims • Visual changes • Essential to document visual acuity and range of • Examine eyelids and globe position • Forehead/mid-face eye movements • Visual acuity and range of eye numbness • CT facial bones and sinuses movement • Enophthalmos • Ophthalmology review for visual symptoms or • Forehead sensation • Chemosis orbital injury (within 24 hours) • Sub-conjunctival haemorrhage

Nasoethmoid orbital • Palpate nasal bones • Posterior displacement of • Prone to injury in high-velocity mid-facial trauma fracture • Visual acuity nasal pyramid • Nasoethmoid orbital fractures can be minimally • Examine eyelids and globe position • Telecanthus displaced • Palpate and exert pressure on • Enophthalmos • Mobility or crepitus on palpation is abnormal medial orbital rim • Epiphora • Refer for CT facial bones and maxillofacial services (within 24 hours)

CSF, cerebrospinal fluid; CT, computed tomography

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three months post-injury.14 Typically, there Training Supervisor – Southern GP Training, Corio 14. Gonen L, Monteiro E, Klironomos G, et al. is a positional element to the rhinorrhoea, Bay Medical Centre, Corio, Vic Endoscopic endonasal repair of spontaneous and Nicholas Agar MBBS, FRACS (OHNS), ENT Surgery traumatic cerebrospinal fluid rhinorrhea: A review occurring when patients lower their head Consultant, Barwon Health, Geelong, Vic and local experience. Neurosurg Clin N Am 2015;26(3):333–48. forwards. Competing interests: None. 15. Chi JJ, Alam DS. Facial trauma: Evaluation If CSF rhinorrhoea is suspected, a few Provenance and peer review: Not commissioned, and management. In: Cameron J, Cameron A, drops of the fluid should be collected and externally peer reviewed. editors. Current surgical therapy. 11th edn. sent for beta-2-transferrin assay, which is Philadelphia: Elsevier Saunders, 2014; p. 1070–81. References 16. Sargent LA. Nasoethmoid orbital fractures: 14 specific for CSF. These patients should 1. Stevens MR, Emam HA. Applied surgical Diagnosis and treatment. Plast Reconstr Surg be transferred immediately to a hospital anatomy of the nose. Oral Maxillofacial Surg Clin 2007;120(7 Suppl 2):16–31S. N Am 2012;24(1):25–38. with ENT and neurosurgery support for 2. Mondin V, Rinaldo A, Ferlito A. Management further management. of nasal bone fractures. Am J Otolaryngol 2005;26(3):181–85. Nasal injury with 3. Oluwasanmi AF, Pinto AL. Management of nasal trauma – Widespread misuse of radiographs. facial fracture British J of Clin Gov 2000;5(2):83–85. Traumatic nasal injuries with high- 4. Atighechi S, Baradaranfar MH, Akbari SA. Reduction of nasal bone fractures: A comparative force trauma should be suspected for study of general, local and topical anesthesia concomitant facial fractures. Computed techniques. J Craniofac Surg 2009;20(2):382–84. tomography (CT) imaging should be 5. Renner GJ. Management of nasal fractures. Otolaryngol Clin North Am 1991;24(1):195–213. ordered and these patients referred 6. Desrosiers AE, Thaller SR. Pediatric nasal to plastics or maxillofacial services for fractures: Evaluation and management. J Craniofac Surg 2011;22(4):1327–29. assessment if indicated. Table 1 provides a 7. Lawton B, Hadj A. Laceration repair in children. summary of associated facial fractures. Aust Fam Physician 2014;43(9):600–02. 8. Trott A. Wounds and lacerations. 4th edn. Conclusion Philadelphia: Saunders, 2012; p. 137–60. 9. Weller MD, Drake-Lee AB. A review of nasal Traumatic nasal injuries encompass a trauma. Trauma 2006;8(1):21–28. wide range of potential complications, 10. Kasperek Z, Pollock G. Epistaxis: An overview. Emerg Med Clin North Am 2013;31(2):443–54. where prompt recognition and timely 11. Zahed R, Moharamzadeh P, Alizadeharasi S, management are key to good functional Ghasemi A, Saeedi M. A new and rapid and aesthetic outcomes. method for epistaxis treatment using injectable form of tranexamic acid topically: A Authors randomized controlled trial. Am J Emerg Med 2013;31(9):1389–92. Joo H Koh MBBS, DipSurg. Anatomy, ENT 12. Elcock M. Nasal septal haematomas: A case Service Registrar, Barwon Health, Geelong, Vic. series and literature review. Emerg Med [email protected] 1999;11(1):41–44. Osama Bhatti MBBS, General Practice Registrar, 13. Alshaikh N, Lo S. Nasal septal abscess in Southern GP Training, Corio Bay Medical Centre, children: From diagnosis to management and Corio, Vic prevention. Int J Pediatr Otorhinolaryngol Abbas Mahmood MBBS, FRACGP, GP Consultant, 2011;75(6):737–44.