ID Design 2012/DOOEL Skopje, Republic of Macedonia Open Access Macedonian Journal of Medical Sciences. 2016 Sep 15; 4(3):413-419. http://dx.doi.org/10.3889/oamjms.2016.081 eISSN: 1857-9655 Clinical Science The Impact of the Nasal Trauma in Childhood on the Development of the Nose in Future Gabriela Kopacheva-Barsova1*, Slavica Arsova2 1University Clinic for Ear, Nose and Throat, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Vodnjanska 17, Skopje 1109, Republic of Macedonia; 2University Clinic of Psychiatry, Ss Cyril and Methodius University of Skopje, Vodnjanska 17, Skopje 1109, Republic of Macedonia Citation: Kopacheva-Barsova G, Arsova S. The Impact of Abstract the Nasal Trauma in Childhood on the Development of the Nose in Future. Open Access Maced J Med Sci. 2016 AIM: To prevent and to treat nasal trauma in children properly, because it can lead to displacement Sep 15; 4(3):413-419. http://dx.doi.org/10.3889/oamjms.2016.081 or depression of the nasal bones or septum. Second, our aim was, for the patient to recognise and Keywords: nasal fractures in children; nasal growth; create a mature decision for eventual nose changes which will be made with the operative treatment of recent traumatic deformities; rhino surgery in intervention or they are not mature enough and the decisions were made by their parents. children and adolescents; psychological behaviour. *Correspondence: Gabriela Kopacheva Barsova, PhD. University Clinic for Ear, Nose and Throat, Faculty of MATERIAL AND METHODS: Our retrospective study was made at University Clinic for Ear, Nose Medicine, Ss Cyril and Methodius University of Skopje, and Throat, Faculty of Medicine, Ss Cyril and Methodius University of Skopje in the period of 6 Vodnjanska 17, Skopje, MK 1109, Republic of Macedonia. E-mail: [email protected] years (2005 -2016). Seventy-three patients were admitted with recent or previous nasal trauma or Received: 01-Jul-2016; Revised: 19-Jul-2016; nasal deformity. The first group of 32 were children and adolescents from 6-14 years old who were Accepted: 20-Jul-2016; Online first: 02-Aug-2016 admitted to our hospital because of recent nasal trauma. The second group of 41 children and Copyright: © 2016 Gabriela Kopacheva-Barsova, Slavica Arsova. This is an open-access article distributed under adolescents from 6-14 years old were admitted to our hospital because of previous nasal trauma, the terms of the Creative Commons Attribution License, which was not treated on time, or it was not treated properly. They were admitted to our clinic for which permits unrestricted use, distribution, and reproduction in any medium, provided the original author surgical intervention septo/rhinoplasty. The second group of patients fills the brief psychological and source are credited. questioner prepared by Clinical psychiatrist from University Clinic of Psychiatry, in Skopje, and their Competing Interests: The authors have declared that no psychological reactions were taken into consideration. competing interests exist. RESULTS: Eleven of the children and adolescents who had nasal fracture without dislocation, who have no symptoms, minimal swelling, and no septal deviation or hematoma, were observed with a specific follow-up: 3 days after nasal fracture, then every week in the first month, after 1 month, and after 3 months period. Sixteen of children and adolescents who had a nasal fracture with subluxation of nasal septum were operated with closed reduction (repositio nasi) under general anaesthesia. The others with septal hematomas and subperichondrial abscess were treated as in adults’ patients. The second group of 41 children and adolescents from 6-14 years old consisted with with the previous nasal trauma which was not treated on time or it was improperly treated. In 24 (58.54%) of these patients septoplasty was performed and in 17 (41.46%) was performed rhino septoplasty. CONCLUSION: Often, difficult septal deformations in children are followed with deformation of the nasal pyramid (rhino scoliosis, rhino lordosis). In those cases, we cannot solve septal pathology without nasal pyramid intervention in the same time and opposite. Clinical reports have not produced solid evidence for the statement that septal surgery has no negative effect on nasal growth or can serve for correcting abnormal growth. The functional and esthetic problems of the patient, however, mean a continuous stimulus for further clinical and experimental investigations. Introduction The most common causes of nasal fractures in this age group are auto accidents, usually involving bicyclists or pedestrians (40%), sports injuries (25%), Nasal fractures have been reported as 1 of intended injuries such as weight lifting (15%), and the 3 most commonly encountered paediatric facial home injuries (10%). Child abuse also must be bone fractures. The nasal bones and mandible are the considered. facial bones most commonly fractured in children. Fractures of the bony nasal pyramid do not Nasal fractures occur more commonly than do occur as frequently as in adults, because of the lesser mandibular fractures because they require less force prominence of the nasal bones during childhood to produce. because the greater part of the nasal skeleton is _______________________________________________________________________________________________________________________________ Open Access Maced J Med Sci. 2016 Sep 15; 4(3):413-419. 413 Clinical Science _______________________________________________________________________________________________________________________________ cartilaginous. Therefore, fractures of the facial bones Naso-orbito-ethmoid fractures are uncommon occurrences in children younger than Naso-orbito-ethmoid fractures occur with high five years of age, but the incidence increases with impact to the central midface and involve complete increasing age and peaks between 16 and 20 years. separation of the nasal bones and the medial walls of Most of these injuries are minor (almost in 85%) [1-4]. the orbits from the frontal bone and the infraorbital rim. The bones typically are fragmented and displaced posteriorly into the ethmoid region. The medial canthal Anatomy tendons, which are attached to the medial walls of the The sutures bordering the nasal bones have orbits, are shifted laterally with the fracture segments, not been yet ossified and can "split off" in a case of resulting in increased inner canthal distance trauma. The most frequent lesion is the septal fracture (traumatic telecanthus) [12, 13]. with dislocation. The upper one-third of the nose is supported by the paired nasal bones and the frontal processes of the maxilla; the lower two-thirds are Clinical manifestation of nasal fractures in maintained by cartilaginous structures. The superior children portion of the nasal bones is thick and relatively Unfortunately, most of the nasal fractures in resistant to fracture. In contrast, the inferior portion is children are not refers to the ENT - specialist thin and weak. The bony nasal septum articulates with immediately. Evaluation of nasal symptoms following the undersurface of the nasal bones to provide nasal trauma includes nasal obstruction, nasal support to the nasal dorsum. The lacrimal bones and bleeding, pain, anosmia, and cosmetic deformity. ethmoid labyrinth lie deep to this bony pyramid [5-7]. The typical symptoms of nasal septal Blood supply of the nose, derived from the hematoma and/or abscess are a progressive nasal internal and external carotid arteries. Kiesselbach obstruction (95 percent), persistent or worsening pain plexus, the vascular watershed area of the (50 percent), rhinorrhea (25 percent). All children with anteroinferior nasal septum, is the site of origin of facial trauma should be assessed for associated most nosebleeds. Because of the rich nose blood injuries to the cervical spine, central nervous system, supply frequency and intensity of epistaxis and chest, orbits, and teeth [14-16] (Fig. 1). swelling in patients with nasal trauma are very If symptoms present with the change in visual common. acuity, diplopia, and sensory deficits should have a prompt evaluation for neurologic or ophthalmologic trauma. Pathogenesis Direct blows to the nose can fracture the nasal skeleton and lead to displacement or depression of the nasal bones or septum. Because the nasal pyramid is variably cartilaginous during childhood, greenstick fractures are more common. Rupture of a triangular (dorsolateral) cartilage from the piriform aperture is a difficult diagnosis. It appears with dorsum hematoma, caused by rupture of the external brunch of the anterior ethmoid artery, On the outside, the hematoma is often connected with facial oedema. Expansion of the hematoma separates Figure 1: Septal hematoma after previous nasal trauma the cartilage from the mucoperichondrium, obstructing blood flow to the nasal cartilage and causing Patient physical examination and pressure-induced avascular necrosis of the nasal evaluation cartilage. Septal perforation and irreversible damage result after three to four days of ischemia. The The septum should be examined for fracture, accumulated blood and necrotic tissue become a displacement, laceration, discoloration, and abnormal “good” place for infection of the nasal mucosa [8, 9]. swelling. The intranasal cavity should be evaluated using an appropriate lighting in all children with nasal The replacement of necrotic tissue by fibrous trauma. The signs and symptoms of nasal septal tissue, retraction of scar tissue, and loss