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