Nasal Trauma

Nasal Trauma

 

Definition

Nasal trauma is defined as any injury to the nose or related structure that may result in bleeding, a physical deformity, a decreased ability to breathe normally because of obstruction, or an impaired sense of smell. The injury may be either internal or external.

Description

The human nose is composed of bone, soft tissue, and cartilage. It serves as a passageway for air to flow from the outside environment into the lower respiratory tract and lungs. At the same time, the nasal passages warm and humidify the air that enters the body.
Internal injuries to the nose typically occur when a foreign object (including the fingers) is placed in the nose or when a person takes in drugs of abuse (inhalants or cocaine) through the nose. External injuries to the nose are usually blunt force injuries related to sports participation, criminal violence, parental abuse, or automobile or bicycle accidents. This type of injury may result in a nasal fracture. The nasal bones are the most frequently fractured facial bones due to their position on the face, and are the third most common type of bone fracture in general after fractures of the wrist and collarbone. A force of only 30g is required to break the nasal bones, compared to 70g for the bones in the jaw and 200 g for the bony ridge above the eyes. The pattern of the fracture depends on the direction of the blow to the nose, whether coming from the front, the side, or above the nose. Although not life-threatening by itself, a fractured nose may lead to difficulties in breathing as well as facial disfigurement.
Fractures resulting from trauma to the nose may involve the bones of the septum (the partition of bone and cartilage dividing the two nostrils) as well as the bones surrounding the eyes. These bones include the nasal, maxilla, lacrimal, and frontal bones. Direct trauma to the bridge of the nose may also result in damage to a part of the base of the skull known as the cribriform plate. This injury in turn may allow cerebrospinal fluid to leak out of the skull and leave the body through the nose. Fractures may also damage the membranes that line the nasal passages, leading to possible formation of scar tissue, obstruction of the airway, and damage to the child's sense of smell.
In addition to fractures, external injuries of the nose include soft-tissue injuries resulting from bites (human and animal), insect stings, cuts, or scrapes. Penetrating injuries to the nasal area caused by air gun or BB pellets are also reported with increasing frequency in older children and adolescents. When fired at close range, these pellets can penetrate the skin and cheekbone and lodge in the nasal septum or the sinuses near the nose.
Lastly, nose piercing as a fashion trend is a type of intentional injury to the nose that has several possible complications, including infections of the cartilage and soft tissues in the nose; blockage of the airway due to a loosened stud or other nose ornament; and gastrointestinal emergencies caused by accidental swallowing of nose jewelry.

Causes and symptoms

Causes

External trauma to the nose may be accidental (transportation accidents, animal bites, air gun injuries, and sports injuries) or intentional (fights, criminal assault, domestic violence, nose piercing). Nasal injuries from athletic activities may result from contact with equipment (being hit in the face by a baseball, hockey ball, or other small ball hit at high speed, or by the bat or stick itself) or the bodies of other players (football, boxing, martial arts, rugby). Nasal injuries from piercing include bacterial infections of the skin and nasal cartilage, allergic reactions to the jewelry, tissue damage, and periodic bleeding.
In a few cases, external trauma to the nose may also be iatrogenic, or caused by medical care. Most of these injuries result from medical examination of the nose—particularly in emergency circumstances—or as complications of plastic surgery. In a few cases damage to the nose is caused by radiation therapy for cancer.
Internal injuries to the nose may be either mechanical (caused by foreign objects in the nose or by picking or scratching the tissues lining the nose) or chemical (caused by environmental irritants or substance abuse).
Chemical injuries to the nose are caused by accidental or purposeful breathing or sniffing of irritating substances. These may include tobacco smoke; household cleaners (ammonia and chlorine bleach) and furniture polish; ozone and other air pollutants; cocaine; and glue, paint thinners, solvents, and similar household products that produce toxic vapors. An increasingly common form of chemical injury to the nasal membranes in toddlers is alkali burns caused by leakage from small batteries placed in the nose. While chemical damage to the nose is usually accidental in younger children, it is more often the result of substance abuse in adolescents. Taking cocaine through the nose ("snorting") or inhalant abuse ("sniffing" or "huffing") are the most common causes of chemical damage to the nose in older children or teenagers.

Symptoms

The symptoms of physical trauma to the nose may include:
  • Flattening or other deformation of the shape of the nose
  • Infections of the cartilage or soft tissue
  • Epistaxis or bleeding from the nose
  • Crepitus. Crepitus is the crackling or crunching sound heard when the ends of a fractured bone are rubbed together
  • Pain and tissue swelling
  • Airway blockage from bleeding, fluid discharge, or tissue swelling
  • Rhinitis. Rhinitis is an inflammation of the mucous membranes lining the nose. In the case of a fracture, rhinitis may lead to increased tear production in the eyes and a runny nose
  • Septal hematoma. A septal hematoma is a mass of blood from torn tissue that may collect within the cartilage that divides the two nostrils. It may become infected and form an abscess that eventually destroys the cartilage
  • Bruising or discoloration (ecchymosis) of the tissues around the eye
  • Leakage of cerebrospinal fluid through the nostrils
Chemical trauma to the nose may result in:
  • Runny nose and watering of the eyes
  • Pain
  • Loss of the sense of smell
  • Nasal congestion and sneezing
  • Reddening and swelling of the mucous membranes lining the nose
  • Eventual destruction of the cartilage in the nasal septum and the tissues lining the nose
Some common irritants that may be encountered in the home and workplace include:
  • cleaning solutions and powders
  • ammonia
  • environmental tobacco smoke
  • bleach
  • metalworking fluids
  • ozone
  • sulfur dioxide
  • paint thinners
  • arsenic
  • chromic acid
  • copper dust and mists
Sequelae following exposure to these chemicals are based not only on the concentration of the irritant but also on factors specific to the individual. Reactions vary among persons, even with similar exposures.

Diagnosis

Diagnosis of a fracture is normally based on a history of nasal trauma and clinical presentation. Epistaxis may or may not be present. An intranasal examination is performed in order to look for a septal hematoma that may result in serious consequences such as death of the septal cartilaginous tissue. The nose is also checked for tenderness, mobility, stability, and crepitance.
X rays are normally not indicated, however, in more severe fractures involving multiple bones, a computed tomography (CT) scan may be required. The physician should look for associated injuries such as periorbital (surrounding the eye) ecchymosis, watery eyes, or diplopia (double vision) that may indicate orbital injuries. In addition, dental fractures and a cerebrospinal fluid (CSF) leak should be looked for. CSF leaks indicate a more severe injury possibly involving an ethmoid bone fracture.
The physician may also ask for photographs taken prior to the injury in order to determine the extent of deformity. Photographs may also be taken to document the injury in regards to possible legal actions.
In order to diagnose trauma sustained by a chemical injury, a history of exposure to potentially toxic chemicals should be ascertained. In addition, the patient should also bring information related to the types of chemicals that he or she has been exposed to. If injury occurs in the workplace, Material Safety Data Sheets should be available in the employer's poison control center that list the chemical components of commercial materials. Measurements of air from the patient's work area may also be obtained. Symptomatic improvement on off-days followed by a subsequent return of symptoms when returning to work confirms that the illness is work related. The physician should perform an intranasal examination to determine the extent of the chemical injury. A chest x ray as well as a pulmonary function test may be ordered to determine if there is any subsequent lower respiratory tract involvement.

Treatment

Timing

Nasal injuries should be treated as promptly as possible to prevent complications. Batteries placed in the nose should be removed within 4 hours to prevent burns and other damage to the tissues from leaking chemicals. If a septal hematoma has developed, the doctor must remove it as quickly as possible to prevent infection or eventual death of the tissues in the nasal septum. Lastly, if the child has been bitten by an animal, the injury must be cleansed as soon as possible to lower the risk of rabies.
Treatment of nasal fractures is best performed during the first three hours after the injury. If this is impossible, management of a nasal fracture should be done within three to seven days. Timing is of utmost importance when treating nasal fractures because delays longer than seven to 10 days may allow the broken bones to set without proper alignment, or lead to such complications as scar tissue formation and airway obstruction. Poorly set nasal fractures usually require surgical correction.

Specific procedures

Foreign objects in the nose can be removed by nasal suction in most cases. Most nosebleeds are treated by 5-30 minutes of direct pressure on the nostrils, with the patient's head placed in an upright position. The doctor may also pack the nose with gauze coated with petroleum jelly. If the bleeding does not stop, or if it appears to originate in the upper nose, the doctor will consult a head and neck surgeon or an otolaryngologist for specialized evaluation of the bleeding.
Air gun or BB pellets that have penetrated the nose or nearby sinuses are generally removed with the help of an endoscope, which is a slender tubular instrument that allows the doctor to examine the inside of a body cavity.
Treatment of nasal fractures depends on the extent of the injury; the most difficult fractures to treat are those that involve the nasal septum. The doctor will usually reduce the fracture, which means that he or she will restore the damaged bones to their proper position and alignment. Although local anesthesia is usually sufficient for treating nasal fractures in adults and older teenagers, general anesthesia is usually given when treating these injuries in younger children.
Reductions of nasal fractures may be either open or closed. A closed reduction involves manipulation of the bones without cutting into the overlying skin. This type of reduction will be performed for fractures of the nasal bones that are limited in size and complexity. Open reductions are performed for more complex nasal fractures. In an open reduction, the nasal bones are moved back to their original location after the surgeon has made an incision in the overlying skin. This procedure is done for fractures involving dislocation of the septum as well as the nasal bones. In addition, an open reduction is necessary if the child has a septal hematoma or an open fracture in which the skin has been perforated. If a septal hematoma is present, the doctor will drain it and pack the nose to prevent subsequent accumulation of blood. The nasal bones are held in the proper position with external splints as well as the internal packing, and the splints are kept in place for 7-10 days. The patient will be given antibiotics to lower the risk of infection and may be referred to an otolaryngologist or plastic surgeon for further evaluation. Ice packs or cold compresses can be applied at home to lower swelling and ease discomfort.
In the case of animal bites, the patient may be given passive or active immunization against rabies if there is a chance that the dog or other animal is rabid. This precaution is particularly important for animal bites on the nose or other parts of the face, as the incubation period of the rabies virus is much shorter for bites on the head and neck than for bites elsewhere on the body.
Complications can arise following treatment and therefore follow-up is necessary. Problems that may occur resemble symptoms of nasal fractures. Others include infection, CSF leakage, scar tissue build-up, and a saddle nose deformity where the bridge of the nose is markedly depressed.
Treatment for trauma caused by irritant inhalation involves removing the patient from the contaminated area or decreasing exposure time. Other measures include using a saline nasal spray or topical steroids. For acute injuries oxygen or supportive treatment for any subsequent lower respiratory tract involvement may be administered.
If the injury is occupation-related, changes should be made in order to eliminate future incidents. These changes may include having the patient wear a respiratory protection device while working. In addition, the employer should be made aware of the situation and employ measures to prevent future incidents.

Prognosis

Most types of nasal trauma have a good prognosis. Nosebleeds or tissue damage caused by scratching or picking at the nose usually clear completely once these habits are stopped. Infections or allergic reactions caused by foreign objects in the nose or piercing usually clear up promptly after the object or piece of jewelry is removed. Nasal fractures that do not involve the nasal septum or other facial bones and receive prompt treatment generally heal without deformities of the nose, cartilage destruction, or other complications. More extensive facial fractures, however, may require a second operation to correct the positioning of the bones and restore the appearance of the nose.
The prognosis for soft-tissue injuries to the nose depends on the cause and extent of the injuries. Such tearing or crushing injuries as those caused by bites take longer to heal than simple cuts, and may require plastic surgery at a later date to restore the appearance of the nose.
Damage to the tissues lining the nose caused by exposure to tobacco smoke or other irritants in the environment is usually reversible once the patient is removed from contact with the irritating substance. Erosion or destruction of the nasal cartilage as a result of inhalant or cocaine abuse, however, usually requires surgical treatment.

Prevention

Although most cases of nasal trauma happen inadvertently, some measures can be employed in order to prevent injury. Patients should be aware of the symptoms of nasal fracture and should seek medical attention as soon as possible to prevent more invasive reductions. Protective equipment should also be worn when playing sports. Employees should also be aware of irritating chemicals in their workplace and appropriate measures should be taken to avoid exposure.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Fractures of the Nose." Section 7, Chapter 86 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
Jackler, Robert K., and Michael J. Kaplan. "Ear, Nose, and Throat." In Current Medical Diagnosis and Treatment, edited by Lawrence M. Tierney, Jr., et al. New York: Lange Medical Books/McGraw-Hill, 2001.

Periodicals

Alvi, A., T. Doherty, and G. Lewen. "Facial Fractures and Concomitant Injuries in Trauma Patients." Laryngoscope 113 (January 2003): 102-106.
Anderson, Carrie E., MD, and Glenn A. Loomis, MD. "Recognition and Prevention of Inhalant Abuse." American Family Physician 68 (September 1, 2003): 869-876.
Brinson, G. M., B. A. Senior, and W. G. Yarbrough. "Endoscopic Management of Retained Airgun Projectiles in the Paranasal Sinuses." Otolaryngology and Head and Neck Surgery 130 (January 2004): 25-30.
Kalavrezos, N. "Current Trends in the Management of Frontal Sinus Fractures." Injury 35 (April 2004): 340-346.
Mahajan, M., and N. Shah. "Accidental Lodgment of an Air Gun Pellet in the Maxillary Sinus of a 6-Year-Old Girl: A Case Report." Dental Traumatology 20 (June 2004): 178-180.
Ross, Adam T., MD, and Daniel G. Becker, MD. "Fractures, Nasal and Septal." eMedicine July 13, 2004. http://www.emedicine.com/ent/topic159.htm.
Rupp, Timothy J., MD, Marian Bednar, MD, and Stephen Karageanes, DO. "Facial Fractures." eMedicine August 29, 2004. http://www.emedicine.com/sports/topic33.htm.
Tu, A. H., J. A. Girotto, N. Singh, et al. "Facial Fractures from Dog Bite Injuries." Plastic and Reconstructive Surgery 109 (April 1, 2002): 1259-1265.

Organizations

American Academy of Family Physicians (AAFP). 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (800) 274-2237 or (913) 906-6000. http://www.aafp.org.
American Academy of Otolaryngology—Head and Neck Surgery. One Prince Street, Alexandria, VA 22314-3357. (703) 836-4444. http://www.entnet.org.
American College of Sports Medicine (ACSM). 401 West Michigan Street, Indianapolis, IN 46202-3233. (317) 637-9200. Fax: (317) 634-7817. http://www.acsm.org.

Key terms

Crepitus — A crackling or crunching sound heard when the ends of a fractured piece of bone rub against each other.
Diplopia — The medical term for seeing double.
Ecchymosis (plural, ecchymoses) — The medical term for a bruise. Ecchymoses may develop around the eyes following a nasal fracture.
Epistaxis — The medical term for a nosebleed.
Hematoma — A localized collection of blood that accumulates in an organ, tissue, or body space as the result of leakage from a broken blood vessel. Hematomas sometimes develop within the nasal cartilage when the nose is fractured.
Iatrogenic — Referring to injuries caused by a doctor. Nasal trauma may occasionally result from a doctor's examination of the nose or complications from plastic surgery.
Otolaryngologist — A doctor who specializes in diagnosing and treating disorders of the ears, nose, and throat.
Reduce — To restore a part of the body to its normal position or place, as in treating a fracture or dislocation. The repositioning of the bone or body part is called a reduction.
Rhinitis — An inflammation of the mucous membranes that line the nasal passages.
Rhinoplasty — Plastic surgery of the nose to repair or change the shape of the nose.
Septal hematoma — A mass of extravasated blood that is confined within the nasal septum.
Septum — The partition of bone and cartilage in the nose that separates the two nostrils.
References in periodicals archive ?
Some common complications include nasal trauma, tooth avulsion, oral-pharyngeal laceration, laceration of the vocal cords, and tracheal laceration, perforation, and hypoxemia.
She denied any history of headaches, epistaxis, postnasal drip, or nasal trauma.
26 ( ANI ): After suffering a severe nasal trauma in a car wreck, a Chinese man will soon undergo a transplant that will replace his damaged nose with a new nose that has been grown on his forehead.
Difficult transit of the nasotracheal tube is a risk factor for nasal trauma (3).
For comparison purposes, we also obtained US images from 12 control subjects who had no history of nasal trauma or surgery.
Biomatrix recently announced FDA clearance to market HylaSine(R), the company's viscoelastic gel device intended for use in nasal/sinus cavities as a space occupying gel stent to separate the mucosal surface and to help control minimal bleeding following surgery or nasal trauma.
The obstruction had been caused when he sustained nasal trauma 5 years earlier.
4) In cases in which nasal trauma has caused epistaxis, ligation of the anterior ethmoidal vessels is often the procedure of choice.
She also denied any history of head or nasal trauma and nasal or sinus surgery.
On the other hand, the nasal trauma and the history of bleeding in a premature newborn, combined with findings of a unilateral nasal mass and evidence of a nasal vault defect on CT, strengthened the theory that the mass represented a large basal transcribriform meningoencephalocele.
An 8-year-old boy complaining of worsening nasal congestion presented to the emergency room with a diagnosis of sinusitis 1 week after experiencing unspecified nasal trauma in an accident.