Definition, Description, Causes and symptoms, Diagnosis, Treatment, Prognosis, Prevention
Nasal trauma is defined as any injury to the nose or related structure that may result in deformity, decreased inhalation due to obstruction, or an impaired sense of smell (olfaction).
The nose is composed of bone, soft tissue, and cartilage. It functions to serve as a passageway for air from the environment to flow into the lower respiratory tract and lungs, at the same time warming and humidify air.
The nasal bones are the most frequently fractured facial bones due to their foremost position on the face. Although not life threatening, fractures may lead to aesthetic and functional deformities. Children have a more cartilaginous nose than adults and are more resilient to trauma due to force.
Fractures of the nose vary with the type and direction of force that has been inflicted. Fractures resulting from trauma to the nose may involve the bones of the septum as well as bones surrounding the orbit including the nasal, maxilla, lacrimal, and frontal bones. Fractures and other trauma may also damage the membranes that line the nasal passages. Damage to these membranes is serious since it can lead to obstruction, increased secretion, or an impaired sense of olfaction.
Causes and symptoms
Nasal trauma results from fractures, dislocations, foreign bodies such as digits, chemical irritants, burns; or may be iatrogenic in which complications of a physician's exam or surgical treatment result in injury. Most injuries are caused by auto accidents, sports injuries, fights, work related accidents, or leisure activities. Falls are a more common cause of nasal injury in children. Trauma can also occur to neonates as a result of birth. There is also an increased incidence of fractures following rhinoplasty, or plastic surgery, performed on the nose.
All severe blows to the nose may result in a nasal fracture. After such a blow, the nose may appear slightly deformed as well as shifted laterally or depressed. Other symptoms include:
- airway obstruction
- epistaxis (profuse bleeding from the nose)
- crepitance (the crackling heard and the sensation felt when broken bones are moved over each other)
- ecchymosis (a purplish area of the nose resulting from fracture and caused by extravasation of blood into the skin)
- septal hematoma (a mass of extravasated blood that confined within the nasal septum)
- rhinitis (an inflammation of the mucous membranes that line the nasal passages)
- nasal vestibular stenosis (a narrowing of the nasal passages)
In addition to fracture, trauma may be caused by chemical inhalation. This is normally due to repetitive inhalation of toxic materials that may, in addition to irritating the nasal passages, cause damage to the lower respiratory tract and lungs. Irritant gases may cause damage by direct contact with membranes and a proceeding chemical reaction can result in a release of free radicals causing membrane damage.
Initial symptoms of chemical irritation may include rhinorrhea or runny nose, pain, and/or nasal congestion. Certain chemical irritants may also cause burning of the mucous membranes of the nose. Irritation may also cause redness of the eyes, coughing, sneezing, itching, and a deficit in olfaction and taste.
Some common irritants that may be encountered in the home and workplace include:
- cleaning solutions and powders
- environmental tobacco smoke
- metalworking fluids
- sulfur dioxide
- paint thinners
- 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 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 of nasal fractures is aimed at restoring nasal function and reestablishing the aesthetic appearance of the nose. Treatment 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 since delays longer than seven to 10 days may result in significant bone healing and possibly require surgical intervention including rhinoplasty.
The treatment options depend upon the extent of the injury. Reductions, or restorations, can be performed under local or general anesthesia. A closed reduction involves manipulation without a skin incision. This type of reduction will be performed for unilateral or bilateral fractures of the nasal bones, or if the fracture of the nasal-septal complex is insignificant. If there is a persistent deformity following treatment an open reduction may be needed.
Open reductions are performed for more complex nasal fractures. This involves manipulating the bones back to their original location after an incision in the skin has been made. This procedure is done for fractures involving dislocation of the nasal bones and the septum. In addition, an open reduction is indicated for a septal hematoma or for open fractures in which the skin has been perforated. If a septal hematoma is present, it should be drained and packed to prevent subsequent accumulation of blood. The patient should be given antibiotics and may be referred to an otolaryngologist or a plastic surgeon for further evaluation.
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. This 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.
Most patients who sustain nasal trauma recover following treatment. Prognosis can be improved with patient compliance with any antibiotics prescribed and follow-up visits with their physician.
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.
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Laith Farid Gulli, M.D.
Robert Ramirez, B.Sc.
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