Nasal Trauma

Nasal Trauma: Anatomy & Initial Assaults - Broken Beak Basics

• Nasal Pyramid:
  • Bones: Paired nasal bones, frontal process of maxilla.
  • Cartilages: Upper lateral, lower lateral (alar), septal cartilage.
• Blood Supply Hotspots:
  • Kiesselbach's plexus (anterior), common for epistaxis.
  • Woodruff's plexus (posterior), for posterior bleeds.
• Common Causes:
  • Road Traffic Accidents (RTA), assault, sports injuries.
• Fracture Types:
  • Simple: Single line, displaced/undisplaced.
  • Comminuted: Multiple fragments.
  • Greenstick: Incomplete, seen in children.

⭐ Nasal bones are the most commonly fractured facial bones.

Clinical Assessment: Signs & Symptoms - Detective Work on Deck

• History Taking:
  • Mechanism (MOI: direct blow, fall), timing of injury.
  • Previous nasal trauma/surgery, any pre-existing deformity.
  • Epistaxis: duration, severity, laterality.
• Key Symptoms:
  • Pain, swelling, visible external deformity (ask patient about changes).
  • Nasal obstruction, difficulty breathing through nose.
  • Anosmia (loss of smell), epistaxis.
  • Diplopia, infraorbital paresthesia (if orbital/zygomatic involvement).
• Critical Signs (Examination):
  • External: Inspect for deformity (deviation, depression), palpate for tenderness, crepitus, bony step-offs, instability. Note edema, ecchymosis.
  • "Raccoon eyes" (bilateral periorbital ecchymosis) → strongly suggests skull base fracture.
  • Internal (Anterior Rhinoscopy is vital):
    • Nasal Septum: Meticulously check for septal hematoma (bluish, boggy, fluctuant swelling - surgical emergency!), deviation, lacerations.
    • Mucosal tears, active bleeding points.
  • CSF Rhinorrhea: Clear, watery nasal discharge? Test with Halo/Ring sign (double ring); confirm with Beta-2 transferrin assay.

⭐ Always examine the nasal septum to rule out a septal hematoma, which is a surgical emergency.

Initial Assessment Algorithm:

Key Injuries & Imaging Insights - Hematomas, Fractures & Films

• Nasal Bone Fractures: Classified by severity:
  • Type I: Simple, unilateral or bilateral.
  • Type II: Comminuted, with or without depression.
  • Type III: Complex, involving septum, orbit, or ethmoids.
• Septal Hematoma:
  • Bilateral, fluctuant, reddish/bluish swelling.
  • ⚠️ Urgent Incision & Drainage (I&D) vital.
  • Risks: Cartilage necrosis, saddle nose, septal abscess.

  ⭐ A septal hematoma, if untreated, can lead to cartilage necrosis and saddle nose deformity within 3-4 days.

• Septal Abscess:
  • Presents with fever, severe pain.
  • Requires I&D and systemic antibiotics.
• Imaging:
  • Plain X-rays (Lateral, Waters' view): Limited utility; often not needed for isolated nasal fractures.
  • CT Scan: Indicated for:
    • Suspected complex fractures (e.g., naso-orbito-ethmoid).
    • CSF leak suspicion.
    • Orbital involvement.
    • Pre-operative planning for Open Reduction Internal Fixation (ORIF).

Management Strategies & Complications - Fixing Noses & Future Notes

• Conservative: Ice, analgesia, head elevation (for minor/undisplaced #).
• Closed Reduction (CR): For cosmetically/functionally significant displacement.
  • Timing: Ideally <3 hours (pre-swelling); OR 5-10 days (adults), 3-7 days (children) post-swelling.
  • Technique: Local/General Anesthesia; Walsham's, Asch's forceps; internal/external splinting.
• Open Reduction (ORIF): For severe comminution, failed CR, late presentation >3 weeks, or septal fracture needing septorhinoplasty.
• Septal Hematoma: Prompt I&D, packing, antibiotics. ⚠️ Prevents cartilage necrosis & saddle deformity.

⭐ Closed reduction of nasal fractures is best performed after swelling subsides, typically between 5 to 10 days post-injury in adults.

• Management Flow:

• Complications:
  • Early: Epistaxis, septal hematoma/abscess, infection, CSF leak, pain, swelling.
  • Late: External deformity (deviation, saddle nose), nasal obstruction, septal perforation, synechiae, anosmia, chronic sinusitis.

High‑Yield Points - ⚡ Biggest Takeaways

• Nasal bone fractures are the most common type of facial fractures.
• Septal hematoma requires urgent incision and drainage to prevent saddle nose deformity or septal abscess.
• CSF rhinorrhea, testing positive for glucose or β2-transferrin, suggests a cribriform plate fracture.
• "Raccoon eyes" (bilateral periorbital ecchymosis) can indicate an anterior cranial fossa fracture.
• Nasal packing for epistaxis control post-trauma carries a risk of Toxic Shock Syndrome.