AETIOLOGY AND MANAGEMENT
Nasal bone fractures are common (40% of all facial injuries) especially on weekend nights! Nasal trauma can result in damage to skin, bone and cartilage. Complications of such fractures include:
CSF leak – straw coloured rhinorrhea
Septal deviation leading to nasal obstruction
Do not miss septal haematomas - if left untreated, they can lead to abscesses and/or necrosis of the septal cartilage and resultant saddle deformity and/or septal perforation.
Some of these patients may have other associated injuries i.e base of skull fractures, which should be investigated by A&E and referred to the neurosurgical/trauma/maxillofacial teams before involving ENT.
Patients with associated base of skull fracture/other facial injuries
Septal haematoma – requires surgical drainage
Severe traumatic epistaxis requiring nasal packing which is usually secondary to anterior ethmoidal artery (about 90% of traumatic epistaxis stops with conservative methods)
Who to admit
Under ENT: Patients who have a septal haematoma or traumatic severe epistaxis, with no other major injury.
Joint care with neurosurgeons/maxillofacial surgeons etc: Patients who have other major injuries but who may also have a septal haematoma or severe traumatic epistaxis.
Patients with an isolated nasal fracture and no septal haematoma or epistaxis do not normally require admission under ENT but will require ENT emergency clinic follow up.
Assessment and Management
Patients with isolated nasal injuries don't have to be seen out-of-hours as the nose is too swollen immediately post trauma and can only be effectively assessed five to seven days later in an ENT emergency clinic.
You may be asked to rule out a septal haematoma, which is blood collecting under the lining of the septal cartilage causing a purple, boggy/fluctuant swelling inside the nose on both sides. This is sometimes mistaken for a deviated nasal septum but if you look in the other nostril, the septum will appear deviated to that side as well. Presence of a haematoma can be confirmed by aspirating blood and clot with a green needle.
Figure 4 – Septal haematoma. Note the bilateral cherry red appearance
If you can see blood or haematoma inside the nose, this is not a septal haematoma. To reiterate, a septal haematoma collects beneath the mucosa and perichondrium of the septum and presents as a swelling rather than frank clot.
Patients discharged from A&E with nasal trauma should be booked into the ENT emergency clinic seven to ten days afterwards for manipulation and further treatment.
NB: X-Rays of the nose are pointless in assessing nasal bone fractures alone (this is not the case for mid-face fractures).
Patients can be assessed in ENT emergency clinic seven to ten days after injury to determine if they are suitable for a manipulation under anaesthesia.
This can be local or general anaesthesia based on patient’s preference and local policy.
Manipulation must take place within 14 days after the injury otherwise the bones will heal in the deformed position. The patient should be informed that the deformity might not be corrected completely. Any residual deformity even after manipulation may require more surgery 12 months or more after the injury (eg septorhinoplasty).
Author: Andrew Senior
Last Update: 08/11/2015