Nasal Trauma: Fractures, Septal Hematoma



Nasal Trauma: Fractures, Septal Hematoma


Chen He

Shirley Hu



INTRODUCTION

In addition to functional impairment, facial injuries pose potential psychological and social consequences, because the face is vital to human appearance, emotion, and identity. Thus, although treatment of facial injuries in the emergency department (ED) and urgent care setting must focus first on life-threatening issues, important secondary considerations are preservation of function and long-term cosmesis. The nose is a defining facial feature that also provides important physiologic function. Nasal fractures are the most frequently isolated facial fracture, likely owing to the physical prominence of the nose.


PATHOPHYSIOLOGY/EPIDEMIOLOGY


Nasal Fractures

The nose is composed of very thin bone that can be fractured with minimal force. The bony structure of the nose is formed by the maxilla, frontal bone, and a number of smaller bones. The bony prominence of the nose, located between the brows, is formed by the nasal part of the frontal bone, which ends in a serrated nasal notch. From here, the left and right nasal bones emanate, bridging the frontal bone to the frontal process of the maxilla. Internally, the roof of the nasal cavity is the ethmoid bone’s cribriform plate, through which the sensory fibers of the olfactory nerve pass. As such, damage to this region can result in anosmia. The nasal septum separates the two nares and is composed of bone proximally and cartilage toward the nasal tip. Finally, the floor of the nose is formed from the incisive bone and the horizontal plates of the palatine bones, which join at the midline to form the posterior nasal spine.

Nasal bone fractures most commonly occur from blunt trauma.1 In adults, the most frequent causes are fights and traffic accidents. Young males are most likely to sustain nasal injuries, with peak incidence occurring at age 20 to 30 years. In children, the most frequent cause is sports.

Patients present with swelling, pain, ecchymosis, and/or bleeding, with symptoms dependent on time from injury. No specific classification system exists for nasal bone fractures, but severity of injury is defined by number and complexity of fractures, degree of displacement, and open versus closed injuries. Low-velocity injuries (eg, falling from a standing position or walking into a wall) often lead to simple fractures, whereas high-velocity injuries (eg, motor vehicle accidents) tend to be associated with multiple or complex fractures. Understanding the mechanism of injury not only helps to predict the severity of the facial injury but can also assess the risk of associated brain or cervical injuries.



Septal Hematoma

The nasal septum separates the left and right nares of the nasal cavity; it contains bone and cartilage and is normally about 2 mm thick. Proximally, the perpendicular plate of the ethmoid and the vomer combine to form the bony structure of the septum. Distally, the septum is composed of septal cartilage, ending in a fleshy external end known as the columella. At the base, a narrow strip of bone, called the maxillary crest, runs the length of the septum.

A nasal septal hematoma can occur when blood collects in the space between the septal cartilage and its overlying perichondrium (Figure 19.1). This condition requires emergent diagnosis because the septal cartilage does not have its own blood supply, so pressure from the hematoma can lead to ischemia and destruction of the septum. This condition is more common in children (Figure 19.2).


APPROACH/THE FOCUSED EXAM

The initial evaluation of nasal trauma should focus on threats to the airway and on stopping active bleeding. Within the first few hours of the injury, full evaluation of the anatomy at the site is still possible. However, usually by the time of presentation to an ED or urgent care setting, significant edema has developed, distorting the shape of the nose and limiting detailed examination. Patients often have some degree of nasal airway obstruction, which is not concerning unless concomitant oral airway compromise exists. Other common presenting symptoms are pain and tenderness, visible deformity, or epistaxis.

Externally, the nose should be visually inspected for swelling, deformity, or bleeding. It should be palpated for tenderness, crepitus, and abnormal movement. Each nare should be held closed to make sure that the other is patent for breathing. The patient should also be asked to identify whether there is any change to their sense of smell. A muffled or hyponasal voice may suggest occlusion of the nose or nasopharynx. Evaluation for the presence of a nasal septal hematoma should be done urgently to allow for timely drainage.