Evaluation and Management
Nasal trauma is a common occurrence in pediatric and adult patients because of the exposed and central position of the nose on the face.1–4 There is a broad spectrum of primary and secondary nasal trauma deformities that the craniomaxillofacial surgeon must be able to address. This chapter reviews the evaluation and treatment of nasal trauma and secondary nasal deformities.
The nose and perinasal tissues have functional and aesthetic roles. The aesthetic value of the nose is a key aspect of facial appearance and a very recognizable feature of the face. It is also the most exposed and prominent area of the face. The nasal form is directly related to its function. When treating nasal trauma, clinicians should aim at optimizing function as a primary objective in conjunction with the aesthetic goals. Nasal function is important for normal respiration, humidification, speech production, and sensations associated with smell and as an aesthetic facial feature.
Nasal fractures are the most common facial fractures seen and occur at least twice as often in males as in females.1–6 The high frequency of nasal fractures can be attributed to its prominent location in the facial skeleton and the comparatively smaller amount of force needed to produce a fracture when compared with other facial bones. Athletic injuries, interpersonal altercations, falls, and motor vehicle accidents (MVAs) account for the greatest proportion of causes. In the children and adolescents, sports and falls are the major causes of isolated nasal bone fractures.2–4,7,8 For example, a study of sports-related fractures in U.S. high schools has found a 10.1% rate of fractures with the highest rate in football, basketball, and soccer.4 The investigators found that when facial fractures occurred, nasal fractures were the most common injury and resulted in more than 3 weeks of time lost or medical disqualification from participation in sports, in addition to incurring substantial costs to the patient’s family and health care system.
Regional differences in the presentation of nasal fractures can be observed. In a retrospective study of Brazilian children aged 5 to 17 years, Cavalcanti and Melo have found that facial injuries were 3-fold more frequent in males aged 13 to 17 years; the most common causes of these injuries were falls and MVAs.3 Among facial injuries in that study, nasal fractures were also most common, 51.3%, followed by the zygomatic-orbital complex, 25.4%. In another retrospective study, Hwang et al have reviewed and analyzed the medical records of 236 patients with facial bone fractures caused by athletic activity who were treated at one institution between 1996 and 2007.9 The investigators noted that the age group with the highest frequency of these injuries was 11 to 20 years (40.3%), with a significant male predominance across all age groups (13.75 : 1). There were 128 isolated nasal fractures, with soccer accounting for 39%, followed by other sports, including martial arts.
Nasal injuries have been shown to be common in adults and children and may be associated with significant morbidity. Associated injuries of adjacent structures should be suspected based on common injury patterns. The age and the environment play a key role in determining the injury incidence and pattern.
The nasal bones are paired and joined at the midline; they articulate with the frontal bone superiorly and the frontal process of the maxillary bones laterally. Caudally, they interact with the upper quadrilateral cartilages. Basally, they articulate with the nasal septum, which is formed by the perpendicular process of the ethmoid and the vomer inferiorly (Fig. 20-1).
Nasal air passage may be affected by a variety of conditions. Anatomically the internal and external nasal valves must be patent, with the former having an angle of at least 10 to 15 degrees. A deviated nasal septum, nasal spurs, concha bullosa, nasal polyps, and inflammatory sinonasal disease represent examples of altered anatomy that potentially become sources of nasal obstruction and may contribute to nasal airflow obstruction (Fig. 20-2).
FIGURE 20-2 Internal structures of the nose. A, B, coronal and axial sections of the nasal region. C, D, Coronal and axial sections of the deviated septum that is S-shaped and obstructing both nasal cavities. (Netter illustrations from www.netterimages.com, © Elsevier Inc., All rights reserved.)
The neurosensory innervations of the nose are rich and complex (Fig. 20-3). The overlying nasal skin receives its innervation from the dorsal nasal and external nasal nerves, branches of the anterior ethmoidal and ophthalmic (to infratrocheal) nerves, respectively. Intranasally, the septum and lateral walls are innervated by branches of the sphenopalatine and anterior and posterior ethmoidal nerves. The nasal floor receives some fibers from the nasopalatine nerve and from the greater palatine nerve. The parasympathetic supply originates from the superior salivatory nucleus in the medulla, travels with the nervus intermedius and cranial nerve VII to the geniculate ganglion, and continues along the greater petrosal nerve and through the vidian canal to reach the pterygopalatine ganglion. The postganglionic fibers travel to the sinonasal mucosal, including the septum and turbinates.
Although concerns exist among clinicians about nasal tip edema or vascular insufficiency resulting from operative management of nasal injuries and the use of vasoconstrictors, this has not been substantiated by research studies. Lymphoscintigraphy, along with cadaver dissections and histologic studies, have revealed that the primary blood supply for the nasal tip arises from the lateral nasal branches of the facial artery (Fig. 20-4). Other arteries supplying the nasal tip include the columellar branch of the superior labial artery and the external nasal branch of the anterior ethmoid artery. Moreover, it was found that the major arterial, venous, and lymphatic vessels course at or superficial to the musculoaponeurotic layer of the nose. Therefore, open approaches must limit dissection deep to this musculoaponeurotic layer to maintain nasal tip blood supply and drainage conduits.10
A detailed history exploring the mechanism and timing of injury, and loss of consciousness, will help distinguish isolated nasal and septal fractures from those likely to be associated with other injuries. Any history of prior nasal and/or septal trauma or surgery should also be documented. Recent pretraumatic photographs may be helpful to appreciate the extent of nasal and septal deformities. The possibility of nonaccidental trauma must be considered. Concussion and brain injury symptoms such as headache, nausea or emesis, dizziness, disorientation, or lethargy must be elicited and managed appropriately by the trauma and neurology teams.
Observing the nasal dorsum from the frontal, worm’s eye, and bird’s eye views will help the clinician appreciate any external nasal deformities. Overlying edema is frequently present with decreased definition of the melonasal angle and may mask the severity of the underlying skeletal deformity. The clinician should examine for the presence of nasal and septal deviation, step deformities, and crepitus on palpation. The intranasal examination with a nasal speculum, appropriate lighting, suction, and vasoconstrictor is important to assess the status of the cartilaginous and bony nasal septum, rule out septal hematoma, and determine the origin and extent of epistaxis and/or cerebrospinal fluid (CSF) rhinorrhea. In some cases, it may be helpful to use nasoendoscopy with a fiberoptic scope to evaluate the posterior nasal complex and nasopharynx further. Those skilled in the use of this type of instrumentation may also find it helpful to evaluate the posterior airway and the presence of bleeding.
A detailed facial examination is also important and should include visual acuity, extraocular muscle movement, pupil size and reactivity, intercanthal distance, medial canthal tendon position, mandibular range of motion, and occlusion. In many cases, forces great enough to fracture the nasal and septal bones are substantial enough to injure adjacent structures, such as the globe and orbit floor.
During the examination, the astute clinician will recognize that some patients may exhibit signs and symptoms of a concussion. As such, a symptom-driven neurologic examination is important in a subset of patients with facial injuries. Sports-related concussions associated with facial fractures are often undertreated and those with other causes may be missed entirely. Patients who have complaints of headaches, irritability, confusion, visual changes related to traumatic eye injury, poor sleep patterns, or other related symptoms should have an evaluation by a properly trained specialist who sees and treats concussions on a regular basis. This is particularly important for patients who plan on returning to physical activity or sports that might involve blows to the head.
The internal nasal valve primarily determines nasal resistance to airflow because this is typically the narrowest zone.11–14 This valve is triangular in shape and is formed by the junction of the caudal upper lateral cartilages and nasal septum.15–23 Inferiorly, it is bound by the nasal floor and posteriorly by the inferior turbinates. It has a cross-sectional area of approximately 55 mm2, with an angle of 10 to 15 degrees in whites. Fixed and dynamic causes of valve obstruction may be responsible. For instance, dynamic obstruction on inspiration may be seen with post-traumatic weakness of the upper or lower lateral cartilage. The Cottle test, in which the cheek is pulled laterally, may improve nasal airflow by pulling the upper lateral cartilage laterally and opening the internal valve area.24 Imaging modalities such as computer tomography (CT) may demonstrate the presence of contributing factors such as sinonasal disease, concha bullosa, and a posterior septal spur or septal deviation.
A variety of options are available for imaging and categorizing nasal fractures and the surrounding region.25–30 Many isolated nasal injuries with no loss of consciousness and a clear history of the mechanism can be diagnosed and treated without the need for exposing the patient to radiation. Plain radiographic films may be adequate to assess the extent and displacement of nasal bone fractures when no other injuries are suspected, but they are used less often with the advent of CT.
Additionally, because of extensive overlap of other anatomic structures, some nasal fractures cannot be completely visualized with plain films alone. CT, although not required in every patient, provides excellent detail. In addition, concomitant fractures such as orbital, naso-orbital ethmoid, zygomatic, maxillary, and frontal sinus or cribriform plate fractures may be identified more easily and treated more precisely. On occasion, identification of these additional fractures may alert the clinician to possible complications, such as obstruction of the nasolacrimal duct with its associated epiphora or suspicion of a dural tear with CSF rhinorrhea. On occasion, pneumocephalus may be identified if the injuries extend into the anterior cranial base. Recently, cone beam CT has been used in dental offices and other settings to visualize bony lesions, dysmorphology, and fractures. If one suspects injury extensive enough to cause multiple fractures at multiple sites, cone beam CT may not be recommended because imaging of the brain tissues may be needed to evaluate the possibility of epidural or subdural bleeding, parenchymal brain injury, or bleeding in the cisterns.
For most routine nasal fractures, operative management of nasal fractures requires consideration for the timing, anesthetic, setting in which treatment is rendered, and details of the operative approach.31–33 The recommended time frame to repair nasal fractures is within the first week after injury. It is acceptable to perform immediate treatment, but at times it may be helpful to allow swelling to decrease prior to definitive treatment. Some recommend delaying surgery because it is may sometimes be difficult to judge the adequacy of reduction in the presence of significant edema. However, surgeons must remember that the elastic cartilaginous framework may be difficult to reduce as fibrin organization and fibrosis ensues; thus, delayed repairs beyond 1 week may become increasingly more difficult to treat with closed reduction alone. Children have a tendency to heal the bony tissue more quickly, which may make it more difficult to achieve a detailed repositioning. Treatment within the first several days facilitates the healing process, limits patient disability, and decreases the patient’s time spent away from school, work, or other activities.34
Local anesthesia or the use of sedation can be used, but it may put the patient at increased risk for bleeding in and around the airway. This can lead to laryngospasm in patients who are obtunded, particularly children. When the nasal complex is bleeding, it may complicate airway management and reduce the surgeon’s ability to reduce the fracture adequately under good conditions in a safe manner. We prefer to treat nasal and septal fractures with a brief general anesthetic in the operating room using an endotracheal tube or laryngeal mask ventilation device. Either airway option can be used for adults or children.
While the authors prefer general anesthesia for children during operative manipulation of nasal fractures. However, there are advocates for the choice of either local or general anesthesia, and some data to support that decision. Contributing factors may include patient cooperation, financial constraints, operator experience or comfort, and others.
Cook et al compared the manipulation and reduction of nasal fractures under local anesthesia (LA) and general anesthesia (GA). In this study, LA was administered with 0.5% bupivacaine blocking the infraorbital, infratrochlear, and external nasal nerves.35 Patients in the LA group rated how painful the combined anesthesia administration and fracture manipulation had been on a scale from 1 to 5 at the 4-hour and 8-week time point after reduction. They also rated nasal airway patency and the surgeon rated the cosmetic result. After manipulation, the patency of nasal airways was comparable between the LA and GA groups. The local anesthesia group rated their median pain score as 3 out of 5. Pain was attributable to the infiltration of LA solution. When asked about their choice of anesthesia in case they would require nasal manipulation in the future, 24 of 25 patient in the LA group and 16 of 25 in the GA group indicated that they would opt for LA. There were no reported cases of perioperative airway compromise documented in these patients.
The same investigators also randomized two LA techniques among 50 consecutive adult patients with clinically displaced nasal fractures.36 One group received blocks of the infraorbital, infratrochlear, and external nasal nerves by intranasal infiltration and the other group was given generalized infiltration of the nasal dorsum by an external route. All patients received intranasal cocaine. Postoperatively, patients recorded their overall discomfort level and subjective nasal airway patency. The surgeon also recorded the cosmetic result. They found the internal route to be significantly more painful (p < .001) and with no advantage to the patient with respect to postoperative ai/>