Key points

Introduction

The nose is one of the most prominent features of a person’s face. Thus, repair of nasal trauma to its original form and function is paramount. Repairing the aesthetic of the nose to the pretrauma form has become just as important as repairing function. Although there may not be a functional deficit with a poor aesthetic outcome, there are potential psychological sequelae, such as depression and low self-esteem. ^, However, because of its multiple aesthetic and anatomic subunits, trauma management and repair can be challenging. Comprehensive management requires thorough evaluation, intimate knowledge of nasal anatomy, proper selection of repair and reconstructive techniques, and diligent postoperative wound care.

In 2011, there were more than 5 million emergency department visits caused by head and neck injuries and 41.8% of these injuries resulted in an open wound. Motor vehicle accidents also account for a significant number of severe facial lacerations, with the annual incidence estimated to be more than 146,000 cases per year that require hospital evaluation and care. With the high frequency of facial trauma presenting to the emergency department and other routes of presentation, surgeons need to be comfortable with overall management and the potentially complex reconstruction involved with soft tissue trauma to the nose.

Anatomy

The nose is centered in a person’s face and is one of the first features people notice. It is composed of several anatomic and aesthetic subunits that can make its repair and reconstruction a challenge. Its location at the center of the face provides it with bilateral as well as cephalic and caudal vascular supply and innervation. Structural support is critical for the function and aesthetics of the nose. Figs. 1 and 2 show bone and cartilage components of the nose.

Sagittal view of nose showing bone and cartilage structures.

Cartilaginous structures of the nose.

The boney components of the nose include:

• •

  Nasal bones

• •

  Frontal bone

• •

  Frontal process of the maxilla

• •

  Anterior nasal spine of the maxilla

• •

  Palatine process of the maxilla

• •

  Perpendicular plate of the ethmoid

• •

  Vomer

Cartilaginous components of the nose include:

• •

  Septal cartilage

• •

  Lateral process of septal nasal cartilage

• •

  Major alar cartilage (lateral and medial crus)

• •

  Minor alar cartilage

• •

  Accessory nasal cartilage

External nose vascular supply:

• •

  Inferior: columellar artery from the superficial labial artery

• •

  Lateral: lateral nasal artery from the angular artery and infraorbital artery terminal branches

• •

  Superior dorsum: dorsal nasal artery from the ophthalmic artery

• •

  Dorsum: external nasal branch of anterior ethmoidal artery

Internal nose vascular supply:

• •

  Posterior lateral: posterior lateral nasal branches from the sphenopalatine artery

• •

  Septum: posterior septal branches from the sphenopalatine artery

Innervation.

• •

  Superior dorsum: infratrochlear nerve from the ophthalmic branch

• •

  Mid-dorsum: external nasal branch from the anterior ethmoidal nerve of the ophthalmic branch

• •

  Inferior lateral dorsum: infraorbital nerve of the maxillary branch

Patient evaluation overview

When assessing a patient for nasal trauma, a systematic approach should be taken consistently in order to have a complete accounting of the patient’s injuries and to prevent missing injuries. Standard Advanced Trauma Life Support (ATLS) protocols should be initially followed and the patient should be stabilized. Once this has been accomplished, a focused head and neck trauma examination should be performed to fully assess injuries that are potentially missed on secondary and tertiary survey. Pertinent history, such as mechanism of trauma, previous trauma and surgical history to the region, time frame of injury, and functional status, should be obtained if possible and appropriate for the setting.

When examining for nasal trauma, examination should include visual inspection of the external nose and internally with a nasal speculum examination and anterior rhinoscopy. The internal nasal passageway should be inspected for patency, active bleeding, septal hematoma, foreign bodies, septal deviation, and through-and-through injury to the external nose. External trauma to the nose should be thoroughly inspected visually and with instrumentation. Structural stability and mobility should also be evaluated with palpation. Extension into the nasal passageway, cartilage involvement, and nasolacrimal duct involvement should all be noted. In pediatric patients and high-anxiety patients, full examination and initial cleansing may have to be performed after the area has been locally anesthetized or the patient is under anesthesia. Fig. 3 shows the importance of full irrigation and inspection in order to fully appreciate the extent of the injury. The patient had underlying fractures and intranasal mucosal involvement.

( Left ) Degloving laceration of the nasal tip, dorsum, and alar rim with underlying nasal bone fractures following an all-terrain vehicle accident. ( Right ) Wound margins grossly approximated with instruments showing minimal tissue loss.

Clinical judgment should be used when obtaining imaging. Most moderate to severe soft tissue injuries warrant obtaining maxillofacial computed tomography (CT) without contrast in order to rule out underlying fractures. It is also important to rule out other facial fractures and injuries. Plain film radiographs, including anterior-posterior, lateral, and Water views, may be obtained if CT is unavailable.

Photographic documentation should also be obtained. The damaged tissues should be thoroughly irrigated with sterile saline in order to clean out the wound and also provide representative photographs of the injuries. Thoroughly washing out the injured area allows surgeons to visualize the full extent of the injury and to determine whether there is avulsed tissue. In addition, pressure irrigation has been shown to be beneficial in reducing the bacterial load of soft tissue wounds. Ideally, photographic views should include frontal, lateral, worm’s-eye, and bird’s-eye views. This photography helps with reconstruction in appropriate relative dimensions and potentially for future secondary reconstruction. Photography also helps with managing patient expectations throughout the reconstructive and healing process.

Presurgical management

A flexible reconstructive plan should be formulated after thorough examination and pertinent history is obtained. This plan includes determining timing of repair, antibiotic use, anesthetic technique, and reconstruction method.

Definitive repair of soft tissue facial trauma should be delayed for emergent and urgent lifesaving surgery. After the patient is stabilized, there is limited evidence for timing of repair for soft tissue trauma of the face. Many investigators encourage early cleansing, debridement, and repair of soft tissue injuries to the face in order to prevent delayed complications such as infection, dehiscence, and additional scarring. ^, However, there is no consensus regarding how many hours or days from initial injury is acceptable before proceeding with repair and reconstruction. Hochberg and colleagues report an ideal repair time of 8 hours from injury or within 3 to 5 days if broad-spectrum antibiotics have been administered and an antibiotic ointment is applied to the wounds.

The evidence base for the use of prophylactic antibiotics in soft tissue trauma of the face is limited. Meta-analysis has shown that infection rates of soft tissue trauma range from 1.1% to 12%, with a mean of 6% in patients not treated with prophylactic antibiotics. Studies have also shown that the use of prophylactic antibiotics for simple nonbite wounds has not shown a reduced rate of infection. When it comes to contaminated wounds and immunocompromised patients, there is a lack of evidence for or against antibiotic use; however, antibiotics are typically given for immunocompromised patients because of the risk of severe complications. In general, clinical judgment should be used when evaluating the level of wound contamination and host factors such as diabetes, malnutrition, and immunocompromised states. Tetanus vaccinations and boosters should be updated as needed for all patients with potentially contaminated nasal and facial trauma.

The treatment plan includes determining whether the repair should be performed under local anesthesia, sedation, or needs to be completed in the operating room under general anesthesia. Most minor to moderate soft tissue trauma requiring repair in adult patients can be performed under local anesthesia. Complex lacerations, injuries with avulsed tissue requiring local flaps, grossly contaminated wounds, and complex animal bites are ideally repaired in the operating room under general anesthesia.

Thoughtful local infiltration with an anesthetic such as lidocaine with 1:100,000 epinephrine around the injury can be performed in many cases. In particular, deformation caused by the volume injected and limited use around the distal tip of the nose should be taken into consideration. Blocking bilateral infraorbital nerves and infratrochlear nerves can be used for field anesthesia of the external nose. Obtaining true internal and external nasal field anesthesia also requires addition of bilateral transoral V2 blocks (sphenopalatine ganglion blocks) and septal infiltrations. Local anesthesia should be used for postoperative comfort even if repair is performed under general anesthesia.

The focus of this article is nasal soft tissue trauma management; however, concurrent fractures commonly present with soft tissue facial trauma. In most cases of isolated nasal fracture with concurrent overlying soft tissue trauma that does not communicate with the bone, soft tissue management, including primary closure, should be performed initially. Fracture reduction can be performed in a delayed fashion after edema has resolved, allowing more accurate bone reduction. Patients presenting with complex soft tissue nasal trauma and fractures requiring general anesthesia can have repair of both hard and soft tissues in 1 operation if it is performed before significant edema sets in. On occasion, overlying lacerations can be used to access fractures in naso-orbitalethmoid fractures. However, there is limited evidence for timing of nasal bone fractures with concurrent soft tissue injury that requires repair.

Injuries

The prominence of the nose makes it a frequent area of damage, which commonly leads to isolated nasal trauma. However, facial trauma also regularly presents as a spectrum and combination of injuries. Thus, repair of soft tissue nasal trauma is often performed at the same time as repair of concomitant facial injuries.