CC
A 26-year-old male presents to the emergency department after an altercation at a bar with evidence of recent epistaxis and trouble breathing through his nose.
Nasal bone fractures are the most common facial fractures because of the relatively minimal force required to fracture these thin bones and the prominent position of the nose relative to other facial structures. These fractures commonly occur in males in the second and third decades of life but also account for about 30% of pediatric facial fractures. The most common cause of nasal fractures is blunt trauma to the face from interpersonal violence, motor vehicle collisions (MVCs), falls, and sporting injuries. Septal fractures have been associated with nasal bone fracture in 42% to 96% of cases. Left untreated, nasal bone and septal fractures can have a significant impact not only on cosmetic appearance but also on nasal airway function.
HPI
The patient was involved in an altercation at a bar several hours before presentation. He received a single blow from a right fist to the left side of his nose . He denies any subsequent falls or loss of consciousness. Immediately after his injury, he noted approximately 30 minutes of brisk epistaxis, which eventually resolved with external pressure. His pain is localized to his external nose and has been consistent in severity since the injury. He endorses difficulty breathing through his left nare but otherwise denies diplopia, visual changes, clear rhinorrhea, facial weakness, excessive tearing, and paresthesia. On further questioning, he also denies neck or back pain, headache, nausea, vomiting, dizziness, and malocclusion . He thinks his nose appears crooked compared with before the injury.
Key points during the history taking:
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Knowing the mechanism of facial trauma is key in the initial workup. Compared with an isolated blow to the nasal complex, for example, a patient presenting with facial injuries after an MVC should prompt suspicion for more severe injuries and multiple facial fractures.
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Symptoms such as telecanthus, diplopia, vision loss, clear rhinorrhea, malocclusion, facial weakness, and facial numbness may indicate more severe injuries.
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It is important to include questions about symptoms suggestive of possible intracranial or ocular injuries in your review of systems. This includes headache, nausea, vomiting, and dizziness.
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Preinjury appearance can be assessed by patient or by photographs that the patient may be able to provide.
PMH/PSH/medications/allergies/SH/FH
The patient has an unremarkable medical history. There is no previous history of facial fractures, nasal surgeries, or preexisting nasal deformities. He denies a prior history of chronic nasal obstruction. He denies prior nasal or sinus surgery. He denies any history of cocaine use.
Key points:
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It is essential to ask about preexisting nasal form and function as well as prior nasal obstruction, trauma, and surgeries. This will help with surgical planning and setting expectations after surgical intervention.
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Cocaine compromises nasal mucosal blood flow, which can lead to ischemic necrosis and subsequent septal perforation.
Examination
The patient’s Advanced Trauma Life Support primary survey is negative, and his Glasgow Coma Scale score is 15.
General. The patient is a well-developed and well-nourished male in mild distress from pain and nasal obstruction.
Eyes. Pupils are equal, round, and reactive to light and accommodation; extraocular muscles are intact. Visual acuity is 20/20 in both eyes. Visual fields are intact by confrontation, without monocular or binocular diplopia. There is no evidence of hyphema (blood in the anterior chamber of the eye), chemosis (subconjunctival edema), or subconjunctival hemorrhage or epiphora (excessive tearing). The patient exhibits bilateral infraorbital edema that is more severe on the left. The intercanthal distance is normal, measuring 31 mm (range, 30–33 mm).
Maxillofacial. There is minimal edema of the nose with an obvious deviation of the dorsum to the right ( Fig. 53.1 ) The bony nasal dorsum is tender to palpation, with bony crepitus over the radix and upper dorsum. The alar base appears normal and coincident with the remainder of the face. Nasal tip projection is adequate, though the columella does collapse with downward palpation on the tip. There is no clear rhinorrhea suggesting cerebrospinal fluid (CSF) leak (and thus no obvious indication of skull base fracture).
Intranasal. Using a fine suction, several blood clots were evacuated from both nares. Nasal speculum examination using a headlight and prior application of a topical vasoconstrictor (oxymetazoline [Afrin] spray or 4% cocaine) reveals a 2-cm left nostril mucosal laceration over the cartilaginous septum with obvious lateral displacement. The septum is otherwise symmetric without significant edema or ecchymosis. On gentle palpation with pinky finger, there is no fluctuance on either side of the septum, thus confirming no septal hematoma. The inferior turbinates are visualized and intact, and the inferior meatus is identified.
Key points to consider specifically for nasal injury include:
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Intracanthal distance: An increased distance can indicate a naso-ethmoid-orbital (NOE) complex fracture and should prompt imaging.
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Excessive tearing can be suggestive of lacrimal apparatus injury.
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Collapse of the columella should raise suspicion for a cartilaginous septal fracture.
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Clear rhinorrhea (especially drainage that increases when patient bends over or strains) is indicative of possible CSF or skull base fracture. The authors recommend obtaining a sample for β 2 -transferrin and consider imaging for further management planning.
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Septal edema that does not improve with topical decongestant paired with fluctuance to palpation should raise high suspicion for septal hematoma (blood collection between the perichondrium and quadrangular cartilage). This can disrupt the blood supply to the cartilage, resulting in septal necrosis, septal abscess formation, and a subsequent saddle nose deformity. This type of injury requires immediate drainage.
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Consider endoscopic intranasal examination for a more comprehensive evaluation of the intranasal structures and septum. This can be especially useful if the patient is having persistent epistaxis from an unknown site.
Imaging
Imaging studies are recommended in the setting of high force trauma, especially in a patient with loss of consciousness (even if brief). In the setting of isolated nasal trauma without further evidence of other craniofacial injuries (based on thorough history and physical examination), plain film radiographs have not shown to add value in regard to treatment planning. More so, plain films have a low specificity (false-positive rates as high as 66%) and are limited in their ability to distinguish old from new fractures (only 15% of nasal bone fractures heal by ossification). They cannot detect cartilaginous injuries, which occur more often in the pediatric population.
In cases in which imaging is indicated (clinical examination limited because of extensive edema or additional fractures of the face or skull base suspected), computed tomography (CT) of the face has become the gold standard for evaluation of the nasal bones and paranasal sinuses. That being said, recent literature shows that most surgeons do not believe imaging changes the treatment plan in isolated nasal fractures.
In the current patient, a facial CT scan demonstrated bilateral nasal bone fracture with deviation to the right and bowing of the septum ( Fig. 53.2 ). Preinjury photographs and scans (if available) can be extremely helpful for delineating injury displacement and can serve as a guide in surgical correction.
Labs
Routine labs are not usually indicated for the diagnosis and management of nasal fractures unless indicated by medical history. A toxicology screen and blood alcohol level should be obtained in cases in which drug or alcohol use has been reported or suspected. In the event of persistent epistaxis that is not easily controlled with conservative management such as oxymetazoline spray, pressure or nasal packing, coagulation studies can be obtained to evaluate for underlying bleeding disorders (the most common bleeding disorder being von Willebrand disorder).
Assessment
Bilateral nasal bone and nasal septal fracture; Facial Injury Severity Score of 1. There is no evidence of septal hematoma or skull base fracture.
Treatment
Treatment for nasal bone fractures begins with a detailed history and, if present, control of hemorrhage. A history of nasal trauma, surgery, deviation, and obstruction should be obtained. The mechanism, including injuring agent, direction of blows, timing of injury, and postinjury epistaxis, should be determined. A preinjury photograph can be very helpful. Obtaining a detailed history allows the surgeon to better evaluate the extent of the injury, including external deformity, septal deviation, or hematoma as well as any associated injury (including lacrimal system, NOE fracture, and skull base injuries). The anticipated difficulty of reduction and ability for patient to tolerate an awake procedure is an important factor in the choice of anesthesia (local versus general).
Control of epistaxis
In the event of persistent epistaxis despite the use of a topical vasoconstrictor and pressure, control can be achieved with choice of nasal packings, with or without the use of hemostatic agents. The placement of anterior and posterior nasal packing should be precise, and the surgeon must be aware of potential complications, such as infection, dehydration, and altered ventilation from obstructive and physiologic derangements in pulmonary mechanics. In the event of traumatic epistaxis resulting from diffuse mucosal disruption or laceration, silver nitrate, or electrocautery is often not sufficient to control the bleeding unless it is arising from a punctate source and may actually contribute to further mucosal irritation. Absorbable packing or topical hemostatic agents, such as absorbable oxycellulose thrombogenic dressing (Surgicel) or resorbable chitosan-based hemostatic splint (PosiSep), can be used to pack off anterior bleeding. Additional agents, such as topical thrombin-gelatin hemostatic matric (Floseal), can be applied around absorbable packing for additional hemostasis. Bleeding that persists despite anterior packing or bleeding in the posterior oropharynx should raise suspicion for a posterior bleed. Posterior bleeding may require a balloon (with anterior and posterior component) as a means of tamponade. Nasal packs are usually left in place for a minimum of 24 to 48 hours but can stay in for up to 5 days if the bleeding was significant. The patient should be prescribed antibiotics while the packing is in place to avoid risk of toxic shock syndrome. Adequate control of blood pressure and the patient’s pain can also assist in the management of epistaxis.
A thorough external and internal nasal examination is essential with a nasal speculum or ideally a rigid nasal endoscope. Undetected and untreated septal injuries have been found to contribute to postreduction nasal deformities and nasal obstruction. A thorough examination should be done after adequate anesthesia and decongestion of the nasal mucosa has been achieved with a topical mixture of 4% lidocaine with oxymetazoline.
Treatment options include open or closed reduction. The timing of repair can be immediate or delayed. Immediate closed reduction should be done if there is no significant edema that would compromise assessment and understanding of the extent of injury or deformity. With significant edema, surgery should be postponed to allow the edema to resolve (typically 3–5 days). It is generally recommended that nasal bone fractures be treated within 10 days of injury for optimal results. An uncomplicated displaced nasal bone or septal fracture with no preexisting nasal or septal deformity is most amenable to closed reduction.
Contraindications to closed reduction include severely comminuted fracture of the nasal bones and septum, open septal fracture, delayed presentation (over 3 weeks after initial injury), nasal bone fracture that occurs with an NOE or Le Fort pattern fracture, or anterior skull base fracture.
Closed reduction is most often performed with Boies elevator, which provides rigidity with minimal risk of mucosal trauma. Other instruments (Asch forceps, Walsham’s forceps) can be used as well based on surgeon preference.
Surgical approach
In the current patient, the nasal bones and septum were treated with a standard closed reduction. The Boies elevator was used to elevate the depressed nasal bone with concomitant medial pressure on the opposite, lateralized nasal bone ( Fig. 53.3 ). The nasal bony pyramid was subsequently straightened ( Fig. 53.4 ). For the septal fracture, the Asch forceps in combination with gentle finger manipulation were used to reset the cartilaginous septum at the nasal spine. The septum was splinted with Doyle splints and secured with a transseptal suture at the caudal septum. An Aquaplast dorsal splint was then custom fit to the patient’s nasal dorsum.
