Pediatric nasal bone and septal fractures represent a large number of craniofacial injuries in children each year. Due to their differences in anatomy and potential for growth and development, the management of these injuries varies slightly from that of the adult population. As with most pediatric fractures, there is a bias toward less-invasive management to limit disruption to future growth. Often this includes closed reduction and splinting in the acute setting followed by open septorhinoplasty at skeletal maturity as needed. The overall goal of treatment is to restore the nose to its preinjury shape, structure, and function.
Key points
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Pediatric nasal fractures are less common in younger children but become increasingly more prevalent with age and comprise nearly one-third of all pediatric facial fractures.
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The nasal septum is an important growth center for nasal/midface development and disturbances in potential future growth are considered when determining a treatment plan.
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Immediate intervention for complications such as septal hematoma is critical to prevent abscess formation, septal perforation, or other late/delayed deformities later in life.
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The majority of pediatric nasoseptal fractures can be managed with closed reduction and splinting.
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Formal open septorhinoplasty at skeletal maturity is an important aspect of treatment of pediatric nasal bone fractures because many patients develop or have persistent nasal deformity/dysfunction even after closed reduction.
Introduction
Although craniofacial trauma in the pediatric population is less common than in adults, it still accounts for approximately 11% of all pediatric emergency room visits. Although less common than in the adult population, nasal bone fractures make up close to one-third of these visits, making them similarly one of the most injured structures in the facial skeleton. This may also underrepresent the true incidence as often when fractures do occur, unless severely displaced, parents do not seek medical intervention and fractures heal spontaneously. Previous studies have shown that fractures predominantly occur in men and the frequency of injury increases as children grow closer to adulthood. , As children age, the causes of nasal fractures also change beginning with the most common being falls from height in younger children, sports-related injuries in adolescents and assault/motor vehicle collisions in the later teenage years. These fractures can occur in isolation but are also often a part of more complex facial fractures such as nasoorbitoethmoid fractures. The treatment of these injuries depends on the severity of the injury, degree of displacement, functional impairment, and age of the patient.
Nasal development/anatomy
The newborn pediatric nose is more protected from injury due to its lesser projection from the face, mainly cartilaginous structure, and increased prominence of the frontal bone/supraorbital rims due to the increased cranial/facial ratio in infants. In young children, the paired nasal bones are also separated in the midline by a patent suture and much of the nasal septum is cartilaginous and unossified. Due to these anatomical differences, the nose is less likely to take the brunt of facial impact and is more pliable to distribute forces and resist fracture. However, because there is a lack of ossified overlying nasal bone structure, much of this force is transmitted to the septum, which can result in increased injury or dislocation. This may go unnoticed at the time of the incident but can lead to significant growth and functional disturbance later in life.
The nose then undergoes 2 distinct growth phases from 2 to 5 years of age and again during puberty reaching its adult size at approximately 16 to 18 years in girls and 18 to 20 years in boys. Much of this growth has been purported to be from growth centers in the nasal septum located at the sphenoseptal and septopremaxillary areas. , The latter area is also hypothesized to be integral in maxillary and overall midface growth. Fractures to the pediatric nasal septum may result in potential growth disturbances and delayed deformities due to altered growth patterns. It is challenging to know which is most impactful to growth—the initial trauma, the surgical repair, or the impact on airflow. Normal growth is likely multifactorial. In addition to an intact growth center, the ability to breathe more air through the nasal airway is likely a major contributor to normal growth and development. Restoring normal nasal airflow is a key factor in the decision for treatment in a young patient.
As children reach their teenage years, their nasal anatomy becomes more consistent with the adult nose. Externally, the upper third of the nose comprises paired nasal bones, the middle third with support from upper lateral cartilages, and lower third from lower lateral cartilages. The nasal septum has much more ossified bony support with the perpendicular plate of the ethmoid and vomer comprising the posterior septum and quadrangular cartilage making up the anterior portion. The nose is rich in blood supply with branches of the external and internal carotid contributing to its vascularity. The confluence of 5 terminal branches in the anterior septum (superior labial, anterior and posterior ethmoidal, greater palatine, and sphenopalatine) represents Kiesselbach’s plexus, which is the source of most nasal bleeds (epistaxis).
Diagnosis
As with all trauma patients, the initial evaluation of the pediatric craniofacial trauma patient should follow Pediatric Advanced Life Support guidelines and include a primary and secondary survey ensuring intact airway, breathing, circulation, and evaluation of neurological status and any other concomitant injuries. Ensuring an adequate airway is of utmost importance because the pediatric airway is narrower and more collapsible. In addition, infants are obligate nasal breathers and obstruction of the nasal airway due to trauma that otherwise could be tolerated in an adult can lead to severe feeding challenges, or even respiratory collapse in an infant. After the patient has been stabilized, a focused history and physical of the head and neck can be performed. A thorough clinical history should be performed to understand the nature of the injury. Although it is rare for child abuse to be the cause of pediatric facial trauma, it should always be considered, and appropriate referrals placed if it is suspected.
History
Questioning should highlight the mechanism of injury, timing, presence of nasal obstruction and whether any subjective change to the appearance of the nose has occurred. This can help elucidate the potential severity and/or morphology of potential underlying fractures to the nasal bridge or septum. Preinjury photographs can be extremely helpful to assess any changes from preinjury state and set expectations for posttreatment appearance.
The presence of epistaxis can be a particularly important finding. Although epistaxis can be present from soft tissue injury alone, it is almost always present in the setting of underlying nasal fracture/septal disruption, and as such, it is rare to have a fracture in the absence of nasal bleeding. Other findings such as vision changes, salty taste in the throat, and clear nasal drainage may help elucidate concomitant injuries such as orbital fractures, basilar skull fractures, cribriform plate fractures, or cerebrospinal fluid (CSF) leaks, respectively. If these are suspected, further imaging or diagnostic workup may be necessary.
The diagnosis of CSF leaks can be challenging to differentiate from normal clear mucous drainage. Some possible ancillary studies/findings include the “halo sign” from placing drainage on filter paper. Because CSF diffuses faster than blood or mucous, there should be a central area of blood surrounded by an outer ring of CSF. This however has shown to have poor sensitivity and specificity because water, saline, and other watery substances diffuse at a similar rate to CSF. Some also advocate for testing the nasal drainage for glucose or beta-2-transferrin; however, the former has poor sensitivity/specificity and the latter although highly sensitive and specific is often not necessary, requires 1 mL of fluid, and can take up to a week to result. Perhaps, the simplest approach is continued observation after cross-sectional imaging because nasal drainage will often abate after a few days, whereas CSF leak will usually be persistent/consistent.
Pain that is increasing after injury should raise suspicion for septal hematoma. Normally, after the trauma, there is gradually decreasing pain. If a patient returns with severe pain within the first few days after injury, a septal hematoma may be present.
Examination
As with any evaluation, a consistent and reproducible approach will allow for improved accuracy and prevent missing critical findings on examination. This should include evaluation of the entire head and neck to rule out any other injuries. It is common to focus on obvious deformity and miss important concomitant injuries. Specifically for suspected nasal fractures this can begin with inspection in the anteroposterior, sagittal and worms eye views assessing for edema, ecchymosis, evidence of previous epistaxis (dried blood at the nares), and obvious deviation of the nasal dorsum and septum. Depending on the timing of presentation, postinjury edema may obscure gross deformities. Moreover, due to the more pliable nature of nasal tissues in children the underlying cartilaginous septum may fracture/displace with no obvious external signs/symptoms. A subtly displaced nasal dorsum may be suggestive of an underlying nasal septal dislocation/fracture but symptoms of septal deviation/obstruction may not become more apparent until the subsequent 2 to 3 days. An assessment of nasal airway patency is important, especially in infants. To do this, the child can be observed feeding, which is a time of obligatory nasal breathing. A helpful technique is to use a stethoscope that the tubing can be detached from the bell. Placing the end of the tubing directly to the nose allows the examiner to isolate the location and strength of audible airflow between left and right nares. Close follow-up for repeat evaluation and examination is therefore important.
Intranasal inspection should then be performed with a nasal speculum and proper lighting. Adequate pain control and often moderate sedation may be necessary to perform this depending on the child’s age. Evaluation for septal deviation or nasal blockage may indicate a fractured septum. Persistent clear nasal drainage can be a sign of an underlying CSF leak or cribriform plate fracture and should be managed as above. Lacerations, bleeding, unilateral deviation of the septum, or focal swelling of the septal mucosa may indicate the presence of a septal hematoma. Although septal hematomas are a rare complication of nasal trauma, they have been shown to be more common in children. Appropriate and timely diagnosis/treatment is quintessential to prevent septal necrosis, abscess, loss of septal support, and late deformity such as collapse of the nasal dorsum or “saddle nose deformity.”
Palpation of the nasal bones, septum, anterior nasal spine, and anterior tip of the nose evaluating for tenderness, step-offs, or mobility can also indicate an underlying fracture or septal pathologic condition. Palpation and inspection should then be continued throughout the remainder of the craniofacial skeleton because it is important to rule out concomitant injuries. Racoon eyes, battle sign, and hemotympanum may indicate a basilar skull fracture. Midface mobility or dental malocclusion may indicate concomitant maxillary fracture. A thorough eye examination including inspection for symmetry, visual acuity, extraocular eye movements, and pupillary examination should be performed on every child to rule out underlying orbital or ocular pathologic condition. Change in position of the orbits, telecanthus, or gaze restriction may indicate an underlying orbital fracture. Finally, a detailed neurologic examination assessing the 12 cranial nerves should also be evaluated.
In cases of suspected nasal bone fractures, imaging may not always be necessary but it is often obtained by the emergency department before consultation. Physical examination findings alone should be sufficient for diagnosis. Plain films are of limited benefit because they have poor detail and in the setting of a primarily cartilaginous structure in children have a low sensitivity. Some authors argue that ultrasound provides better detail than plain films, although its sensitivity is also low making it questionable in terms of clinical usefulness. If there is a concern due to a higher energy mechanism of injury or signs of other concomitant injuries, a high-resolution computed tomography should be performed for a better evaluation of the underlying bony architecture and for better surgical and procedural planning.
Treatment
Epistaxis
Epistaxis, or nosebleed, can typically be controlled by applying direct pressure to both nasal alae for at least 10 minutes. For persistent nasal bleeding, the use of topical decongestants such as oxymetazoline, or anterior nasal packing may be helpful. In severe cases, where an uncontrollable nasal bleed is occurring, it is essential to secure the airway and perform endoscopy to either isolate the source of bleeding or perform adequate packing, including a possible posterior nasal pack.
Septal Hematomas
Septal hematomas are more common in children than in adults due to the more cartilaginous nature of the septum causing buckling/underlying injury without disruption of the mucosa. Septal hematomas must be promptly decompressed and managed quickly to prevent further complications. This can be done by draining the hematoma through a mucoperichondrial incision, followed by nasal packing or transseptal “through and through” quilting sutures to decrease the risk of recurrence. The patient should be examined the next day after drainage to confirm that it has not reaccumulated. Children should be treated with antibiotics, such as augmentin, to prevent infection and septal abscess formation. After the procedure, it is important to follow the child for 12 to 18 months to evaluate for any late deformities. Early intervention and proper management of septal hematomas can help prevent long-term nasal deformities and maintain the normal structure and function of the nose ( Fig. 1 ).
