Nose fracture

Nose fracture is a trauma of the nose, in which there is a violation of the integrity of the bone pyramid of the nose with or without displacement of bone fragments. Fractures of the nasal bones or damage to cartilage can lead to edema, pain, abnormal mobility, crepitus, nasal bleeding, and bruising in the near-orbital region. The diagnosis is usually made on the clinical picture. Treatment includes reposition, stabilization with an internal tamponade or splinting.

[1], [2], [3], [4]

Epidemiology

According to various authors, from 43 to 53% of injuries of ENT organs are injuries of the nose and paranasal sinuses, more often observed in men aged 15–40 years.

[5], [6], [7], [8], [9], [10]

Causes of the nose fracture

A nose fracture can result from various types of injuries:

• household (criminal, fall from height of own growth, falling as a result of an epileptic seizure or in an alcohol intoxication);
• sports (mainly in boxing, various types of martial arts, etc.):
• traffic accident (as a result of a traffic accident);
• production (mainly with non-compliance with safety regulations);
• military injuries.

[11], [12]

Pathogenesis

Among the bones of the facial skeleton, the bones of the nose are most susceptible to fractures due to their central localization and protrusion above the face. Depending on the mechanism of injury, fractures of the upper jaw, eye sockets, the ethmoid plate and damage to the nasolacrimal duct are possible.

As a result of a strong blow to the area of the external nose, a fracture of the nasal bones, frontal processes of the upper jaw, lateral cartilages of the nose and, in most cases, of the nasal septum, both in the cartilage and bone regions, occurs. The most frequently observed lateral displacements of the external nose, accompanied by the separation of the seam between the nasal bones and the frontal processes of the upper jaw or a fracture of the nasal bones. Even if there is no displacement of the pyramid of the nose, then any other displacement of bone fragments relative to each other is almost always observed. In all cases, one or another degree of edema, bruising and abrasion of the soft tissues of the nose is also observed. In case of a fracture of the nasal septum, bruising of the mucous membrane is observed with a possible rupture of the latter. In the course of the nasal septum fracture line, microhematomas are formed that can cause extensive hematoma of the nasal septum with abscess formation.

[13], [14], [15], [16], [17]

Symptoms of the nose fracture

As a result of trauma, patients always notice pain in the nasal region, aggravated by palpation of the nose; in most cases, the crepitus of bone fragments is revealed. With a combined fracture of the bones of the nose and the ethmoid labyrinth, subcutaneous emphysema is formed in the periorbital region, which is confirmed by the presence of air crepitus on palpation. In connection with a rupture of the nasal mucosa at the time of injury, nose bleeding always occurs, which, as a rule, stops on its own. However, with severe damage, they can be profuse, non-stop and recurrent nosebleeds.

Traumatic deformity of the nose can be represented by shifting the back of the nose to the right or left (more often to the right), recession of the nose sting to the right or left (more often to the left), recession of the bone and / or cartilage part of the back of the nose with the formation of a "open book" ). With an extremely strong direct blow, it is possible to completely ignite the back of the nose, the so-called pug's nose.

When the lattice plate fractures with a rupture of the dura mater, nasal liquorrhea appears, which is detected when the head is tilted forward. Concomitant nasal hemorrhage may make it difficult to diagnose the outflow of cerebrospinal fluid. The first day is characterized by the symptom of "double spot", which is expressed in the appearance of an outer bright ring around the blood spot. After the cessation of nasal bleeding, nasal discharge in the nasal liquor becomes light.

In case of facial traumas, hemorrhage into the anterior chamber of the eye (hyphema),, eyeball displacement (enophthalmos), compression of oculomotor muscles ( diplopia ), accompanied by a decrease in vision up to its complete loss (amaurosis) appear frequently.

Forms

Depending on the strength of the action and the characteristics of the traumatic factor, its orientation and the depth of penetration of the nose injury, they can be open (with damage to the skin) or closed (without damage to the skin).

Classification of deformations of the external nose:

• rhinoskoliosis - lateral displacement of the nose;
• Rhinokifos - deformation of the nose with the formation of a hump;
• rinolordoe - retraction of the nasal bridge (saddle nose);
• platyrinine - a wide and relatively short nose;
• brachirinia is an overly wide nose.
• leptorinium - excessively narrow (thin) nose.

Complications and consequences

Complications include cosmetic deformities and functional obstruction of the nasal cavity. Hematoma septum can lead to aseptic necrosis of cartilage, followed by deformation. Fractures of the ethmoid plate can cause meningitis and abscess of the brain.

[18], [19]

Diagnostics of the nose fracture

When collecting the history, the prescription of the injury was ascertained, by whom and by what object it was inflicted (by hand, foot, stick, etc.), the nature of the injury (sports, household, transport, etc.), the severity and duration of nasal bleeding, presence of loss of consciousness, nausea and vomiting. In addition, they find out associated diseases and the presence of nasal injuries in the past.

[20],

Physical examination

On palpation of the bones of the nose reveal pain, crepitus of bone fragments, air and mobility of the external nose in the bone section. Determine the degree of swelling of the soft tissues of the nose and the type of deformation of the pyramid of the nose. Anterior rhinoscopy reveals the degree of swelling of the nasal mucosa, the location of the rupture of the mucous membrane in the anterior sections of the nose and the source of nasal bleeding, as well as the possible curvature of the nasal septum.

[21]

Laboratory research

Conduct clinical studies, including complete blood count, urine, biochemical blood test. ECG and other methods. These studies show the degree of blood loss, changes from other organs and systems, which can make adjustments to the tactics of patient management.

Detection of glucose in nasal secretions in their study indicates the presence of cerebrospinal fluid, characteristic of a fracture of the ethmoid plate with a rupture of the dura mater. In this case, it is necessary to treat the patient in the neurosurgical department.

[22], [23], [24]

Instrumental studies

Radiation imaging, such as radiography and especially CT, for injuries of the nose is highly informative. When radiography of the bones of the nose or skull in the lateral projection always reveal the presence of a fracture of the bones of the nose: visible fracture lines, displacement of bone fragments relative to each other in the sagittal plane. CT in the coronary and axial projections more accurately shows the fracture lines, the displacement of bone fragments in different planes, and also reveals the fracture of the nasal septum with the direction of displacement. In addition, combined damage to the walls of the paranasal sinuses, eye sockets, skull bones, hematosinus, etc. Is detected.

Ultrasound echography in some cases helps to clarify the extent of traumatic injury.

Endoscopic examination of the nasal cavity allows you to inspect the posterior sections of the nasal cavity and septum of the leg. At the same time, microhematogenous lines corresponding to the fracture lines of the nasal septum are observed, as well as tears of the mucosa with exposure of cartilage or bone.

Trauma to the facial part of the skull is often accompanied by hemorrhage in the eyelid area and around the orbit (“eyeglass symptom”), but this symptom can also be a sign of a fracture of the skull base, an injury to the cavernous sinus. To clarify the diagnosis in this case it is necessary to pronounce a lumbar puncture. When the base of the skull is fractured, blood is present in the cerebrospinal fluid (subarachnoid hemorrhage). Suspicion of a fracture of the skull base occurs when the patient is unconscious, stunned, convulsions, etc. This obliges the doctor to fix the patient's head in relation to the body (there are special corsets), to transport the patient on a hard stretcher. Even X-ray examination can not be done immediately, because it is necessary to turn the head.

[25], [26], [27],

Indications for consulting other specialists

Any nasal trauma involves consulting a neurosurgeon to rule out or confirm a brain injury. Moreover, it is necessary in case of a severe condition of a patient with loss of consciousness and with other neurological symptoms.

In case of combined damage to the orbit and zygomatic bone, consultation with an oculist and maxillofacial surgeon is necessary.

In case of a nasal injury resulting from a fall during an epileptic seizure or loss of consciousness, a neurologist's consultation is indicated.

In the presence of a concomitant pathology of the cardiovascular system, the summer and other systems, consultation of the therapist, cardiologist, etc. Is necessary.

[28], [29]

Screening

Identification of persons with traumatic injuries of the nose is carried out taking into account complaints of pain, deformities in the nasal area, history data (trauma of the nose) and inspection data (swelling of the soft tissues of the nose, deformity of the external nose, pain, crepitus of bone fragments during palpation).

[30], [31], [32]

Differential diagnosis

It is necessary to distinguish an acute and consolidated fracture of the bones of the nose, in which there is a deformation of the pyramid of the nose, but there is no swelling of the soft tissues and mucous membrane of the nasal cavity, painfulness and strengthening of bone fragments during palpation.

[33], [34]

Treatment of the nose fracture

Emergency treatment consists of symptomatic treatment with cold and pain relief. The reduction is indicated only for fractures with visible deformity of the nose or obstruction of the nasal passages. The basis for the termination of reposition measures is the restoration of the shape of the nose or the improvement of breathing. That is why, in some cases, the reposition is delayed for 3-5 days, which allows to reduce swelling. Nasal fractures in adults are usually repaired under local anesthesia, children are shown general anesthesia. The blunt-end elevator is introduced into the nasal passage and placed under the indented bone of the nose, lifting it anteriorly and to the side, while pressing on the other side of the nose, giving the back of the nose a position along the middle line. The nose can be stabilized by installing tampons in the nasal passages (strips of gauze moistened with antibiotics), placing them high on the threshold of the nose, or by external splinting. Internal tamponade continues for 4-7 days, external splinting - up to 7-14 days.

If the cartilage is damaged, reposition is often not required. If the deformity persists after the edema subsides, reposition and splint under local anesthesia. The hematoma of the nasal septum must be drained immediately to prevent infection and necrosis of cartilage. A broken partition is difficult to fix in the correct position and often it has to be operated later.

The goals of the treatment of a nose fracture are to restore the shape of the external and internal function of the nose.

[35]

Indications for hospitalization

1. Fracture of the bones of the nose with severe external deformity.
2. Fracture of the bones of the nose, combined with damage to the paranasal sinuses, eye socket, brain.
3. Fracture of the bones of the nose, accompanied by severe or recurrent traumatic nasal bleeding.

[36]

Non-drug treatment of nasal fracture

In the first 5-6 hours after injury, ice is applied to the injury area, in case of nosebleeds, anterior loopback or posterior tamponade of the nose is possible.

[37],

Drug treatment of nasal fracture

Necessarily the introduction of tetanus toxoid according to the scheme. Prescribed analgesics (metamizole sodium, tramadol, ketorolac, etc.), sedatives (oxazepam, phenobarbital, etc.). General and local antibiotic therapy, hemostatic therapy, and symptomatic agents are used to combat wound infection and prevent secondary complications.

[38]

Surgical treatment of nasal fracture

The treatment tactics depend on the nature and depth of the injury, the severity of the general and neurological symptoms. In the presence of bruises and injuries of soft tissues, abrasions without damaging the bone structures of the facial skeleton, primary surgical treatment is performed and the bleeding is stopped. At the same time, it is necessary to strive for maximum preservation of tissues and remove only non-viable ones. Due to the abundant blood supply to the face, wound healing occurs well. The primary suture on the nose (usually cosmetic) is applied during the day after the injury.

If there is a fracture of the nasal bones with displacement of bone fragments without damaging the nasal septum and external cosmetic defects, the main treatment method is reposition (contraction) of the nasal bones with subsequent internal and less often external fixation of bone fragments. The best method is considered reposition in the first day, but it can be carried out within three weeks after the injury. If, according to anamnesis and objective research, a degree of brain concussion (headache, nausea, vomiting, weakness, neurological symptoms) is diagnosed, reposition of the bones of the nose is postponed to a later date (after 5-6 days).

Fragments of the nasal bones are set in the position of a patient sitting or lying down using application anesthesia (lubrication of the mucous membrane with 10% lidocaine solution, 2% tetracaine solution, etc.) or infiltration anesthesia by injection of 1% procaine solution (2% lidocaine solution) in a dose of 2-3 ml in the area of fracture.

Reposition at lateral displacement of the external nose is produced by the method of the so-called finger reposition, that is, the pressure of the thumb of the right hand when curved to the left and, accordingly, the left hand - when curved to the right. Finger pressure can be significant. At the time of the displacement of fragments to the normal position, a characteristic crunch is usually heard.

For depressed nasal bone fractures, nasal elevators according to Yu.N. Volkov. After adequate anesthesia, the right or left nasal elevator is introduced into the nasal cavity, respectively, at a predetermined depth and the anatomical position of the nasal dorsum is restored to the anterior and upward traction.

When a simultaneous displacement of bone fragments posteriorly and to the side is diagnosed, a finger-instrument reposition of anterior elevation with the corresponding elevator is carried out with the thumb and, at the same time, the thumb displaces the lateral displacement. In the absence of elevators, the reposition of the bones of the nose is done with straight tweezers or with a clamp, the ends of which are wrapped with gauze or put on a rubber tube.

After reposition of the bones of the nose, the fixation of bone fragments with the help of a tamponade of the nose is sometimes necessary, as indicated by the mobility of the bone fragments, which is determined by palpation. In case of a multiple fracture of the nasal bones, a stronger and longer fixation is needed, which can be ensured by tamponade turunda soaked immediately before the injection into the nose with molten paraffin (melting point 50-54 ° C). After application of anesthesia, the upper and middle sections of the nasal cavity are tamped, the paraffin hardens quickly and fixes the bones of the nose well, while nasal breathing through the lower sections of the nose can be maintained. Paraffin tampon is removed after 7 days, but it can be in the nose for up to 12 days, which is important for proper healing of the fragments.

In most cases, a fracture of the bones of the nose is combined with a fracture of the nasal septum. Existing techniques for the treatment of acute fractures of the nasal bones without taking into account the nasal septum fracture result in a high incidence of post-traumatic deformity of the nose (14-50%) and nasal breathing, forcing patients to re-seek medical attention in the delayed period.

This circumstance explains the lack of effectiveness of the closed reposition of the nasal bones used in patients with a combined fracture of the nasal bones and nasal septum and shows the need to develop an adequate treatment algorithm for patients with an acute fracture of the nasal bones.

In case of a nasal injury, accompanied by deformation of the external nose and a fracture with curvature of the nasal septum that violate nasal breathing, it is recommended to apply the tactic of one-stage correction of the intranasal structures and elimination of the cosmetic defect of the external nose - acute rhinoseptoplasty. Operations are performed, as a rule, under intubation anesthesia. At the first stage, endonasal surgeries are performed to restore nasal breathing (different variants of septoplasty). At the second stage, cosmetic defects of the external nose are eliminated. Access for surgery on the external nose can be both open and closed: for the elimination of defects, implantation of various materials is widely used (auto grains, canned cartilage, polymeric materials, silicone, etc.). Injuries to the nose, accompanied by persistent defects and deformities, require surgical (cosmetic, plastic, aesthetic) correction, which nowadays is performed in many otorhinolaryngological clinics.

[39], [40]

Further management

Patients who underwent surgical treatment should be in the hospital for 7-10 days. If after removal of tampons of wear and / or removal of fixing (plaster) dressings, no nose bleeding occurs during the day and the result of surgical treatment is satisfactory, the patient can be discharged.

[41], [42]

Information for the patient

The patient must, within a month after injury, observe a benign regimen. Eliminate physical exertion, visits to the bath, sauna. It is undesirable to wear glasses for three weeks after the injury. In some cases, after injury, it is advisable to use vasoconstrictor nasal drops for 7-10 days. Within one month after injury, it is recommended to take a synupret under the scheme in order to relieve traumatic changes in the nasal mucosa.

[43]

Forecast

Nose fracture has a favorable prognosis. In severe concomitant injury, the prognosis depends on the degree of brain damage. Approximate terms of disability at a nose fracture are 14-28 days from the date of injury.

[44], [45]