Nasal fracture

A nasal fracture is a nasal injury in which the integrity of the nasal bone pyramid is disrupted with or without displacement of bone fragments. Nasal bone fractures or cartilage damage may cause swelling, pain, abnormal mobility, crepitus, nosebleeds, and bruises in the periorbital region. Diagnosis is usually made based on the clinical picture. Treatment includes repositioning, stabilization with internal tamponade or splinting.

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Epidemiology

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

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Causes nasal fracture

A broken nose can result from various types of injuries:

• domestic (criminal, falling from one’s own height, falling as a result of an epileptic seizure or while intoxicated);
• sports (mainly when practicing boxing, various types of martial arts, etc.):
• transport (as a result of a road traffic accident);
• industrial (mainly due to failure to comply with safety regulations);
• military injuries.

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Pathogenesis

Among the bones of the facial skeleton, the nasal bones are most susceptible to fractures due to their central location and protrusion above the surface of the face. Depending on the mechanism of injury, fractures of the maxilla, orbits, cribriform plate, and damage to the nasolacrimal duct are possible.

A strong blow to the external nose results in a fracture of the nasal bones, frontal processes of the maxilla, lateral cartilages of the nose and, in most cases, the nasal septum, both in the cartilaginous and bone sections. The most common type of lateral displacement of the external nose is accompanied by a separation of the suture between the nasal bones and the frontal processes of the maxilla or a fracture of the nasal bones. Even if there is no displacement of the nasal pyramid, some displacement of the bone fragments relative to each other is almost always observed. In all cases, there is also some degree of swelling, bruising and abrasions of the soft tissues of the nose. In case of a fracture of the nasal septum, bruising is observed in the mucous membrane with possible rupture of the latter. Microhematomas are formed along the fracture line of the nasal septum, which can cause an extensive hematoma of the nasal septum with abscess formation.

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Symptoms nasal fracture

As a result of trauma, patients always report pain in the nasal area, which intensifies with palpation of the nose; in most cases, crepitus of bone fragments is detected. With a combined fracture of the nasal bones and the ethmoid labyrinth, subcutaneous emphysema is formed in the periorbital region, which is confirmed by the presence of crepitus of air during palpation. Due to the rupture of the nasal mucosa during trauma, nosebleeds always occur, which, as a rule, stop on their own. However, with severe damage, they can be profuse, long-term and recurrent nosebleeds.

Traumatic deformation of the nose may be represented by a displacement of the bridge of the nose to the right or left (usually to the right), a sinking of the slope of the nose to the right or left (usually to the left), a sinking of the bone and/or cartilaginous part of the bridge of the nose with the formation of a saddle-shaped nose (an "open book" fracture). With an extremely strong direct blow, a complete calcination of the bridge of the nose is possible, the so-called pug nose.

In case of a cribriform plate fracture with a rupture of the dura mater, nasal liquorrhea appears, revealed when the head is tilted forward. Concomitant nasal hemorrhage can complicate the diagnosis of cerebrospinal fluid leakage. In the first day, the "double spot" symptom is characteristic, expressed in the appearance of an external light ring around the blood spot. After the nosebleed stops, the discharge from the nose with nasal liquorrhea becomes light.

Often, facial injuries result in hemorrhage into the anterior chamber of the eye (hyphema), displacement of the eyeball (enophthalmos), compression of the oculomotor muscles ( diplopia ), accompanied by decreased vision up to its complete loss (amaurosis).

Forms

Depending on the strength of the action and characteristics of the traumatic factor, its direction and depth of penetration, nasal injuries can be open (with damage to the skin) or closed (without damage to the skin).

Classification of external nose deformities:

• rhinoscoliosis - lateral displacement of the nose;
• rhinokyphosis - deformation of the nose with the formation of a hump;
• rhinolordosis - depression of the bridge of the nose (saddle nose);
• platyrinin - a wide and relatively short nose;
• brachyrinia - an excessively wide nose.
• leptorhinia - an excessively narrow (thin) nose.

Complications and consequences

Complications include cosmetic deformities and functional obstruction of the nasal cavity. Septal hematoma may lead to aseptic necrosis of the cartilage with subsequent deformity. Fractures of the cribriform plate may cause meningitis and brain abscess.

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Diagnostics nasal fracture

When collecting anamnesis, they find out how long ago the injury was received, who inflicted it and what object it was inflicted with (hand, foot, stick, etc.), the nature of the injury (sports, household, transport, etc.), the severity and duration of the nosebleed, the presence of loss of consciousness, nausea and vomiting. In addition, they find out concomitant diseases and the presence of nasal injuries in the past.

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Physical examination

Palpation of the nasal bones reveals pain, crepitation of bone fragments, air and mobility of the external nose in the bone section. The degree of swelling of the soft tissues of the nose and the type of deformation of the nasal pyramid are determined. Anterior rhinoscopy reveals the degree of swelling of the nasal mucosa, the location of the rupture of the mucosa in the anterior parts of the nose and the source of nosebleeds, as well as possible curvature of the nasal septum.

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Laboratory research

General clinical studies are conducted, including a general blood test, urine test, biochemical blood test, ECG and other methods. These studies show the degree of blood loss, changes in other organs and systems, which can make adjustments to the patient's management tactics.

The detection of glucose in nasal discharge during their examination indicates the presence of cerebrospinal fluid, characteristic of a cribriform plate fracture with a rupture of the dura mater. In this case, the patient must be treated in the neurosurgical department.

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Instrumental research

Radiation methods of examination, such as radiography and especially CT, are highly informative in nasal trauma. Radiography of the nasal bones or skull in the lateral projection always reveals the presence of a nasal bone fracture: fracture lines, displacement of bone fragments relative to each other in the sagittal plane are visible. CT in the coronal and axial projections more accurately shows fracture lines, displacement of bone fragments in different planes, and also reveals the location of the nasal septum fracture with the direction of displacement. Additionally, combined damage to the walls of the paranasal sinuses, eye sockets, skull bones, hematosinus, etc. is revealed.

In some cases, ultrasound echography helps to clarify the extent of traumatic injury.

Endoscopic examination of the nasal cavity allows for examination of the posterior sections of the nasal cavity and the septum. In this case, microhematoma lines corresponding to the fracture lines of the nasal septum are observed, as well as ruptures of the mucous membrane with exposure of cartilage or bone.

Trauma to the facial part of the skull is often accompanied by hemorrhage in the eyelids and around the eye socket (the "spectacle symptom"), but this symptom may also be a sign of a skull base fracture, cavernous sinus injury. In this case, a spinal puncture is necessary to clarify the diagnosis. A skull base fracture is characterized by the presence of blood in the cerebrospinal fluid (subarachnoid hemorrhage). A skull base fracture is suspected when the patient is unconscious, stupefied, convulsing, etc. This requires the doctor to fix the patient's head in relation to the body (there are special corsets), and transport the patient on a hard stretcher. Even an X-ray examination cannot be done immediately, since it requires turning the head.

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Indications for consultation with other specialists

Any nasal trauma requires a consultation with a neurosurgeon to rule out or confirm brain trauma. This is especially necessary in the case of a serious condition of the patient with loss of consciousness and other neurological symptoms.

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

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

In the presence of concomitant pathology of the cardiovascular system, pulmonary artery and other systems, consultation with a therapist, cardiologist, etc. is necessary.

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Screening

Identification of individuals with traumatic injuries to the nose is carried out taking into account complaints of pain, deformations in the nasal area, anamnesis data (nose trauma) and examination data (swelling of the soft tissues of the nose, deformation of the external nose, pain, crepitation of bone fragments upon palpation).

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Differential diagnosis

It is necessary to distinguish between acute and consolidated fractures of the nasal bones, in which there is deformation of the nasal pyramid, but there is no swelling of the soft tissues and mucous membrane of the nasal cavity, pain and crepitus of bone fragments upon palpation.

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Treatment nasal fracture

Emergency care consists of symptomatic treatment with cold and pain relief. Reposition is indicated only for fractures with visible deformation of the nose or with obstruction of the nasal passages. The basis for stopping repositioning measures is restoration of the shape of the nose or improvement of breathing. That is why, in some cases, reposition is postponed for 3-5 days, which allows the swelling to decrease. Nasal fractures in adults are usually reduced under local anesthesia; general anesthesia is indicated for children. A blunt elevator is inserted into the nasal passage and placed under the depressed nasal bone, lifting it forward and to the side, while pressing on the other side of the nose, giving the bridge of the nose a position along the midline. The nose can be stabilized by installing tampons in the nasal passages (gauze strips moistened with antibiotics), placing them high in the vestibule 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, repositioning is often not required. If the deformity persists after the swelling has subsided, repositioning and splinting are performed under local anesthesia. A nasal septum hematoma must be drained immediately to prevent infection and cartilage necrosis. A broken septum is difficult to fix in the correct position and often has to be operated on later.

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

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Indications for hospitalization

1. Fracture of the nasal bones with pronounced external deformation.
2. Fracture of the nasal bones, combined with damage to the paranasal sinuses, eye socket, and brain.
3. Fracture of the nasal bones, accompanied by severe or recurrent traumatic nosebleeds.

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Non-drug treatment for a broken nose

In the first 5-6 hours after the injury, ice is applied to the area of injury; in case of nosebleed, anterior loop or posterior nasal tamponade may be used.

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Drug treatment of a broken nose

The introduction of antitetanus serum according to the scheme is mandatory. Analgesics (metamizole sodium, tramadol, ketorolac, etc.), sedatives (oxazepam, phenobarbital, etc.) are prescribed. General and local antibacterial therapy, hemostatic therapy and symptomatic agents are used to combat wound infection and prevent secondary complications.

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Surgical treatment of a broken nose

The treatment tactics depend on the nature and depth of the injury, the severity of general and neurological symptoms. In the presence of bruises and wounds of soft tissues, abrasions without damage to the bone structures of the facial skeleton, primary surgical treatment is performed and bleeding is stopped. In this case, 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 within 24 hours after the injury.

In the presence of a fracture of the nasal bones with displacement of bone fragments without damage to the nasal septum and external cosmetic defects, the main method of treatment is repositioning (repositioning) of the nasal bones followed by internal and, less often, external fixation of bone fragments. The optimal method is considered to be repositioning on the first day, but it can also be carried out within three weeks after the injury. If, according to the anamnesis and objective examination, a concussion of the brain of degree (headache, nausea, vomiting, weakness, neurological symptoms) is diagnosed, the repositioning of the nasal bones is postponed to a later date (after 5-6 days).

Nasal bone fragments are reduced with the patient sitting or lying down using topical anesthesia (lubrication of the mucous membrane with a 10% lidocaine solution, 2% tetracaine solution, etc.) or infiltration anesthesia by injection of a 1% procaine solution (2% lidocaine solution) at a dose of 2-3 ml into the fracture area.

Repositioning of the lateral displacement of the external nose is performed by the so-called finger repositioning method, i.e. by pressing the thumb of the right hand when the curvature is to the left and, correspondingly, the left hand when the curvature is to the right. The force of finger pressure can be significant. At the moment of displacement of the fragments to the normal position, a characteristic crunch is usually heard.

In case of depressed fractures of the nasal bones, nasal elevators according to Yu.N. Volkov are used for repositioning. After adequate anesthesia, the right or left nasal elevator is inserted into the nasal cavity to a pre-measured depth, and the normal anatomical position of the nasal dorsum is restored by traction forward and upward.

When simultaneous displacement of bone fragments backwards and to the side is diagnosed, finger-instrument reduction is performed by traction forwards with the appropriate elevator and simultaneously the lateral displacement is reduced with the thumb. In the absence of elevators, reduction of the nasal bones is performed with straight tweezers or clamps, the ends of which are wrapped in gauze or a rubber tube is put on them.

After repositioning the nasal bones, fixation of bone fragments with a nasal tamponade is sometimes necessary. The indication for this is the mobility of bone fragments, determined by palpation. In case of multiple fractures of the nasal bones, a stronger and longer fixation is needed, which can be provided by a turunda tamponade soaked in melted paraffin (melting point 50-54 °C) immediately before insertion into the nose. After application anesthesia, the upper and middle sections of the nasal cavity are tamponed; the paraffin quickly hardens and fixes the nasal bones well, while nasal breathing can be maintained through the lower sections of the nose. The paraffin tampon is removed after 7 days, but it can remain in the nose for up to 12 days, which is important for proper fusion of the fragments.

In most cases, a nasal bone fracture is combined with a nasal septum fracture. Existing methods of treating acute nasal bone fractures without taking into account the nasal septum fracture lead to a high number of cases of post-traumatic deformation of the nose (14-50%) and impaired nasal breathing, which forces patients to seek medical help again in a delayed period.

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

In case of nasal trauma accompanied by deformation of the external nose and fracture with curvature of the nasal septum, which disrupt nasal breathing, it is recommended to use the tactics of one-stage correction of intranasal structures and elimination of the cosmetic defect of the external nose - acute rhinoseptoplasty. Operations are usually performed under endotracheal anesthesia. At the first stage, endonasal operations are performed to restore nasal breathing (various types 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: to eliminate defects, implantation of various materials (autocartilage, preserved cartilage, polymeric materials, silicone, etc.) is widely used. Nasal trauma accompanied by persistent defects and deformations require surgical (cosmetic, plastic, aesthetic) correction, which is currently performed in many otolaryngology clinics.

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Further management

Patients who have undergone surgical treatment must stay in hospital for 7-10 days. If after removing the tampons and/or fixing (plaster) bandages, no nosebleeds occur within 24 hours and the result of surgical treatment is satisfactory, the patient can be discharged.

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Information for the patient

The patient should follow a gentle regimen for a month after the injury. Physical activity, visiting a bathhouse, or sauna are excluded. Wearing glasses for three weeks after the injury is undesirable. In some cases, it is advisable to use vasoconstrictor nasal drops for 7-10 days after the injury. It is recommended to take Sinupret according to the scheme for one month after the injury in order to stop traumatic changes in the nasal mucosa.

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Forecast

A nasal fracture has a favorable prognosis. In severe combined trauma, the prognosis depends on the degree of brain damage. The approximate period of disability for a nasal fracture is 14-28 days from the moment of injury.

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