Nasal injuries: causes, symptoms, diagnosis, treatment

Nasal injuries are divided by origin into domestic, sports, industrial and wartime. The most common of them are domestic and sports. Domestic injuries are caused by an accident or a conflict situation resolved by fists. Injuries from accidents are caused by a fall on the face of subjects who are intoxicated or by tripping over some obstacle. Most often, this type of injury occurs in children. Due to the elasticity of the nasal pyramid and the cartilaginous framework, they do not experience immediate destructive consequences, but subsequently, with further development of the facial skeleton, and in particular the structures of the nose, these injuries can cause the development of various dysgenesis, which were discussed above.

In adults, domestic and sports injuries cause more extensive destruction at the moment of the injury itself, since the nasal skeleton is more rigid and fragile. Industrial injuries are not so common. They also occur in various accidents in industrial conditions (falls from heights, explosions, impacts from moving machinery, etc.). Wartime injuries are caused by shrapnel or bullet wounds. They are usually combined with wounds to deep facial tissues and are often life-threatening to the victim. These injuries occur during military operations, but, like gunshots, they can occur during an attempt at murder or suicide or as a result of an accident due to careless handling of a weapon. The consequences of nasal trauma can be associated with cosmetic or functional disorders, as well as a combination of both.

Pathological anatomy. The type, shape, and depth of damage to the nose are determined by many factors: density, mass, speed of movement of the traumatic object, position of the victim, direction of head movement (oncoming, moving away, or evasive), and direction of the force vector causing the injury. There are injuries to the bone skeleton of the nose, its cartilaginous framework, and combined injuries to both structures of the nasal pyramid, open and closed fractures of the nasal bones, fractures of the nasal bones without displacement and with displacement - lateral and in the sagittal plane with the formation of a "collapsed" nose. Open fractures of the nose can be both with damage to the skin and with a rupture of the mucous membrane into the nasal cavity. Fractures of the cartilaginous framework are most often observed in adults due to compaction and fragility of the nasal septum, which at the age of over 50 years often becomes saturated with calcium salts and acquires the density of bone tissue.

Fractures of the nasal bones themselves may be combined with fractures of the bony parts of the skull, as well as the ascending branch of the maxilla, zygomatic bone, contusion and fracture of the upper alveolar process and incisors. These injuries are within the competence of maxillofacial surgeons who are proficient in methods of splinting and repositioning fractures of the facial bones and jaws with the application of bone sutures and replantation of teeth. As for ENT specialists - rhinologists, their competence includes repositioning of dislocated parts of the nasal pyramid and endonasal manipulations to restore patency of the nasal passages.

Symptoms of a nasal injury. A contusion of the nasal pyramid is an injury that can cause pronounced reflex reactions - from severe pain to traumatic shock, accompanied by dilated pupils, bradycardia, shallow breathing, pale skin and loss of consciousness. Often, with contusions of the nose and frontal region, depending on the force of the blow, concussion or brain contusion may be observed.

A severe contusion of the frontal-nasal region should be classified as a TBI, in which 60-70% of cases involve a concussion. The signs of the latter are loss of consciousness from a few seconds to a few minutes; nausea and vomiting are common. After regaining consciousness, victims complain of headache, dizziness, tinnitus, weakness, sweating, and sleep disturbances. Memory loss is often observed - the patient does not remember the circumstances of the injury, nor the short period of events before and after it. Other signs include pain when moving the eyes and diplopia. There is no damage to the bones of the cranium. The pressure of the cerebrospinal fluid and its composition do not change significantly. These symptoms usually disappear in 2-3 weeks, and with appropriate treatment - even earlier.

Brain contusion with frontal-nasal trauma is a more severe form of its damage, differing from concussion by the presence of areas of damage to the brain tissue, subarachnoid hemorrhage, and in some cases - fractures of the vault and base of the skull. Considering that massive nasal injuries are often accompanied by contusions of the frontal lobes of the brain, an ENT specialist should be guided in the classification of degrees of brain contusion.

Mild brain contusion is characterized by loss of consciousness for a period of several minutes to 1 hour. After regaining consciousness, victims usually complain of headache, dizziness, nausea, etc. Brady- or tachycardia, sometimes increased blood pressure, may be detected. Nystagmus, asymmetry of tendon reflexes, meningeal symptoms, etc. are noted, which usually disappear 2-3 days after the injury.

A moderate brain contusion is accompanied by loss of consciousness for a period of several tens of minutes to 6 hours. Amnesia is expressed, sometimes mental disorders are observed. Multiple vomiting and transient disorders of vital functions are possible. Clear meningeal symptoms usually develop. Focal symptoms are determined by the localization of the brain contusion. These may be pupillary and oculomotor disorders, limb paresis, sensitivity disorders, speech disorders, etc. Over the course of 3-5 weeks, the listed symptoms gradually disappear, but can persist for a long time, becoming meta-, stress-dependent, i.e., recurring in a reduced form.

Severe brain contusion is characterized by loss of consciousness from several hours to several weeks. There are threatening disturbances of vital functions with disturbance of respiratory rate and rhythm, sharp increase or decrease of blood pressure, fever. Primary brainstem symptoms often prevail in the neurological status: floating eye movements, gaze paresis, dilation or constriction of the pupils, swallowing disorders, changing muscle tone, pathological foot reflexes, etc. In the first days after the injury, these symptoms obscure the focal signs of brain contusion, which, when the frontal lobes are affected, are distinguished by their own characteristics. Generalized or focal seizures and signs of cerebral edema are sometimes observed. General cerebral and especially focal symptoms regress slowly; pronounced residual motor disorders and changes in the mental sphere are often observed.

Objective symptoms of nasal trauma include swelling and bruising on both sides of the bridge of the nose, extending to the face and lower eyelids, and sometimes to the subconjunctival space. Open fractures are characterized by wound damage to the skin, external bleeding, or a wound covered with bloody crusts. Fractures of the nasal bones and cartilaginous framework are characterized by displacement of the nasal pyramid or a collapse of the bridge of the nose. Palpation of the fracture area causes sharp pain and a feeling of crepitus and mobility of the bridge of the nose. In some cases, emphysema phenomena occur in the fracture area and in the surrounding tissues, manifested by an increase in tissue volume and crepitus of air bubbles. Emphysema occurs when the mucous membrane of the nose is damaged and difficulty in nasal breathing occurs due to a hematoma and traumatic edema when the victim tries to blow his nose. Emphysema initially occurs at the root of the nose, then spreads to the lower eyelids, face, and can even spread to the neck. Particularly pronounced emphysema occurs with ethmoid-orbital fractures. With particularly severe injuries to the frontal-nasal region, accompanied by fractures of the base of the skull and ruptures of the dura mater, nasal liquorrhea is observed.

During anterior rhinoscopy, blood clots, displacement of the nasal septum, and its thickening as a result of subperiosteal hematoma are detected in the nasal passages. The nasal turbinates are enlarged, blocking the nasal passages. A final diagnosis is established by X-ray of the nose in profile, as well as in projections visualizing the paranasal sinuses and ethmoid bone.

The clinical course of a nasal injury depends on its severity, the presence of dislocation phenomena, and the degree of involvement of the brain in the traumatic process. Nasal injuries often resolve on their own without medical intervention, but after this, there are often TS or other deformations that subsequently require certain plastic surgeries.

Treatment is determined by the time of injury, its severity and type of anatomical disorders. In severe fresh injuries characterized by open fractures or wounds, skeletal fragmentation, lateral displacement or collapse of the nasal bridge, surgical intervention is undertaken that corresponds to the type and severity of the injury. In this case, repositioning of displaced fragments is carried out with restoration of the nasal passages and the external shape of the nose, preferably using a photograph of the victim. Atraumatic sutures are applied to the wound; in case of tissue rupture and loss, a free autoplasty method is used, borrowing a skin flap from a non-hairy part of the body or forearm.

Surgery is performed under local application and infiltration anesthesia or general anesthesia, observing the rules of asepsis and antisepsis. The surgical intervention is completed with nasal tamponade and application of a fixing bandage and a metal angular splint to the bridge of the nose. Intranasal tampons, if soaked with an antibiotic solution using a syringe and needle, can be kept for up to 4-5 days, then they are removed and after washing the nasal cavity with a sterile antiseptic solution, the nasal cavity is tamponed again (loosely) for 1-2 days, after which the tampons are finally removed. The external fixing bandage is kept for up to 10 days. After its removal, the swelling of the nose and surrounding tissues increases slightly, but then passes after 2-3 days. After the operation, antibiotics, analgesics, sedatives, vitamins C and strong6 are prescribed, antitetanus serum is administered. In case of massive blood loss, intravenous blood substitutes are administered, transfusions of fresh citrated blood and red blood cell mass are performed. All victims with a nasal injury and complaints of headache should be examined by a neurologist before surgery. In the presence of concussion or bruise of the brain, the neurologist determines the indications and contraindications for surgery.

Postoperative course. In the first 2-3 days, swelling of the face, bruises around the eyes are observed, sometimes quite significant, which disappear by the end of the 2nd week after the injury or operation.

After trauma and surgery, some patients experience an increase in body temperature up to 38°C, caused by traumatic stress or concussion.

In cases where proper surgical treatment was not performed within the next 2 days after the injury due to wound infection, surgical intervention is postponed until complete recovery and final consolidation of the fragments.

When cicatricial adhesions form in the nasal cavity and its external deformation, surgical intervention to rehabilitate the respiratory and cosmetic functions of the nose is performed no earlier than 4-6 months later, during which time the scarring process is finally completed.

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