Nasal and septal injury

Nasal fractures

Nasal injury is common.  A fractured nose can be classed as open or closed (depending on whether the mucosa is broken or intact) and it is important to determine any involvement of the septum, as this can make repositioning the nose more difficult.  Early and proper repositioning is key to avoiding complications and malformations.

Aetio-pathology

Most commonly due to a blow to the face (fights, accidents, sports, airbags, falls etc).

  • Frontal force: simple nasal fracture +/- nasal flattening
  • Lateral force: if mild, may only depress one nasal bone.  If severe, can displace the entire nasal bone group and septum (complicated nasal fracture).  There may be twisting/buckling and fragmentation that can complicate reduction procedures
  • Superior force: rarer but can have serious septal involvement and may dislocate the bony cartilage from the bone.

Signs/Symptoms

  • Epistaxis
  • Change in nasal appearance
  • Nasal obstruction
  • Infraorbital bruising (ecchymosis)

Reduction

Closed reduction (i.e. non-surgical, use mild sedation)

  • Used for simple fracture of nasal bone or naso-septal complex

Open reduction (i.e. surgical reduction)

  • Used for extensive fracture-dislocation of nasal bones/septum; open septal fractures; persistent deformity after closed reduction; the presence of a septal haematoma/deformity; recent intranasal surgery

NB Most cases are non-urgent so can wait several days (up to 14) before surgery.

Septal Haematoma

This is a common and serious complication of trauma.  They are collections of blood in the subperichondrial space, and cause a build-up of pressure on the underlying cartilage, causing hypoxia and eventually necrosis.  They have to be drained immediately to prevent this and septal perforation/saddle deformities

A septal hematoma can usually be diagnosed by inspecting the septum with a nasal speculum or an otoscope. An asymmetric septum that is blue/red may indicate a haematoma. Palpation along the septum, feeling for swelling or widening of the septum, may also give clues.

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