NASAL INJURY

INTRODUCTION

• the most prominent and anterior feature of

the face
• in cases of facial trauma, nasal fractures
account for approximately 40 % of bone
injuries.
 CAUSES
• Sports
• MVA
• Fights
*In children:
» Falls
» Child abuse
TYPES OF NASAL FRACTURE
• Depressed – d/t
frontal blow – if
severe, may cause
“open-book fx”
• Angulated – lat. blow
 unilat. depression
of nasal bone
 CLINICAL FEATURES
• Swelling of nose
• Periorbital ecchymosis
• Tenderness
• Nasal deformity depressed (front/side) / deviated
• Crepitus & mobility of fractured fragments
• Epistaxis
• Nasal obstruction  d/t septal injury / hematoma
• Laceration of nasal skin
*diagnosis is made based on PE as x-ray may or may not
show fx
*x-ray must include Waters’ view, right & left lateral view &
occlusal view
 MANAGEMENT

• Control bleeding and epistaxis

• Ensure ABC and overall stability of the
patient
• open wound - copious irrigation
- debridement
• Simple fx without displacement : no
treatment needed
• Displacement: may require closed or open
reduction
– Closed reduction:
to realign cartilaginous and bony structures
to their locations before the injury to
decrease discomfort and maximize airway
patency
outcomes are often less than optimal, and
patients should be counseled that nasal
reconstruction might eventually be
necessary
If edema present
- do reduction before edema
- after edema subsided (5-7days)
Difficult to do >2weeks – already healed
• Manual realignment
- applying firm digital pressure in the opposite site
• Using instruments
- Walsham forcep : reduce impacted nasal bone
- Asche’s forcep : reduce displaced septum
- Boies elevator : guided by digital
manipulation from outside
• Unstable fx
- may require intranasal packing & external splintage

Reduction instruments. (Left) Asch forceps,

(center) Walsham forceps, and (right) Boies
elevator.
 - Open reduction
• Rarely required
• Indicated when closed method fail
• Certain septal injuries better reduced by
open methods
 EAR INJURIES
1. Injuries to the external ear
2. Injuries to the middle ear
3. Injuries to inner ear
 Injuries to the pinna
1. Auricular haematoma
blunt trauma to the ear
bleeding occur deep to the perichondrium
separate cartilage – perichondrium (its
source of nutrients)
necrosis of the cartilage
loss of architecture fold & fibrous tissue
formation
permenantly swollen & deformed ear
[“cauliflower ear”]
• S&S:
- pain and swelling, deformity
• Treatment:
- aspiration of the haematoma *under
strict aseptic precaution
- firm pressure dressing - packing all
the concavities of the auricle – prevent
reaccumulation
-prophylactic antibiotics
2. Laceration
Treatment
– Repaired as early as possible
– Goal of treatment: anatomic alignment of
auricle and prevention of complication
(infection, notching, avascular necrosis)

o Thorough antiseptic cleansing

o Perichondrium & skin sticthed
o Broad spectrum antibiotics – 1 week
 3. Total & subtotal avulsion injury

• Injuries resulting in total or subtotal tissue avulsion

• Total
– Tearing away of the auricle
• Subtotal
– Some part of the auricle remained
• Treatment
– When pinna still attached to the head by small pedicle of skin – primary
reattachment (usually successful)

– Completely avulsed pinna

• Surgery
– micro vascular reimplantation when possible
– Oth: skin of avulsed segment of pinna removed, cartilage
implanted und postauricular skin for later reconstruction.
4. Frostbite
• Localized tissue injury secondary to continued exposure to subzero
temperatures
- S&S: vary between erythema,
oedema, bullae formation, necrosis of
skin and subcutaneous tissue
- Treatment:
i. rewarming with moist cotton 38-42 ºC
ii. 0.5% soak for superficial infection, systemic antibiotics for deep infection
iii. analgesic
iv. prevent bullae rupture
 TRAUMA TO EAR CANAL
• Minor laceration
 Q tip injury (scratching ear with hairpin, needle
or matchstick ) or unskilled instrumentation by
physician
 Heal without sequelae
• Major lacerations
 Gun shot wounds, automobile accident or fights
 The condyle of mandible may force through
ant.canal wall
 Cx: stenosis of ear canal
 Treatment
o Aim: attain skin-lined meatus of adequate
diameter
o control bleeding by gentle insertion of ribbon
gauze
o any clots should be carefully removed.
o prescribed antibiotic eardrop
o after 10-14 days, remove the granulation tissue to
promote healing (if present)
• Traumatic rupture of TM
– Trauma - hair pin, match stick or unskilled
attempts to remove foreign body
– Sudden change in air pressure - e.g. slap,
sudden blast, or forceful valsalva(thin atrophic
membrane
– Pressure by fluid column - e.g. diving, water
sports or forceful syringing
– Fracture of temporal bone
• Associated:
– laceration of the canal
– ossicular disarticulation or subluxation of the
stapes
– facial paralysis
– sensorineural hearing loss

• Clinical features:
– bleeding, tinnitus, vertigo and hearing loss

• Complication: Infection - foreign

material (water) - forced into the mid ear
through a ruptured tympanic membrane
• Treatment

– suction clearing
– oral antibiotic – 5-7 days
– keep ear dry

– clean, small traumatic perforations - heal within 3

weeks
• avoid significant barometric pressure changes -
perforation nears closure,
• Avoid water or other fluids in the ear

– surgical repair (large perforation / involve

annulus) – edges of perforation repositioned &
splinted
 Aero-otitis media (otitic barotrauma)
• Non-suppurative condition – failure of eustachian tube to
maintain middle ear pressure at ambient atmospheric level

• Usual cause
– rapid descent during air flight
– underwater diving
– compression in pressure chamber

• Clinical features
– Severe earache
– Deafness & tinnitus
– Vertigo
– Tympanic mbr – retracted, congested, rupture
– Mid ear – air bubble, haemorrhagic effusion
• Mechanism:
– ET allow easy & passive egress of air from mid ear
to pharynx – if mid ear pressure is high
– Reverse – nasopharynx pressure is high – air
cannot enter
• Unless tube is actively open – contraction of muscle
(swallowing, yawn or valsalva manouv.)
– When atmosp. pressure higher than mid ear (critical
level of 90mmHg), ET gets locked
– Sudden –ve pressure in mid ear – retraction of
tympanic mbr, hyperaemia & engorge vessel,
transduction & haemorrhages
– Rarely- rupture of labyrinthine mbr (vertigo &
SNHL)
• Treatment
– Aim : restore middle ear aeration
– Catheterisation or politzerisation of
eustachian tube
– Mild cases - Decongestant nasal drop or
oral nasal decongestion wt anti-histamine
– In present of fluid or failure of above
method - myringotomy to unlock the tube
and aspirate the fluid
• prevention
– Avoid air travel – URTI or allergy
– Swallow repeatedly during descent – sucking sweet
or chewing gum
– Don’t sleep during descend – decrease swallowing
– Valsalva intermittently – autoinflate the tube
– Vasoconstrictor nasal spray, antihistamine, & syst
decongestent – ½ hour bfore descent (previous hx of
this episode)
– Recurrent episode – attention to nasal polyp, septal
deviation, nasal allergy & chr sinus inf.