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Nasal Trauma and Facial Trauma

Nasal trauma is extremely common. Causes  include Assault, Road Traffic accident, Sports injury etc.

Nasal Trauma may involve the following:

  • Fracture of the nasal bones
  • Soft tissue injury
  • Fracture or dislocation of nasal septum
  • Septal haematoma
  • Cerebrospinal fluid (CSF) leak
  • Facial bone fracture

Classification of Nasal Bone fracture:

It is classified on a 1-3 scale depending on severity and extent of trauma.

  1. Class 1 fracture (Chevallet): It is due to frontal or frontolateral blow and runs from maxillary spine to nasal bone. IT causes vertical fracture of the septum with a depressed or displaced distal portion of the nasal bone.
  2. Class 2 fracture: It is due to lateral blow and results in horizontal fracture of the septum (Jarjavy) or C shaped fracture of the septum involving perpendicular plate of ethmoid, septal cartilage and frontal process of maxillae.
  3. Class 3 fracture: It is due to more severe trauma. It causes nasal bone fracture with ethmoid labyrinth. The perpendicular plate of ethmoid rotates backwards and the septum collapses into the face.

Clinical features:

Symptoms:

  • H/O trauma
  • Epistaxis
  • Nasal blockage
  • Airway obsturction
  • Swollen nose and face
  • Periorbital and subconjunctival ecchymosis
  • Nasal deformity
  • Watery discharge
  • Diplopia and epiphora

Examination:

Check for airway, bleeding, swelling of nose and face, soft tissue injury, septal haematoma, external deformity, CSF leak, and ocular movement.

Investigations:

No investigation in simple case. X-ray skull or nasal bones lateral view can e done. A CT scan can be done in maxillofacial injury.

Management:

Check the airway and exclude septal haematoma.

  1. Patient comes early without swelling or oedema: Manipulation of fracture nose with digital pressure or using Walsham’s forceps under local or general anaesthesia. The septum can be manipulated using Asche’s forceps. Some time manipulation may be accompanied by and excision of the septal fracture and overlapping segment through a Kilian incision.
  2. Patient comes with swelling or oedema: Give antibiotic, analgesic, nasal drops and re-assess in 5-7 days for manipulation when swelling subsides. Sometimes patient may not need any manipulation. Manipulation should never be delayed forr more than 2 weeks post injury
  3. Class 3 fracture needs open reduction.
  4. If patient comes late (>3 weeks): Septoplasty or Septorhinoplasty may be needed.
  5. If septal Haematoma- Aspiration or incision and drainage and antibiotics.
  6. If soft tissue injury: Toileting/ suture of the wound.
  7. If CSF leak: Conservative treatment if not healed, repair of leak.

CSF Rhinorrhoea:

Causes:

  • Traumatic-RTA
  • Spontaneous- following Functional Endoscopic Sinus Surgery (FESS)
  • Nasal surgery, brain surgery
  • Nasal tumours

Clinical Features: Clear watery nasal discharge, increases during straining, coughing.

Investigations:

  • Checking glucose content of rhinorrhoea.
  • B2 (beta 2) transferrin assay (a protein present in CSF)
  • Flurescein test (Fluorescein injected into the CSF via lumbar puncture and can be detected in nose by gamma camera
  • CT scan detect fracture

Treatment:

Usually the leak closes spontaneously. Oral penicillin and sulphdmidine are used as antibiotic prophylaxis, ceftriaxone can be used.

  • Pt. is kept in propped up position.
  • Avoidance of straining and coughing
  • If not healed in 4-6 weeks time then: Surgical repair by endoscopic approach or external ethmoidectomy using fascia lata, temporalis fascia or mucoperiosteum of middle turbinate.

 

Source: Review of Otolaryngology, Head and Neck Surgery by Dr. M. A. Matin

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