Tag along for our 21st episode which focuses on the ins and outs nasal traumas, including patient workup, differential diagnoses, management and a few clinical pearls!

Show Notes

Introduction  

Hey everyone and welcome to The Oto Approach, a podcast created by medical students for medical students, to teach you about all things otolaryngology. I'm your host Gizelle, and today we're going to talk about Nasal Trauma. Tag along for a discussion on this interesting topic!

Prevalence

Nasal trauma is the most common facial injury worldwide, with nasal bone fractures being the commonest facial skeleton fracture1! This is due to the outward projection of the nose placing it at higher risk of injury, as well as the relative weakness of nasal structures2. The incidence is reported at 0.53%. 

Etiology

The mechanism of injury leading to nasal trauma varies. In the adult population, the most common causes of fractures to the nasal bone are interpersonal violence, motor vehicle accidents, sporting accidents, and falls2. In children and adolescents, the most common etiologies are sporting and motor vehicle accidents2. It is interesting to note that of all sport-related nasal traumas, ball-related sports such as soccer, basketball, and baseball are more common than fighting-related sports, such as boxing2. In North America, traffic accidents are the most common etiology overall, followed by interpersonal violence2.

Nasal bone and septal fractures have a much higher prevalence in men and boys as compared to women and girls2. This difference has been attributed to the higher incidence of interpersonal violence between men and boys.

Anatomy

Before we do a deep dive into the etiology of nasal trauma, let’s first review the relevant anatomy. The nose is structurally supported by 3 main types of tissue: cartilage, bone, and skin. The proximal portion of the nose is composed of bone while the distal portion is cartilaginous. There are two paired nasal bones that attach to the frontal bone superiorly at the nasofrontal suture and to the maxilla laterally, at the nasomaxillary suture2.  Underlying the nasal bones are the ethmoid bones. The perpendicular plate of the ethmoid bone is met by the vomer, an independent bone inferiorly, below the vomer is the maxillary crest. These three bones, the perpendicular plate of the ethmoid, the vomer, and the maxillary crest, make up the bony nasal septum. Anterior to the bony nasal septum is the quadrangular cartilage which varies in thickness between 0.7-3.0 mm, with the thickest portion at the base of the septum, this forms the remainder of the nasal septum3. The rest of the cartilaginous portion of the nose consists of five parts: the septal nasal cartilage, the lateral nasal cartilages, the major and minor alar cartilages, and the vomeronasal cartilage. The septal nasal cartilage, located at the midline of the nose, is also referred to as the quadrangular cartilage and varies in thickness between 0.7-3.0mm, with the thickest portion located at the base of the septum3.

There is a region located in the middle one third of the nose, referred to as the “keystone area”, that is critical in maintaining stability of the nasal dorsum4. This region is comprised of the nasal bones superiorly, the upper lateral cartilages inferiorly, the quadrangular cartilage anterior-inferiorly, and the ethmoid bone posterior-inferiorly4,5. These four components are tightly interconnected with muco-periosteum, muco-perichondrium, and dense fibrous tissue4. This area has clinical importance in nasofacial aesthetics as it is responsible for dorsal contour and orientation of the nasal dorsum beyond the nasal bone5.

Another important anatomical feature of the nose is the support of the nasal tip, which is supplied by the paired alar cartilages, forming a tripod or an “M-arch”8. This arch is supported in space through attachment to various structures. Understanding of this support mechanism is fundamental in performing a rhinoplasty. The mechanisms of support can be divided into major and minor tip support. Major tip support can be divided into 3 factors. First is the size, shape, and strength of the alar cartilages8. Second is the attachment of the medial crural footplate to the inferior end of the nasal septum8. Lastly is the “scroll region” which is bordered by the superior margins of the lower lateral cartilage and the inferior margins of the upper lateral cartilages8. Minor tip support includes the anterior nasal spine, lateral crural attachment to the piriform aperture, inter-domal septum, membranous septum, dorsal septum, and the overlay of skin and soft tissue covering the nasal tip8. It is important to note that the relative importance of each aspect of the nasal tip support mechanism can very between patients.

Compared to adults, children’s noses have anatomical differences which underly the differences seen between adult and pediatric nasal traumas. Firstly, because the nasal bones are not fully developed, nasal fractures are less common7. It is the cartilaginous projections from the anterior nose that are at risk of injury in facial traumas. These cartilages bend and as a result, blunt force dissipates in the surrounding structures, causing widespread edema7. Additionally, the septal cartilage can be dislocated which is a risk for acute airway obstruction and long term growth disturbances7. As children approach adolescence, the nasal bone structure develops to resemble that of an adult, and the accompanying injuries change accordingly.

Patient workup

The initial work up and management of nasal trauma is crucial to successful outcomes. Nasal and septal bone fractures have a variety of presentations. They can be unilateral or bilateral, non-displaced or severely depressed, comminuted– meaning broken in more than one place, or greenstick – meaning the bone is bent or cracked instead of broken into separate pieces2. Additionally, fractures are not limited to the nasal bone and can include the nasal or septal cartilages and even the surrounding facial bones in more severe injuries2. Due to the complexity of nasal injuries, proper diagnosis is important.

History:

When assessing a new nasal trauma patient, the Advanced Trauma and Life Support protocol, or ATLS, is used in Canada to dictate the initial management and resuscitation of all trauma patients. A primary trauma survey should be performed first to address airway, breathing, circulation, and disability for any life-threatening problems2,6,7. It is essential for this to be done prior to a thorough history and physical as patients with airway or hemodynamic issues may decompensate quickly without medical attention6. Next, a thorough history of the events surrounding the trauma is necessary to determine the type and severity. You may be able to gather this information from the patient, however, in some cases, the history may need to be obtained collaterally from a witness or the police in the case of violent etiology.

You should inquire about when the incident occurred – this will impact whether or not the fracture should be reduced in the emergency department or if you should allow the swelling to subside first. It is also important to ask about the patient’s history of bleeding, including bleeding disorders or if they are on blood thinners, in that an epistaxis consult may be needed. Motor vehicle accidents tend to cause the most severe nasal traumas. In these cases, it is important to if they know roughly what speed the vehicle was moving at during the time of the collision. The direction of impact force will determine the type and severity of the fracture2. Lateral-type injuries are more common and tend to cause less severe damage and thus have a better prognosis2. They typically cause in-fractures on the impacted side, meaning the bone is shifted medially, and out-fractures on the opposite side, meaning the bone is shifted laterally2. Head-on injuries are typically more severe and result in splaying out fractures where both lateral nasal bones break outwards2.

Next, you should inquire about the patient’s symptoms. Inquire about rhinorrhea, specifically with a sweet/salty taste, as this can indicate a cerebrospinal fluid leak7. Next, ask about new nasal obstruction or difficulty breathing, this can provide insight into the severity of the fracture.

Additionally, you should assess the patient’s ability to smell. This can be difficult because there is almost always nasal edema immediately following the accident which can impact smell6. If that is the case, smell should be reassessed after swelling has subsided. Persistent anosmia or hyposmia (loss or reduced sense of smell, respectively) will occur in approximately 5% of patients suffering from head injuries6. In one third of cases, it will resolve spontaneously.

It is important to understand the baseline, premorbid appearance of the patient by asking them if they notice any obvious deformities7. Old photographs should be used to assess for deformities. As the nose is an integral part of facial aesthetics, you should ask the patient if they are bothered by the appearance of their nose following the injury. This is an excellent way to incorporate patient-centered care. Asymptomatic patients who are unbothered by the appearance may wish to forgo reduction. This will help in understanding the injury and planning its management. Additionally, you should ask the patient about any prior nasal traumas, surgeries, allergies, or sinus pathologies. Individuals with a history of a rhinoplasty or reconstructive surgery are more susceptible to nasal injury2. To follow, a complete review of systems should be conducted to understand any underlying medical conditions or previous injuries that may impact their susceptibility to injury or ability to recovery after treatment.

Finally, a very important aspect of the history in nasal trauma includes inquiring about non-accidental causes of injury. This is especially important in cases of pediatric nasal trauma, as child abuse should be thoroughly investigated to rule out potential danger to the child.

Physical:

A thorough physical examination of the head and neck must be conducted, including inspection of the mouth, eyes, and ears. Close attention should be paid to the nasal cavity and nasal dorsum.  An overhead light and a nasal speculum can aid in this examination. A few important things to look for include exposed bone or cartilage, nasal pyramid deviation, telecanthus, and saddle nose deformity. Telecanthus is an increased intercanthal distance which can indicate naso-orbital ethmoid fracture2. Saddle nose deformity is a collapse of the middle vault in relation to the nasal tip and dorsum. This deformity can indicate significant dislocation or fracture of the septum2. Additionally, it is extremely important to look for a septal hematoma (in this case, a sub-muco-perichondral accumulation of blood), which can present as a fluctuating red or blue discoloration along the septum2. This would require immediate drainage within the first 24h following the trauma to prevent the development of a saddle deformity, necrosis or an abscess. If left untreated, a hematoma can lead to a perforation in the nasal septum2. Lastly, assess for clear rhinorrhea because, as previously mentioned, it may indicate a leak of CSF. Red flag symptoms that indicate more severe damage include telecanthus, diplopia, clear rhinorrhea, malocclusion, and facial weakness or numbness2. When a patient presents with facial weakness or numbness in the setting of trauma, you should consider the possibility of a temporal bone fracture.

Investigations:

Imaging modalities and laboratory tests can aid in evaluating nasal traumas. The gold standard imaging modality is a CT scan of the facial bones without IV contrast2. This is reserved for scenarios when there is concern for more extensive facial injuries or when the previously stated red flags are present.

As outlined by Choosing Wisely Canada, there is clear evidence that plain film x ray provides no contribution to assessing nasal trauma, which is supported by their low specificity and sensitivity, as 55.7% and 63.3%, respectively9. The decision to reduce a nasal fracture depends on factors that cannot be assessed with x ray, including patient preference, obstruction to breathing, and external and cartilaginous deformity9. Despite their limited contribution, plain film x rays continue to be ordered for nasal trauma patients, resulting in underdiagnosis and undertreatment of nasal injuries9.  Ultrasonography is being studied to aid in diagnosing nasal bone fractures but does not currently compare to the utility of a CT2. The two occasions when laboratory tests may be useful are severe epistaxis with extensive blood loss and suspicion of a CSF leak. In these situations, a CBC with coagulation studies can be used to assess blood loss, and fluid testing for beta-2-transferrin can be used to confirm a CSF leak2.

Differential Diagnosis

A proper diagnosis for a nasal trauma is important in planning the management. The differential should include injuries to the surrounding facial skeleton2. There are 4 major diagnoses that we will discuss here. The first is naso-orbito-ethmoid complex fracture. This occurs when a fracture to the nasal bone extends posteriorly into the ethmoid air cells and medially to the canthus of one or both eyes2. The hallmark for this condition is traumatic telecanthus2. The second diagnosis is orbital facture. The main indicators of orbital fracture are preorbital edema or ecchymosis. If the floor of the orbit is fractured, patients may present with hypothesia of the cheek or limitation of extraocular muscles2. The third differential is a skull base fracture which is typically seen in high velocity impact traumas such as in motor vehicle accidents. A common presentation for skull base fracture is bilateral periorbital ecchymosis - also known as “racoon eyes”, or postauricular ecchymosis - also known as “battle’s sign” 2. These patients are at increased risk for CSF leaks, spinal fractures, and concussion2. Finally, we will consider Le Fort fractures, named after Rene Le Fort, who studied cadavers subject to blunt force trauma to determine the lines of weakness in the maxilla10. These fractures make up 10-20% of all facial fratures10. It is important to note that the pterygoid plate is involved in all Le Fort fractures and while the absence of a pterygoid fracture rules out a Le Fort fracture, the presence of a pterygoid fracture does not necessarily indicate a Le Fort fracture10. Le Fort fractures are classified into three groups based on the direction of the fracture and each have accompanying head and cervical spine injuries. The three groups are type 1 - horizontal, type 2 - pyramidal, and type 3 – cranial facial10. Type 1 fractures result from downward force directed to the lower rim of the maxilla10. Type 2 fractures result from trauma to a pyramidal shaped region defined by the bridge of the nose and extends laterally to the inferior rim of the orbit10. Type 3 fractures cover the largest surface area and include force anywhere between the lower half of the orbit to the inferior border of the maxilla10.

Treatment

Next, we will cover treatment options for nasal trauma. Nasal injuries often require urgent assessment and intervention. Since the nose is a central feature of facial aesthetics as well as an integral component of respiration, the proper treatment of nasal traumas is critical to patient quality of life6,7. Delay in time before management has been shown to produce worse outcomes1. This is likely because as time progresses following an injury, the injured structures begin to heal, making management more difficult and thus yielding worse outcomes.

Prior to treating underlying injuries, control of epistaxis and closure of lacerations should be performed. Epistaxis can often be controlled with digital pressure, but in more severe cases, may require nasal packing or cauterization2. Please refer to our episode on epistaxis for more information on management. Once acute problems have been solved, long term management can be considered. We will discuss three levels of management for nasal traumas: conservative management, nasal bone manipulation, or invasive surgical intervention. Conservative measures are usually reserved for patients without obvious cosmetic deformities or nasal obstructions. Conservative management includes elevating the head and icing the injured area to decrease facial edema. Once the swelling has settled, patients should be reassessed for nasal deformities which could have been previously masked by the swelling2.

In the United States, rates of nasal bone fractures have been increasing since 2000, yet the rate of repairs has remained relatively stable2. This suggests a gradual change to more conservative and non-operative forms of management. While conservative management may be adequate in certain cases, surgical intervention is often required and has been shown to produce more satisfactory patient outcomes1. Closed reduction of the nasal septum is typically the first line treatment for fractures causing deviation or airway obstruction2. This procedure may be performed under local anesthetic; however, general anesthesia is preferred for patient comfort and airway protection, and is the mainstay for pediatric patients2,7. There is debate over when nasal reduction should be performed. Some say it is best to perform a reduction in the 5-7 days following injury while others argue that edema should fully resolved first, which may take up to 2 weeks2. However, as previously mentioned, waiting 2 weeks carries the risk of worse cosmetic outcomes and patient satisfaction as the bones will begin to heal in place2. A closed reduction can be performed with a flat instrument such as a Boies or Sayre elevator to reduce fractured bony fragments2. Post-operatively, nasal splints are placed against the nasal dorsum to aid in keeping the septum aligned2. Closed reduction is contraindicated in severe comminuted fractures of the nasal bone, open septal fractures, fractures that are delayed in presentation by 2-3 weeks, and Le Fort fractures which require open reduction12.

Lastly, an open septorhinoplasty can be performed for fractures that cannot be reduced via a closed approach. Open septorhinoplasty should be considered in cases included complex bony and cartilaginous injuries that require extensive manipulation, grafting, osteotomies, and careful suturing11. This invasive surgical procedure is generally avoided due to the risk of devascularization of damaged cartilaginous tissue2. Additionally, cartilage grafts inserted during rhinoplasties are more susceptible to infection and absorption2. As such, in the case that a rhinoplasty is required to correct the injuries, it is recommended to wait 3-6 months following the initial trauma2. In cases of sport-related nasal trauma such as hockey or boxing, surgeons will often counsel patients on the impact recurrent trauma has on repair outcomes as revisions can be very challenging. As such, patients may be told they must wear more protective equipment such as a caged helmet, or in more severe cases, discontinue their sport, before the surgeon will agree to perform the repair, out of best interest for the patient.

Prognosis

Patients show a variation in recovery following treatment of nasal trauma. Residual nasal deformity is the main complaint, presenting in 9-50% of patients who underwent a closed reduction2. Residual deformity or nasal obstruction can be attended to with a follow up spetorhinoplasty2. This procedure should be delayed by 3-6 months to allow for healing of lacerations and cartilaginous injuries2. Outcomes can be improved by addressing nasal fractures promptly following injury, however, patients with prior deformity or obstruction are at higher risk of needing revision following the initial procedure2.

There are significant consequences to delaying or forgoing treatment of nasal trauma, including cosmetic deformity, nasal obstruction, and loss or altered sense of smell. Amongst these, nasal valve collapse is commonly seen in patients who forgo treatment11. In such cases, trauma to the inner and outer nasal valves can causes scarring, resulting in nasal obstruction and nasal impaired breathing. This can be assessed using the Cottle Maneuver which tells you if widening the nasal valves will improve the patient’s breathing11. If valve collapse is the cause of their problem, a septoplasty may be performed. 

Clinical Pearls

-       The nasal bones are the most frequently fractured in the maxillofacial area2.

-       A high proportion of patients presenting with nasal bone fractures will have injury to their nasal septum that will go unnoticed2.

-       In isolated nasal bone fractures, imaging is not necessary and should be avoided unless initial assessment suggests otherwise2.

-       For optimal cosmetic results, closed reduction of the nasal bone should be performed within 2 weeks of the trauma2.

-       It is important to assess for airway obstruction and the previously mentioned red flag signs to avoid patient decompensation following nasal trauma.

Closing remarks

Thank you to Gizelle Francis for developing this script.

We would like to extend our sincerest thanks to the Saint John Regional Hospital Department of Surgery within the Horizon Health Network for their generous support.

Thank you so much for listening to our podcast! We hope you’ll tune in to our next episode! Please head to our website at www.theotoapproach.com for our show notes, and to sign up for our newsletter to stay up to date with our latest episodes.

References

1.     Hope N, Young K, Mclaughlin K, Smyth C. Nasal Trauma: Who Nose what happens to the non-manipulated? Ulster Med J. 2021 Jan;90(1):10-12. Epub 2021 Feb 26. PMID: 33642627; PMCID: PMC7907914.

2.     Klinginsmith M, Katrib Z. Nasal Septal Fracture. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK555912/

3.     Bell, D. Nasal septal cartilage. Reference article, Radiopaedia.org. (accessed on 28 Aug 2022) https://doi.org/10.53347/rID-95834

4.     Kim IS, Chung YJ, Lee YI. An anatomic study on the overlap patterns of structural components in the keystone area in noses of koreans. Clin Exp Otorhinolaryngol. 2008 Sep;1(3):158-60. doi: 10.3342/ceo.2008.1.3.158. Epub 2008 Sep 30. PMID: 19434249; PMCID: PMC2671748.

5.     Simon, Patrick & Lam, Kent & Sidle, Douglas & Tan, Bruce. (2013). The Nasal Keystone Region: An Anatomical Study. JAMA facial plastic surgery. 15. 1-3. 10.1001/jamafacial.2013.777.

6.     Hwang K, Yeom SH, Hwang SH. Complications of Nasal Bone Fractures. J Craniofac Surg. 2017 May;28(3):803-805. doi: 10.1097/SCS.0000000000003482. PMID: 28468171. Desrosiers AE 3rd, Thaller SR. Pediatric nasal fractures: evaluation and management. J Craniofac Surg. 2011 Jul;22(4):1327-9. doi: 10.1097/SCS.0b013e31821c932d. PMID: 21772190.

7.     Dibelius G, Hohman MH. Rhinoplasty Tip-shaping Surgery. [Updated 2022 Feb 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK567750/

8.     Arnstead, N., Chan, Y., Kilty, S. et al. Choosing Wisely Canada rhinology recommendations. J of Otolaryngol - Head & Neck Surg 49, 10 (2020). https://doi.org/10.1186/s40463-020-00406-9

9.     Patel BC, Wright T, Waseem M. Le Fort Fractures. [Updated 2022 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK526060/

10.  Akama T, Tsuda T, Terada R, Tanaka S, Tanaka H, Yoshitatsu S, Nishimura H, Inohara H. A Case of Traumatic Nasal Valve Stenosis Successfully Treated with Open Rhinoplasty and Z-Plasty. Ear Nose Throat J. 2022 Jul 12:1455613221115100. doi: 10.1177/01455613221115100. Epub ahead of print. PMID: 35818845.

11.   Alvi S, Patel BC. Nasal Fracture Reduction. [Updated 2022 May 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK538299/