Management of Nasal Trauma

Stephen W. Perkins, M.D., F.A.C.S., and Steven H. Dayan, M.D.

Aesthetic Plastic Surgery, Volume 26, Issue s01, pp S3-S3

Nasal bones are the most commonly fractured bones in the face and the third most commonly fractured bones in the body. The nose, the most projected feature of the face, is the leading structure encountered in a traumatic event. It is estimated there are, on average, 51,200 nasal fractures per year in the United States. However, there are probably more incidences, as many patients with nasal fractures do not seek treatment or treatment may go unreported. In a severely traumatized patient with ife-threatening injuries, it is not unusual for a nasal fracture to be unrecognized. Additionally, nasal fractures may not be specifically diagnosed when it occurs in conjunction with other fractures of the face. Infant or childhood nasal trauma is notorious and/or airway obstruction. Commonly, the patient who is seeking cosmetic or functional rhinoplasty has experienced a previously unnoticed or forgotten traumatic event in which the nasal bones or cartilages were damaged. Unfortunately, even when a nasal fracture is diagnosed, the mechanism of injury is often not well understood, leading to an inadequate treatment plan. This results in a less than ideal reduction and an unsatisfactory outcome. Possibilities of complications may ensue including the difficult to correct twisted nose deformity.

Incidence and Injury Pattern

Most facial fractures afflict people between the ages of 15 and 40 years and are three times more likely to occur in males. Nasal and facial fractures in adults are commonly reported to be the result of motor vehicle accidents (MVA), sports injury, altercations, or falls. The variability in frequency may depend on th eurban location in which the study has been performed. The mechanism by which the injury occurred and the patients awareness may affect the manner in which it is reported. Patients who have sustained nasal fracture during altercations will have a 15-20% chance of reporting a second nasal trauma. These patients’ lifestyles afford a particular susceptibility to repeated facial trauma. Additionally, these patients may be quick to recognize and report a nasal trauma. Interestingly, it has been noted that previous rhinoplasty patients are at an increased risk for nasal fractures, especially males, within one year of the procedure. It seems intuitive that the still settling post-rhinoplastic nose is vulnerable to outside forces and this information needs to be conveyed to the patient. Fortunately, it has been our experience that the post-rhinoplastic patient rarely ignores a nasal injury and reliably seeks medical attention.

Injuries to the nose that occur during an altercation (e.g., a fist) tend to not injure other facial features. Once the patient seeks medical attention, the practioner is allowed to concentrate on diagnosing the nasal injury. Conversely, motor vehicle accidents tend to result in severe nasal fractures that are frequently associated with additional maxillofacial injuries. Twenty percent of patients who have sustained facial skeleton injuries have multiple facial bone fractures. When high imipact trauma fractures the bones of the midface, the nose also tends to be injured. It is estimated that 28% of patients who sustain midfacial fractures experience an associated nasal fracture. In this situation, the nasal fracture may be neglected resulting in a missed diagnosis.

Children’s noses are mostly cartilaginous and possess small nasal bones that are softer and more compliant, absorbing little of the energy from the force. However, they are not immune to nasal fractures. It is well known that birth trauma can result in nasal septal deviation. It is estimated that the incidence of nasal septal deformities ranges between 1.25% - 23% of all newborns. A forceps-assisted or a breech delivery are often associated with the injury, but intrauterine forces may also be responsible for neonatal cartilage deformities. Fortunately, these deviations can be treated easily, expeditiously, and without complication in the early neonatal period, preventing long term sequelae.

Similar to adults, older children and adolescents are also injured as a result of sports injury, MVA, and falls, however, also included are playground assaults and injuries from animals. It is important not to disregard abuse as a cause of childhood nasal trauma. Also of particular importance in pediatric patients are sports related injuries, one of the most preventable causes of nasal fractures. Fifty percent of pediatric facial fractures are secondary to sports-related injury, and 65% of these patients will experience a nasal fracture. Softball, a popular recreational sport enjoyed by both males and females, is the most likely cause of sports-related nasal fracture in children. This has led to The U.S. Consumer Protection Safety Commission June of 1996 official recommendations for protective face gear on batting helmets.

Following nasal trauma, children are especially susceptible to septal hematoma and its subsequent complications. The cartilages of the nose tend to buckle and twist rather than fracture, producing a separation between the perichondrium and the cartilge resulting in a hematoma. This can occur in the absence of nasal bone fractures, with minimal signs and symptoms of nasal trauma. Unfortunately, childhood nasal trauma is often unappreciated, manifesting as external and internal nasal deformities in adult life.

Mechanism of Injury

The nasal bones are the most fragile of the external bones, having the least amount of tolerance to an impact force. The resultant fracture of the nose can be surprisingly predictable based on the forces of injury. Most common nasal fractures are due to a literal force. Murray studied the pathophysiology of fractured nasal bones in fresh cadaver heads. He concluded that 24-50 kilopascals of lateral force results in two fracture lines that run parallel on the ipsilateral thin nasal bone along the dorsum meeting at the junction of the thick and thin bones. In this type of injury the nose may appear deviated, however, it is only an illusion caused by a depression of the unilateral bony fragment. This type of injury carries a good prognosis for restoration and a normal airway. On the other hand, a deviating fracture of the nose occurs with lesser lateral dorce (16-66 kilopascals) and a greater frontal force (114-312 kilopascals) (Fig. 3). A relatively greater force is needed from a frontal impact to produce a fracture because the nasal bones are buttressed by the frontal process of the maxilla, the nasal spine and the perpendicular plate of the ethmoid. The inciting factor leading to the deviation is the combination of fractures to both nasal bones, the cartilaginous, and bony septum. A c-shaped fracture in the septum results in deviation of the nasal bones to greater than one width of the nasal bridge.