Nasal Injury

Nasal injuries comprise a significant proportion of all ENT referrals. The mechanism of injury varies from sports related accidents to alleged assaults and a high suspicion of concurrent facial fractures is paramount.

 

Clinical findings

 

History of trauma 

Initial epistaxis - vast majority settle with first-aid alone. Rarely, bleeds can be significant and life threatening.

Nasal deformity

Nasal obstruction

CSF rhinorrhoea/otorrhoea - likely base of skull fracture (rare) 

Patients are referred to ENT for two main reasons; 

  1. Nasal deformity 

  2. Septal haematoma 

Nasal manipulation

 

After a nasal injury has occurred the nasal bones can appear deviated. In a short window post injury (approximately 2 weeks) when the bones are still healing, a manipulation can take place to reset the nose in a more cosmetic central position. 

A period of around 4 days is usually allowed to all swelling to reduce.

Nasal manipulation is usually performed under a general anaesthetic, however, it can be achieved under local anaesthetic. Manipulation Under Anaesthetic is a very crude operation in which the nasal bones are pushed back into alignment. MUA only works on bony deviation and has no effect on a deviation of the nasal cartilage. 

 

Manipulation rules:

 

  • If injury < 2 weeks old - Arrange to review the patient in ENT Casualty five days (or as soon as possible thereafter) after the day of the injury. This allows any swelling to adequately reduce and aids analysis of the deviated nasal skeleton

 

  • If Injury > 3 weeks – it is too late to perform an MUA operation. Advise the patient to see their GP in 6 months if they are unhappy with the appearance of the nose. The GP can then refer to OPD for consideration for septorhinoplasty

  • 2- 3 weeks post injury is a grey area

 

For more information on MUA nose, please visit our procedure section.

Septal haematoma

 

The single most important thing to rule out in a nasal injury is a septal haematoma. There is a big medico-legal aspect to this pathology if missed with potentially life threatening sepsis and severe cosmetic and functional sequelae

The septum is partly bone and partly hyaline cartilage. A septal haematoma is a collection of blood or serous fluid between the perichondrium and the cartilage of the nasal septum.

Boggy bilateral septal swelling 

Clinical features (with percentage incidence)

 

  • Recent history of trauma or septal surgery (all cases)

  • Pain (often severe) over the nasal dorsum (50%)

  • Unilateral / Bilateral nasal obstruction (95%)

  • Unilateral/ Bilateral red boggy swelling in the region of the nasal septum. – This is fluctuant when palpated with a probe

  • Rhinorrhea (25%)

  • Septal deviation is usually unilateral and will be hard when probed! A haematoma is soft and boggy

  • Fever (25%)

 

There are two reasons to stress the importance of not missing a septal haematoma:

 

  1. Nasal Septal Abscess. The blood is a potential space for infection. The septum lies in the triangle of danger, an area of the face that drains back into the cavernous sinus via valveless veins. The end product can be an infective venous sinus thrombosis causing marked morbidity or even death.

  2. Septal collapse. Remember the blood supply to the septum is poor and runs in the nasal mucosa. A haematoma can disrupt this blood supply and result in cartilaginous necrosis causing a marked nasal deformity and facial profile collapse. This deformity is colloquially known as a saddle nose deformity.

 

Management of septal haematoma

 

Early treatment is essential to prevent complications

 

  1. Admit. Keep nil by mouth

  2. IV antibiotics and fluids. The septum lies in the danger triangle and potential spread of infection can be catastrophic.

  3. Incision and Drainage, under GA, +/- insertion of a drain. This is performed on the day/night of admission.

  4. The patient should be warned about the possibility of nasal deformity from collapse of the septum, despite I&D.