20 Multiple Nasal Injuries
Multiple injuries to the nose create a special set of tissue circumstances involving the postoperative consolidation of fractures in a more or less optimal position, the presence of organized hematomas, and periosteum that is thickened and obliterated due to scarring. 1 These changes are typical of injuries sustained in contact sports such as boxing, ball sports, and ice hockey, which typically lead to repetitive trauma that includes fractures of the nasal bones and cartilage. The surgical correction of these noses follows special laws that relate to problems of tissue memory. Emphasis is placed upon wide undermining of the soft-tissue envelope with the division of adhesions and the resection of excess scar tissue. Posttraumatic humps should be removed in continuity with the periosteum, which is fixed by scar tissue and generally cannot be dissected. Low lateral osteotomies may provide definitive closure of an open roof. If this is unsuccessful, the use of extended spreader grafts or closure with fascia lata or a cartilaginous onlay graft is indicated. Fig. 20.1 illustrates the pathogenic mechanism of a posttraumatic periosteal reaction with the formation of a typical hump.
Case 19
Introduction
A 22-year-old man sustained multiple nasal injuries resulting in a posttraumatic nasal hump and deviated septum.
Findings
Frontal view ( Fig. 20.2a ) shows a posttraumatic hump with asymmetric widening of the nasal pyramid. Profile view ( Fig. 20.2b ) and three-quarter view ( Fig. 20.2c ) show a bony dorsal hump.
Fig. 20.2d , Fig. 20.2e , and Fig. 20.2f show corresponding views taken 2 years after revision surgery.
Surgical Procedure
The deviated septum was removed through a hemitransfixion incision and straightened extracorporeally. The straight neoseptum was then reimplanted along with spreader grafts. The dorsal hump was removed en bloc, and medial and lateral curved osteotomies were performed ( Fig. 20.2g ).
Psychology, Motivation, Personal Background
Nasal airway obstruction can be a serious handicap, especially in competitive sports. Nasal bone fractures are a frequent occurrence in contact sports such as ice hockey, ball sports, boxing, and judo. The old maxim that a boxer′s nose should be straightened only after retirement cannot be consistently followed. Repetitive trauma, dislocations, or posttraumatic epistaxis will often necessitate surgical intervention.
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