All head and neck trauma cases should initially be evaluated and managed as closed head injuries. The head and neck has a very rich blood supply and consequently brisk bleeding is often present but this should not distract from prompt, systematic evaluation of the patient. Swift assessment of the airway, breathing, circulation and cervical spine is imperative. A thorough systematic secondary survey is also essential.

Nasal Trauma

The nose is particularly prone to injury as a result of its prominent central location and the low tensile strength of its skeleton (Figure 18.1). A combination of soft tissue injury, nasal bone fracture, septal deviation/fracture/haematoma or cerebrospinal fluid (CSF) leak may occur. Typical symptoms of nasal injury include:

• Epistaxis (nose bleed)
  
• Noticeable cosmetic deformity
  
• Nasal airway compromise.

Peri-orbital and subconjunctival bruising (ecchymosis) may also be present. Nasal trauma often occurs in conjunction with other maxillofacial injuries and these need to be carefully excluded.

It is important to note the nature of the injury and any previous history of trauma or nasal deformity. The nasal septum should be assessed for any obvious deformity or a septal haematoma. Unless seen almost immediately after the trauma, soft tissue swelling and tenderness makes clinical assessment challenging. In uncomplicated cases, it is advisable to reassess the patient in 5–7 days following the injury, allowing time for the bruising and swelling to subside. Radiological investigations have no role in uncomplicated nasal injuries, but may be useful in the presence of other maxillofacial injuries.

Management is dependent on the nature and extent of injury.

Soft Tissue Injuries

Wounds should be débrided and cleaned. Abrasions are best left open to heal and simple steristrips may be used to close small lacerations. Larger wounds should be sutured. Tetanus immunisation status needs to be ascertained and cover ensured in the presence of an open wound.

Epistaxis

Epistaxis is common with nasal injuries. Most cases resolve with conservative measures and application of direct pressure. If there is a nasal fracture, closed fracture reduction may be needed to stop the bleeding. In persistent cases nasal packing may be needed to arrest the bleeding.

Nasal Bone Fracture

Uncomplicated fractures without a cosmetic or functional problem only require simple reassurance and no intervention. With simple displaced fractures (Figure 18.2) closed reduction under local or general anaesthetic may be required. Fracture reduction should be carried out either immediately after the injury (before marked soft tissue swelling sets in) or 5–7 days after the injury (to allow distortion due to swelling to resolve).

After 2 weeks the fractured bones start to fix. Fracture reduction after this period can be very difficult if not impossible. Such delays should therefore be avoided. Open fractures may necessitate general anaesthesia and open reduction. If there is malunion of nasal bones a formal septorhinoplasty procedure may be needed.

Septal Haematoma

Haematoma (unilateral or bilateral) formation under the perichondrium separates the perichondrium from the septal cartilage (Figure 18.3). Septal cartilage relies on the perichondrium for blood supply. If the haematoma is left untreated for more than 48 hours cartilage necrosis occurs.

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