51 Nasal Trauma

The commonest causes of nasal trauma are assault, road traffic accident and sports injuries. Injury to the nose may result in a combination of soft tissue injury, fracture of the nasal bones, fracture or dislocation of the septum, septal haematoma, cerebrospinal fluid (CSF) leak and facial bone fracture. Evidence shows nasal bone fractures may be mobile up to about 3 weeks’ post-injury and manipulation under anaesthesia (MUA) may be successful up to 27 days post-injury.

51.1 Classification of Fracture of the Nasal Bones

An isolated nasal fracture is usually caused by low-velocity trauma. If the nose is fractured by high-velocity trauma, then facial fractures are often an accompaniment. Nasal fractures are classified on a 1 to 3 scale depending on their severity and extent.

• Class 1 fracture: Usually due to a frontal or frontolateral blow and results in a vertical fracture of the septum (Chevallet’s septal fracture) with a unilateral depressed or displaced distal portion of the nasal bone.

• Class 2 fracture: Nearly always due to lateral trauma and results in a horizontal (Jarjavay’s septal fracture) or C-shaped fracture of the septum involving the perpendicular plate of the ethmoid and the septal cartilage in combination with a fracture of the frontal process of the maxillae. The fracture therefore involves displacement of both nasal bones to the side opposite the blow.

• Class 3 fracture: Indicates that the velocity of the trauma has been even greater and results in a nasal fracture which extends to include the ethmoid labyrinth. The perpendicular plate of the ethmoid rotates backward and the septum concertinas into the face, raising the tip of the nose and revealing the nostrils. There is a marked depression of the nasal bones, which are pushed under the frontal bones, and there is an apparent widening of the space between the eyes (telecanthus).

51.2 Clinical Features

Trauma to the nose may be part of a more extensive injury to the facial skeleton and base of skull. It should be remembered that the most important consideration in maxillofacial injuries is the maintenance of an airway. A history of trauma to the midface accompanied by epistaxis, a noticeable nasal deformity and nasal airway obstruction are the usual complaints. Nasofrontoethmoid fractures may produce symptoms of diplopia and epiphora. It is important to carefully record the time and nature of the trauma, previous episodes of nasal or facial trauma, and whether the nasal deformity is new or old. Trauma to the head and neck should be noted as should any other injuries. Tenderness, periorbital and/or facial haematoma and soft tissue swelling of the nose, face and peri-orbital areas may make the initial assessment difficult. It is appropriate in uncomplicated cases to reassess the patient 5 to 10 days after the injury. The nasal swelling is often accompanied by periorbital and sub-conjunctival ecchymosis.

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