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On-Site Management of Nasal Injuries

Thomas Stackhouse, MD

Emergencies Series Editor: Warren B. Howe, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 8 - AUGUST 2021


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In Brief: The on-site sports medicine physician must determine when nasal injuries can be treated at the site and when they must be referred. Conditions indicating referral include high-speed impact, loss of consciousness, associated facial injuries, and septal hematoma. Knowing the mechanism of injury is important; for example, inferior blows are likely to cause septal fracture, whereas lateral blows frequently result in displaced nasal bones. The physical exam includes careful inspection and palpation of surrounding structures as well as an intranasal exam. When the history and exam are benign, ice, elevation, topical decongestants, and a second exam in 1 to 2 days are the treatment of choice. Epistaxis must also be controlled.

Primary care physicians need to feel comfortable assessing patients who sustain blunt nasal trauma, one of the more common sports injuries. While nasal injuries caused by motor vehicle accidents are often associated with significant midfacial, central nervous system, or ophthalmologic pathology, sports-related nasal injuries are usually isolated and rarely constitute an emergency. The primary physician with a good understanding of normal nasal anatomy and function may effectively evaluate and treat many of these patients.

Initial Exam

The sports physician must recognize when nasal trauma necessitates urgent referral (figure 1: not shown). Any trauma associated with a worrisome mechanism of injury, such as high-velocity impact in baseball or bicycling, should prompt referral. Nasal trauma associated with a loss of consciousness, vision problems or extensive periorbital swelling, occlusal abnormalities, or facial paresthesias (infraorbital nerve damage) also justifies an emergency room evaluation and otolaryngology consultation. Persistent brisk epistaxis despite pressure, elevation, and nasal decongestants also will require further urgent care (see "Pinpointing and Controlling Epistaxis," below). Finally, an intranasal examination revealing a possible septal hematoma should prompt early otolaryngology referral, as well.

More common, and perhaps more challenging, are situations that involve significant nasal trauma but no obvious need for an urgent referral. Appropriate management is greatly facilitated by first obtaining an accurate history.

The mechanism of injury, including both the direction of the blow and its intensity, will guide the subsequent examination. Inferior blows to the cartilaginous vault (the lower two-thirds of the nose) are more likely to cause septal fractures and dislocations, while lateral blows frequently result in displaced nasal bones (upper one-third). If the lateral blow is moderate, a unilateral depressed nasal bone is common. Occasionally, a severe blow will displace the entire nasal pyramid to one side.

Frontal injuries to the bony dorsum from typical sports activity will rarely result in a fracture that requires surgical management. However, intense frontal trauma, possibly as a result of a baseball incident, can result in extensive fractures of the nasoethmoid complex and cause a depressed, widened nasal bridge. These patients often have significant midfacial injury, including possible cribriform plate fracture with cerebrospinal fluid leakage (1).

Determining the extent of damage requires careful evaluation of the external nasal anatomy, intranasal structures, orbital and periorbital area, maxilla, and oral cavity. Inspection with palpation as tolerated will help localize the pathology. Findings need to be interpreted with an understanding of the preinjury anatomy and function. This can be achieved by asking the patient and others present whether the nasal appearance has changed, and by questioning the patient about the quality of the nasal airway preinjury versus postinjury.

Simple identification of a nasal fracture is not the goal of the diagnostic workup. Evaluation is aimed at identifying a clinically significant nasal injury and treating it appropriately. Clinically significant findings include any injury that the patient feels has altered the nasal appearance or function and has persisted beyond the expected resolution of the early nasal swelling and congestion complaints.

Intranasal Exam

The intranasal exam is sometimes difficult for physicians without detailed training. In addition, examination within hours of the injury may be compounded by persistent bleeding and/or swelling. Topical decongestants, appropriate lighting, a nasal speculum, and a Frazier suction tip for blood removal are necessary for a thorough exam. However, these aren't usually needed to rule out a septal hematoma if one is comfortable with the variations in normal nasal anatomy as identified on anterior rhinoscopy.

Labeling an enlarged inferior turbinate as a polyp or septal hematoma probably occurs when the speculum does not penetrate adequately into the nasal vestibule. An otoscope can substitute for a nasal speculum, but the speculum of the otoscope must be placed fully into the vestibule with its tip beyond the nasal vestibule to visualize the anterior septum. The physician must identify the septum and inferior turbinate as separate structures that can sometimes be juxtaposed. This will help ensure that he or she has a good grasp of the anatomy and help prevent erroneous interpretations.

A septal hematoma should be suspected if the septum is bulging into the nasal cavity (figure 2). Palpation is frequently required to differentiate a deviated septum from a soft, fluctuant hematoma. Hematomas can be unilateral or bilateral and are more commonly associated with inferior blows involving the cartilaginous vault. Drainage and anterior packing by an otolaryngologist are usually required to ensure adequate blood supply to the septum and prevent subsequent abscess and quadrangular cartilage necrosis (saddle deformity).

[FIGURE 2]

Radiographs of the nasal bones are not helpful and should be obtained only if needed for potential legal issues and documentation (2-5). These films are often difficult to interpret because of suture lines and possible prior trauma. Facial computed tomography is often necessary to identify orbital fractures and should be obtained when the patient has signs or symptoms suggesting a more complex midfacial injury, such as paresthesias, prominent periorbital swelling, or vision complaints.

Primary Treatment

When the history and exam are benign, it is almost never wrong to treat the patient with ice, elevation, and topical decongestants and to repeat the examination in 1 or 2 days. Applying topical decongestants every 10 to 30 minutes is acceptable early treatment for bleeding and preferred initially over hemostatic surgical packing. Systemic antibiotics are required if packing is placed or an associated nasal laceration (open fracture) is repaired.

Most lacerations over the nasal dorsum can be repaired by the primary physician using a 5-0 or 6-0 slowly absorbable suture such as PDS II (Ethicon, Inc, Somerville, NJ) for the dermal layer and a 6-0 nonabsorbable stitch for the skin. Soft-tissue injury to the nasal tip, ala, or columella may require closure by an otolaryngologist because minor defects can create relatively major deformities. Removal of dried blood is important to ensure identification of all such soft-tissue defects.

Otolaryngology Referral

The otolaryngologist should be notified as soon as a clinically significant injury has been documented. Most head and neck surgeons will prefer to evaluate nonemergencies within 2 to 5 days after the injury, when swelling has improved. Procedures are optimally done within 5 to 10 days when fractures are still easily amenable to closed reduction. Immediate surgical treatment in the emergency room or office setting is typically not optimal because of bleeding, swelling, and patient anxiety and discomfort.

Closed fracture reduction yields acceptable functional and cosmetic results in over 70% to 80% of patients (6,7). It is the treatment of choice for an acute, uncomplicated, displaced fracture of the nasal bones. Occasionally, an intranasal gauze or surgical hemostatic packing will be needed for several days to treat epistaxis and prevent recurrent prolapse of the nasal bone.

Persistent functional or cosmetic problems may require open reduction under general anesthesia. Open reduction, which involves intranasal incisions along the bony pyramid and septum, allows for more aggressive direct manipulation of the displaced nasal bones and septal injury. Open reduction is needed for more complex acute injuries and when surgical repair of simple fractures has been delayed beyond several weeks.

Minimizing Sequelae

The consequences of a delayed or missed diagnosis will vary depending on the nature of the injury. A simple nasal fracture that has subsequently healed in a displaced location will require an open procedure (rebreaking of the bones). More problematic would be delayed repair of a significant orbital wall injury that could lead to troublesome diplopia and the need for oculoplastic surgery.

The consequences of an untreated septal hematoma, as stated earlier, may include cartilage necrosis and septal destruction. Subsequent nasal obstruction and associated external depression of the nasal dorsum (saddle deformity) can be difficult to correct. Fortunately, hematomas of the septum are rare and relatively easy to diagnose on anterior rhinoscopy and palpation.

References

  1. Colton JJ, Beekhuis GJ: Management of nasal fractures. Otolaryngol Clin North Am 120216;19(1):73-85
  2. Renner GJ: Management of nasal fractures. Otolaryngol Clin North Am 1991;24(1):195-213
  3. Martinez SA: Nasal fractures: what to do for a successful outcome. Postgrad Med 120217;82(8):71-77
  4. Nigam A, Goni A, Benjamin A, et al: The value of radiographs in the management of the fractured nose. Arch Emerg Med 1993;10(4):293-297
  5. Illum P: Legal aspects in nasal fractures. Rhinology 1991;29(4):263-266
  6. Owen GO, Parker AJ, Watson DJ: Fractured-nose reduction under local anaesthesia: is it acceptable to the patient? Rhinology 1992;30(2):89-96
  7. Illum P: Long-term results after treatment of nasal fractures. J Laryngol Otol 120216;100(3):273-277


Pinpointing and Controlling Epistaxis

Traumatic epistaxis is often an indication of a cartilaginous or bony fracture with mucosal disruption and typically will resolve with ice, elevation, and topical decongestants. Packing with tampons (figure A) or gauze is acceptable but should be a last resort because of its associated morbidity: Placement of a good pack is painful, and as a foreign body the tampon continues to be a source of discomfort, as well as potential infection, until it is removed in 3 to 4 days.

[FIGURE A]

In fact, patients who require packing should probably see an otolaryngologist within 24 hours for further evaluation. More often than not, hemostasis will be effected or sustained without the need for long-term packing.

In nontraumatic epistaxis evaluated in the office, identification of the source of bleeding is critical and requires a nasal speculum, headlight, and Frazier suction tip. After blood clots have been completely removed, it is usually possible to identify an anterior source, which is almost always on the septum. Silver nitrate cautery should be attempted but may not work for prominent arterial problems. A nasal tampon can then be used for hemostasis until electrocautery is available from an otolaryngologist.

Nontraumatic epistaxis evaluated at the sport site is treated with topical decongestants and local pressure (squeezing the nostrils together) for 15 minutes, repeating as necessary.

If the source of the bleeding appears to be the posterior half of the nasal cavity (which is the case in about 10% of patients who have nontraumatic epistaxis), it probably stems from the sphenopalatine arterial system. This is called posterior epistaxis and is best treated with topical decongestants because direct cautery or packing is very difficult to do effectively. Hemostasis is almost always achieved if the clot is first removed and then the patient sniffs oxymetazoline hydrochloride until he or she can expectorate it from the back of the throat. This process is repeated until hemostasis is achieved. Bleeding that persists beyond 10 to 20 minutes of therapy may require a posterior pack and/or surgery.

Subsequent hemostasis is then usually ensured by having the patient follow a prophylactic schedule of low-dose topical decongestant application over the next 3 to 4 days (table A). Activities such as bending, blowing, and straining should be limited. Obviously, the patient's concomitant medical problems such as hypertension or coagulopathy need to be addressed, as well.

Table A. Schedule for Applying Topical Decongestant in Posterior Epistaxis

DayFrequency*
1Every 2-3 hr
2Every 3-4 hr
3Every 4-6 hr

*Around-the-clock application of low-dose oxymetazoline hydrochloride 0.05%.


Dr Stackhouse is an otolaryngologist in private practice in Bellingham, Washington. He is a diplomate of the American Board of Otolaryngology-Head and Neck Surgery. Dr Howe is the team physician at Western Washington University in Bellingham and an editorial board member of The Physician and Sportsmedicine. Address correspondence to Thomas Stackhouse, MD, 2940 Squalicum Pkwy, Suite 203, Bellingham, WA 2021225.


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