Assessing Nasal Trauma: What Healthcare Professionals Need to Know

Nasal trauma is a common injury encountered in medical practice, ranging from minor abrasions to severe fractures and deformities. Proper assessment of nasal trauma is crucial, as it can prevent long-term complications such as breathing difficulties, chronic pain, and cosmetic deformities. This guide aims to provide a thorough understanding of how to assess nasal trauma, tailored for medical students and healthcare professionals.

Anatomy of the Nose

Before delving into the assessment of nasal trauma, it's essential to have a solid understanding of the nasal anatomy. The nose consists of both external and internal structures that contribute to its function and appearance.

External Nose:

Nasal Bone: The upper part of the nose is supported by the paired nasal bones, which form the bridge of the nose.

Cartilage: The lower two-thirds of the nose are made up of cartilage, including the upper lateral cartilages and the lower lateral cartilages.

Nasal Septum: This structure divides the nasal cavity into two nostrils and is composed of both bone and cartilage.

Soft Tissue: The skin, muscles, and connective tissue overlay the bony and cartilaginous framework, giving the nose its shape.

Internal Nose:

Nasal Cavity: This is a large air-filled space above and behind the nose in the middle of the face.

Turbinates: These are bony structures inside the nose covered by mucous membrane, which help humidify and filter the air we breathe.

Sinuses: These are air-filled spaces within the bones around the nasal cavity, which include the maxillary, frontal, ethmoid, and sphenoid sinuses.

Understanding these structures is crucial for identifying the specific areas affected by trauma and the potential complications that may arise.

Types of Nasal Trauma

Nasal trauma can vary significantly in severity and can be classified into several types:

Soft Tissue Injuries:

Lacerations: Cuts to the skin or mucosa, often requiring suturing.

Contusions: Bruises without breaking the skin, typically caused by blunt force.

Abrasions: Scrapes or superficial damage to the skin, usually not severe but may lead to scarring.

Fractures:

Nasal Bone Fracture: The most common type of nasal fracture, often resulting from direct trauma. This can cause deformity, swelling, and difficulty breathing.

Septal Fracture: A break in the nasal septum, which can lead to a deviated septum and breathing difficulties.

Complex Fractures: These involve multiple bones, such as the nasal bones, maxilla, and orbital floor, and often require surgical intervention.

Septal Hematoma:

A collection of blood between the septal cartilage and its overlying mucosa, which can lead to cartilage necrosis if not drained promptly.

Deformities:

Deviated Septum: A common result of trauma, where the nasal septum is displaced from its normal position.

Saddle Nose Deformity: A depression in the nasal bridge due to cartilage damage or loss.

Initial Assessment of Nasal Trauma

When assessing a patient with nasal trauma, a systematic approach is essential to ensure that all potential injuries are identified and managed appropriately.

History Taking:

Mechanism of Injury: Understanding how the injury occurred provides insights into the possible types of trauma. For example, a direct blow to the face is more likely to cause fractures, while a fall might result in soft tissue injuries.

Symptoms: Ask the patient about pain, difficulty breathing, nasal obstruction, epistaxis (nosebleed), and any changes in the appearance of the nose.

Previous Nasal Surgery or Trauma: A history of previous nasal issues can complicate the assessment and management of the current injury.

Physical Examination:

Inspection: Begin by visually inspecting the nose for asymmetry, swelling, bruising, lacerations, and any obvious deformities. Look for signs of septal hematoma, such as a blueish or swollen appearance of the nasal septum.

Palpation: Gently palpate the nasal bones and surrounding structures for tenderness, crepitus (a crackling sound indicating a fracture), and step-offs (a palpable discontinuity in the bone).

Intranasal Examination: Use a nasal speculum and a good light source to examine the nasal cavity. Look for septal deviations, hematomas, and mucosal tears. Check for any foreign bodies that may have entered the nasal cavity during the trauma.

Imaging:

X-rays: While nasal fractures are often diagnosed clinically, X-rays can help confirm the diagnosis, particularly in complex fractures. A Waters view or lateral view is commonly used.

CT Scan: For more severe trauma, a CT scan provides a detailed view of the nasal bones, septum, and surrounding structures. It is particularly useful in assessing complex fractures and associated injuries such as orbital fractures.

Special Considerations:

Airway Management: Ensure the patient’s airway is not compromised. In severe nasal trauma, swelling can obstruct the nasal passages, making breathing difficult. Be prepared to manage airway emergencies, including intubation if necessary.

Cervical Spine Precautions: In cases of significant facial trauma, always consider the possibility of cervical spine injury, especially if the trauma involved a high-energy mechanism like a motor vehicle accident. Immobilize the cervical spine until cleared by appropriate imaging.

Management of Nasal Trauma

The management of nasal trauma depends on the severity and type of injury. The goal is to restore function and appearance while preventing complications.

Initial Management:

Control of Epistaxis: Nosebleeds are common in nasal trauma. Apply direct pressure by pinching the nostrils together for 10-15 minutes. If bleeding persists, consider using nasal packing or topical vasoconstrictors like oxymetazoline.

Ice Application: Apply ice packs to reduce swelling and pain. Ice should be applied intermittently, 20 minutes on and 20 minutes off.

Pain Management: Administer analgesics as needed. NSAIDs are commonly used, but avoid them if there's a risk of exacerbating bleeding.

Wound Care: Clean any lacerations with saline or antiseptic solution. Suturing may be required for larger lacerations.

Reduction of Nasal Fractures:

Closed Reduction: For uncomplicated nasal fractures without significant displacement, closed reduction can be performed within the first 7-10 days post-injury. This involves realigning the bones manually, often under local or general anesthesia.

Open Reduction: In cases of severe or complex fractures, open reduction may be necessary. This involves surgically exposing the bones and repositioning them, often with the aid of internal fixation devices.

Management of Septal Hematoma:

Drainage: A septal hematoma should be drained promptly to prevent cartilage necrosis and subsequent deformity. This is typically done under local anesthesia, followed by nasal packing to prevent reaccumulation of blood.

Antibiotics: Prescribe antibiotics to prevent infection, as septal hematomas are prone to becoming infected and leading to abscess formation.

Management of Nasal Deformities:

Deviated Septum: If the septum is deviated and causing symptoms like nasal obstruction, a septoplasty may be indicated. This procedure involves straightening the septum to improve airflow.

Cosmetic Concerns: For patients concerned about the cosmetic appearance of their nose post-injury, a referral to a plastic surgeon or ENT specialist may be necessary for rhinoplasty.

Follow-Up Care:

Monitoring for Complications: Patients should be monitored for complications such as infection, persistent deformity, or chronic nasal obstruction. Regular follow-up visits are essential.

Rehabilitation: In cases where nasal trauma has affected the patient’s breathing or caused significant cosmetic deformity, physical therapy and psychological support may be necessary.

Complications of Nasal Trauma

Nasal trauma can lead to several complications if not managed appropriately:

Chronic Nasal Obstruction:

Persistent nasal obstruction may result from untreated septal deviations or unresolved fractures. This can lead to chronic breathing difficulties and an increased risk of sinus infections.

Infection:

Infections can occur if wounds are not properly cleaned and treated or if a septal hematoma is not drained. Infected hematomas can lead to abscess formation and cartilage destruction.

Cosmetic Deformity:

Even with proper management, some patients may develop cosmetic deformities such as a crooked nose or saddle nose deformity. These often require surgical correction.

Sleep Apnea:

Severe nasal trauma that leads to significant airway obstruction can contribute to the development or worsening of obstructive sleep apnea.

Psychological Impact:

The psychological impact of nasal trauma should not be underestimated, particularly if the patient experiences significant changes in their appearance. Counseling and support may be necessary.

Conclusion

Assessing and managing nasal trauma requires a thorough understanding of nasal anatomy, a systematic approach to evaluation, and appropriate management strategies to prevent complications. By following these guidelines, healthcare professionals can ensure that patients with nasal trauma receive the best possible care, minimizing the risk of long-term issues and ensuring optimal outcomes.