The nose is the most commonly traumatised structure on
the face due to its prominence.
A nasal septal hematoma
is a feared complication that should be picked up as soon
as possible, and the hematoma should be evacuated
within 12 hours due to the potential of septal cartilage
necrosis. Nasal septal cartilage necrosis can result in
a saddle nose deformity with nasal obstruction. Nasal
trauma can also result in a nasal fracture with resultant
nasal obstruction and/or cosmetic deficits such as a
saddle or crooked nose.
The critical window for a closed nasal reduction for
treatment of nasal fracture is before two weeks in adults
and before one week in pediatric patients. The treatment
for persistent nasal deformities beyond one month after
injury may require a functional septorhinoplasty.
The nose is frequently
traumatised in facial injuries
and this often results from
motor vehicle accidents, sportsrelated
injuries and altercations.
When the injury is significant, this
can result in nasal fractures with its
accompanying nasal deformity.
There are two main problems that
nasal trauma can result in: a nasal
septal hematoma or nasal fracture
with nasal obstruction or nasal
deformities.
Nasal Septal
Hematoma
A nasal septal hematoma is one of
the most feared complications that
can occur through nasal trauma.
Though uncommon, a septal
hematoma can lead to
complications such as septal
abscess, septal perforation and
cartilage necrosis with potential
saddle nose deformity.
A nasal septal hematoma can
usually be diagnosed with a careful
clinical examination, using a good
light source with a nasal speculum.
If a fluctuant reddish-blue swelling
is noted on the anterior part of the
nasal septum, drainage of the
hematoma should be performed
urgently to prevent complications
as mentioned above.
Nasal Fracture
A nasal fracture can be diagnosed
clinically if there is gross deviation
of the nose from its pre-injury
appearance. An x-ray, though
frequently performed may not
always be necessary as it does not
change the management.
You may apply the following first aid
measures when a nasal fracture is
diagnosed.
- If the nose is bleeding, apply
digital pressure over the lower
half of the soft fleshy part of the
nose for 15 minutes to slow down
bleeding.
- The head should be tilted
forward during this time to
prevent aspiration of the blood
into the lungs.
- Place ice wrapped in a cloth or a
bag of frozen peas over the nose
for about 15 minutes at a time.
This process can be repeated
hourly throughout the day. Using
ice packs at the time of injury
and for one to two days
afterward helps to reduce pain,
swelling and nose bleeds. Take
breaks between applications and
do not apply the ice directly to
the skin.
- Take paracetamol or nonsteroidal
anti-inflammatory drugs
(NSAIDs) to reduce pain. The pain
is usually worse in the first five
days after the injury.
- Nasal decongestants such as
oxymetazoline can be used to
help with the nasal obstruction.
However, these should not be
used beyond five days.
- Elevate the head, especially
when sleeping, to avoid increased
swelling of the nose. Prop the
head up with pillows or lift the
head of the bed by placing large
blocks or phone books under the
mattress.
A closed nasal reduction can be
attempted within three hours of
injury, before swelling sets in or
between three to fourteen days when the swelling has improved.
This helps in the evaluation of the
precise nasal deformity that the
patient is suffering from. This
procedure can be performed under
local anaesthesia and is usually
painless.
A satisfying “click” can usually be
felt or even heard when the nasal
fracture is pushed back in place
(Refer to Figure 1). There is usually
increased swelling over the nose
and some periorbital bruising may
sometimes occur post nasal
reduction. Small amounts of nose
bleeding is usually expected in the
first 48 hours after a nasal
reduction. A nasal cast is usually
applied over the next week to
protect the reduced nasal
fragments. It is important that the
patient avoids all contact sports
(e.g. basketball, football) for the
next six weeks following a closed nasal reduction, till the nasal
fragments are healed in place.
Nasal Deformities
Subsequently, post-traumatic nasal
deformity is one of the most
common reasons that patients seek
consultation in the doctor’s clinic.
Depending on the type of nasal
deformity, this can result in
functional impairment and aesthetic
problems.
Two challenging problems
to be addressed in the posttraumatic
nose are the crooked
nose and saddle nose deformities.
The only definitive treatment for
these conditions would be a
functional septorhinoplasty, if it
continues to trouble the patient.
Dr Chua Yu Kim,
Dennis
Dr Dennis Chua is an
Associate Consultant
in the Department of
Otorhinolaryngology
(ENT) in Tan Tock Seng
Hospital. He completed
his subspecialty in
facial plastic surgery
at the University of Virginia, United States
of America (USA) in 2013. He is passionate
about research and has presented in
conferences globally. Besides having
published in international peer reviewed
journals, he also co-authored book chapters
on functional nasal surgery and facial
trauma.