Nasal trauma

Definition

Nasal trauma is defined as any injury to the nose or related structure that may result in bleeding, a physical deformity, a decreased ability to breathe normally because of obstruction, or an impaired sense of smell. The injury may be either internal or external.

Description

The human nose is composed of bone, soft tissue, and cartilage. It serves as a passageway for air to flow from the outside environment into the lower respiratory tract and lungs. At the same time the nasal passages warm and humidify the air that enters the body.

Internal injuries to the nose typically occur when a foreign object is placed in the nose or when a person takes in drugs of abuse (inhalants or cocaine) through the nose. External injuries to the nose are usually blunt force injuries related to sports participation, criminal violence, child abuse , or automobile or bicycle accidents. This type of injury may result in a nasal fracture. The nasal bones are the most frequently fractured facial bones due to their position on the face, and they are the third most common type of bone fracture in general after fractures of the wrist and collarbone. A force of only 30 g is required to break the nasal bones, compared to 70 g for the bones in the jaw and 200 g for the bony ridge above the eyes. The pattern of the fracture depends on the direction of the blow to the nose, whether coming from the front, the side, or above the nose. Although not usually life-threatening by itself, a fractured nose may lead to difficulties in breathing as well as facial disfigurement.

Fractures resulting from trauma to the nose may involve the bones of the septum (the partition of bone and cartilage dividing the two nostrils) as well as the bones surrounding the eyes. These bones include the nasal, maxilla, lacrimal, and frontal bones. Direct trauma to the bridge of the nose may also result in damage to a part of the base of the skull known as the cribriform plate. This injury in turn may allow cerebrospinal fluid to leak out of the skull and leave the body through the nose. Fractures may also damage the membranes that line the nasal passages, leading to possible formation of scar tissue, obstruction of the airway, and damage to the child's sense of smell.

In addition to fractures, external injuries of the nose include soft-tissue injuries resulting from bites (human and animal), insect stings , cuts, or scrapes. Penetrating injuries to the nasal area caused by air gun or BB pellets were as of 2004 also reported with increasing frequency in older children and adolescents. When fired at close range, these pellets can penetrate the skin and cheekbone and lodge in the nasal septum or the sinuses near the nose.

Lastly, nose piercing as a fashion trend is a type of intentional injury to the nose that has several possible complications, including infections of the cartilage and soft tissues in the nose; blockage of the airway due to a loosened stud or other nose ornament; and gastrointestinal emergencies caused by accidental swallowing of nose jewelry.

If a patient's nasal trauma leads doctors to suspect child abuse, the incident must be reported to the police.

Demographics

The demographics of nasal trauma vary according to the type of injury. Internal nasal injuries are unusual in infants but occur fairly frequently in toddlers and young children as a result of playfulness or curiosity. Children often insert small hard objects (buttons, coins, watch batteries, dried peas or beans, plastic parts from toys , etc.) in their nostrils. One Japanese study of children brought to the emergency room for removal of foreign bodies from the respiratory and digestive tracts found that the nose was the most common location (39.4% of patients) of these objects. Sixty-seven percent of the children treated were between one and four years of age, with two-year-olds the most common age group. Another common cause of injury to the nasal passages in children is scratching or picking the inside of the nose, often as a reaction to dry and itching nasal membranes during the heating season in colder climates.

In older children and adolescents, however, the single most common cause of internal nasal injuries is inhalant abuse or ingesting cocaine through the nose ("snorting"). Inhalants include such substances as toluene (paint thinner, nail polish remover, rubber cement, airplane glue), butane (lighter fluid, spray paint, room fresheners, hair spray), chlorinated hydrocarbons (dry cleaning fluid, spot removers, typewriter correction fluid), and acetone (rubber cement, permanent markers, nail polish remover). According to the American Academy of Family Practice (AAFP) and the U.S. Department of Health and Human Services, nearly 20 percent of children in the United States have used inhalants at least once by the time they are in eighth grade. The average age of children experimenting with inhalants is 13, with Hispanic and Caucasian youth more likely to abuse these substances than African Americans. With regard to cocaine, figures from the National Institute on Drug Abuse (NIDA) from the late 1990s indicate that that 3.2 percent of all eighth graders in the United States have used cocaine at least once, although young adults between the ages of 18 to 25 are the age group with the highest usage of the drug.

Nose piercing as a fashion statement is most common among adolescents and young adults. One study of undergraduates at a university in upstate New York found that 51 percent had body piercing, with the nose and ears the most common sites. Seventeen percent of these students reported medical complications from the piercing, ranging from skin or cartilage infections to periodic bleeding from the nose. A less common cause of internal injuries to the nose in older children and adolescents is the use of magnetized jewelry as a substitute for body piercing. The external piece of jewelry is held in place on the outside of the nostril by a small magnet placed inside the nose. Displacement of these magnets has been reported to cause bleeding and perforation of the nasal septum, while accidental swallowing of these magnets may require emergency surgery. One British hospital reported no fewer than 24 such cases over an eight-week period.

With regard to nasal fractures, one group of American researchers estimates that they account for about 24 percent of all facial fractures. The most common single cause is assault, accounting for 41 percent of nasal fractures. The second most common cause is automobile accidents (27%), followed by sports injuries (11%). Falls account for most other nasal fractures in children, although dog bites are reported with increasing frequency as a cause of nasal fractures in children below 16 years of age. Adolescents who have had plastic surgery on the nose (rhinoplasty) are at increased risk of nasal fractures in later life.

As many as 10 percent of nasal injuries in younger children, however, result from physical abuse. Doctors in the early 2000s are advised to consider abuse as a possible diagnosis when evaluating nasal fractures in children under six years of age. Suspected child abuse must be reported to police.

Causes and symptoms

Causes

External trauma to the nose may be accidental (transportation accidents, animal bites, air gun injuries, and sports injuries) or intentional (fights, criminal assault, domestic violence, nose piercing). Nasal injuries from athletic activities may result from contact with equipment (being hit in the face by a baseball, hockey ball, or other small ball hit at high speed, or by the bat or stick itself) or the bodies of other players (football, boxing, martial arts, rugby). Nasal injuries from piercing include bacterial infections of the skin and nasal cartilage, allergic reactions to the jewelry, tissue damage, and periodic bleeding. Direct trauma and/or delayed type hypersensitivity reaction to nickel may occur from nasal rings and jewelry, facial adornments which as of 2004 are increasingly popular.

In a few cases, external trauma to the nose may also be iatrogenic, or caused by medical care. Most of these injuries result from medical examination of the nose—particularly in emergency circumstances—or as complications of plastic surgery.

Internal injuries to the nose may be either mechanical (caused by foreign objects in the nose or by picking or scratching the tissues lining the nose) or chemical (caused by environmental irritants or substance abuse).

Chemical injuries to the nose are caused by accidental or purposeful breathing or sniffing of irritating substances. These may include tobacco smoke; household cleaners (ammonia and chlorine bleach) and furniture polish; ozone and other air pollutants; cocaine; and glue, paint thinners, solvents, and similar household products that produce toxic vapors. An increasingly common form of chemical injury to the nasal membranes in toddlers is alkali burns caused by leakage from small batteries placed in the nose. While chemical damage to the nose is usually accidental in younger children, it is more often the result of substance abuse in adolescents. Taking cocaine through the nose ("snorting") or inhalant abuse ("sniffing" or "huffing") are the most common causes of chemical damage to the nose in older children or teenagers.

Symptoms

The symptoms of physical trauma to the nose may include the following:

• flattening or other deformation of the shape of the nose
• infections of the cartilage or soft tissue
• epistaxis, or bleeding from the nose
• crepitus, or the crackling or crunching sound heard when the ends of a fractured bone are rubbed together
• pain and tissue swelling
• airway blockage from bleeding, fluid discharge, or tissue swelling
• rhinitis or inflammation of the mucous membranes lining the nose (In the case of a fracture, rhinitis may lead to increased tear production in the eyes and a runny nose.)
• septal hematoma, a mass of blood from torn tissue that may collect within the cartilage that divides the two nostrils (It may become infected and form an abscess that eventually destroys the cartilage.)
• bruising or discoloration (ecchymosis) of the tissues around the eye
• leakage of cerebrospinal fluid through the nostrils

Chemical trauma to the nose may result in the following:

• runny nose and watering of the eyes
• pain
• loss of the sense of smell
• nasal congestion and sneezing
• reddening and swelling of the mucous membranes lining the nose
• eventual destruction of the cartilage in the nasal septum and the tissues lining the nose

When to call the doctor

Parents should call the doctor at once in the event of a nose injury when the following conditions are apparent:

• The child is bleeding profusely from the nose.
• The child is having difficulty breathing normally.
• The injury involves an air gun, BB gun, or animal or human bites.
• The child is seeing double, has other visual disturbances, or staggers when trying to walk.
• The child's nasal discharge is watery as well as bloody.
• The child is known to have inserted a battery into the nose or to have swallowed such a battery or piece of nose jewelry.
• The child's appearance or behavior suggests inhalant or cocaine abuse. Some danger signals are: a chemical odor on the child's breath; constant runny nose; unusual or excessive use of nose drops or decongestants ; sores inside or around the mouth; stains on the fingernails; dazed appearance; anxiety , sleep disturbances, nausea and vomiting ; slurred speech; visual disturbances; and loss of physical coordination.

Diagnosis

History and physical examination

In many cases the diagnosis of an injury to the child's nose is obvious to the doctor from taking a history, particularly if the parent witnessed the accident or saw the child putting something in his nose. The physical examination depends in part on the history. If the child's nose is bleeding without a history of a fall, blow to the face, or other obvious cause, the doctor gently examines inside the nose with a handheld speculum of the type used to examine the ears, in order to see where the nasal bleeding originates. Bleeding from the lower part of the nose is more common and usually less serious. In most cases the doctor is able to tell whether there is a foreign object in the nose or whether the child has been scratching or picking at the nose. Bleeding from the upper part of the nose closer to the throat is more serious because it can block the airway and because it may indicate that the child has a bleeding disorder rather than a traumatic injury. The doctor may then examine the child's throat for signs of blood from the upper nose trickling down into the throat. He or she will remove any blood clots from the nose with suction.

In the case of a known accident, sports injury, or assault, the doctor begins with the ABCs, which means that he or she will check the child's airway , breathing , and circulation . The doctor will usually have the child sit upright or lie on one side, and will remove blood clots, broken teeth, or other foreign bodies from the nose or throat. He or she will then carry out a systematic examination of the child's face and head. The most common pattern of examination moves from the inside of the nose and mouth to the outside of the face and from the bottom of the face to the top.

The doctor looks for signs of bruising and tissue swelling as well as bleeding and gently palpates, or touches, the various facial bones for movement and stability. If the doctor suspects that the nose itself is fractured, he or she will listen for crepitus when the nose is gently moved and will look for evidence of a dislocated septum or a septal hematoma, which will appear as a bluish bulging mass within the nasal septum. The child's teeth will be examined for looseness, and the muscles and nerves of the face will be evaluated. If there is a discharge from the nose, the doctor will look at it to see whether it contains cerebrospinal fluid, which would indicate damage to the bones of the skull as well as the nasal bones. Lastly, the doctor examines the child's eyes to make sure that the pupils are responding normally to light and that the child is not seeing double or having other visual problems that might indicate nerve damage or damage to the eye itself.

In cases involving animal bites or other tearing or crushing injuries to the skin and external tissues of the nose, the doctor carefully cleanses the broken skin with soap and water or disinfectants such as benzalkonium chloride as well as checks for fractured facial bones.

Many of the early signs of inhalant or cocaine abuse are not specific to these disorders; however, a careful history-taking and examination of the child's eyes, nose, and throat may lead the doctor to ask the child or adolescent appropriate questions about his or her use of inhalants or cocaine.

Imaging studies and laboratory tests

Computed tomography (CT) scans are the type of imaging study most commonly done to evaluate suspected nasal fractures. X-ray studies may be ordered to identify the location of a foreign body if it is metal, such as a pellet from a BB gun or air gun, or to evaluate the nasal area for evidence of repeated fractures when abuse is suspected. A blood test will be performed prior to surgery in order to determine the child's blood type, clotting time, and complete blood count. In some cases the doctor may order a filter paper or glucose content test of nasal secretions to check for the presence of cerebrospinal fluid.

In some cases, the physician may ask the child's parents for photographs taken prior to the injury in order to determine the extent of deformity or other injuries to the nose. Photographs may also be taken for documentation if abuse is suspected and also for documentation of injuries for later plastic surgery.

Drug-specific blood or urine tests may be ordered for children or adolescents suspected of abusing inhalants or cocaine.

Treatment

Timing

Nasal injuries should be treated as promptly as possible to lower risk of infection. If the child has been bitten by an animal, the injury must be cleansed as soon as possible to lower the risk of rabies . Batteries placed in the nose should be removed as soon as possible, preferably within four hours to avoid serious burns from their contents. If a septal hematoma has developed, the doctor must remove it as quickly as possible to prevent infection or eventual death of the tissues in the nasal septum.

Treatment of nasal fractures is best performed during the first three hours after the injury. If this is impossible, management of a nasal fracture should be done within three to seven days. Timing is of utmost importance when treating nasal fractures because delays longer than seven to 10 days may allow the broken bones to set without proper alignment or lead to such complications as scar tissue formation and airway obstruction. Poorly set nasal fractures usually require surgical correction.

Specific procedures

Foreign objects in the nose can be removed by nasal suction in most cases. Most nosebleeds are treated by five to 30 minutes of direct pressure on the nostrils, with the child's head placed in an upright position. The doctor may also pack the child's nose with gauze coated with petroleum jelly. If the bleeding does not stop or if it appears to originate in the upper nose, the doctor will consult a head and neck surgeon or an otolaryngologist for specialized evaluation of the bleeding.

Air gun or BB pellets that have penetrated the nose or nearby sinuses are generally removed with the help of an endoscope, which is a slender tubular instrument that allows the doctor to examine the inside of a body cavity.

Treatment of nasal fractures depends on the extent of the injury; the most difficult fractures to treat are those that involve the nasal septum. The doctor will usually reduce the fracture, which means that he or she will restore the damaged bones to their proper position and alignment. Although local anesthesia is usually sufficient for treating nasal fractures in adults and older teenagers, general anesthesia is usually given when treating these injuries in younger children.

Reductions of nasal fractures may be either open or closed. A closed reduction involves manipulation of the bones without cutting into the overlying skin. This type of reduction is performed for fractures of the nasal bones that are limited in size and complexity. Open reductions are performed for more complex nasal fractures. In an open reduction, the nasal bones are moved back to their original location after the surgeon has made an incision in the overlying skin. This procedure is done for fractures involving dislocation of the septum as well as the nasal bones. In addition, an open reduction is necessary if the child has a septal hematoma or an open fracture in which the skin has been perforated. If a septal hematoma is present, the doctor will drain it and pack the nose to prevent subsequent accumulation of blood. The nasal bones are held in the proper position with external splints as well as the internal packing, and the splints are kept in place for seven to ten days. The child is given antibiotics to lower the risk of infection and may be referred to an otolaryngologist or plastic surgeon for further evaluation. Ice packs or cold compresses can be applied at home to reduce swelling and ease the child's discomfort.

In the case of animal bites, the child may be given passive or active immunization against rabies if there is a chance that the dog or other animal is rabid. This precaution is particularly important for animal bites on the nose or other parts of the face, as the incubation period of the rabies virus is much shorter for bites on the head and neck than for bites elsewhere on the body.

Prognosis

Most types of nasal trauma have a good prognosis. Nosebleeds or tissue damage caused by scratching or picking at the nose usually clear completely once the child stops these habits. Infections or allergic reactions caused by foreign objects in the nose or piercing usually clear up promptly once the object or piece of jewelry is removed. Nasal fractures that do not involve the nasal septum or other facial bones and receive prompt treatment generally heal without deformities of the nose, cartilage destruction, or other complications. More extensive facial fractures, however, may require a second operation to correct the positioning of the bones and restore the appearance of the nose.

The prognosis for soft-tissue injuries to the nose depends on the cause and extent of the injuries. Such tearing or crushing injuries as those caused by bites take longer to heal than simple cuts and may require plastic surgery at a later date to restore the appearance of the nose.

Damage to the tissues lining the nose caused by exposure to tobacco smoke or other irritants in the environment is usually reversible once the child is removed from contact with the irritating substance. Erosion or destruction of the nasal cartilage as a result of inhalant or cocaine abuse, however, usually requires surgical treatment.

Prevention

Preventive strategies for nasal trauma depend on the child's age group. For younger children, parents should take the following precautions:

• Keep such small objects as coins, disk batteries, and buttons in childproof drawers or cabinets and throw out broken toys or toy parts.
• Use a humidifier during heating season to prevent drying and itching of the nasal membranes and coat the inside of the child's nose with petroleum jelly.
• Quit smoking completely or stop smoking inside the house.
• Open windows or otherwise ventilate the room when using ammonia, chlorine bleach, oven cleaner, degreasers, spray paints, dry cleaning fluid, furniture polish, or other household products that give off strong vapors at room temperature. Keep all such products in a childproof cabinet or closet.
• Teach the child basic rules of safety in playing with household pets as well as in dealing with large dogs and other animals outside the house. Have pet dogs or cats immunized against rabies.
• Drive safely and make sure the child is using an age-appropriate protective seat or seat belt.
• Make sure that the child understands basic safety precautions and traffic laws before allowing him or her to ride a bicycle in the street.
• Check the home for safety hazards that might lead to falls (for example, loose carpeting, poorly lit stairwells, and toys allowed to lie on the floor after play).
• Teach the child to deal with quarrels with other children without physical fighting and set the child a good example in relationships with others.

For older children and adolescents, parents should take the following steps:

• Set a good example of safe driving and make sure that teenagers have a mature attitude toward driving before they acquire a driver's license.
• Inform themselves about such problems as drug abuse, bullying, or violence in dating relationships, and learn to identify the signs of these problems in their children.
• Make sure that their child's sports teams use the appropriate safety equipment, that the equipment is in good condition, and that the teams have appropriate adult supervision.
• Discourage the child from nose piercing and similar fads or at least make certain that he or she has the procedure done at a reputable business that follows Food and Drug Administration (FDA) guidelines for cleanliness and sterilization of equipment.
• Teach safe and responsible use of BB guns and air guns.

Parental concerns

Parental concerns regarding nasal trauma depend on the cause and severity of the injury. Minor nosebleeds and uncomplicated fractures of the nose caused by accidents generally heal without problems and are quickly absorbed into the family's routine. Complex fractures or other injuries requiring a second operation may require explanation or discussion with the child. Nasal injuries related to the neighborhood environment (street crime, chemical pollution), lifestyle choices (body piercing, smoking in the home), or family dysfunction (substance abuse, domestic violence), however, suggest the need for professional counseling and changes in the family's structure, geographical location, or increased level of functioning.

Resources

BOOKS

"Fractures of the Nose." Section 7, Chapter 86 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

PERIODICALS

Alvi, A., T. Doherty, and G. Lewen. "Facial Fractures and Concomitant Injuries in Trauma Patients." Laryngoscope 113 (January 2003): 102–6.

Anderson, Carrie E., and Glenn A. Loomis. "Recognition and Prevention of Inhalant Abuse." American Family Physician 68 (September 1, 2003): 869–76.

Brinson, G. M., B. A. Senior, and W. G. Yarbrough. "Endoscopic Management of Retained Airgun Projectiles in the Paranasal Sinuses." Otolaryngology and Head and Neck Surgery 130 (January 2004): 25–30.

Chhetri, Dinesh K., and N. L. Shapiro. "A Case of a BB-Gun Pellet Injury to the Ethmoid Sinus in a Child." Ear, Nose, and Throat Journal 83 (March 2004): 176–80.

Higo, R., et al. "Foreign Bodies in the Aerodigestive Tract in Pediatric Patients." Auris, Nasus, Larynx 30 (December 2003): 397–401.

Karkos, P. D., et al. "Magnetic Nasal Foreign Bodies: A Result of Fashion Mania." International Journal of Pediatric Otorhinolaryngology 67 (December 2003): 1343–45.

Mahajan, M., and N. Shah. "Accidental Lodgment of an Air Gun Pellet in the Maxillary Sinus of a 6-Year-Old Girl: A Case Report." Dental Traumatology 20 (June 2004): 178–80.

Mayers, L. B., et al. "Prevalence of Body Art (Body Piercing and Tattooing) in University Undergraduates and Incidence of Medical Complications." Mayo Clinic Proceedings 77 (January 2002): 29–34.

McCormick, S., et al. "Children and Mini-Magnets: An Almost Fatal Attraction." Emergency Medical Journal 19 (January 2002): 71–3.

Tu, A. H., et al. "Facial Fractures from Dog Bite Injuries." Plastic and Reconstructive Surgery 109 (April 1, 2002): 1259–65.

ORGANIZATIONS

American Academy of Family Physicians (AAFP). 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: http://www.aafp.org.

American Academy of Otolaryngology—Head and Neck Surgery. One Prince Street, Alexandria, VA 22314–3357. Web site: http://www.entnet.org.

American College of Sports Medicine (ACSM). 401 West Michigan Street, Indianapolis, IN 46202–3233. Web site: http://www.acsm.org.

WEB SITES

Gluckman, William, Robert Baricella, and Huma Quraishi. "Epistaxis." eMedicine , January 23, 2004. Available online at http://www.emedicine.com/ped/topic1618.htm (accessed November 12, 2004).

Mayo Clinic Staff. "Tattoos and Piercings: What to Know before You Go under the Needle." MayoClinic.com , June 3, 2004. Available online at http://www.mayoclinic.com/invoke.cfm?objectid=3DC17F76-13E3-499BAE9111954BDFFCA5 (accessed November 12, 2004).

Ross, Adam T., and Daniel G. Becker. "Fractures, Nasal and Septal." eMedicine , July 13, 2004. Available online at http://www.emedicine.com/ent/topic159.htm (accessed November 12, 2004).

Rupp, Timothy J., Marian Bednar, and Stephen Karageanes. "Facial Fractures." eMedicine , August 29, 2004. Available online at http://www.emedicine.com/sports/topic33.htm (accessed November 12, 2004).

Rebecca Frey, PhD