Nasal Injury and Nasal Foreign Bodies

The nasal bones are the most commonly fractured bones of the face as they occupy a prominent, exposed position and have little structural support. They may be undiagnosed.

Changes in appearance and function can be prevented by prompt, appropriate management. Rhinoplasty and septoplasty procedures are often performed to correct untreated fractures.

The nose is close to several important structures. This injury should be regarded as a head injury and a careful search be made for other facial injuries.

Epidemiology

This is more commonly seen in young men aged 15-30 years.¹ There is also a peak in the elderly, secondary to falls.²

Presentation

There is usually evidence of facial trauma. Obvious deformity of the nose may be seen. Other signs may include:

• Swelling
• Skin lacerations
• Crepitus and instability
• Bruising
• Epistaxis and/or cerebrospinal fluid (CSF) rhinorrhoea:
  • Epistaxis implies mucosal disruption which increases suspicion of fracture, including possible nasal septum fracture
  • The typical history of a CSF leak is that of clear, usually unilateral watery discharge

The diagnosis is usually made on clinical findings and does not require an X-ray.³ Plain films are known to miss approx. 50% of fractures.

Refer to ear, nose and throat

• If there is marked deviation.
• Epistaxis that is failing to settle.
• Septal haematoma; this requires incision and drainage to prevent abscess and/or necrosis.
• There is CSF rhinorrhoea; implies breach of the cribriform plate. CT and referral to neurosurgery is required.
• Widening of intercanthal distance suggests nasoethmoidal fracture which requires surgical repair.

Management

Patients with uncomplicated fractures can be:

• Given advice on using ice/simple analgesia. These will decrease the oedema and pain.
• Discharged and reviewed at ear, nose and throat (ENT) clinic in 5 days. Adhesions to the surrounding soft tissue can occur in as few as 5-10 days. Fractured nasal bones usually heal in 2-3 weeks.
• Fracture reduction can be performed when it is possible to assess and manipulate the mobile nasal bones. This is usually within 5-10 days in adults and 3-7 days in children.⁴
• Patients with little swelling may be suitable for immediate reduction.
• Closed reduction is preferred by most surgeons.
• Antibiotics are indicated if there is a laceration overlying the fracture, or if a septal haematoma has been incised.

Most common in pre-school children.
Common foreign bodies (FBs):

• Beads
• Buttons
• Sweets
• Nuts
• Seeds
• Peas

Presentation

• They may present immediately if they are observed.
• There may be a clear history of nasal obstruction.
• They may present late, with a history of a persistent offensive discharge from one nostril.

Refer to ear, nose and throat

• If the foreign body is in a posterior position.⁵
• The patient is very uncooperative or agitated.
• You are not experienced and/or confident.

Management

Before you start, make sure you have the correct equipment and the child is being adequately held, in an accommodating position. Fewer attempts will reduce the anxiety of parent and child.

• Use topical anaesthetic and vasoconstrictor (reduces swelling) spray in the affected nostril
• Blow positive pressure through the nose - preferably by the parent blowing sharply through the child's mouth whilst obstructing unaffected nostril.⁶ This has been shown to be relatively untraumatic, with success rates of 79%.
• Use nasal speculum and a hook or thin forceps, to hold object. Be careful not to push the FB further back.
• Application of strong suction is sometimes sufficient to draw the object out.
• Pass a narrow balloon catheter past the FB, inflate and remove the catheter, pulling the FB with it. The Fogarty is preferred (compared to a Foley) as it is stiffer and stronger.
• Examine for signs of other FB, e.g. nasal, ear, inhaled etc.

Refer to ENT if unsuccessful after 2 attempts.

NB: If the FB is a small button battery, moisture within the cavity may lead to tissue damage. Irrigation or nasal wash should not be used. If the battery leaks, there may be liquefactive necrosis and organ injury. It should be removed immediately.

This is a defect through any portion of the cartilaginous or bony septum, with no overlying mucoperichondrium or mucoperiosteum on either side.

Presentation

This may present with:^7,8

• Nasal whistling sound
• Discharge from the nose
• Nasal congestion
• Infection, e.g. cellulitis, fever, discharge
• Epistaxis

Aetiology

• Traumatic:
  • Nose-picking
  • Trauma
  • Septal haematoma may cause infection and abscess formation ( which may lead to perforation) if not treated promptly.
• Iatrogenic:
  • Septal surgery
  • Nasal intubation
• Inflammation or malignancy:
  • Rodent ulcer
  • Other malignancy
  • Wegener's granuloma, sarcoidosis
  • Infection; tuberculosis, syphilis
• Related to inhalations:
  • Inhalation of chrome or sulphurous salts, mercury or phosphorous
  • Vasoconstrictive nasal sprays
  • Cocaine sniffing

Management

• A fibreoptic endoscope may be necessary to visualise fully the extent and position of the perforation.
• Treatment is symptomatic:
  • Nasal douching with saline helps keep the mucosa moist. This helps reduce crusting and bleeding
  • Nasal emollients, e.g. Bactroban®, can be applied to the inside of the nose before bedtime
• Patients who need oxygen delivered via a nasal cannula, should have the prongs of the cannula positioned so the jet of oxygen is not directed at the nasal septum.
• Surgical closure is difficult.⁹