In an adult, it’s easy to diagnose a nasal fracture when the nose is “bent out of shape”. However, a broken nose in an uncooperative child with swelling around the nose and face can go undiagnosed. Unrecognized nasal fractures can have serious consequences.
Causes
- Falls
- Motor vehicle accidents
- Physical altercations
- Sports accidents
Nasal fractures result from a direct blow to the nose. The causes of the fractures vary with the age of the patient. In toddlers, falling down and hitting their nose is a common reason for the fracture. As the child gets older (children 5 years of age or older), motor vehicle accidents are implicated and during the teenage years, physical altercations and sports accidents play a prominent role.
Signs & symptoms
- Pain-tenderness
- Swelling-bruising
- Bleeding-epistaxis
- Difficulty breathing
- Septal deformity
- Septal hematoma
- CSF Leak-fluid leaking through the nose from the brain
- Other facial fractures
- Loss of the sense of smell
The initial complaints often consist of pain, swelling and bruising of the nose, as well as, involving the area under the eyes with or without nasal bleeding.
The septum is a partition that separates the right nostril from the left and is made up of cartilage and bone. If there is a strong blow to the nose, the septum may be bent or fractured causing bleeding, nasal obstruction, or a “blood blister” on the inside of the nose (septal hematoma)…
Such severe trauma may also fracture the eye socket, cheek bone or jaw bone. Attention must also be given to the possibility of injury to the cervical spine (neck).
CSF leak (Cerebrospinal Fluid) is a watery-like fluid dripping through the nose that comes from the fluid that surrounds the brain. It happens in severe facial trauma and is a worrisome complication that is readily diagnosed when the suspicion is high.
Treatment
- Give pain medication
- Treat the edema – the swelling of nose and face
- Use sedation or general anesthesia for diagnosis and treatment if needed
- Control bleeding
- Maintain adequate airway
- Correct nasal deformity
- Drain septal hematoma
- Prevent shock
- Avoid damaging facial growth centers
- Obtain Neurosurgical consultation for CSF leak
The treatment depends on the age of the patient and the severity of the injury. The majority of nasal fractures can be managed conservatively. In uncomplicated nasal fractures, image studies (X-rays) are not helpful. At times, acetaminophen (Tylenol) for pain and ice placed over the swollen nose is all that’s needed.
If there is an uncomplicated nasal deformity — with appropriate sedation — a closed reduction is carried out (using an instrument, the displaced nasal bone or cartilage is ‘popped back’ into a normal position). There is no cutting of the nasal tissue. On the other hand, if surgery is required, care is needed so as not to interfere with the immature child’s growth centers.
Major concerns of clinicians in facial trauma patients — aside from relieving pain — are to maintain an adequate airway, control bleeding and prevent shock. Some refer to these concerns as the ABC’s of trauma patients: Airway (breathing), bleeding and circulation.
Once the ABC’s are stabilized, examination of the nose in a child, using sedation or general anesthesia, may reveal a septal hematoma. If present, immediate drainage of the hematoma is done to prevent erosion of the nasal cartilage, nasal deformity and damage to the growth centers. A deviated septum and nasal fracture are carefully manipulated back to their normal, original position,
SUMMARY
Most of the nasal fractures in children and adolescents can be managed conservatively. The immature nose has more nasal cartilage and possesses specific facial centers for bone growth Clinicians should be careful to do as little manipulation as possible of the nasal bones and septum in children and teenagers with nasal fractures to minimize interference with the facial growth centers.
The purpose of this article is to familiarize the parent with nasal fractures. If your child has some of the signs or symptoms as noted above, do not hesitate to see your physician or go to the emergency room.
References
- Nasal-Septal Fracture. Herve’ J. LeBoeuf, MD, Francis B. Quinn, MD. UTMB (University of Texas Branch)
- “Clinical Experience” — garnered from many years of direct patient care.