Nasal Trauma

NASAL TRAUMA

Introduction

Nasal trauma is the most common facial traumas. 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. The position of nose makes nasal bones, cartilage, and soft tissue particularly vulnerable to external injuries. Nose has many blood vessels positioned close to the surface. As a result, nasal trauma often results in nosebleeds. 

Types of nasal trauma

Common types of nasal trauma include:

- Epistaxis

· Nasal fractures

· Chemical irritation or injuries inside the nose

· Obstruction by a foreign object

· Nasal septal hematoma

Causes

External nasal trauma can occur when force is exerted on nose. Common causes of external nasal trauma include:

- falls

- sports injuries

- motor vehicle accidents

- physical assault or abuse

Internal nasal trauma can occur when the cartilage or the blood vessels inside the nose get damaged. Common causes of internal nasal trauma include:

- infections from nasal piercings

- irritation caused by inhaling certain substances

- sniffing cocaine or other illegal drugs

- picking or scratching inside the nose

- getting a foreign object lodged in nose

Clinical manifestations

Symptoms of nasal trauma can range from mild to severe, depending on the type and extent of injury.

 

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 
•  septal hematoma, a mass of blood from torn tissue 
•  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 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

Diagnosis

• History : Important features to note are mechanism of injury, timing of injury, patient age, previous nasal procedures, trauma, ENT problems and use of intranasal decongestant or steroids.
• Examination : This should start distally and move proximally. Important features to note are significant rhinorrhoea (evaluate for a CSF leak) or haemorrhage. Check for other clinical features.
• Imaging : X-ray and CT scan can be done to evaluate suspected nasal fractures. X-ray studies may be ordered to identify the location of a foreign body if it is metal.

Management

Treatment plan will vary, depending on the type and severity of nasal trauma. Minor cases of nasal trauma can be treated at home, using basic first aid and home care strategies. 

First aid treatment

· To treat minor nosebleeds:

- Sit upright and lean forward to reduce blood pressure in nose.

- Pinch both nostrils shut at the soft portion of nose for 5 to 15 minutes.

- While completing these steps, breathe through mouth and keep head higher than heart.

- Refrain from picking or blowing nose for several hours afterward.

· Apply ice for 10 to 20 minutes at a time throughout the day for the first few days after injury. Wrap the ice in a thin cloth or towel to protect skin from frostbite.

· Take anti-inflammatory pain relievers, such as ibuprofen.

· Sleep with head raised to reduce pain and swelling.

· Contact the doctor, if nasal fracture or foreign object is suspected. 

Cauterization or packing

If nasal bleeding that lasts longer than 20 minutes or recurs frequently, contact doctor. Two common treatments of nosebleeds are nasal packing and cauterization. In packing, doctor will place gauze or an inflatable balloon inside one or both nostrils to exert pressure on the broken blood vessels in order to stop bleeding. In other cases, they may use cauterization to stop nosebleeds. In this procedure, they apply either a topical medication to the broken blood vessels or use a heating device to seal them closed. 

Medications

· Painkillers to ease discomfort

· Antibiotics to treat infections

· Nasal sprays to reduce irritation

Surgeries

· In most cases, foreign objects in the nose can be removed by nasal suction or removed with the help of an endoscope.

· In case of nasal fracture

- 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.

- Patients with little swelling may be suitable for immediate reduction.

- In some cases, reconstructive surgery may require to repair a nasal fracture.

· If septal hematoma is present, the doctor will drain it and pack the nose to prevent subsequent accumulation of blood.

Nursing management

· Reassure the patient to reduce anxiety and promote compliance.

· Determine the severity of the nasal airway obstruction; a patient with a blocked nasal airway needs humidification, oral hygiene, and other comfort measures.

· Keep the patient’s head elevated 30 degrees to promote drainage, reduce edema, and maintain a patent airway.

· If a nasal fracture has occurred, head of bed should be raised to promote drainage, lessen edema and make patient more comfortable.

· Watch for nasal bleeding and frequent swallowing; inspect the pharynx with a penlight if bleeding is suspected; keep emergency suction equipment at the patient’s bed side.

· Check vital signs and airway frequently to ensure that the packing hasn’t slipped posteriorly, which could block the oral airway.

· Encourage the patient to expectorate oral secretions; record the amount and describe the secretions.

· Provide comfort measures, and administer analgesics, as needed, to decrease pain and promote participation in care.

· Uses a face tent to provide humidified air, and frequently perform oral hygiene measures; because air breathed in through the mouth isn’t humidified like air breathed in through the nose, the oral mucous membranes can become dry.

· Inform the patient of limitations and safety measures, such as not blowing his nose to prevent injury to the surgical site; if sneezing is necessary, the patient should open the mouth to release the pressure of the sneeze.

· Tell the patient to notify the practitioner if signs or symptoms of hemorrhage, or hematoma, bleeding, headache, foul smelling drainage occur.

· Record the frequency and amount of drainage.