【Overview】.
It can occur alone or simultaneously with other jaw fractures. The external nose protrudes from the face and is susceptible to injury from impact, fall, gunshot and explosive shrapnel. External nasal trauma accounts for 50% of nasal trauma, among which laceration and nasal bone fracture are common. The type of fracture is related to the direction and size of the violence. External nasal trauma is often accompanied by nasal septum trauma with cartilage dislocation, bending, fracture, mucosal laceration and nasal septum perforation. Song Lihua, Department of Otolaryngology, Affiliated Hospital of Inner Mongolia National University
[Disease classification
Otorhinolaryngology
Disease Description】
The external nose protrudes from the center of the face and is susceptible to impact or fall and nasal bone fracture. The upper part of the nasal bone is thick and narrow, while the lower part is thin and wide, so most nasal fractures are only of the nose and the lower part of the nasal bone. The direction and size of the violence determine the type of fracture. Severe nasal fractures are often accompanied by fractures of the nasal septum and dislocation of the cartilage. The fracture is often accompanied by a mucosal tear.
Symptoms and signs]
The most common symptoms are local pain, nasal bleeding, collapse or deviation of the upper part of the nasal bridge, and subcutaneous petechial hemorrhage. After a few hours, the soft tissues of the nose are swollen, and subcutaneous emphysema may appear after blowing the nose, with a twisting sensation when touched, while the deformity is concealed, but pain to touch is obvious. The nasal septal cartilage is deviated from the midline and the anterior edge protrudes to one side of the nasal cavity. If there is a submucosal hematoma, the nasal septum bulges to one or both sides. If secondary infection occurs, septal abscess is caused and cartilage necrosis may lead to saddle nose deformity.
Clinical manifestations
1. Displacement and deformity The type of nasal bone fracture depends on the nature, direction and size of the violence. If the force of the blow comes from the side, one side of the nasal bone can be fractured and displaced into the nasal cavity, resulting in curved nasal deformity; if the force of the blow is larger, the bilateral nasal bones together with the nasal septum can be fractured at the same time, so that the entire nasal bone is displaced to the opposite side, and the nasal deformity is more obvious; if the external force strikes directly at the root of the nose, a transverse fracture can occur, so that the nasal bone is separated from the frontal bone and the fracture piece is displaced into the nasal cavity. At the same time, the nasal septum and sieve bone injury can be complicated; if the nasal bone is hit by the violence in front of the nasal bone, comminuted fracture and no collapse displacement can occur, and saddle nose deformity can appear.
2. Nasal bleeding The mucosa of the nasal cavity is closely connected with the periosteum, and nasal bone fractures are often accompanied by bleeding due to tearing of the nasal mucosa.
3. Nasal breathing disorder After nasal bone fracture, nasal breathing disorder may occur due to nasal obstruction due to fracture fragment displacement, nasal mucosa edema, nasal septum hematoma and blood clot accumulation.
Petechiae of the eyelids Petechiae may occur after nasal bone fracture due to bleeding from the tissues into the bilateral eyelids and under the conjunctiva.
Cerebrospinal fluid leakage can occur when the nasal fracture is accompanied by sieve injury or fracture of the anterior cranial recess. Initially, the cerebrospinal fluid mixed with blood leaks out, and later, the blood decreases or only the clear cerebrospinal fluid flows out.
Etiology of the disease
Trauma.
[Pathophysiology].
Local hemorrhage and edema after trauma.
Diagnostic tests
Lateral nasal bone x-ray. When nasal septal hematoma is suspected, it can be confirmed by puncture aspiration. The diagnosis of nasal bone fracture is mainly based on injury history, clinical features and local examination. When there is no local swelling after nasal bone fracture, the displaced deformity is visible and the fracture site can be detected by palpation. After swelling is obvious, the displaced deformity of the fracture can be concealed, and the diagnosis can be confirmed only after careful examination of the inside and outside of the nose and frontal and lateral nasal bone x-ray.
Treatment plan
Hemostasis, debridement and suturing and infection prevention are the same as general trauma.
1. Fracture repositioning should be carried out as early as possible to avoid misalignment healing and difficult repositioning in the future. We call the affected side of the upper nasal cavity surface anesthesia, with the reset device into the nasal bone depression, placed under the nasal bone upward, at this time can often hear the nasal bone reset when the “click” sound. The depth of the resetting instrument end into the nasal cavity should not exceed the line of the medial canthus on both sides to avoid damaging the sieve plate, and if there is dislocation of the nasal septum cartilage, it should be reset simultaneously. The nasal cavity needs to be filled after the reset in order to provide support and hemostasis. Then pain relievers should be taken and infection should be prevented.
2. Treatment of nasal septal hematoma and abscess The blood clot in the hematoma is difficult to be absorbed and needs to be removed surgically at an early stage to avoid cartilage necrosis. The incision should be large enough to make an L-shaped incision for thorough drainage, postoperative nasal cavity filling to prevent recurrence, and control infection with anti-inflammatory drugs.
【Treatment measures】.
The treatment of nasal bone fracture should be carried out early to rectify the displaced fracture fragment. Due to the rich blood flow in the nose and the thin bone fragments, if the fracture is not reset early, it is easy to have misalignment healing and make the reset difficult.
(I) External nasal repositioning method is applicable to laterally displaced nasal fractures. Under local infiltration anesthesia and nasal mucosa performance anesthesia, the fracture fragment is repositioned by compressing the outwardly protruding fracture fragment with both thumbs.
(ii) Intranasal repositioning method For inwardly collapsed displaced nasal bone fractures. Under local anesthesia, a periosteal separator with a rubber tube or oiled gauze is inserted into the nasal cavity so that its front end is extended to the fracture and the inwardly displaced fracture fragment is pushed forward and outward, while the thumb and index finger of the other hand are used to assist in the lateral nasal repositioning. After resetting, the fracture is stuffed with iodoform gauze to prevent re-displacement of the fracture fragment and to help stop bleeding. 5-6 days later, the intranasal stuffing can be removed.
(1) Lift the collapsed nasal bone with the nasal bone repositioner (2) Reset the fracture unilaterally with the nasal bone repositioning forceps (3) Reset the fracture bilaterally with the nasal bone repositioning forceps
If nasal bone repositioning forceps are available, the two rostral ends of the forceps can be inserted into the nostrils, and the lateral and upper walls of the nose can be repaired successively, and the blood clots and secretions in the nasal cavity can be aspirated with absorption, and then a rubber tube wrapped with iodoform gauze can be placed in the nasal vestibule to assist in shaping. The nasal splint can be made of impression adhesive, lined with dressing and fixed with adhesive tape without pressure on the nose. One or two small gauze rolls can also be placed on each side of the nose to make it higher than the dorsum of the nose, and then fixed with adhesive tape for protection and shaping. For casualties with cerebrospinal fluid nasal leakage who cannot be blocked nasally, an external nasal splint can be used alone to prevent re-displacement. The external nasal splint or gauze roll can be removed after 7 to 8 days. The casualty is instructed not to squeeze the nose or blow the nose hard for 1 month.
To prevent pressure on the exterior of the nose and to better shape it, a splint can be added to protect the exterior of the nose. Nasal bleeding from a nasal fracture is usually not serious and can be stopped by itself or by blocking the anterior nasal cavity with gauze. If there is damage to the blood vessels in the middle or upper nasal tract, serious nasal bleeding may occur. If the bleeding cannot be stopped by blocking the anterior nasal cavity, the posterior nostril blocking method should be used instead. In case of nasal bleeding, if pressure is applied from outside of the nose, it is not only ineffective, but also may aggravate the displacement of fracture fragments and increase the damage and deformity in the nose. Cerebrospinal fluid nasal leakage should be allowed to flow on its own and antibiotics should be used to prevent infection. It should gradually decrease or stop within 3 to 7 days. If long-term leakage does not stop, neurosurgery should be consulted and dural fissure repair should be performed.
Health care tips
Most of the nasal bone fractures involve only the lower part of the nasal bone because the upper part of the nasal bone is thick and narrow, while the lower part is thin and wide. The size and direction of the violence determines the type of fracture. In young people, the fracture is often a dislocation of a large bone fragment, while in the elderly, it is mostly a comminuted fracture. Severe nasal fractures are often accompanied by fractures of the nasal septum and dislocation of the cartilage. There is often a mucosal tear at the fracture site.
The most common symptoms are nasal bleeding and localized pain, and in severe cases shock may occur. If there is displacement, the upper part of the nasal bridge is collapsed or deviated, and there is a bone rubbing sound when touched.