13-year-old Freya (she/her) has been tackled in rugby and fell onto her nose. It bled initially and her mother has brought her as it is really swollen and looks wonky. “Is it broken, doctor?”
Nasal injuries in children are frequently encountered in paediatric emergency departments. One third of all nasal fractures occur in children, accounting for 60% of all facial fractures seen in the emergency department. The nose is the second most commonly injured site on a child and is more commonly seen in males. The most common locations of injury to the nose are: the nasal tip, the dorsum, and nasal root region with only 32% of injuries involving the nasal skeleton.
Nasal fractures are more common after three years of age, and unlikely below the first year of life, as the nasal bones are hardly ossified. But the bones aren’t the only thing you need to look out for; nasal obstruction and septal haematomas are important to identify and treat urgently.
Nasal trauma in children commonly arises following: falls, contact sports and automobile crashes, typically involving bicyclists or pedestrians. Non accidental injury also must be considered as a potential mechanism.
Important aspects of history should include:
- if there was any deformity immediately
- new-onset nasal obstruction.
It is also important to note any previous nasal injury or pre-existing deformity.
Children with facial trauma are usually apprehensive, so any examination may be limited due lack of cooperation. Pain relief and play therapy will go a long way. Bleeding and swelling often accompany injuries and can limit a thorough examination. Applying local pressure may be necessary prior to starting a formal examination.
The examination should start with inspection of the nose and the surrounding facial structures. It is important to note:
- Periorbital bruising in the absence of other orbital findings is suggestive of a nasal fracture.
- External nasal deformity, epistaxis, oedema, and bruising is highly suggestive of a septal injury. Any deformity more be masked by swelling.
- A flattened, broad nose with an increase of the inner canthal distance and associated with vertical orbital displacement is suggestive of a naso-orbito-ethmoid fracture. The normal mean inner canthal distance is 16 mm at birth and increases to 25 to 27 mm in the mature female and male face, respectively, although there is ethnic variation.
The intranasal cavity should be assessed with a nasal speculum to exclude a septal injury. A septal haematoma can arise without the presence of any external signs. The septum should be examined for the presence of fractures, displacement, lacerations, discoloration, and abnormal swelling. Don’t forget that the nasal septum may be acutely or chronically deviated so you may need to ask about this in the history. Sometimes looking at an old photo helps.
The key findings suggestive of septal hematoma include:
- An asymmetrical septum with a blue/red discolouration
- Swelling of the nasal mucosa that obstructs the nasal passage
- The size of the mass does not change with the application of topical vasoconstricting agents.
Most times a septal haematoma looks like a blueberry up the nostril.
After inspection, the nasal bones should be palpated for tenderness, deformity, mobility and crepitus, although realistically poking a bruised nose may be too painful to tolerate. It is important to note:
- Tenderness over the frontal sinus may indicate frontal sinus fractures.
- Tenderness to palpation of the tip of the nose may be suggestive of a septal hematoma
- Tenderness and instability on palpation of the anterior nasal spine from beneath the upper lip may indicate a significant septal injury.
- Malocclusion is suggestive of a midfacial Le Fort fracture.
It is important to exclude an associated skull fracture which may be indicated by the presence of clear fluid in the nasal cavity. A fracture through the cribriform plate can result in a CSF leak. In an ideal world you can test for beta-2-transferrin (present only in CSF, perilymph, and aqueous humor), but I have yet to hear of EDs which offer this.
The signs and symptoms of nasal septal injury may evolve during the 24 to 72 hours after injury. Children with nasal trauma should be safety-netted to return if anything changes after they go home.
A history and clinical examination should more than suffice in guiding the management of children with nasal injuries. In simple nasal injuries, imaging adds very little. Plain radiographs are of very limited benefit as the majority of the nose in children in cartilaginous and therefore poorly visualised on x-rays.
In injuries associated with more worrying features i.e. CSF leak or malocclusion, CT imaging is the modality of choice due to the risk of a Le Fort fracture or a base of skull injury.
A number of classifications systems have been proposed for nasal injuries. The first and most widely quoted was based on the pattern of injury sustained and the direction of force applied. More recently, a classification system based on pathological findings was proposed. This second classification system has been adapted, to incorporate clinical findings as opposed to the pathologic patterning of injury.
A complicated fracture is classified as a Type II to Type IV fracture with CSF rhinorrhea, airway obstruction, septal haematoma, crush injury, numbness, severe displacement or midface involvement.
The management of nasal trauma in infants and children depends upon their age, the degree of nasal obstruction, and associated injuries. Children with nasal trauma should maintain upright posture to prevent the formation and facilitate the resolution of any associated oedema and hematoma. Patients who have no symptoms, minimal swelling, and no septal deviation or hematoma do not need specific follow-up. Ensure adequate analgesia is given and appropriate advice when to return (on-going bleeding, evolving nasal obstruction, worsening pain).
Epistaxis – Most acute nasal bleeds respond to direct pressure over the anterior nose. Encourage the child to pinch their own nose but if they are unable, asking a parent to perform this has the added benefit of helping reduce the patient’s anxiety. During simple compression, position the child upright and sit them forward. This will help avoid possible aspiration of blood. Distraction and play therapy during compression are useful. In the majority, bleeding is controlled within 5 – 10 minutes.
If direct pressure fails to control bleeding, a number of management options are available but are rarely needed in the emergency department. These include:
- Nasal packing. Tamponading the bleeding point can be very effective but can be very distressing to children. Sedation is often required to facilitate the procedure. It is advisable to seek an ENT opinion before packing a child’s nose, especially if this is traumatic.
- Topical vasoconstrictors. These can be very effective but are not without risks. They are most commonly used in the theatres by the ENT surgeons. Options include topical phenylephrine or oxymetazoline. After application of a vasoconstrictor, direct pressure should be applied for at least 5 minutes before reassessing for further bleeding.
- Tranexamic acid.
- Cautery. In the emergency department, chemical cautery is commonly used, predominately in the adult population. Typically 75% silver nitrate is used to arrest bleeding. Cauterisation is undertaken around the bleeding point. Cautery works most effectively on dry areas so direct cautery of a bleeding point is often unsuccessful until the surrounding area has been treated. Care must be taken to avoid the skin and it is paramount the child is calm and cooperative, which may necessitate sedation. Make sure you don’t cauterise both sides of the septum.
Children presenting with possible fractures or obvious deformity should be reviewed by an ENT specialist; generally this can wait a few days. In the very young, injuries resulting in nasal obstruction should be referred urgently as young children are obligate nasal breathers.
As mentioned previously, swelling and oedema can make an accurate assessment difficult. As such, an immediate referral of a child with a broken nose but no features of airway compromise may not be needed. Children can be referred to an outpatient clinic for review but should be seen within in five to seven days. Short delays in definitive management of up to a week have been shown to have little impact on long term outcome. However, delays over seven days can make reduction of fractures more challenging, largely due to the active growth centres in a child’s nasal bones promote rapid healing.
Potential complications of nasal injuries
A number of potential complications can arise as a result of nasal trauma, particularly if there is a fracture. The most common complication is obstruction. This is often due to either soft tissue swelling or a deviation of the septum following an injury. Persistent obstruction following an injury is more likely due to septal deviation and therefore requires assessment by an ENT surgeon.
Poor cosmesis following healing is a common problem reported by patients and is a valid concern for many parents. Recent work has shown that those sustaining fractures at a younger age compared to those that had none, had no differences in functional outcomes but were likely to suffer with deviations of the septum, bumps or humps in the nasal bridge and saddle formation. Ensuring a timely referral to a surgeon may help reduce the incidence of a poor aesthetic result for the patient.
A septal haematoma that is not promptly dealt with can result in a septal abscess or necrosis (and a future flat nose). Though infection can remain localised, cases of intracranial infection via tracking through the cavernous sinus have been reported. Cavernous sinus thrombosis is also a recognised complication of septal haematomas. Damage to the cribiform plate with a resulting CSF leak is also a potential avenue for intra-cranial infection.
Rarer complications but still clinically important include:
- Lacrimal duct obstruction
- Maxillary hypoplasia
- Naso-oral fistula
- Anosmia. If this occurs following trauma, it very rarely returns.
A clever history and examination are key.
Ensure you examine the inside of the nose especially for a septal haematoma
Adequate analgesia and distraction will make examination much easier
Radiological investigations have little use in simple injuries.
Direct pressure for at least 10 minutes should stop most cases of epistaxis.
Make sure, if referring to clinic, the child is seen within a week.
You have examined Freya and she has no signs of obstruction, no septal haematoma and her bleeding as stopped. She does seem to have a deviated septum however, so you discharge her with advice for simple analgesia, safety-netted and referred her for rapid access ENT clinic within seven days.
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