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 injury locations to the nose are the nasal tip, the dorsum, and the 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 to a lack of cooperation. Pain relief and play therapy will go a long way. Bleeding and swelling often accompany injuries and can restrict a thorough examination. Applying local pressure may be necessary before a formal exam.
The examination should start with examining the nose and the surrounding facial structures. It is important to note:
- Periorbital bruising in the absence of other orbital findings suggests a nasal fracture.
- External nasal deformity, epistaxis, oedema, and bruising are highly suggestive of a septal injury. Any deformity may be masked by swelling.
- A flattened, broad nose with increased inner canthal distance and associated with vertical orbital displacement is suggestive of a naso-orbito-ethmoid fracture. The average 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 fractures, displacement, lacerations, discolouration, 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 humour), 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 superficial nasal injuries, imaging adds very little. Plain radiographs are of minimal benefit as most of the nose in children is 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.
Several classification 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 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 helpful. 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 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 theatres by ENT surgeons. Options include topical phenylephrine or oxymetazoline. After applying 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.
An ENT specialist should review children presenting with possible fractures or obvious deformities; generally, this can wait a few days. Injuries resulting in nasal obstruction in the very young should be referred urgently as young children are obligate nasal breathers.
Swelling and oedema can make an accurate assessment difficult. As such, the 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
Several potential complications can arise from nasal trauma, mainly if a fracture occurs. 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 than those with none had no differences in functional outcomes but were likely to suffer from 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 the 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 cribriform 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; she has no signs of obstruction, no septal haematoma, and her bleeding has stopped. However, she seems to have a deviated septum, so you discharged her with advice for simple analgesia, safety-netted and referred her for rapid access ENT clinic within seven days.
Baek HJ, Kim DW, Ryu JH, Lee YJ. Identification of Nasal Bone Fractures on Conventional Radiography and Facial CT: Comparison of the Diagnostic Accuracy in Different Imaging Modalities and Analysis of Interobserver Reliability. Iran J Radio. 2013 Sep; 10(3): 140–147.
Beck R, Sorge M, Schneider A, Dietz A. Current approaches to epistaxis treatment in primary and secondary care. Dtsch Arztebl Int. 2018 Jan; 115(1-2): 12–22
Béquignon E, Teissier N, Gauthier A, Brugel L, De Kermadec H, Coste A, Prulière-Escabasse V. Emergency Department care of childhood epistaxis. Emerg Med J. 2017;34(8):543
Burnius M, Perlin D Pediatric ear, nose, and throat emergencies. Pediatr Clin North Am. 2006;53(2):195
Caglar B, Serin S, Akay S, Yilmaz G, Torun A, Adibelli ZH, Parlak I. The accuracy of bedside USG in the diagnosis of nasal fractures. Am J Emerg Med 2017 Nov;35(11):1653-1656.
Calder N, Kang S, Fraser L, Kunanandam T, Montgomery J, Kubba. A double-blind randomized controlled trial of management of recurrent nosebleeds in children. Otolaryngol Head Neck Surg. 2009;140(5):670
Elden LM, Potsic WP. Otolaryngology trauma. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1663.
Hester TO Campbell JP. Diagnosis and management of nasal trauma for primary care physicians. J Ky Med Asoc. 199795(9):386
Higuera S, Lee E I, Cole P, Hollier L H, Jr, Stal S. Nasal trauma and the deviated nose. Plast Reconstr Surg. 2007;120(7, Suppl 2):64S–75S
Hoppe IC, Kordahi AM, Paik AM, Lee ES, Granick MS (2014) Age and sex-related differences in 431 pediatric facial fractures at a level 1 trauma center. J Craniomaxillofac Surg 42(7):1408–1411
Joseph J, Martinez-Devesa P, Bellorini J, Burton MJ. Tranexamic acid to help treate nosebleeds. Cochrane review. 2018
Lkas Anschuetz B, KaiserN, Dubach P, Caversaccio M lun nasal trauma in children:a frequent diagnostic challenge. Euro Arch Oto-Rhin-Larng.2019. 276; :85-91
Lopez MA, Liu JH, Hartley BE, Myer CM. Septal hematoma and abscess after nasal trauma. Clin Pediatr (Phila). 2000;39(10):609
Precious DS, Delaire J, Hoffman CD. The effects of nasomaxillary injury on future facial growth. Oral Surg Oral Med Oral Pathol. 1988; 66:525-530.
Puricelli MD, Zitsch RP. Septal Hematoma Following Nasal Trauma. J Emerg Med. 2016 Jan;50(1):121-2.
Rohrich RJ, Adams WPJr, Nasal fracture management: minimizing secondary nasal deformities, Plast. Reconstr. Surg. 2000, 266-273
Schlosser RJ, Bolger WE. Nasal cerebrospinal fluid leaks: critical review and surgical considerations.Laryngoscope. 2004;114(2):255
Stucker FJ Jr, Bryarly RC, Shickley WW. Management o nasal trauma in children. Arch Oolaryngol. 1984: 110 (3): 90
Thomson CJ, Berkowitz RG. Extradural frontal abscess complicating nasal septal abscess in a child. Int J Pediatr Otorhinolaryngol. 1998;45(2):183
Wu KH, Tsai FJ, Li TC, Tsai CH, Peng CT, Wang TR. Normal values of inner canthal distance, interpupillary distance and palpebral fissure length in normal Chinese children in Taiwan. Acta Paediatr Taiwan. 2000;41(1):22.
Yoon HY, Han DG. Delayed Reduction of Nasal Bone Fractures Arch Craniofac Surg. 2016 Jun; 17(2): 51–55