Nasal fracture ent ppt

presentation of nasal fracture including introduction, classification & clinical aspects with management.

1. Nasal fracture -dr ayushree

2. Introduction Definition Anatomy in brief Clinical aspects Classification Evaluation Management Complications

3. DEFINITION The prominence and delicate structure of the nose make it vulnerable to a broad spectrum of injury, which accounts for why it is the most frequently fractured facial bone. Most common facial fracture (between 40–50%). 3rd most common fracture of the bony skeleton Force required to create a fracture of the nasal structure is small, possibly as little as 25 pounds of pressure

4. Why to worry ? Although these injuries often do not appear to be severe, the mistake of undertreating nasal trauma can lead to significant long-term problems. External deformity, nasal obstruction, septal perforation and other complications (e.g., chronic sinusitis) will persist and sometimes worsen months or years after the original insult. Injuries in children may also lead to devastating growth retardation of the nose and midface. Thoughtful assessment and proper management of nasal injuries can reduce the risk of these sequelae, thereby reducing the need for delayed corrective septorhinoplasty .

5. CAUSES Physical fights, assaults , domestic violence. Contact sports Falls (common in children) Motor vehicle accidents Falls from syncope or impaired balance in the elderly and etc.

6. HISTORY Any history of a fall or force directed toward the mid face Details of the injury either assault or any RTA (mechanism, speed, location, direction of force , any restraining force) Was there an epistaxis at the time of trauma? Or any watery discharge Loss of sense of smell ( can also be due to oedema hence should be re assessed after the oedema subsides) Was there a previous history of facial trauma or surgery? The difference from the nasal appearance before the trauma (for medicolegal and future treatment as well. ) Was there a previous functional impairment in breathing before the trauma? etc.

7. PATHOGENESIS Direction of the force: Frontal direction : in fracture of the lower margin of the nasal bones High frontal : nasal orbital ethmoid fracture Heavier force : severe flattening or splaying of the nasal bones and fracture of the septum Lateral forces : depression of the ipsilateral nasal bone, out fracture of the contralateral nasal bone

8. • If twisted or buckled : the fractured bony and/or cartilaginous fragments are often interlocked, septum dislocated off the maxillary crest Note. This is important to identify because achieving an adequate result with a closed technique may be impossible in such a situation. • Children’s noses: mostly cartilaginous and their nasal bones are softer and more compliant, absorbing little of the energy from the force of trauma. It is also a common fact that birth trauma could be the cause for septal deviations in these patients. Septal hematoma is more common in children. In children it is better to avoid open reduction procedures and stick to closed manipulation technique.

9. Classification system

10. ROWE & KILEY (1968) Described fractures of the nasal bones & or nasal septum according to the impact only: Lateral nasal injuries Anterior nasal injuries Drawback : only included the impact factor & nothing else (not the force or bone involved)

11. MURRAYS PATHOLOGICAL CLASSIFICATION Various weights were dropped on cadavers noses & the resultant fractured nasal pyramid was dissected out. The fracture lines are described & particular reference is directed to the involvement of the septum in grossly deviated noses.

12. On the basis of pattern of fracture :

13. HARRISON’S CLASSIFICATION: CLASS 1 CLASS 2 CLASS 3 CHEVALLET FRACTURE mostly depressed fractures of nasal bones JARAWAY FRACTURE These # cause a significant amount of cosmetic deformity. high velocity trauma. AKA nasoorbital #/ naso ethmoidal #.. The # line runs parallel to the dorsum of the nose and naso maxillary suture and joins at a point where the nasal bone becomes thicker In this group not only the nasal bones are fractured, the underlying fronto nasal process of the maxilla is also fractured. Ethmoidal labyrinth & orbit is intact These fractures are always associated with Le Fort fracture of the upper face involving the maxilla also Ethmoid being thin & full of air cells forms a low resistence ‘crumple zone” Clinically :present as a depression over the nasal bone area. tenderness and crepitus over the affected nasal bone. Radiological evidence may or may not be present. clinical diagnosis Clinically : telecanthus is seen & medial canthal ligament may be disrupted from lacrimal crest. Epiphora can also be there due to lacrimal crest injury.

14. MARKOWITZ ET AL CLASSIFICATION :NOE FRACTURE ON THE BASIS OF MEDIAL CANTHAL TENDON & DEGREE OF COMMUNITION OF THE FRAGMENTS OF BONE OF ITS ATTACHMENT: TYPE 1 : #LINE LEAVES A CENTRAL SEGMENT OF BONE WITH MCT ATTACHED. TYPE 2 : INVOLVES CUMMUNITION OF THE CENTRAL SEGMENT BUT MCT REMAINS FIRMLY ATTACHED TO A DEFINABLE SEGMENT OF BONE. TYPE 3: SEVERE CENTRAL FRAGMENT COMMUNITION WITH DISRUPTION OF THE MCT INSERTION SITES.

15. On the basis of DIRECTION OF BLOW : Stranc & Robertson classification : LATERAL BLOW FRONTAL BLOW More common Less common Less severe damage More severe damage and leads to more residual deformity Better prognosis So associated with poor prognosis.

16. Plane 1 Plane 2 Plane 3 Damage to anterior nasal spine ,the anterior septum & lower ends of nasal bones. More extensive damage to nasal bone & ascending maxillary process Naso -orbital-ethmoidal disruption Dislocation & telescoping of the ULC & septum may also be found. Septum has significant deviation & may lack stability to support dorsum Nasal bone & septum is severely communited & overlapped Does not involve the orbital rims Associated with other injuries like midface & cranial base fractures.

17. SYMPTOMS Bruising of the skin and subcutaneous tissues pain Swelling Deformity Difficulty breathing Nosebleeds Deviation and asymmetry Epiphora

18. PHYSICAL EXAMINATION Adequate lighting Acute edema may hide deformities; however, a careful search for intranasal injury must take place Patient should be placed in a comfortable, slightly reclined position Nose should be externally observed from all angles Bleeding can be controlled with topical cotton pledgets soaked in vasoconstrictors – 0.25% phenylephrine – 4% cocaine, which also provides anesthesia. Any open wound Nasal airway evaluation : (a) Obstruction (b) Hematoma (c) Septal deviation

19. • Other signs: – (a) Oedema (b)Skin laceration (c)Periorbital ecchymosis (d)cerebrospinal fluid (CSF) rhinorrhoea (e) Olfactory disorders Palpation : Evidence of nasal fracture Mobility : of the nasal bones is assessed by grasping the dorsum btw two fingers and firmly rocking the pyramid back & forth Crepitations can also be felt

20. Frankfurt horizontal plane : from the superior aspect of EAC to inferior most point of infra orbital rim

21. Internal examination Assessment of nasal cavity using speculum via direct visualization or using endoscopy ( use of 0 or 30 degree 4mm rod telescope) Not entirely necessary However may provide additional information and rule out the following: – (a)Mucosal tears (b) Lacerations (c)Ecchymosis (d)Hematoma Push the tip of the nose upward to check for integrity of the septal support system. Retained blood clots should be removed with suctioning or swabbing using a frazier suction procedure.

22. Radiography Plain x ray films High resolution USG CT SCAN Most commonly done Ultrasound using 10 MHz probe gives a clear view In cases of only severe injury Advantage Easily accessible & cheap . Excellent sensivity & specificity esp regarding lateral nasal wall fracture Can not be missed even in prescence of edema No radiation injury In injuries involving naso -orbital-ethmoidal complex. Disadvantage Inability to cartilaginous injury esp in children. Limited scope that may miss fracture outside the area of interest & Can misinterpret normal suture lines , vascular indentation lines, & developmental thinning of nasal bones anatromical issues that prevent adequate trasducer contact

23. 3 D RECONSTRUCTED CT SCAN

24. INITIAL TREATMENT Practitioners who are called upon to treat individuals who have been appropriately stabilized before consultation must still follow the protocol set forth by the American College of Surgeons Advanced Trauma Life Support course. Therefore it is mandatory that every new evaluation begins with an assessment of the ABCs (airway, breathing, and circulation) This is especially critical for cases in which narcotics and sedatives may be ordered by the consultant for pain management or bedside procedures. A patient with a tenuous airway or poor hemodynamic reserve may unexpectedly experience decompensation if signs such as increasing heart rate, tachypnea, or changing mental status are not appreciated. Nose bleeding & septal hematoma should be assessed too Check for other facial fractures, e.g. orbital rim, mandible Treatment begins with management of external soft tissue injuries (clean lacerations and carefully repair them)

25. Epistaxis Can range from minor mucosal oozing to life threatening large blood vessls bleed.

26. SEPTAL HEMATOMA High risk of complications if left untreated can lead to necrosis if left untreated for 3 days. L ong term complications : saddle deformity, perforation, columellar retraction & nasal bone widening Needle drainage ASAP & several small openings are left to allow for independent drainage. Prophylactic treatment with an antibiotic (e.g., Augmentin or clindamycin) S plints and transeptal dissolving sutures are placed to obliterate the potential space & prevent re collection. Untreated may result in intracranial abscess, cavernous sinus thrombosis, or meningitis

27. BILATERAL SEPTAL HEMATOMA

28. TIMING OF REDUCTION Selection of appropriate timing is very important to obtain the best re-alignment possible The development of fibrous connective tissue within the fracture line becomes the limiting factor starting at around 10 days to 2 weeks after injury. Hence the best time is to start before this phase. A short period of delay is recommended during first 2-3 days to allow diminution of oedema so that nasal bone position is best appreciated. Treatment before this delay is reasonable only if patient comes to medical attention within an hour or two after injury before edema has obscured the underlying structure.

29. Closed reduction Open reduction CR involves manipulation of the nasal bones without incision & is generally the preferred choice OR may include a range of techniques including septoplasty , osteotomy or septorhinoplasty . Indication: Unilateral / bilateral # of nasal bones # of nasal septal complex with nasal deviation of less than half of the width of nasal bridge Bilateral # with dislocation of nasal dorsum & significant pathological changes Infracture of nasal dorsum

30. Anesthesia for closed reduction Proper pain management has become a very crucial topic these days. However use of general anesthesia is not very feasible due to the various risks associated with it plus scheduling conflicts & operating room availability these days. Therefore alternative plan without sacrificing timely management includes: Combination of topical & injected anesthetic agent

31. After infiltration of c/l side topical soaked pledgets are placed posteriorly along the deep internal branch for 5 minutes to have maximum anesthesia. To reduce the acidity caused by the injection itself buffering the lidocaine with 7.5% NaHCO3 in a 1 dilution by volume Infiltration should be done by a thin needle (27 gauge ) and slowly to lessen the pain from soft tissue dissection by LA. Application of EMLA cream over the nose 1hour before the reduction has in combination with topical has been proven to be equally effective (less discomfort to patient as well) Topical infilteration Cotton pledegets soaked in 4% cocaine or 0.05% oxymetazoline combined with 4% topical lidocaine are placed strategically over the nasal cavity. 1% lidocaine with 1:100,000epinephrine is injected along the septum, lateral wall & floor of nasal cavity External nasal branch is blocked by via an inter cartilaginous injection of the dorsum from rhinion to supratip Branches of anterior or posterior ethmoid , sphenoplataine & nasopalatine nerves Branches of nasopalatine nerve are blocked with an injection at the base of columella & nasal tip just inside the nasal sill.

32. CLOSED REDUCTION Most preferred treatment modality Even if large deviations are seen closed reduction can be attempted prior to rhinoplasty as this would simplify the task of the plastic surgeon I n mild cases when fragments are still in contact finger manipulation alone is sufficient but in this surgeon doesn’t have much control & often will fail if there is impaction and can even result in worse deformity than before.

33. REDUCTION INSTRUMENTS (Left) Asch forceps (Center) Walsham forceps (Right) Boies elevator

34. USING A BLUNT ELEVATOR

35. USE OF GRASPING INSTRUMENTS

36. CARTILAGENOUS CORRECTION WITH CLOSED REDUCTION The correction of the cartilaginous injuries with CR is often difficult & unsuccessful. For ULC avulsion with medial displacement : reduction is possible if performed soon after the injury followed by 10-14 days of internal packing. If beyond 2 weeks then go for intercartilagenous incision with removal fibrous adhesion . Is still there is poor response then go for cartilage grafting can be offered.

37. Causes of failure of closed reduction Most common cause within 1 st week to 10 days is unreduced septal fracture Beyond 2 nd week is fibrous tissue formation causing inadequate remodeling. Even after proper timely reduction there is persistent deviation,then it can be a Green stick fracture

38. GREEN STICK FRACTURE Conversion of greenstick # to a complete one by osteotomy followed by application of splint.

39. Care after reduction Avoidance of activity that can lead to further trauma for next 6-8 weeks. Regular nasal saline spray or irrigation are recommended to remove blood and to avoid adhesions Antibiotic coverage should also be given Refraining from nasal blowing.

40. DOYLE SPLINT

41. Open reduction Immediate repair Delayed repair In case the closed reduction fails Usually 6 months or more Using standard method of rhinoplasty

42. 1. Through existing laceration 2. Approach :

43. 3.Lateral rhinotomy 4. Transcolumellar incision incision

44. FIXATION A Small gauze wires (26 or more ) passed through pre drilled holes can secure fragments to stable parts of maxillary of frontal bone Use of slow absorbing sutures instead wires Titanium microplates & fibrin glue can also be used (alt bioabsorbale fixation method that may help in speed wound healing & reduce post op hematoma) Use of cantilever bone in case of significant loss of dorsum Autologus cranial bone or rib bone or cartilage or homograft bone or cartilage can also be used Lag screw fixation

45. Titanium microplates Lag screw fixation

46. Midline repositioning of quadrangular cartilage of the septum and the vomer. The septum is repositioned in its original midline position together with the quadrangular cartilage and vomer. As small suture may be placed from the anterior nasal spine to the anterior portion of the septum to maintain its reduction.

47. Alternative methods

48. COMPLICATIONS Early Late Septal hematoma 1. Untreated hematoma : lead to sub perichondrial fibrosis & partial nasal airway obstruction 2. Edema 2. synechiae 3. Ecchymosis 3. Residual osteitis 4.Csf leak 4. Chronic rhinosinusitis 5. Epistaxis 5. Cosmetic Deformity