3. Nasal Trauma 3.1 Fractures of the nose A.

Definition A nose fracture is a break in the bone or cartilage over the bridge, in the sidewall, or septum (line dividing the nostrils) of the nose. The nasal septum is the central partition in the nose made of bone and a rubbery substance (called cartilage) which separates the two nostrils. It is rarely situated absolutely in the middle but in most people it is straight and fairly centrally placed. The location of the nose makes it susceptible to injury by a wide variety of causes. In fact, nasal fractures are more common than those of any other bone in the body. Fractures of the nose usually result from a direct assault. As a rule, no serious consequences result, but the deformity that may follow often gives rise to obstruction of the nasal air passages and to facial disfigurement. B. Incidence Nasal fractures are the third most common types of fractures. Nasal fractures are often cited as the most common type of facial fracture, accounting for approximately half of all facial fractures in several studies. Zygomatic (22%), blowout (12%), mandibular bone (8%), and maxillary bone (9%) fractures follow in frequency. C. Etiology
Most commonly, nasal bone fractures are sustained in fights (34%), accidents (28%), and sports (23%).

In children, nasal fractures are most commonly due to falls.

D. Pathophysiology The direction of force to the nose during injury determines the pattern of the fracture.

Frontal force causes damage ranging from simple fracture of the nasal bones to flattening of the entire nose. Lateral force may depress only one nasal bone; however, with sufficient force, both bones may be displaced. Lateral force can cause severe septal displacement, which can twist or buckle the nose. Septal fragments may interlock, creating further difficulty in reduction. Superior-directed force (from below) rarely occurs. It may cause severe septal fractures and dislocation of the quadrangular cartilage.

Unilateral fracture involves only one side of the nose. It causes little displacement and deformity. Bilateral fractures are more common, with the depression or displacement of both nasal bones to one side. The nose appears flattened or deviated with an S and C configuration. Complex fractures may also involve the septum, ascending process of the maxilla and frontal bones of the face. The septal cartilage bulges or deviates to one side partially or totally obstructing the nares

E. Signs and Symptoms

bleeding from the nose externally and internally into the pharynx swelling of the soft tissues adjacent to the nose deformity.
Obstruction of nasal breathing Mouth breathing Twisting of nasal septum Excoriation of nasal mucosa Echhymosis Pain Tenderness on palpation

F. Laboratory studies In cases with a significant amount of bleeding or where a patient may require operative intervention, the following blood tests should be obtained:

Complete blood cell (CBC) count To check baseline level of hemoglobin and platelet count Coagulation studies (prothrombin time [PT] / activated partial thromboplastin time [aPTT]) Blood typing and cross-matching for packed red blood cells In the event transfusion should be required

G. Diagnostic procedures The nose is examined internally to rule out the possibility that the injury may be complicated by a fracture of the nasal septum and a submucosal septal hematoma. Because of the swelling and bleeding that occur with a nasal fracture, an accurate diagnosis can be made only after the swelling subsides. Clear fluid draining from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. Because cerebrospinal fluid contains glucose, it can readily be differentiated from nasal mucus by means of a dipstick (Dextrostix). Usually, careful inspection or palpation will disclose any deviations of the bone or disruptions of the nasal cartilages. An x-ray may reveal displacement of the fractured bones and may help rule out extension of the fracture into the skull.
Facial x-ray series:

If suspicion for other facial injury exists, then a complete facial radiographic series should be obtained. Computed tomography (CT) scan o provides the best information regarding the extent of bony injury in nasal and facial fractures, particularly digital volume tomography (DVT).[12] Again, cartilaginous injury is likely to be missed. Intranasal cavity examination H. Medical Management

Pharmacologic Therapy
Systemic decongestant Topical nasal steroid sprays to relieve nasal edema Analgesics for pain

As a rule, bleeding is controlled with the use of cold compresses. The nose is assessed for symmetry either before swelling has occurred or after it has subsided. The patient is referred to a specialist, usually 3 to 5 days after the injury, to evaluate the need to realign the bones. Nasal fracture Control bleeding Reduce edema Antibiotics Analgesics agents Decongestant nasal spray Rhinoplasty Deviated septum Removed the obstruction Treat chronic infection Treat allergies Flonase Singulair Antibiotics Antihistamine Submucosal resection Septoplasty

I. Surgical Management Nasal fractures are surgically reduced 7 to 10 days after the injury. Septoplasty o for client with septal dislocation Minimal removal of cartilage, repositioning of septum in
midline

Nasal packing to hold fragments together (fractured) o

Plaster of paris or thermostat splint

Fractures left longer than 10-14 days, a formal rhinoplasty may be performed. No clear recommendation exists regarding the type of surgical approach or the timing of surgery in patients with nasal fractures. Standard therapy instructs the surgeon to perform closed or open reduction between 3 and 7 days, and up to 2 weeks, depending on which source is consulted. The potential for optimal results lies in the reduction of the fracture within the first several hours following the injury before significant edema has appeared. If this window has passed, subsequent reassessment of the injury is advisable, with correction planned between 4-7 days following the injury. Studies have shown that as the significance of the nasal deviation increases, successful reduction of the nasal fracture becomes more difficult. Recent literature indicates a significant dissatisfaction with closed reduction results, suggesting that open approaches may reduce the need for future revision procedures. Clearly, each fracture and patient must be individually assessed, and proper clinical judgment must be applied to achieve overall patient satisfaction. A further delayed approach can be taken if the fracture is first identified after significant bony healing has occurred. Waiting at least 3-6 months to perform surgery allows fractures to stabilize and wounds to heal. Most surgeons agree that closed reduction is often an imperfect solution to restore the nose to its preinjury condition. However, note that the satisfaction of the surgeon and the satisfaction of the patient are generally discordant.[5] That is, patient satisfaction after closed reduction is significantly higher than that of the surgeon. If the patient is made aware of this issue, a decision can be made as to whether to defer surgery or to proceed with an attempt at reduction; the procedure results in improvement, but the results are not perfect. For further reading, please see the eMedicine article Nasal Fracture Reduction.

J. Nursing Management 1. The nurse instructs the patient to apply ice packs to the nose for 20 minutes four times each day to decrease swelling. 2. Elevate the head of the clients bed. 3. Pinch the nostrils at the tip for a minimum of 10 minutes if bleeding occurs . 5. Increase
supplemental humidification.

4. Packing inserted to stop bleeding 5. Rinse the mouth to keep moisten 6. Instruct client to avoid blowing the nose with force

7. Avoid sports activities for 6 weeks The patient who experiences bleeding from the nose (epistaxis) because of injury or for unexplained reasons is usually frightened and anxious. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the patient to breathe through the mouth. This in turn causes the oral mucous membranes to become dry. o Mouth rinses will help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Nasal fracture Apply ice and keep head elevated Instruct the patient to apply ice packs 20 min. 4x daily to decrease swelling Packing inserted to stop bleeding Rinse the mouth to keep moisten Avoid sports activities for 6 weeks Deviated septum

Keep head of the bed elevated Encourage to do frequent oral hygiene Instruct client to avoid blowing the nose with force Discussed to the client the S/S of bleeding ,infection and when to contact the physician. K. Nursing Diagnosis 1. Ineffective breathing pattern related to nasal obstruction Risk for fluid volume deficit related to bleeding 2. Acute pain related to nasal fracture 3. Anxiety related to pain and need for emergency care 4. Disturbed body image related to nasal deformity 5. Risk for fluid volume deficit related to bleeding L. Nursing Care Plan M.Citation / References http://emedicine.medscape.com/article/878595-treatment#a1128 http://emedicine.medscape.com/article/84829-medication#1

Reporter: Rae Marie G. Aquino