The nose may be injured in various forms of sport, in personal assaults and in traffic accidents. Injury to the nose may result in one or a combination of several of the following:

1 epistaxis ;

2 fractures of the nasal bones;

3 fracture or dislocation of the septum;

4 septal haematoma.

FRACTURE OF THE NASAL BONE:

 The fracture is often simple but comminuted. It may be compound, with an open wound in the skin over the nasal bones.

1. Swelling and discoloration of the skin and subcutaneous tissues cover- ing the nasal bones and the vicinity.

2 Tenderness.

3 Mobility of the nose

4 Deformity.

This may or may not be present and is of importance in deciding upon treatment.

TREATMENT

Fractured noses usually bleed and the epistaxis should be controlled first. Lacerations should be cleaned meticulously to avoid tattooing with dirt and sutured carefully with very fine suture material if necessary. X-rays are of doubtful value in nasal fractures and are difficult to interpret. If a previously straight nose is now bent, it must be broken. If it is not bent after an injury, no treatment is necessary.The key to whether treatment is necessary is the presence of deformity, which is more readily appreciated by standing behind the patient and looking down on the nose. If no deformity is present, no ma- nipulation or splinting is required. If deformity is present, decide whether it is bony or cartilaginous. If the nasal bones are displaced, reduction will be necessary.

When to reduce the fracture:

Nasal fractures can be reduced immediately after the injury with little addi- tional discomfort by simple manipulation, but the appropriate medical at- tendant is rarely present. More often, the patient presents himself to the casualty officer some time later, by which time oedema may obscure the extent of any deformity and preclude manipulation. The oedema will settle over 5–7 days and the patient should be referred to the ENT surgeon within a week of injury. He can then choose the most convenient time to carry out reduction. After 2 weeks, the bone may be so fixed as to render manipulation impossible, and deformity may be permanent.The optimum timing is usually 7–10 days after the injury. Reduction of fractured nasal bones The nose should be painted with cocaine paste or sprayed thoroughly with a mixture of lidocaine and phenylephrine to reduce bleeding. Reduction is carried out under general anaesthetic with an endotracheal tube and pharyngeal pack. Anything less than this may be dangerous,because blood can be inhaled. Simple lateral angulation of the nasal bones can often be reduced, with an audible click, by digital pressure on the nose. Depressed nasal fractures will require elevation with Walsham’s forceps. If the nasal bones are excessively mobile, splinting with plaster of Paris is necessary. Nasal fractures are now often reduced in outpatients under local anaes- thetic.The nose is cocainized and the external nasal nerve at its exit below the nasal bone is blocked with lignocaine. Nasal bone manipulation can then be carried out with minimal discomfort.

Late treatment of nasal fractures

If a patient with a fractured nose presents months or years after injury, manipulation is clearly not possible, and formal rhinoplasty is necessary. This involves elevation of the skin from the nasal skeleton, mobilization of the nasal bones by lateral saw cuts and realignment. It is a difficult pro- cedure and makes adequate early treatment of nasal fractures all the more important.

Septal dislocation with fracture

Nasal injury may result in deviation of the nasal septum, causing airway ob- struction. If no external deformity exists, treatment is by septoplasty or submucous resection (SMR) after a period of weeks or months. Sometimes the septal displacement is accompanied by external nasal deformity that is maintained by the misplaced septum. In such a case, reduction of the nasal bones may be achieved only if the septum is corrected surgically at the same time. Such surgery must be done before the nasal bones have set.

Septal haematoma

Sometimes, soon after a punch on the nose, the victim complains of very severe or complete nasal obstruction. This may be caused by a septal haematoma —the result of haemorrhage between the two sheets of muco- perichondrium covering the septum. It is often (but not always) associated with a fracture of the septum. The appearance is quite distinctive. Both nasal passages are obliterated by a boggy, pink or dull red swelling replacing the septum.

TREATMENT Treatment may be expectant in the case of a very small haematoma, but a large one requires incision along the base of the septum, evacuation of the clot, the insertion of a drain, and nasal packing to approximate the septal coverings of muco-perichondrium. Antibiotic cover should be given in an attempt to avert the development of a septal abscess.The patient should be warned that deformity of the nose may ultimately occur.