Nasal Trauma

Question 1

Which arteries supply blood to the inside of the nose?

Answer 1

Blood supply to the nose is from branches of the maxillary (sphenopalatine and greater palatine) and the anterior and posterior ethmoidal arteries (from the ophthalmic). These anastomose together at 5 points in the cartilage of the nose known as Little’s Area (keisselbach’s plexus) and is the site of 90% of nosebleeds. 10% comes from the sphenopalatine which tends to be problematic due to the high pressure of this artery, usually you will only be able to stop the bleeding with posterior packing.

Question 2

What commonly causes nose bleeds?

Answer 2

Idiopathic (vast majority) 
Trauma 
Iatrogenic
Foreign body 
Inflammatory 
Neoplastic
Hypertension 
Coagulopathies

Question 3

What are the management steps for epistaxis?

Answer 3

1. Resuscitate if needed
2. Assess which side, discern how long it has been bleeding and calculate blood loss
3. Check drug history for antiplatelets and anticoagulants
4. Ask patient to pinch soft part of nose and breath through mouth, lean forwards and spit blood into a bowl for 20 minutes. Apply ice to dorsum of nose
5. Encourage blowing out of nasal clots and prepare to cauterize with silver nitrate
6. Apply cotton ball soaked in 1:200’000 adrenaline to vasoconstrict or use a topical local anaesthetic e.g. Co-phenylcaine
7. Apply cautery for 2 seconds starting from the edge and moving inwards in a circle, never cauterise both sides or risk perforation
8. If bleeding point isn’t visible, then refer to ENT
9. Anterior packing if bleeding continues and posterior packing failing this. Note apply topical anaesthesia before commencing. Anterior packing of both nostrils can increase pressure against septum.

If packing takes place patient must be reviewed in hospital.

Question 4

Where exactly in the nose is bleeding most likely to be found?

Answer 4

Note bleeding is almost always septal so look here first

Question 5

How should you manage serious posterior epistaxis?

Answer 5

Examination under anaesthesia – diathermy and packing
Arterial ligation – endoscopic ligation of the sphenopalatine artery
Embolization – of the internal maxillary or facial artery can be lifesaving but can also cause a stroke. Final resort is external carotid ligation.

Question 6

What advice should patients be given on discharge after epistaxis?

Answer 6

Apply antiseptic if possible, such as Naseptin or Muciprocin
Self-care advice involves reducing the risk of re-bleeding. Patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks should be avoided. The same applies for patients who have just been cauterised, as any strain on the nostril may induce a re-bleed.

Question 7

What must you exclude after a nasal fracture?

Answer 7

Must exclude significant head or c-spine injuries

Question 8

What usually causes a broken nose?

Answer 8

Punch
Crash of heads
Fall

Causes a broken nasal bone

Question 9

How do broken noses present?

Answer 9

Short lived epistaxis
Nasal deformity
Pain
Facial swelling and black eyes

Question 10

How should a nose fracture be investigated?

Answer 10

Examine from behind and above and along line of nose

X-ray not required but may be useful to exclude other trauma

Question 11

When diagnosing a broken nose what must you check for before moving onto management?

Answer 11

Check for septal haematoma which usually presents with nasal obstruction and requires urgent incision and drainage and cover with antibiotics. Will see a bilateral red swelling that can be differentiated from deviated septum by probing – haematomas are boggy whilst septa are firm. Left untreated will results in necrosis and saddle nose deformity.

Question 12

How is a broken nose managed?

Answer 12

Analgesia using ice
Close any skin injury
Reassess 5-7 days post injury
Manipulation under anaesthetic can be performed 2 weeks post injury before the bone sets

Question 13

How should a broken nose be managed if there is CSF rhinorrhoea?

Answer 13

If CSF rhinorrhoea – will test positive for glucose in laboratory and contain beta tau and transferrin. If traumatic conservative management is best with 7-10 days bed rest with the head elevated. Avoid coughing, sneezing and nose-blowing. Surgery rarely needed and cover with antibiotics and pneumococcal vaccine.

Question 14

How does a nasal foreign body present?

Answer 14

Usually inserted by children.

Organic material presents early with purulent unilateral discharge
Inorganic bodies remain for a long time

Question 15

How should you examine for a foreign body in the nose?

Answer 15

Use aurosocpe to examine the nose

Question 16

What is the management for a foreign body in the nose?

Answer 16

Ask child to blow their nose
Parental kiss – blow into child’s mouth with non-affected nostril is forced shut
If child older and cooperative, then may be possible to grab with crocodile forceps
Batteries need urgent removal
Refer to ENT if failed attempt or uncooperative patient

Question 17

What causes septal perforation?

Answer 17

Most commonly occurs after septal surgery
Trauma – nose picking, foreign body, laceration and septal haematoma
Inhalants – nasal steroid/decongestant spray and cocaine abuse
Infection – TB, syphilis and HIV

Question 18

How does a septal perforation present?

Answer 18

Perforations irritate, whistle, crust and bleed

Question 19

How should a septal perforation be managed?

Answer 19

Symptomatic
Saline nasal irrigation
Petroleum jelly application to edge of the perforation
Surgery is rarely helpful

Question 20

What is septoplasty?

Answer 20

Septoplasty – repairs deviated septum usually when it is obstructing airflow

Question 21

What is a septorhinoplasty?

Answer 21

Septorhinoplasty – straighten the shape of the nose for cosmesis and airway improvement

Question 22

What post surgical management is required after a septoplasty or septorhinoplasty?

Answer 22

For both must not blow nose for 1 week and have saline nasal irrigation 4 x a day for 2 weeks to prevent crusting.

Question 23

What is nasal saline irrigation?

Answer 23

Sniff a saline solution into the nostril – this helps keep the nose clean and prevent crusting. Create with one teaspoon of salt and one of bicarbonate of soda. Mix 1 pint of cooled boiled water. Fill a squeezy bottle and spray up into the nose letting it drain out.