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Nasal fractures |
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Isolated nasal fracture, clinical features: 1. Flattened or deviated nose 2. Swelling 3. Epistaxis 4. Septal deviation 5. Septal haematoma 6. Mouth breathing 7. Tenderness over nasal bones 8. Mobility
Due to the prominence of the nose, nasal injuries are fairly common. Be sure that the nasal deformity was not a previous injury. Check for septal deviation and a septal haematoma by inspecting the nasal airways. Leakage of CSF (cerebro-spinal fluid) indicates a fracture thought the cribiform plate of the ethmoid bone. This carries a risk of meningitis, and prophylactic antibiotics should be commenced.— Augmentin or amoxicillin.
Epistaxis should be treated by packing the nose. If this is not successful, insert an epistaxis catheter to control bleeding from branches of the anterior ethmoidal artery. Blood should be cross-matched as a preliminary to urgent referral to ENT.
It is usually wise to review the patient after 48—72 hours to allow for initial swelling to subside. Displaced nasal cartilages can be manipulated by digital pressure alone. Fractures of the nasal bones and frontal processes of the maxillae should be reduced by closed manipulation with Walsham’s nasal forceps and Asche’s septal forceps under GA.
Opinions differ as to the ideal timing for manipulation. It should certainly not be delayed for more than 10 days from time of injury. Manipulation is required to restore an obstructed nasal airway or for cosmetic improvement. After a prolonged period manipulation becomes increasingly difficult and elective rhinoplasty at a later date may be required.
External splinting is often required. This can be done with a T-shaped plaster-of-Paris splint and packing the nose with ribbon gauze impregnated with Whitehead’s varnish. The nasal packing is removed after 24 hours and the splint after 10 days.
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