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Acute nasal trauma in children
Acute Nasal Trauma in Children By Charles A. East and Gerry O ' D o n a g h u e Oxford, England 9 Fifty consecutive nasal injuries in children are described. The most i m p o r t a n t causative factors w e r e domestic injuries (40%} and sport trauma (34%1. Over 90% initially presented to d e p a r t m e n t s o t h e r than ear, nose, and throat. T w e n t y cases required examination under general anesthesia. The severity of these injuries may be u n d e r e s t i m a t e d unless intranasal e x a m i n a t i o n is performed. 9 1987 by Grune & Stratton, Inc. INDEX WORDS: Nasal trauma, children,
T IS A L M O S T I N E V I T A B L E that an injury to the nose will be sustained at some time by all children. Disturbance of the growth centers I essential to normal development may cause significant cosmetic and functional disability. Because of these factors patients should be carefully examined and expeditiously referred for a specialist opinion when indicated. Reconstructive surgery is often required although it may not be requested until many years later when continued misdirected growth has produced a severe disability. 2 The responsibility for preventing these deformities lies with those who initially evaluate these patients. This study demonstrates the pattern of these injuries, highlights some pitfalls in their evaluation, and outlines an approach to management.
I
MATERIALS A N D METHODS This study comprises 50 consecutive children up to the age of 16, who were referred to the Ear, Nose and Throat department at the Radcliffe Infirmary, Oxford with nasal injuries. Initial examination had been in the Casualty department or by family practitioners or pediatricians. A small number had come to the department directly. The age and sex of the child and the circumstances of the injury were recorded in each case. Parents were asked in detail about the appearance of the nose prior to injury and were told to be precise about any resulting deformity. A thorough intranasal examination was undertaken to determine the position of the cartilages, to assess the mucosa, and to evaluate the patency of each nostril. Photographic records were obtained in those with significant injury and in all cases where litigation was considered likely. When a satisfactory examination was impossible the injury was assessed under anesthesia. RESULTS
The ages of the children ranged from 3 weeks to 15 years with a peak incidence from 5 to 8. There were
more than twice as many males as females and 64% of the injuries occurred between the months of May and September. Most patients presented soon after their injury; 39 within 24 hours and all but one of the remainder within a week. Referrals were from casualty (60%), general practitioners (24%), self referrals (10%), and pediatricians (6%). The etiology of the injuries is summarized in Table 1. Most domestic injuries were due to falls in or near the home. Two children appeared to be accident prone; one had his tenth nasal injury! Falls through windows or glass doors caused the most severe injuries, including on one occasion almost complete avulsion of the nasal tip. There was one case of complete nasal obstruction due to a septal hematoma. Sports injuries occurred during contact sports, but five were the result of using gymnastic apparatus. Unlike other facial injuries, traffic accidents were not a predominate etiological factor. One 18-month-old Asian child was the victim of child abuse and presented 3 weeks following injury. The child's father had a poor command of English and the diagnosis might have been missed were it not for the severity of the trauma. The child had no other injuries (Fig 1). Many injuries such as abrasions and lacerations were confined to the soft tissues of the nose. Nineteen children had a skeletal injury (either a fracture, dislocation of bone or a tear, or displacement of the nasal cartilages). Twenty of the 50 cases (40%) required general anesthesia to evaluate or correct the injury. Epistaxis complicating these injuries was usually mild and was treated by cautery following the application of topical anesthetic and vasoconstrictors to the nasal lining. Only one child required blood transfusion and nasal packing under general anesthesia. DISCUSSION
Injuries to the nose in childhood occur frequently and their significance is often overlooked or underestimated. The degree of injury can be difficult to evaluate even to the experienced observer. Several factors account for this. A child who has suffered recent trauma may be apprehensive about an examination. Table 1. Causes of Nasal Injury in the 50 Children
From the Department of Otolaryngology, Radcliffe Infirmary, Oxford, England. Address reprint requests to Charles A. East, Royal Ear Hospital, Huntley St, WCIE 6AU England. 9 1987 by Grune & Stratton, Inc. 0022-3468/87/2204-0003503.00/0 308
Domestic Sport Road traffic accident Fights Miscellaneous Total
20 17 4 4 5 50
Journal of Pediatric Surgery, Vol 22, No 4 (April), 1987: pp 308-310
NASAL TRAUMA IN CHILDREN
309
Fig 3. Elevation of the tip allows inspection of the nasal cavities. The caudal septum is dislocated into the right nostril. Fig 1.
Massive nasal hematoma from nonaccidental injury.
,i
Fig 2. Recent injury in a 6-year-old child. Note the associated facial swelling.
The soft tissues of the nose in children swell more rapidly and can thus conceal an underlying deformity (Fig 2). Fractures are commonly of the greenstick variety and can easily escape diagnosis: many exhibit little external deformity even when the internal architecture of the nose is severely disrupted. The cartilages of the nose in children are softer than in adults, and tend to twist and buckle. Subperichondrial hemmorrhage and subsequent fibrosis occur more rapidly, and this may result in deformation of the nose. As over 90% of patients present initially to other medical services, what constitutes a reasonable approach for the clinician occasionally confronted with these injuries? Careful history taking is essential, particularly when child abuse may be the cause: it is estimated that between 30% to 50% of these children have a facial injury. 3 Examination of the nose should be within the skill of every doctor and must include examination of the nasal cavities. A simple light source and gentle pressure elevating the nasal tip with the thumb is usually sufficient to display the important intranasal structures (Fig 3). However, a fractious child may not allow even this timid approach and examination may have to be undertaken under anesthesia.
310
EAST AND O'DONAGHUE
The nasal septum in children is usually in the midline and rarely more than 2 to 4 m m thick. 4 A boggy swelling and blue discoloration represents either a septal h e m a t o m a or abscess formation, and is an indication for urgent ear, nose, and throat referral. The consequences of a missed diagnosis are serious. H e m a toma formation even in the absence of infection m a y devascularize large segments of cartilage on which the structural support and future growth of the nose depend. Aseptic liquefaction of devascularized cartilage m a y occur rapidly and even be complete by four days. 5 A n untreated septal abscess m a y cause meningitis or cavernous sinus thrombosis. The external examination of the nose should include gentle palpation of the bridge for assymmetry. While a ten day delay in the treatment of nasal fractures in the adult is acceptable, such injuries in children should be treated within four days. W h e n seen early, these injuries can usually be treated by closed reduction under general anesthesia, to restore the nose
to its original appearance and ensure an adequate airway. Open techniques, if indicated, must be conservative and concentrate on repositioning rather than excising skeletal elements, thus avoiding d a m a g e to the growth centers. The results of septal reconstructive procedures performed months or years following injury are less likely to have a satisfactory outcome. In recent published series nearly 30% required revision within 2 years, and the figure m a y be even higher when the children reach adulthood. Despite this, a strong case can be made for conservative surgery on the septum and nasal bones when there is a severe deformity or marked nasal obstruction, as these features can themselves interfere with nasal growth. 6'7 Nasal injuries in children are not preventable. Thus, it is important to make every effort to minimize the deformities that they cause. M a n y difficult nasal reconstructions and tedious submucous resections can be avoided if proper treatment is instituted at the time of injury. 8
REFERENCES
1. Rock WP, Brain DJ: Effects of nasal trauma during childhood upon growth of the nose and midface. Br J Orthod 10:38-41, 1983 2. Pirsig W: The influence of trauma on the growing septal cartilage. Rhinology 13:39-46, 1975 3. Becker DB, Needleman H, Kotelchuck M: Child abuse: Orofacial trauma and its recognition by dentists. J Am Dent Assoc 97:24-28, 1978 4. Olsen K, Carpenter R, Kern E: Nasal septum injury in children. Arch Otolaryngol 106:317-20, 1980
5. Fry HJH: Pathology and treatment of haematoma of the nasal septum. Br J Plast Surg 22:331-335, 1969 6. Huizing EH: Septum surgery in children: Indications, surgical technique and long term results. Rhinology. 17:91-100, 1979 7. Pirsig W: Septal plasty in children, influence on nasal growth. Rhinology 15:193-204, 1977 8. FomonS, Schattner A, Bell J, et al: Arch Otolaryngol 55:321325, 1952
T IS A L M O S T I N E V I T A B L E that an injury to the nose will be sustained at some time by all children. Disturbance of the growth centers I essential to normal development may cause significant cosmetic and functional disability. Because of these factors patients should be carefully examined and expeditiously referred for a specialist opinion when indicated. Reconstructive surgery is often required although it may not be requested until many years later when continued misdirected growth has produced a severe disability. 2 The responsibility for preventing these deformities lies with those who initially evaluate these patients. This study demonstrates the pattern of these injuries, highlights some pitfalls in their evaluation, and outlines an approach to management.
I
MATERIALS A N D METHODS This study comprises 50 consecutive children up to the age of 16, who were referred to the Ear, Nose and Throat department at the Radcliffe Infirmary, Oxford with nasal injuries. Initial examination had been in the Casualty department or by family practitioners or pediatricians. A small number had come to the department directly. The age and sex of the child and the circumstances of the injury were recorded in each case. Parents were asked in detail about the appearance of the nose prior to injury and were told to be precise about any resulting deformity. A thorough intranasal examination was undertaken to determine the position of the cartilages, to assess the mucosa, and to evaluate the patency of each nostril. Photographic records were obtained in those with significant injury and in all cases where litigation was considered likely. When a satisfactory examination was impossible the injury was assessed under anesthesia. RESULTS
The ages of the children ranged from 3 weeks to 15 years with a peak incidence from 5 to 8. There were
more than twice as many males as females and 64% of the injuries occurred between the months of May and September. Most patients presented soon after their injury; 39 within 24 hours and all but one of the remainder within a week. Referrals were from casualty (60%), general practitioners (24%), self referrals (10%), and pediatricians (6%). The etiology of the injuries is summarized in Table 1. Most domestic injuries were due to falls in or near the home. Two children appeared to be accident prone; one had his tenth nasal injury! Falls through windows or glass doors caused the most severe injuries, including on one occasion almost complete avulsion of the nasal tip. There was one case of complete nasal obstruction due to a septal hematoma. Sports injuries occurred during contact sports, but five were the result of using gymnastic apparatus. Unlike other facial injuries, traffic accidents were not a predominate etiological factor. One 18-month-old Asian child was the victim of child abuse and presented 3 weeks following injury. The child's father had a poor command of English and the diagnosis might have been missed were it not for the severity of the trauma. The child had no other injuries (Fig 1). Many injuries such as abrasions and lacerations were confined to the soft tissues of the nose. Nineteen children had a skeletal injury (either a fracture, dislocation of bone or a tear, or displacement of the nasal cartilages). Twenty of the 50 cases (40%) required general anesthesia to evaluate or correct the injury. Epistaxis complicating these injuries was usually mild and was treated by cautery following the application of topical anesthetic and vasoconstrictors to the nasal lining. Only one child required blood transfusion and nasal packing under general anesthesia. DISCUSSION
Injuries to the nose in childhood occur frequently and their significance is often overlooked or underestimated. The degree of injury can be difficult to evaluate even to the experienced observer. Several factors account for this. A child who has suffered recent trauma may be apprehensive about an examination. Table 1. Causes of Nasal Injury in the 50 Children
From the Department of Otolaryngology, Radcliffe Infirmary, Oxford, England. Address reprint requests to Charles A. East, Royal Ear Hospital, Huntley St, WCIE 6AU England. 9 1987 by Grune & Stratton, Inc. 0022-3468/87/2204-0003503.00/0 308
Domestic Sport Road traffic accident Fights Miscellaneous Total
20 17 4 4 5 50
Journal of Pediatric Surgery, Vol 22, No 4 (April), 1987: pp 308-310
NASAL TRAUMA IN CHILDREN
309
Fig 3. Elevation of the tip allows inspection of the nasal cavities. The caudal septum is dislocated into the right nostril. Fig 1.
Massive nasal hematoma from nonaccidental injury.
,i
Fig 2. Recent injury in a 6-year-old child. Note the associated facial swelling.
The soft tissues of the nose in children swell more rapidly and can thus conceal an underlying deformity (Fig 2). Fractures are commonly of the greenstick variety and can easily escape diagnosis: many exhibit little external deformity even when the internal architecture of the nose is severely disrupted. The cartilages of the nose in children are softer than in adults, and tend to twist and buckle. Subperichondrial hemmorrhage and subsequent fibrosis occur more rapidly, and this may result in deformation of the nose. As over 90% of patients present initially to other medical services, what constitutes a reasonable approach for the clinician occasionally confronted with these injuries? Careful history taking is essential, particularly when child abuse may be the cause: it is estimated that between 30% to 50% of these children have a facial injury. 3 Examination of the nose should be within the skill of every doctor and must include examination of the nasal cavities. A simple light source and gentle pressure elevating the nasal tip with the thumb is usually sufficient to display the important intranasal structures (Fig 3). However, a fractious child may not allow even this timid approach and examination may have to be undertaken under anesthesia.
310
EAST AND O'DONAGHUE
The nasal septum in children is usually in the midline and rarely more than 2 to 4 m m thick. 4 A boggy swelling and blue discoloration represents either a septal h e m a t o m a or abscess formation, and is an indication for urgent ear, nose, and throat referral. The consequences of a missed diagnosis are serious. H e m a toma formation even in the absence of infection m a y devascularize large segments of cartilage on which the structural support and future growth of the nose depend. Aseptic liquefaction of devascularized cartilage m a y occur rapidly and even be complete by four days. 5 A n untreated septal abscess m a y cause meningitis or cavernous sinus thrombosis. The external examination of the nose should include gentle palpation of the bridge for assymmetry. While a ten day delay in the treatment of nasal fractures in the adult is acceptable, such injuries in children should be treated within four days. W h e n seen early, these injuries can usually be treated by closed reduction under general anesthesia, to restore the nose
to its original appearance and ensure an adequate airway. Open techniques, if indicated, must be conservative and concentrate on repositioning rather than excising skeletal elements, thus avoiding d a m a g e to the growth centers. The results of septal reconstructive procedures performed months or years following injury are less likely to have a satisfactory outcome. In recent published series nearly 30% required revision within 2 years, and the figure m a y be even higher when the children reach adulthood. Despite this, a strong case can be made for conservative surgery on the septum and nasal bones when there is a severe deformity or marked nasal obstruction, as these features can themselves interfere with nasal growth. 6'7 Nasal injuries in children are not preventable. Thus, it is important to make every effort to minimize the deformities that they cause. M a n y difficult nasal reconstructions and tedious submucous resections can be avoided if proper treatment is instituted at the time of injury. 8
REFERENCES
1. Rock WP, Brain DJ: Effects of nasal trauma during childhood upon growth of the nose and midface. Br J Orthod 10:38-41, 1983 2. Pirsig W: The influence of trauma on the growing septal cartilage. Rhinology 13:39-46, 1975 3. Becker DB, Needleman H, Kotelchuck M: Child abuse: Orofacial trauma and its recognition by dentists. J Am Dent Assoc 97:24-28, 1978 4. Olsen K, Carpenter R, Kern E: Nasal septum injury in children. Arch Otolaryngol 106:317-20, 1980
5. Fry HJH: Pathology and treatment of haematoma of the nasal septum. Br J Plast Surg 22:331-335, 1969 6. Huizing EH: Septum surgery in children: Indications, surgical technique and long term results. Rhinology. 17:91-100, 1979 7. Pirsig W: Septal plasty in children, influence on nasal growth. Rhinology 15:193-204, 1977 8. FomonS, Schattner A, Bell J, et al: Arch Otolaryngol 55:321325, 1952