© Borgis - New Medicine 3/1999, s. 6-7
Mieczysław Chmielik1, Hubert Wanyura2, Iwona Jakubczyk1
Management of nasal trauma in children
1 Department of Paediatric Otorhinolaryngology, Warsaw Medical School, Poland
Head: Prof. Mieczysław Chmielik M.D.
Summary
Management of different nasal traumas, nasal fractures, and maxillary fractures in children are discussed. The principles of treatment are based on experience of the paediatric otorhinolaryngology and maxillo-facial surgery departments. The results of proposed treatments are discussed.
The child, who is inquiring and active, often encounters traumas, especially to the nose, because of its projection from the face.
The increased number of accidents related to the development of civilisation results in a growth of incidence of different nasal traumas in children. The number of traditional causes of deformations, such as a kick or a bite, has not decreased.
Time for diagnostic and therapeutic procedures in nasal trauma is limited because of the healing dynamics in children, so the principles of management should be clearly defined. On the other hand, the potential of facial development in a child gives a possibility of better healing of the injuries than in adults.
A trauma to the nose may cause injuries of the:
1. soft tissues,
2. septal and lateral nasal cartilages,
3. nasal bones:
- fracture without displacement,
- fracture with displacement,
4. central midface region.
A nasal injury resulting in soft tissue swelling does not usually require medical treatment except for debridement if an open wound is detected. However, in some cases haematoma along the septum may occur. An abscess of the septum which may develop from the haematoma usually results in the destruction of septal cartilage and severe nasal deformation such as „Saddle nose”. Hence, the septal haematoma should be drained and systemic antibiotics should be administered. If an abscess is detected this management should be also accompanied by inspection of the septal cartilage. If there is a loss of cartilage in regions I or III, simultaneous reconstruction is recommended with preserved cartilage used as a graft.
When the trauma results in nasal fracture with displacement, closed reduction is required in a maximum of 7 days time following the trauma. Delayed closed reduction may cause healing with misalignment. However, swelling occurring after trauma makes the assessment of deformity more difficult.
If closed reduction is ineffective or fixed nasal deformity is observed, septal reconstruction and sometimes rhinoplasty of the pyramid is required. These operations are necessary when dislocated fragments obstruct the airway and nasal breathing is impaired. Operations to improve breathing should be carried out immediately after the diagnosis of nasal airway obstruction, regardless of the child´s age. The surgical procedure should be performed as conservatively as neccessary to obtain a sufficiently functional result. Surgical intervention should take into consideration such principles as symmetry of operation, preservation of cartilage elements, and intact mucous membrane.
If a closed reduction of nasal fracture seems to be ineffective, or more severe symptoms are observed, an injury of the central midface should be considered and diagnostic procedures should be carried out. The role of the central midface skeleton is to protect the central nervous system from trauma. An impact to this region may destroy this so-called „joint area”, which is made up of the nasal bone and medial portion of the orbit. A strong impact may crush the nasal bones and frontal processes of the maxilla. If its kinetic energy is still not absorbed, this impact may produce a penetrating injury involving structures of the interorbital space such as the medial wall of the orbit, ethmoid cells, lamina perpendicularis, and even the orbital floor. The more penetrating the injury, the worse functional and aesthetic complications it produces.
These fractures are called „orbitonasal dislocations”, and they are responsible for severe symptoms such as telecanthus, proptosis, lacrimal system laceration, double vision, and deformation of the nose.
Orbitonasal dislocations require surgical treatment. The purpose of the treatment is to achieve reconstruction of the nasal, sinus and orbital bony structures, fixation of the medial canthuses in their proper position, and restoration of patency of the lacrimal system. The management of these fractures may require the co-operation of specialists in maxillofacial surgery and otolaryngology.
Piśmiennictwo
1. Chmielik M. i wsp.: Reduction of nasal fracutres in children. Int. J. Ped. Otorhinolaryngol. 1986, 11:1-4. 2. Cottle M.H. et al.: Rhino-sphyngomanometry and rhinoeosphyngmomanometry. Int. Rhinology, 1963, 1:23-27. 3. Hotte H.H.: Orbital fractures.Ban Gorcum. Assen 1970. 4. Masing H., Kurze H.N.O.: Operationslehre. Georg Thieme Verlag. Stuttgart, 1971,13-68. 5. Masing H. et al.: Nasal pressure flow studies in adults and children. Rhinology, 1974, 12:137-143. 6. Reny A., Stricker M.: Fractures de l´orbite. Indications ophtalmologiques dans les techniques operatoires. Paris 1969, 1:171. 7. Rougier J. et al.: Chirurgie plastique orbitopalpebrale. Masson, Paris, New York, Barcelona, Milan, 1-498. 8. Tesier P. et al.: Les dislocations orbito-nasales. La canthopexie interne. Bull. Scoc. Opthal. 1970, 84:634-654. 9. Van Loosen J. et al.: Growth characteristics of the human nasal septum. Rhinology 1996, 34, 2:7882. 10. Wanyura H. Własne propozycje leczenia złamań oczodołu. Praca habilitacyjna AM, W-wa 1990, 1-249. 11. Wanyura H.: Złamania szkieletu czaszkowo-twarzowego. Chirurgia głowy i szyi. PZWL W-wa 1996, 116-158.
