Reposition of nasal bones – nasal trauma up to 5 days

What to do?

• Emergency care for superficial injuries (superficial scratches, minor bruises) can be provided at home: the injuries should be washed with soap and water, and ice should be applied to the bruised area. If blood is flowing from the wound, a tampon with hydrogen peroxide should be pressed onto the area for 3–5 minutes.
• Bleeding from the nose - in the absence of signs of fracture of the nasal bones and nasal septum - you can try to stop it yourself (by packing the nasal passage with a tight gauze or cotton swab moistened with hydrogen peroxide or cold water). If the bleeding is severe and, despite all efforts, does not stop, you must call an ambulance.
• If you suspect a fracture of the nasal bones or nasal septum, you should contact a specialized clinic as soon as possible.

Diagnosis of nasal bone fracture

Primary diagnosis is based on the patient's complaints and examination. In this case, it is possible to determine changes in the shape of the nose, asymmetry, and the degree of swelling. Palpation (palpation) can reveal pathological mobility of the back and wings of the nose, pain at the fracture site. You can also hear the crunching of bone fragments. An X-ray examination is prescribed if there are no visible abnormalities in the structure of the nose in the presence of other symptoms of a fracture. X-rays are performed in lateral and frontal projections.

Dangerous symptoms

If you suspect a fracture of the nasal bones or nasal septum, it is important to pay attention to the following signs of combined trauma and complications:

1. heavy bleeding. Possible in case of damage to the nasal mucosa with bone fractures;
2. lacrimation. May occur with combined trauma to the orbit and lacrimal ducts;
3. release of cerebrospinal fluid. It is observed with a fracture of the ethmoid bone, which is adjacent to the upper nasal passages.

It is difficult for a layperson to distinguish between lacrimation and a cerebrospinal fluid leak, so clear or blood-stained fluid coming from the nose should raise suspicion. In such cases, you should seek qualified help as soon as possible.

Indications for surgery

Direct indications for surgical manipulation are:

• closed fractures of the nose - the outer integument is not damaged or the damage is expressed by superficial abrasions;
• open fractures, with damage to superficial tissues and bone fragments in the wound;
• fractures with displacement (there is a pronounced deformation of the nasal skeleton, disrupting the asymmetry of the face).

Fractures are often confused with severe bruises. But there are several signs that unconditionally indicate serious organ injury:

• nosebleeds (external, internal);
• pain around the nose, the intensity of which increases when trying to feel the site of injury;
• swelling of the mucous membrane and soft tissues, leading to difficulties with nasal breathing;
• visible change in the shape of the organ (retraction of the back, pressing inward, displacement to the side);
• crepitus of bone fragments (a characteristic crunch is heard when trying to feel the organ) - this symptom is checked only by specialists, otherwise serious damage can be caused.

If you are injured and have even one of the above symptoms, do not delay, go to the doctor immediately.

Nasal septum fracture

Nose trauma is always accompanied by swelling, which does not allow doctors to perform surgery on the same day, so treatment always begins with conservative therapy. In addition, a nasal injury can be combined with a concussion, in which surgery is undesirable, so a pause of several days is a necessary condition.

The bone of the bridge of the nose may simply sink from the blow, without a fracture. It may break, but not completely, but like a willow branch breaks: the break is only on one side, on the other - everything is intact. These types of fractures are most often observed in children, because their bone tissue contains more elastic fibers than adults. In any case, the bone must be put back in place to restore nasal breathing and the external shape of the nose.

In our country, such operations are performed in two ways.

1. An old method that is still used in some hospitals. Under local anesthesia with a special instrument, similar to a long narrow spatula, the bone is lifted and fixed from below with a tight gauze swab. After a day or two they take it out, and the bone... sometimes it falls off again.
2. A new method that uses anesthesia (general anesthesia). Foreign doctors have proven that fixing tampons are actually not needed. The main thing is to place the bone correctly, because there are no muscles around it that could move it. And it is more convenient to place it correctly if the operation is performed under general anesthesia: the patient does not feel anything, does not experience fear, does not interfere with the surgeon’s work... In this case, a small tampon made of perforated rubber is used, with gauze inside, which serves only to absorb moisture. It does not injure the mucous membrane as much as a tight gauze swab does, and healing proceeds faster. Within a month, a bone callus forms at the site of retraction, which firmly strengthens the bridge of the nose. Such operations are performed abroad and in many domestic clinics.

Deviated nasal septum

In case of injury, a deviated nasal septum occurs less frequently than a fracture or retraction of a bone. But the operation to restore it is more difficult. In most of our hospitals it is performed the old fashioned way, according to the Killian method, developed back in 1901. In front of the place where the curvature is located, the doctor uses a scalpel to cut the mucous membrane, peel it off and cut out the deformed area. Then he presses the mucous membrane tightly with a gauze swab. The tampon lasts up to 5 days.

The problem is that the cartilage of the nasal septum is covered on both sides by the perichondrium, from which it grows, and the mucous membrane is already located on it. In the place where the fragment of the perichondrium is removed along with a piece of cartilage, under the influence of a constant flow of air, the mucous membrane begins to dry out. A hole may form in it, which enlarges over time, while the cartilage becomes exposed and may begin to deteriorate. In such cases, repeated surgery is required to close the resulting hole.

Now there are techniques that allow you to align the septum in a less traumatic way. For example, surgery using a microscope and endoscopic techniques. The doctor inserts a thin fiber-optic tube into the nasal cavity, which has a built-in light guide and a video camera that transmits the image to the monitor screen. Moreover, they reach the place of curvature of the cartilage without damaging the mucous membrane. An incision is made in the skin at the entrance to the nostril. The tissues are moved apart, the deformed section of cartilage is removed, taken out, straightened using a special apparatus, and inserted back. The nasal septum is compressed on both sides with silicone plates and stitched for fixation. A small cosmetic stitch is made at the entrance to the nostril. After a week, the silicone plates can be removed. The septum turns out smooth, the mucous membrane does not suffer or become inflamed, the nose breathes freely.

More about the operation

Nasal fractures account for almost 40% of the total number of facial injuries.
The causes of damage can be a traffic accident, a fall, household injuries, some sports, etc. Repositioning is a surgical procedure aimed at restoring the functionality and anatomy of the nose. The doctor compares bone fragments in an anatomically correct position, helping them to heal faster. The method of surgical intervention depends on the type of injury and its severity. Restoring the shape of the organ is carried out in the following ways:

• finger – used when it is necessary to eliminate lateral deformation. The doctor presses with his fingers on the area of ​​asymmetry until there is a click, which is evidence that the bones are in place. A control x-ray examination is performed both before and after the manipulation;
• instrumental - performed using special instruments (Volkov elevators), which the surgeon inserts into the nasal canals and lifts bone fragments with them, restoring the shape of the organ. A control x-ray examination is performed both before and after the manipulation;
• finger-instrumental – is carried out in the presence of retraction of the back of the nose and displacement of the bones to the side. The otolaryngologist expands the nasal passages with special dilators, returning the displaced fragments to their place and fixes them in their normal position with dense turundas (anterior nasal tamponade), which simultaneously perform a hemostatic function. A control x-ray examination is performed both before and after the manipulation.

In cases of severe open fractures or fractures of all lateral cartilages, open reconstruction of the nasal skeleton is used. This is a full-fledged operation that involves cutting tissue, comparing bone fragments under visual control, and applying sutures. To fix the fragments put in place, tamponade, special plate devices, metal, plastic or plaster splints, etc. can be used.

Where to treat nasal injuries?

It is best to treat a nasal injury in a clinic that specializes in oral and maxillofacial surgery. The diagnosis of a fracture of the nasal bones and nasal septum is usually made on the basis of x-rays.

Such injuries are dangerous not only because of a cosmetic defect. A change in the diameter of the nasal passages due to injury often leads to the subsequent development of persistent vasomotor rhinitis. When one of the nasal passages narrows, the child’s brain, through the neuro-reflex endings located in the mucous membrane, receives a signal about trouble (as with inflammation). In this regard, a reflex secretion of mucous fluid begins, similar to a runny nose. Such a “runny nose” can bother a person throughout his life. Sometimes in such cases, the patient is mistakenly diagnosed with “allergic rhinitis” and appropriate therapy is carried out for a long time, persistently and unsuccessfully. Meanwhile, if correction is carried out in time after an injury, nothing like this will happen.

If surgery is necessary, parents have 7-10 days after the injury (while the swelling subsides) to choose a hospital.

Clinic selection criteria:

• Find out which hospitals perform nasal septum surgeries under general anesthesia. The requirement is understandable: in such ENT departments there are specially trained anesthesiologists, doctors are proficient in modern techniques, the operation can be performed efficiently and comfortably for the child, and recovery will come faster.
• Ask how often such operations are performed in this hospital, including for children.
• If you are going to have surgery on the nasal septum, it is good if it is done under a microscope or using endoscopy.

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