CHAPTER 5

THE EXTERNAL NOSE, NASAL ORIFICES AND
NASAL SEPTUM

NASAL INJURIES

Direct injury to the nose is common. It frequently occurs in sport, such as
boxing, football or rugby; in falls in toddlers, children or adults; and in
accidents, either car accidents or in beating up by thugs.

In children fracture of the nasal bones is uncommon when one considers the
frequency with which they injure their noses. Toddlers often fall while learning
to walk with consequent injury, and children may suffer injury to the face in
falls or by being struck by a swing. They may suffer extensive bruising with
ecchymosis, and not infrequently there is a subperiosteal effusion of blood
over the nasal bones, giving rise to a swelling on one side which takes some
weeks to absorb fully. A direct blow to the nose may splay the nasal bones,
and this may not be apparent radiographically. It may result in a permanent
broadening of the nasal bridge, to the distress of the mother; and, if it is
severe*, it mayTfequire plastic correction when the child is older. The effects of
this may be minimized by the application of narrow adhesive strips across the
bridge at the time of the accident which serve to prevent further splaying when
fibrosis occurs. In children, too, the cartilaginous nasal septum may become
dislodged either out of its sulcus in the columella so that the dislocated
anterior end projects into the anterior naris, or out of its attachment to the
nasal crests of the maxillary and palatine bones so that it becomes deviated to
one side or the other. If this dislocation is diagnosed early enough following
the accident the cartilage may be repositioned under anaesthesia. Again,
children more frequently develop a septal haematoma or abscess than a
fracture of the nasal bones.

Fracture of the Nasal Bones. A direct blow to one side of the nose may
produce a depressed fracture of that nasal bone under its fellow, while a
direct blow on the front of the nose may fracture both nasal bones with
depression of the tip (Fig. 16). The extent of the injury may not be immediately
apparent because of the swelling, but radiography will demonstrate bony
injury. The nose should be inspected with the head thrown back, when any
asymmetry is apparent, and a comparison of the two anterior nares will
reveal any septal dislocation. Gentle palpation of the nasal bones is carried
out with the forefingers, the other fingers being steadied on the sides of the
head. A sensation of elasticity or springing will be experienced on the side
opposite the depressed fracture because the bone has been driven under its
neighbour. Firm pressure on this side may reduce the fracture, the depressed
bone snapping back into place if the fracture is recent. Usually a general
anaesthetic is required because of the pain of such a manoeuvre. Pentothal

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