Nose injuries: causes, symptoms, diagnosis, treatment

Traumas of a nose by origin are divided into everyday, sports, industrial and wartime. The most frequent of them are domestic and sports. Household injuries are caused by an accident or conflict situation resolved by the fist method. Injuries in case of accidents are caused by a drop in the face of subjects who are drunk or when stumbling over an obstacle. Most often this type of injury occurs in children. Due to the elasticity of the pyramid of the nose and the cartilage frame, immediate destructive effects do not occur, but subsequently, with the further development of the facial skeleton, and in particular the structures of the nose, these injuries can be the cause of the development of various dysgenesis, as discussed above.

In adults, domestic and sports injuries cause more extensive destruction at the time of the injury itself, since the skeleton of the nose is more rigid and brittle. Industrial injuries are not so frequent. They also occur in various accidents in production conditions (falling from a height, explosions, impacts by moving machinery, etc.). Traumas of wartime are caused by fragmentation or bullet wounds. They, as a rule, are combined with wounds of deep tissues of the face and are often dangerous for the life of the victim. These injuries occur during combat operations, but, like gunshots, they can occur when attempted to kill or suicide or as a result of an accident with careless handling of weapons. The consequences of nasal trauma can be associated with cosmetic or functional disorders, as well as with their combination.

Pathological anatomy. The type, shape, depth of the lesion in the trauma of the nose are determined by many factors: density, mass, speed of the traumatic object, the position of the victim, the direction of the head movement (counter, retreating or evading), and the direction of the force vector that leads to trauma. There are damage to the skeleton of the nose, its cartilaginous skeleton and associated damage to both structures of the nose pyramid, open and closed fractures of the bones of the nose, fractures of the bones of the nose without displacement and with displacement - lateral and in the sagittal plane with the formation of a "failed" nose. Open fractures of the nose can be both with damage to the skin, and with the breakthrough of the mucous membrane inside the nasal cavity. Fractures of the cartilaginous skeleton are most often observed in adults due to the compaction and fragility of the nasal septum, which is over 50 years old often saturated with calcium salts and acquires a density of bone tissue.

Fractures of the nasal bones can be combined with fractures of the skull bone parts, as well as the ascending branch of the maxilla, malar bone, bruise and fracture of the superior alveolar process and incisors. These injuries are in the competence of maxillofacial surgeons who have methods of splinting and repositioning fractures of facial bones and jaws with the imposition of bone seams and tooth implantation. As for ENT specialists - rhinologists, their competence includes repositioning of the dislocated parts of the nose pyramid and endonasal manipulations to restore the patency of the nasal passages.

Symptoms of a nose injury. Contusion of the nose pyramid refers to traumas that can cause pronounced reflex reactions - from a strong pain sensation to a traumatic shock accompanied by dilated pupils, bradycardia, shallow breathing. Pallor of the skin and loss of consciousness. Often, with bruises of the nose and frontal region, depending on the strength of the impact, there may be phenomena of concussion or a bruise of the brain.

A severe contusion of the frontal-nasal region should be attributed to TBI, in which in 60-70% of cases there is a concussion of the brain. Signs of the latter are loss of consciousness from a few seconds to several minutes; frequent nausea and vomiting. After the restoration of consciousness, the victims complain of headache, dizziness, noise in the ears, weakness, sweating, sleep disturbance. Often there is a loss of memory - the patient does not remember the circumstances of the injury, nor the short period of events before and after it. Of the other symptoms, it should be noted pain in the movement of the eyes, diplopia. Damage to the bones of the cerebral cranium is absent. The pressure of the cerebrospinal fluid and its composition do not change significantly. These symptoms usually disappear after 2-3 weeks, and with the appropriate treatment - before.

A bruise of the brain with frontal-nasal trauma - a more severe form of its defeat. Different from the shock of the presence of areas of damage to the brain, subarachnoid hemorrhage, and in some cases - fractures of the arch and the base of the skull. Considering the fact that massive nose injuries are often accompanied by bruises of the frontal lobes of the brain, the ENT-sietsialist should be guided in the classification of the degrees of bruise of the brain.

A bruised brain contusion of a mild degree is characterized by loss of consciousness for a period of a few minutes to 1 hour. After restoration of consciousness, the victims usually complain of headache, dizziness, nausea, etc. Brady or tachycardia may occur, sometimes an increase in blood pressure. There are nystagmus, asymmetry of tendon reflexes, meningeal symptoms, etc., which usually disappear 2-3 ice after trauma.

Contusion of the brain of the middle degree is accompanied by loss of consciousness for a period of several tens of minutes to 6 hours. Amnesia is expressed, sometimes there is a mental disorder. Possible multiple vomiting, transient disorders of vital functions. Usually develop clear meningeal symptoms. Focal symptomatology is determined by the localization of the brain contusion. It can be pupillary and oculomotor disorders, paresis of limbs, sensitivity disorders, speech, etc. Within 3-5 weeks the listed symptoms gradually disappear, but can persist for a long time, becoming methoso-, stress-dependent, ie, recurring in a reduced form.

A severe brain contusion is characterized by loss of consciousness from a few hours to several weeks. There are threatening violations of vital functions with a disorder of the frequency and rhythm of breathing, a sharp rise or fall of blood pressure, fever. In the neurological status, primary-stem symptomatology often prevails: floating eye movements, gaze pareses, widening or narrowing of pupils, impaired swallowing, changing muscle tone, pathological stop reflexes, etc. These symptoms in the first days after trauma obscure the focal signs of a brain contusion that with lesions of the frontal lobes differ in their features. Sometimes there are generalized or focal seizures, signs of cerebral edema. Cerebral and especially focal symptoms regress slowly; often marked residual motor disorders, changes in the mental sphere.

Objective symptoms of a nose injury include swelling and bruising on both sides in the area of the back of the nose, extending to the face and lower eyelids, sometimes to the subconjunctival space. With open fractures, wound skin damage, external bleeding, or a wound covered with bloody crusts are noted. With fractures of the bones of the nose and the cartilaginous frame, there is a displacement of the nose pyramid or the failure of its back. Feeling the fracture zone causes the patient a sharp pain and a feeling of crepitation and mobility of the back of the nose. In some cases, in the area of the fracture and in the surrounding tissues, there are phenomena of emphysema, manifested by an increase in the volume of tissues and crepitation of air bubbles. Emphysema occurs when the nasal mucosa is damaged and the nasal breathing difficulty arises due to hematoma and traumatic edema when the victim attempts to purge the nose. Emphysema occurs initially at the root of the nose, then spreads to the lower eyelids, the face and can spread even to the neck. Especially pronounced emphysema occurs in the trellis-ophthalmic fractures. With especially severe injuries of the fronto-nasal region, accompanied by fractures of the base of the skull and ruptures of the rigid meninges, nasal liquorrhea is observed.

With anterior rhinoscopy, blood clots, displacement of the septum of the nose, its thickening as a result of subperiosteal hematoma are determined in the nasal passages. The nasal concha is enlarged, the nasal passages are clogged. Radiography of the nose in the profile, as well as in the projections, visualizing the paranasal sinuses and the latticed bone, establish the final diagnosis.

The clinical course of a nose trauma depends on its severity, the presence of dislocation phenomena, and also on the extent to which the brain is involved in the traumatic process. Often the nose traumas go on themselves without the intervention of a physician, but after this often there are tons or other deformities that require later certain plastic surgeries.

Treatment is determined by the prescription of injury, the severity and type of anatomical disorders. In severe fresh injuries characterized by open fractures or injury, fragmentation of the skeleton, a shift to the side, or failure of the back of the nose, a surgical intervention is made, corresponding to the type and severity of the injury. In this case, reposition of the displaced fragments with restoration of the nasal passages and external shape of the nose is performed, preferably from the photograph of the victim. Apply atraumatic sutures to the wound, with the detachment and loss of tissues using a method of free autoplasty, borrowing a skin flap from the non-haired part of the trunk or forearm.

Surgical intervention is performed under local application and infiltration anesthesia or under anesthesia, observing the rules of aseptic and antiseptic. Surgery is completed with a tamponade of the nose and a fixing bandage and a metal angled splint on the back of the nose. Intranasal swabs, if they are impregnated with a syringe and a needle with an antibiotic solution, can be stored up to 4-5 days, then they are removed and after washing the nasal cavity with a solution of a sterile antiseptic, the nasal cavity is again swollen (friable) for 1-2 days, after which the swabs are removed finally. External fixing bandage is kept for up to 10 days. After it is removed, the swelling of the nose and surrounding tissues increases somewhat, but then passes through 2-3 days. After the operation, prescribe antibiotics, analgesics, sedatives, vitamins C and strong6, inject antitetanus serum. In case of massive blood loss, intravenously replacing blood-substituting fluids, transfusion of freshly citrated blood, erythrocyte mass. All victims with a nose trauma and headache complaints should be examined before surgery by a neurologist. In the presence of the phenomena of concussion of the brain or its contusion, the indications and contraindications to the operation are determined by the neurologist.

Postoperative course. In the first 2 to 3 days there is swelling of the face, bruising around the eyes, sometimes very significant, which disappear by the end of the 2nd week after the trauma or surgery.

After trauma and surgical intervention, some patients experience an increase in body temperature to 38 ° C, due to traumatic stress or brain concussion phenomena.

In those cases when proper surgical treatment was not performed within the next 2 days after injury due to infection of the wound, surgical intervention is postponed until the full recovery and final consolidation of the fragments.

In the formation of scarring in the nasal cavity and external deformation, its operative intervention for the rehabilitation of respiratory and cosmetic functions of the nose is carried out no earlier than 4-6 months, during which the process of scarring is finally completed.

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