Nasal trauma is defined as any injury to the nose or related structure
that may result in bleeding, a physical deformity, a decreased ability to
because of obstruction, or an impaired sense of smell. The injury may be
either internal or external.
The human nose is composed of bone, soft tissue, and cartilage. It serves
as a passageway for air to flow from the outside environment into the
lower respiratory tract and lungs. At the same time the nasal passages
warm and humidify the air that enters the body.
Internal injuries to the nose typically occur when a foreign object is
placed in the nose or when a person takes in drugs of abuse (inhalants or
cocaine) through the nose. External injuries to the nose are usually blunt
force injuries related to
participation, criminal violence,
, or automobile or bicycle accidents. This type of injury may result in a
nasal fracture. The nasal bones are the most frequently fractured facial
bones due to their position on the face, and they are the third most
common type of bone fracture in general after
of the wrist and collarbone. A force of only 30 g is required to break
the nasal bones, compared to 70 g for the bones in the jaw and 200 g for
the bony ridge above the eyes. The pattern of the fracture depends on the
direction of the blow to the nose, whether coming from the front, the
side, or above the nose. Although not usually life-threatening by itself,
a fractured nose may lead to difficulties in breathing as well as facial
Fractures resulting from trauma to the nose may involve the bones of the
septum (the partition of bone and cartilage dividing the two nostrils) as
well as the bones surrounding the eyes. These bones include the nasal,
maxilla, lacrimal, and frontal bones. Direct trauma to the bridge of the
nose may also result in damage to a part of the base of the skull known as
the cribriform plate. This injury in turn may allow cerebrospinal fluid to
leak out of the skull and leave the body through the nose. Fractures may
also damage the membranes that line the nasal passages, leading to
possible formation of scar tissue, obstruction of the airway, and damage
to the child's sense of smell.
In addition to fractures, external injuries of the nose include
soft-tissue injuries resulting from
(human and animal), insect
, cuts, or scrapes. Penetrating injuries to the nasal area caused by air
gun or BB pellets were as of 2004 also reported with increasing frequency
in older children and adolescents. When fired at close range, these
pellets can penetrate the skin and cheekbone and lodge in the nasal septum
or the sinuses near the nose.
as a fashion trend is a type of intentional injury to the nose that has
several possible complications, including infections of the cartilage and
soft tissues in the nose; blockage of the airway due to a loosened stud or
other nose ornament; and gastrointestinal emergencies caused by accidental
swallowing of nose jewelry.
If a patient's nasal trauma leads doctors to suspect child abuse,
the incident must be reported to the police.
The demographics of nasal trauma vary according to the type of injury.
Internal nasal injuries are unusual in infants but occur fairly frequently
in toddlers and young children as a result of playfulness or curiosity.
Children often insert small hard objects (buttons, coins, watch batteries,
dried peas or beans, plastic parts from
, etc.) in their nostrils. One Japanese study of children brought to the
emergency room for removal of foreign bodies from the respiratory and
digestive tracts found that the nose was the most common location (39.4%
of patients) of these objects. Sixty-seven percent of the children treated
were between one and four years of age, with two-year-olds the most common
age group. Another common cause of injury to the nasal passages in
children is scratching or picking the inside of the nose, often as a
reaction to dry and
nasal membranes during the heating season in colder climates.
In older children and adolescents, however, the single most common cause
of internal nasal injuries is inhalant abuse or ingesting cocaine through
the nose ("snorting"). Inhalants include such substances as
toluene (paint thinner, nail polish remover, rubber cement, airplane
glue), butane (lighter fluid, spray paint, room fresheners, hair spray),
chlorinated hydrocarbons (dry cleaning fluid, spot removers, typewriter
correction fluid), and acetone (rubber cement, permanent markers, nail
polish remover). According to the American Academy of Family Practice
(AAFP) and the U.S. Department of Health and Human Services, nearly 20
percent of children in the United States have used inhalants at least once
by the time they are in eighth grade. The average age of children
experimenting with inhalants is 13, with Hispanic and Caucasian youth more
likely to abuse these substances than African Americans. With regard to
cocaine, figures from the National Institute on Drug Abuse (NIDA) from the
late 1990s indicate that that 3.2 percent of all eighth graders in the
United States have used cocaine at least once, although young adults
between the ages of 18 to 25 are the age group with the highest usage of
Nose piercing as a fashion statement is most common among adolescents and
young adults. One study of
undergraduates at a university in upstate New York found that 51 percent
had body piercing, with the nose and ears the most common sites. Seventeen
percent of these students reported medical complications from the
piercing, ranging from skin or cartilage infections to periodic bleeding
from the nose. A less common cause of internal injuries to the nose in
older children and adolescents is the use of magnetized jewelry as a
substitute for body piercing. The external piece of jewelry is held in
place on the outside of the nostril by a small magnet placed inside the
nose. Displacement of these magnets has been reported to cause bleeding
and perforation of the nasal septum, while accidental swallowing of these
magnets may require emergency surgery. One British hospital reported no
fewer than 24 such cases over an eight-week period.
With regard to nasal fractures, one group of American researchers
estimates that they account for about 24 percent of all facial fractures.
The most common single cause is assault, accounting for 41 percent of
nasal fractures. The second most common cause is automobile accidents
(27%), followed by
(11%). Falls account for most other nasal fractures in children, although
dog bites are reported with increasing frequency as a cause of nasal
fractures in children below 16 years of age. Adolescents who have had
plastic surgery on the nose (rhinoplasty) are at increased risk of nasal
fractures in later life.
As many as 10 percent of nasal injuries in younger children, however,
result from physical abuse. Doctors in the early 2000s are advised to
consider abuse as a possible diagnosis when evaluating nasal fractures in
children under six years of age. Suspected child abuse must be reported to
Causes and symptoms
External trauma to the nose may be accidental (transportation accidents,
animal bites, air gun injuries, and sports injuries) or intentional
(fights, criminal assault, domestic violence, nose piercing). Nasal
injuries from athletic activities may result from contact with equipment
(being hit in the face by a baseball, hockey ball, or other small ball hit
at high speed, or by the bat or stick itself) or the bodies of other
players (football, boxing, martial arts, rugby). Nasal injuries from
piercing include bacterial infections of the skin and nasal cartilage,
allergic reactions to the jewelry, tissue damage, and periodic bleeding.
Direct trauma and/or delayed type hypersensitivity reaction to nickel may
occur from nasal rings and jewelry, facial adornments which as of 2004 are
In a few cases, external trauma to the nose may also be iatrogenic, or
caused by medical care. Most of these injuries result from medical
examination of the nose—particularly in emergency
circumstances—or as complications of plastic surgery.
Internal injuries to the nose may be either mechanical (caused by
in the nose or by picking or scratching the tissues lining the nose) or
chemical (caused by environmental irritants or substance abuse).
Chemical injuries to the nose are caused by accidental or purposeful
breathing or sniffing of irritating substances. These may include tobacco
smoke; household cleaners (ammonia and chlorine bleach) and furniture
polish; ozone and other air pollutants; cocaine; and glue, paint thinners,
solvents, and similar household products that produce toxic vapors. An
increasingly common form of chemical injury to the nasal membranes in
toddlers is alkali
caused by leakage from small batteries placed in the nose. While chemical
damage to the nose is usually accidental in younger children, it is more
often the result of substance abuse in adolescents. Taking cocaine through
the nose ("snorting") or inhalant abuse
("sniffing" or "huffing") are the most common
causes of chemical damage to the nose in older children or teenagers.
The symptoms of physical trauma to the nose may include the following:
Chemical trauma to the nose may result in the following:
Parents should call the doctor at once in the event of a nose injury when
the following conditions are apparent:
In many cases the diagnosis of an injury to the child's nose is
obvious to the doctor from taking a history, particularly if the parent
witnessed the accident or saw the child putting something in his nose. The
physical examination depends in part on the history. If the child's
nose is bleeding without a history of a fall, blow to the face, or other
obvious cause, the doctor gently examines inside the nose with a handheld
speculum of the type used to examine the ears, in order to see where the
nasal bleeding originates. Bleeding from the lower part of the nose is
more common and usually less serious. In most cases the doctor is able to
tell whether there is a foreign object in the nose or whether the child
has been scratching or picking at the nose. Bleeding from the upper part
of the nose closer to the throat is more serious because it can block the
airway and because it may indicate that the child has a bleeding disorder
rather than a traumatic injury. The doctor may then examine the
child's throat for signs of blood from the upper nose trickling
down into the throat. He or she will remove any blood clots from the nose
In the case of a known accident, sports injury, or assault, the doctor
begins with the ABCs, which means that he or she will check the
. The doctor will usually have the child sit upright or lie on one side,
and will remove blood clots, broken teeth, or other foreign bodies from
the nose or throat. He or she will then carry out a systematic examination
of the child's face and head. The most common pattern of
examination moves from the inside of the nose and mouth to the outside of
the face and from the bottom of the face to the top.
The doctor looks for signs of bruising and tissue swelling as well as
bleeding and gently palpates, or touches, the various facial bones for
movement and stability. If the doctor suspects that the nose itself is
fractured, he or she will listen for crepitus when the nose is gently
moved and will look for evidence of a dislocated septum or a septal
hematoma, which will appear as a bluish bulging mass within the nasal
septum. The child's teeth will be examined for looseness, and the
muscles and nerves of the face will be evaluated. If there is a discharge
from the nose, the doctor will look at it to see whether it contains
cerebrospinal fluid, which would indicate damage to the bones of the skull
as well as the nasal bones. Lastly, the doctor examines the child's
eyes to make sure that the pupils are responding normally to light and
that the child is not seeing double or having other visual problems that
might indicate nerve damage or damage to the eye itself.
In cases involving animal bites or other tearing or crushing injuries to
the skin and external tissues of the nose, the doctor carefully cleanses
the broken skin with soap and water or disinfectants such as benzalkonium
chloride as well as checks for fractured facial bones.
Many of the early signs of inhalant or cocaine abuse are not specific to
these disorders; however, a careful history-taking and examination of the
child's eyes, nose, and throat may lead the doctor to ask the child
or adolescent appropriate questions about his or her use of inhalants or
(CT) scans are the type of imaging study most commonly done to evaluate
suspected nasal fractures. X-ray studies may be ordered to identify the
location of a foreign body if it is metal, such as a pellet from a BB gun
or air gun, or to evaluate the nasal area for evidence of repeated
fractures when abuse is suspected. A blood test will be performed prior to
surgery in order to determine the child's blood type, clotting
time, and complete blood count. In some cases the doctor may order a
filter paper or glucose content test of nasal secretions to check for the
presence of cerebrospinal fluid.
In some cases, the physician may ask the child's parents for
photographs taken prior to the injury in order to determine the extent of
deformity or other injuries to the nose. Photographs may also be taken for
documentation if abuse is suspected and also for documentation of injuries
for later plastic surgery.
Drug-specific blood or urine tests may be ordered for children or
adolescents suspected of abusing inhalants or cocaine.
Nasal injuries should be treated as promptly as possible to lower risk of
infection. If the child has been bitten by an animal, the injury must be
cleansed as soon as possible to lower the risk of
. Batteries placed in the nose should be removed as soon as possible,
preferably within four hours to avoid serious burns from their contents.
If a septal hematoma has developed, the doctor must remove it as quickly
as possible to prevent infection or eventual death of the tissues in the
Treatment of nasal fractures is best performed during the first three
hours after the injury. If this is impossible, management of a nasal
fracture should be done within three to seven days. Timing is of utmost
importance when treating nasal fractures because delays longer than seven
to 10 days may allow the broken bones to set without proper alignment or
lead to such complications as scar tissue formation and airway
obstruction. Poorly set nasal fractures usually require surgical
Foreign objects in the nose can be removed by nasal suction in most cases.
Most nosebleeds are treated by five to 30 minutes of direct pressure on
the nostrils, with the child's head placed in an upright position.
The doctor may also pack the child's nose with gauze coated with
petroleum jelly. If the bleeding does not stop or if it appears to
originate in the upper nose, the doctor will consult a head and neck
surgeon or an otolaryngologist for specialized evaluation of the bleeding.
Air gun or BB pellets that have penetrated the nose or nearby sinuses are
generally removed with the help of an endoscope, which is a slender
tubular instrument that allows the doctor to examine the inside of a body
Treatment of nasal fractures depends on the extent of the injury; the most
difficult fractures to treat are those that involve the nasal septum. The
doctor will usually reduce the fracture, which means that he or she will
restore the damaged bones to their proper position and alignment. Although
local anesthesia is usually sufficient for treating nasal fractures in
adults and older teenagers, general anesthesia is usually given when
treating these injuries in younger children.
Reductions of nasal fractures may be either open or closed. A closed
reduction involves manipulation of the bones without cutting into the
overlying skin. This type of reduction is performed for fractures of the
nasal bones that are limited in size and complexity. Open reductions are
performed for more complex nasal fractures. In an open reduction, the
nasal bones are moved back to their original location after the surgeon
has made an incision in the overlying skin. This procedure is done for
fractures involving dislocation of the septum as well as the nasal bones.
In addition, an open reduction is necessary if the child has a septal
hematoma or an open fracture in which the skin has been perforated. If a
septal hematoma is present, the doctor will drain it and pack the nose to
prevent subsequent accumulation of blood. The nasal bones are held in the
proper position with external splints as well as the internal packing, and
the splints are kept in place for seven to ten days. The child is given
to lower the risk of infection and may be referred to an otolaryngologist
or plastic surgeon for further evaluation. Ice packs or cold compresses
can be applied at home to reduce swelling and ease the child's
In the case of animal bites, the child may be given passive or active
immunization against rabies if there is a chance that the dog or other
animal is rabid. This precaution is particularly important for animal
bites on the nose or other parts of the face, as the incubation period of
the rabies virus is much shorter for bites on the head and neck than for
bites elsewhere on the body.
—A crackling sound.
—The medical term for the bridge of the nose.
—The medical term for a bruise, or skin discoloration caused by
blood seeping from broken capillaries under the skin.
—The medical term used to describe a bleeding from the nose.
—A localized collection of blood, often clotted, in body tissue
or an organ, usually due to a break or tear in the wall of blood vessel.
—A condition that is caused by the diagnostic procedures or
treatments administered by medical professionals. Iatrogenic conditions
may be caused by any number of things including contaminated medical
instruments or devices, contaminated blood or implants, or contaminated
air within the medical facility.
—A doctor who is trained to treat injuries, defects, diseases, or
conditions of the ear, nose, and throat. Also sometimes known as an
—The restoration of a body part to its original position after
displacement, such as the reduction of a fractured bone by bringing ends
or fragments back into original alignment. The use of local or general
anesthesia usually accompanies a fracture reduction. If performed by
outside manipulation only, the reduction is described as closed; if
surgery is necessary, it is described as open. Also describes a chemical
reaction in which one or more electrons are added to an atom or
—Inflammation and swelling of the mucous membranes that line the
—Plastic surgery of the nose to repair it or change its shape.
—A wall or partition. Often refers to the muscular wall dividing
the left and right heart chambers or the partition in the nose that
separates the two nostrils. Also refers to an abnormal fold of tissue
down that center of the uterus that can cause infertility.
Preventive strategies for nasal trauma depend on the child's age
group. For younger children, parents should take the following
For older children and adolescents, parents should take the following
Parental concerns regarding nasal trauma depend on the cause and severity
of the injury. Minor nosebleeds and uncomplicated fractures of the nose
caused by accidents generally heal without problems and are quickly
absorbed into the family's routine. Complex fractures or other
injuries requiring a second operation may require explanation or
discussion with the child. Nasal injuries related to the neighborhood
environment (street crime, chemical pollution), lifestyle choices (body
piercing, smoking in the home), or family dysfunction (substance abuse,
domestic violence), however, suggest the need for professional counseling
and changes in the family's structure, geographical location, or
increased level of functioning.
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One Prince Street, Alexandria, VA 22314–3357. Web site:
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