Nasal Trauma Health Article

Definition

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 breathe normally because of obstruction, or an impaired sense of smell. The injury may be either internal or external.

Description

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 sports participation, criminal violence, child abuse, 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 fractures 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 disfigurement.

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 bites (human and animal), insect stings, 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.

Lastly, nose piercing 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.

Demographics

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 toys, 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 itching 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 the drug.

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 sports injuries (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 police.