Trauma to the Face and
Nose
Dr. Muhammad Arif
Asst. Professor ENT
KGMC/HMC
Fractures of the Face
NASAL BONES AND SEPTUM
Fractures of nasal bones are the most common because of the
projection of nose on the face. Traumatic forces may act
from the front or side. Magnitude of force will determine the
depth of injury.
TYPES OF NASAL FRACTURES
1. Depressed. They are due to frontal blow.
Lower part of nasal bones which is thinner, easily gives
way.
A severe frontal blow will cause “open-book fracture” in
which nasal septum is collapsed and nasal bones splayed out.
2. Angulated. A lateral blow may cause unilateral depression of
nasal bone on the same side or may fracture both the nasal
bones and the septum with deviation of nasal bridge.
Nasal fractures are often accompanied by injuries of nasal
septum which may be simply buckled, dislocated or fractured
into several pieces.
Septal haematoma may form.
Clinical Features
Swelling of nose. Appears within few hours and may obscure
details of examination.
Periorbital ecchymosis.
Tenderness.
Nasal deformity. Nose may be depressed from the front or
side, or the whole of the nasal pyramid deviated to one side.
Crepitus and mobility of fractured fragments.
Epistaxis.
Nasal obstruction due to septal injury or haematoma.
Lacerations of the nasal skin with exposure of nasal bones
and cartilage may be seen in compound fractures.
Treatment
Simple fractures without displacement need no treatment.
Others may require closed or open reduction.
The best time to reduce a fracture is before the appearance of
oedema, or after it has subsided, which is usually in 5–7
days.
It is difficult to reduce a nasal fracture after 2 weeks because
it heals by that time.
1. Closed reduction. Depressed fractures of nasal bones sus-
tained by either frontal or lateral blow can be reduced by a
straight blunt elevator guided by digital manipulation from
outside.
Impacted fragments sometimes require disimpaction with
Walsham or Asch’s forceps before realignment. Septal
fractures are also reduced by Asch’s forceps.
Septal haematoma, if present, must be drained.
2. Open reduction. Early open reduction in nasal fractures is
rarely required. This is indicated when closed methods fail.
Healed nasal deformities resulting from nasal trauma can be
corrected by rhinoplasty or septorhinoplasty.
NASO-ORBITAL FRACTURES
Direct force over the nasion fractures nasal bones and
displaces them posteriorly.
Perpendicular plate of ethmoid, ethmoidal air cells and
medial orbital wall are fractured and driven posteriorly.
Injury may involve cribriform plate, frontal sinus,
frontonasal duct, extraocular muscles, eyeball and the
lacrimal apparatus.
Clinical Features
Telecanthus, due to lateral displacement of medial orbital wall.
Pug nose. Bridge of nose is depressed and tip turned up.
Periorbital ecchymosis.
Orbital haematoma due to bleeding from anterior and posterior
ethmoidal arteries.
CSF leakage due to fracture of cribriform plate and dura.
Displacement of eyeball.
Treatment
1. Closed reduction. In uncomplicated cases, fracture is
reduced with Asch’s forceps and stabilized by a wire passed
through fractured bony fragments and septum and then tied
over the lead plates.
Intranasal packing is given. Splinting is kept for 10 days or
so.
2. Open reduction. This is required in cases with extensive
comminution of nasal and orbital bones, and those
complicated by other injuries to lacrimal apparatus, medial
canthal ligaments, frontal sinus, etc.
FRACTURES OF ZYGOMA (TRIPOD
FRACTURE)
After nasal bones, zygoma is the second most frequently
fractured bone.
Zygoma is separated at its three processes. Fracture line
passes through zygomaticofrontal suture, orbital floor,
infraorbital margin and foramen, anterior wall of maxillary
sinus and the zygomaticotemporal suture.
Orbital contents may herniate into the maxillary sinus.
Clinical Features
Flattening of malar prominence.
Step deformity of infraorbital margin.
Anaesthesia in the distribution of infraorbital nerve.
Trismus, due to depression of zygoma on the underlying coronoid
process.
Restricted ocular movements, due to entrapment of inferior rectus
muscle. It may cause diplopia.
Periorbital emphysema, due to escape of air from the maxillary
sinus on nose blowing.
Waters’ view shows the fracture and displacement the best.
Maxillary sinus may show clouding due to the presence of
blood.
Comminution with depression of orbital floor and herniation
of orbital contents can not be seen on plain X-rays. CT scan
of the orbit will be more useful.
Treatment
Only displaced fractures require treatment.
Open reduction and internal wire fixation gives best results.
Transantral approach is less favourable.
FRACTURES OF ORBITAL FLOOR
Zygomatic and Le Fort II maxillary fractures are always
accompanied by fractures of orbital floor.
Isolated fractures of orbital floor, when a large blunt object
strikes the globes, are called “blow out fractures.”
Orbital contents may herniate into the antrum
Ecchymosis of lid, conjunctiva and sclera.
Enophthalmos with inferior displacement of the eyeball.
Diplopia, which may be due to displacement of the eyeball
or entrapment of inferior rectus and inferior oblique muscles.
Hypoaesthesia or anaesthesia of cheek and upper lip, if
infraorbital nerve is involved.
Diagnosis
Traction Test: Entrapment of inferior rectus and inferior
oblique muscles is diagnosed by asking the patient to look up
and down, or by the traction test. The latter is performed by
grasping the globe and passively rotating it to check for
restriction of its movements.
Waters’ view shows a convex opacity bulging into the
antrum from above (tear-drop opacity).
CT scans may confirm the diagnosis
Treatment
Indications for surgery include enophthalmos and persis- tent
diplopia due to entrapment of muscle.
Trans antral approach
Open approach: using bone grafts from iliac crest, septum or
anterior wall of antrum.
Fractures of the Maxilla
Le Fort I (transverse) fracture runs above and parallel to
the palate. It crosses lower part of nasal septum, maxillary
antra and the pterygoid plates.
LeFortII (pyramidal) fracture passes through the root of
nose, lacrimal bone, floor of orbit, upper part of maxillary
sinus and pterygoid plates. This fracture has some features
common with the zygomatic fractures.
Le Fort III (craniofacial dysjunction). There is complete
separation of facial bones from the cranial bones.
The fracture line passes through root of nose, ethmofrontal
junction, superior orbital fissure, lateral wall of orbit,
frontozygomatic and temporozygomatic sutures and the
upper part of pterygoid plates.
Clinical Features
Malocclusion of teeth with anterior open bite.
Elongation of midface.
Mobility in the maxilla.
CSF rhinorrhoea. Cribriform plate is injured in Le Fort II
and Le Fort III fractures.
Diagnosis
X-rays, helpful in diagnosis of maxillary fractures are
Waters’ view, posteroanterior view, lateral view.
CT scans.
Treatment
Treatment of maxillary fractures is complex. Immediate attention
is paid to restore the airway and stop severe haemorrhage.
Fixation of maxillary fractures can be achieved by:
Interdental wiring.
Intermaxillary wiring using arch bars.
Open reduction and interosseous wiring as in zygomatic fractures.
Wire slings from frontal bone, zygoma or infraorbital rim to the
teeth or arch bars.
FRACTURES OF MANDIBLE
CSF RHINORRHEA
DEFINITION
Leakage of CSF into the nose is called CSF rhinorrhoea.
It may be clear fluid or mixed with blood as in acute head
injuries.
PHYSIOLOGY
Total volume of CSF varies from 90 to 150 mL.
It is secreted at the rate of about 20 mL/h (350–500 mL/
day).
Thus total CSF is replaced three to five times every day.
Normal CSF pressure at lumbar puncture is 50–150 mm
H2O.
Aetiology
Trauma. Most of the cases follow trauma.
Inflammations. Mucoceles of sinuses, sinunasal polyposis, fungal
infection of sinuses and osteomyelitis, can all erode the bone and dura.
Neoplasms. Tumours, both benign and malignant, invading the skull
base.
Congenital lesions. Meningocele, meningoencephaloceles and gliomas
can have associated skull base defect.
Idiopathic. Where cause is unknown and patient has spontaneous leak.
Site of Leakage
CSF from anterior cranial fossa reaches the nose via
Cribriform plate
Roof of ethmoid air cells or
Frontal sinus.
CSF from middle cranial fossa follows injuries to sphenoid
sinus.
In fractures of temporal bone, CSF reaches the middle ear
and then escapes through the eustachian tube into the nose
(CSF otorhinorrhoea)
Diagnosis
History: clear watery discharge from the nose on bending the
head or straining. It may be seen on rising in the morning
when patient bends his head (reservoir sign )
Sudden, gushes in drops when bending and cannot be sniffed
back.
CSF rhinorrhoea after head trauma is mixed with blood and
shows double target sign when collected on a piece of filter
paper. It shows central red spot (blood) and peripheral lighter
halo.
Nasal endoscopy can help to localize CSF leak in some
cases. Otoscopic/microscopic examination of the ear may
reveal fluid in the middle ear in cases of otorhinorrhoea.
Laboratory Tests
Beta-2 transferrin is a protein seen in CSF and not in the
nasal discharge.
Perilymph and aqueous humour are the only other fluids
which contain this protein
Beta trace protein is also specific for CSF and is widely
used in Europe. It is secreted by meninges and choroid
plexus.
LOCALIZATION OF SITE
High-resolution CT scan.
MRI
Intrathecal fluorescein study.
Only 0.25–0.5 mL of 5% fluorescein diluted with 10 mL of
CSF is injected.
Patient lies in 10° head down position for sometime.
Dye can be detected intranasally with the help of endoscope.
Dye appears bright yellow but when seen with a blue filter it
appears fluorescent green.
TREATMENT
Conservative
Surgical
Conservative
Bed rest.
Elevating the head of the bed.
Stool softeners.
Avoidance of nose blowing, sneezing and straining.
Prophylactic antibiotics can be used to prevent meningitis.
Acetazolamide decreases CSF formation.
Lumbar drain if indicated.
Surgical
Endoscopic
Open neurosurgical
