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Table of Contents
ORIGINAL ARTICLE
Year : 2003  |  Volume : 5  |  Issue : 1  |  Page : 1-4

Prevention of serious complications of minor nasal injuries in children


Hassan Al-Husban, P.O. Box 6021, Zarka, Jordan

Date of Web Publication11-Jul-2020

Correspondence Address:
M.D. Hassan Al-Husban
Hassan Al-Husban P.O. 6021, Zarka
Jordan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.289558

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  Abstract 


Objective: To study the serious complications of minor nasal injuries in children.
Patients and Methods: This was a retrospective study of 102 children presented to the emergency rooms of Prince Rashed Ibn Al-Hassan and Prince Hashem Ibn Al-Hussein Hospitals in Jordan between January 1994 and December 1998 with a primary diagnosis of nasal trauma. Twelve children were admitted to the hospital with serious complications, while the others were discharged in the same day with a trival nasal trauma. Patient characteristics, cause of injury, time elapsed before treatment following trauma, and treatment patterns were studied.
Results : Sixty-six out of 102 children were males (male to female ratio was about 2:1). Mean age was 8 years. The most common cause of isolated nasal trauma was simple fall (50%). Out of 102 children with history of nasal trauma only 12 patients (12%) developed serious complications including nasal bone fracture, haematoma or abscess collection and severe epistaxis. The diagnosis was made 1 to 7 days (mean 5 days) after the episode of trauma. Nasal bleeding was the most common symptom while nasal obstruction was the most common sign of complication. Nasal fracture was present in 10 children. Severe nasal bleeding was the cause of admission in 2 children. Haematoma was found in 4 patients, it was associated with cartilage destruction in 1 patient. Abscess of the nasal septum was found at surgery in 2 children, both of them had septal cartilage destruction. Organisms cultured were Staphy. aureus, Strept. pneumonia, and group A B-Hemolytic Strept. They were obtained from both patients with septal abscess and from one patient with septal haematoma.
Conclusions: The incidence of severe complications in nasal injuries is directly related to delay in treatment. Diagnosis of nasal septal haematoma and abscess should be considered in all children with recent nasal trauma, to minimize the risk of nasal deformity and prevent the development of septal complications. All children with even minor nasal injuries should be seen for follow up after 24 and 72 hours to detect early the development of complications.

Keywords: nasal trauma, haematoma, abscess, nasal fracture


How to cite this article:
Al-Husban H. Prevention of serious complications of minor nasal injuries in children. Saudi J Otorhinolaryngol Head Neck Surg 2003;5:1-4

How to cite this URL:
Al-Husban H. Prevention of serious complications of minor nasal injuries in children. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2003 [cited 2022 Dec 8];5:1-4. Available from: https://www.sjohns.org/text.asp?2003/5/1/1/289558




  Introduction: Top


Minor nasal trauma in children is common, but not commonly associated with the development of serious complications such as fracture, hematoma or abscess of the nasal septum[l]. As a consequence, the diagnosis of of these complications may be overlooked and that will lead to late diagnosis, which may be associated with the development of more dangerous complications, in particular, septal cartilage destruction and cosmetic nasal deformity [2],[3],[4],[5], More severe complications, however, such as meningitis [3],[6], cerebral abscess [7],[8], subarachnoid empyema [8], cavernous sinus thrombosis [7], and life-threatening bleeding[9], have been reported. Associated traumatic oedema, preexisting nasal deformity, and occult septal injury account for most of the reduction failures of nasal bone fractures[10].


  Patients and Methods: Top


This was a retrospective study of 102 children presented to the emergency rooms of Prince Rashed Ibn Al-Hassan and Prince Hashem Ibn Al-Hussein Hospitals in Jordan between January 1994 and December 1998 with a primary diagnosis of nasal trauma.

Twelve children were admitted to the hospital with serious complications, while the others were discharged in the same day with a trival nasal trauma. Patient characteristics, cause of injury, time elapsed befofe treatment following trauma, and treatment patterns were studied.


  Results: Top


The study group included 66 boys and 36 girls with a male to female ratio of 2:1. Their mean age was 8 years (range from 2 to 14 years). A history of nasal trauma was obtained in all patients. Patient characteristics, cause of injury, and time elapsed before treatment following trauma for the 12 patients who were admitted are given in [Table 1].
Table 1: Cause &Time elapsed before treatment after nasal injury n=12

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The most common cause of isolated nasal trauma was simple fall (50%), especially in young children bellow 10 years, while in older children, nasal injuries were sustained during playing sports (10%). Other causes were: violence (20%), collisions with stationary objects (10%), falls off a bicycle (3%), traffic injuries (3%) and others 4%.

After eventual diagnosis nasal bone fracture was found in 10 patients, septal haematoma in 4 patients (one with partial septal cartilage destruction), severe epistaxis requiring admission in 2 patients, and septal abscess in 2 patients (both had evidence of septal cartilage destruction).

The mean time elapsed before being seen for hematoma and abscess following nasal trauma was 5 days, and ranged between 1 to 7 days. In 2 patients (33%), the diagnosis was missed on the first visit, and in 1 patient the diagnosis was made at the third visit.

Details of the initial signs and symptom are given in [Table 2]. Nasal obstruction was the most common sign (in 90% of patients). Patients with visible signs of injury such as nasal fracture, epistaxis, or cellulitis were seen earlier than those without.
Table 2: Signs and symptoms at first visit in patients complication. n=12

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Out of the 10 patients with nasal fracture: 2 had haematoma, 1 had septal abscess, 1 with severe epistaxis, and the remaining 6 patients had nasal fracture not associated with other complications. All children with nasal bone fracture underwent closed reduction.

All children with septal haematoma and abscess were admitted and underwent urgent drainage under general anesthesia, together with insertion of Pen Rose drain and anterior nasal packing. Swabs of the fluid drained were sent for microscopic examination and culture. Antibiotics were administered to all patients.

Surgical findings, microbiologic examination results, and antibiotics used, are given in [Table 3]. Organisms cultured were Staph, aureus, Strept. pneumoniae and group A haemolytic streptococcus.
Table 3: Surgical and Microbiological Finding of Hematoma and Abscess. n=6

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  Dicussion: Top


Cosmetic nasal deformity and other complications of nasal injuries are preventable by early diagnosis. Acute suppurative complications of the nasal septum are rare and in general occur when a diagnosis is notably delayed. Chukuzi[7] described 4 patients with brain abscess and 1 with cavernous sinus thrombosis secondary to septal abscess. The average time before being seen was 3-4 weeks.

It is therefore important to identify which children are at risk of experiencing complications among the larger group of children who sustain minor nasal trauma. The literature suggests a strong male predominance [7],[11],[12], and minor nasal trauma is the major casual factor [13],[14], as was found in this study, but other causes also have been reported, including ethmoiditis [15], sphenoditis [16],[17], dental abscess [18] and nasal furuncle [12],[14].

The nasal bones are the most commonly fractured bones in the body. Accurate diagnosis and appropriate surgical intervention is the key in the management of nasal fractures. While these injuries are not life threatening, mismanagement of nasal fractures can lead to both aesthetic and functional deformities[2].

Haematoma and abscess of the nasal septum is defined as a collection of blood or pus between the cartilaginous or bony nasal septum and its normally applied mucoperichondrium or mucoperiosteum [12].

The proposed mechanism of nasal septal haematoma and abscess formation is rupture of the small blood vessels supplying the nasal septum as a result of trauma. Cartilage destruction follows as a result of ischemia and pressure necrosis. This provides an ideal environment for bacterial colonization and subsequent abscess formation [4],[12].

When a boggy nasal swelling is observed and nasal septal haematoma or abscess is suspected, recognition of septal collection may be enhanced by application of topical anaesthetic and decongestant followed by palpation with a wax curette. If the diagnosis is still unclear, simple needle aspiration [12] will confirm the diagnosis, relieve pressure, and provide a specimen for microbiologic examination before definitive drainage and nasal packing.

Management of nasal septal haematoma and abscess is universally accepted to be urgent surgical drainage of the collection with nasal packing and antibiotics cover.

Drainage in children is best achieved under general anaesthesia, by surgical incision followed by nasal packing [3],[4],[6],[12],[19].

The only organisms recovered in our study were Staph, aureus, Strept. pneumoniae, and group A B- haemolytic streptococcus, which suggests that Fluxacillin alone would provide appropriate antibiotic cover. In other studies, however, Haemophilus influenza also has been isolated [6],[8],[12],[20].

Despite the limited numbers available for follow up, it seems that children with septal abscess, cartilage destruction, and positive bacterial culture are more likely to experience nasal deformity, so this group needs long-term follow up.


  Conclusions : Top


The incidence of severe complications in nasal injuries is directly related to delay in treatment. Diagnosis of nasal septal haematoma and abscess should be considered in all children with recent nasal trauma, to minimize the risk of nasal deformity and prevent the development of septal complications.

All children with even minor nasal injuries should be seen for follow up after 24 and 72 hours to detect early the development of complications.



 
  References Top

1.
Alvarez et. al. Sequelae after nasal septum injuries in children. Auris Nasus Larynx 2000; 27(4) : 339-42.  Back to cited text no. 1
    
2.
Rubinstein B, Strong EB, Management of nasal fractures. Arch Fam Med 2000; 9(8):738-42.  Back to cited text no. 2
    
3.
Fearon B, McKendry JB, Parker J. Abscess of the nasal septum in children. Arch Otolaryngol 1961;74:408-412.  Back to cited text no. 3
    
4.
Fry HJH. The pathology and treatment of hematoma of the nasal septum. Br J Plast Surg 1969;22:331-335.  Back to cited text no. 4
    
5.
Olsen KD, Carpenter RJ III ,Kern EB. Nasal septal injury in children. Arch Otolaryngol 1980;106:317-320.  Back to cited text no. 5
    
6.
Eavey RD, Malekzakeh M, Wright HT. Bacterial meningitis secondary to abscess of the nasal septum. Pediatr 1977;60:102-104.  Back to cited text no. 6
    
7.
Chukuzi AB. Nasal septal hematoma in Nigeria. J Laryngol Otol 1992;106:396-398.  Back to cited text no. 7
    
8.
McCaskey CH, Rhinogenic brain abscess. Laryngoscope 1951;61:460-467.  Back to cited text no. 8
    
9.
Yang WG. Et. al. Life-threatening bleeding in a facial fracture. Ann Plast Surg 2001; 46(2) : 159-62.  Back to cited text no. 9
    
10.
Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg 2000 Aug ; 106(2): 266-73.  Back to cited text no. 10
    
11.
Jones TM, Nandapalan V Manipulation of the fractured nose: a comparison of local infiltration anesthesia and topical local anesthesia. Clin Otolaryngol 1999 ; 24(5): 443-6  Back to cited text no. 11
    
12.
Ambrus PS, Eavey RD,Sullivan Baker A, Wilson WR , Kelly JH. Manegement of nasal septal abscess. Laryngoscope 1981;91:575-582.  Back to cited text no. 12
    
13.
Kryger H, Dommerby H. Hematoma and abscess of the nasal septum. Clin Otolaryngol 1987;12:125-129.  Back to cited text no. 13
    
14.
Jalaludin MAB. Nasal septal abscess: retrospective analysis of 14 cases from University Hospital, Kuala Lumpur. Singapore Med J 1993;34:435-437.  Back to cited text no. 14
    
15.
Beck Al. Abscess of the nasal septum complicating acute ethmoiditis. Arch Otolaryngol 1945; 42:275-279.  Back to cited text no. 15
    
16.
Collins MP. Abscess of the nasal septum complicating isolated acute sphenoiditis. J Laryngol Otol 1985;99:715-719.  Back to cited text no. 16
    
17.
Matsuba H. Nasal septal abscess: Unusual causes, complications, treatment and sequelae. Ann Plast Surg 1986;16:161-166.  Back to cited text no. 17
    
18.
Da silva M, Helman J,Eliachar I, Joachims H. Nasal septal abscess of dental origin. Arch Olaryngol 1982;108:380-381.  Back to cited text no. 18
    
19.
Close DM, Guinness MDG. Abscess of the nasal septum after trauma. Med J Aust 1985;142:472-474.  Back to cited text no. 19
    
20.
Chudu KR, Naqvi. Septal abscess caused by Haemophilus infuenzae type B.Pediatr infect Dis 1986; 5:276.  Back to cited text no. 20
    



 
 
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