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AN AUDIT OF 120 CASES OF SIMPLE NASAL BONE FRACTURE.

Byline: Imad Hameed Muhammad Ismail Khan Sanaullah Khan and Sajjad Khan

Abstract

Background: Nasal bone fractures are the commonest type of the bony facial injuries seen in emergency department. The objectives of the present study were to determine the age and gender distribution etiology symptoms signs and complications of simple nasal bone fractures and complications of their closed reduction.

Material and Methods: This cross-sectional study was conducted at Departments of ENT Mardan Medical Complex Mardan and MMM Teaching Hospital D.I.Khan Pakistan from July 2012 to Jun 2013. All patients with simple nasal bone fracture of any age and gender were included. All patients were treated by closed reduction. Data regarding gender age in years age grouping etiology symptoms signs and complications were analyzed as frequency and percentage.

Results: A total of 120 patients with simple nasal bone fractures were included in the study. Males 90 (75%) out-numbered females 30 (25%) with a ratio of 3:1. The mean age of the patients was 20.6614.86 (2-60) with a range of 58 years. The most frequent etiology symptom sign and complication was road traffic accident in 65 (54.15%) epistaxis in 85 (70.80%) external nasal deformity in 92 (76.65%) and septal hematoma in 24 (20%) cases respectively. Persistent postoperative nasal deviation was a complication in seven (5.80%) patients with closed reduction.

Conclusion: Road traffic accident is the most common cause of nasal trauma. Closed reduction for simple nasal bone fracture generally produces acceptable cosmetic results. By knowing the etiology of nasal trauma the risk of nasal injuries can be reduced by taking safety measures and precautions.

Key words: Traffic Accidents; Epistaxis; Nasal Obstruction; Etiology.

Introduction

Being the most prominent and projected in position nose is frequently injured facial structure accounting for approximately 39 % of all bony injuries in facial trauma1 and the third most frequent of all body fractures.12 Road traffic accidents sports injuries interpersonal violence falls and blast injuries all contribute to nasal trauma.3

Nasal trauma commonly presents with epistaxis external nasal deformity periorbital ecchymosis nasal obstruction and pain.4 It can involve all age groups from pediatrics to adults. Adults are predominantly affected with male to female ratio of 2:1.15 In pediatric age group intrauterine forces forceps delivery breech presentation all contribute to nasal trauma. The low face to head volume ratio and protected environment parental supervision are responsible for less nasal trauma in this group.5

Male adults being more involved in occupational trauma violence road traffic accidents falls and sports injuries receive more nasal trauma.6 Nasal bone fractures may occur as simple nasal fracture or associated with other facial injuries like maxillary zygomatic and other mid-face comminuted fractures.7

Simple nasal bone fractures can be diagnosed easily with history and clinical examination however certain radiological studies like x-ray nasal bone lateral view CT of nose and sinuses can help to assess the type and severity of injury and other associated fractures.6

Simple nasal bone fractures can be treated by two methods. One is closed reduction of fragments with digital manipulation or use of Walshlam and Asch forceps. The other method is open reduction.8

The objectives of the present study were to determine the age and gender distribution etiology symptoms signs and complications of simple nasal bone fractures and complications of closed reduction for simple nasal bone fractures.

MATERIAL AND METHODS

This cross-sectional study was conducted at the Departments of ENT Mardan Medical Complex Mardan and Mufti Mehmood Memorial Teaching Hospital D.I.Khan Pakistan from July 2012 to Jun 2013.

An approval from the Ethical Committee of the Hospital was obtained. A written informed consent containing terms about the inclusion in study benefits and risks involved was obtained from each patient.

All patients with simple nasal bone fracture (not associated with fractures of other facial bones) were included. Patients with associated head and neck injuries were excluded. Patients already treated at other centers and referred for further treatment were also excluded from the study. Patients were admitted in ENT ward through emergency or outpatient departments. A thorough history was taken and detailed oto-rhinological as well as general physical examination was carried out. Digital x-ray nose lateral view was done in all cases. Relevant investigations for general anaesthesia were carried out. All findings were recorded on a designed proforma.

All patients were treated by closed reduction using Walshalam and Ache's forceps under general anaesthesia. After manipulating the fractured fragments Plaster of Paris was applied over the nose for stabilization of the nasal skeleton for 7 days in every case. Internal fixation was done by placing anterior nasal packing for 72 hours and plastic splints for one week. Those patients having swelling of the nose at the time of presentation reduction was deferred till the edema got subsided. Postoperatively patients were followed for 6 weeks to see for any persistent deviation of the nose. Those patients who continued to suffer from significant nasal deviation were offered septo-rhinoplasty after 6 months in adult patients and pediatric cases were advised to do it later by the age of 18 years.

Gender age (numerical data) in years and age grouping were demographic variables. Etiology symptoms signs and complications of simple nasal bone fracture and complications of closed reduction were research variables. All variables except age were categorical data. The categorical data was analyzed as frequencies and percentages while numerical data (age in years) was analyzes as mean SD minimum maximum and range. As per protocol of the study no further analysis of data and no test of significance were required. Age grouping was as; 02-10 11-20 21-30 31-40 41-50 more than 50 years.

RESULTS

A total of 120 patients with simple nasal bone fracture were included in the study. Males 90 (75%) out-numbered females 30 (25%) with a ratio of 3:1. The mean age of the patients was 20.6614.86 (260) with a range of 58 years. The age grouping of the patients is given in Table 1.

Table 1: Age grouping of patients with simple nasal bone fractures (n=120)

S.No.###Age grouping###Frequen-###Percent-

###cy###age

1###02 10 years###30###25.00 %

2###11 20 years###45###37.50 %

3###21 30 years###14###11.65 %

4###31 40 years###16###13.35 %

5###41 50 years###09###07.50 %

6###More than 50###06###05.00 %

years

Total###120###100.00 %

Road traffic accidents was the most common etiology with 65 (54.15%) cases followed by sports injuries with 24 (20%) patients violence in 22 (18.35%) patients and blast injuries in nine (7.50%) patients.

The symptoms were epistaxis in 85 (70.80%) nasal obstruction in 45 (37.50%) and headache in 30 (25%) cases. The signs were external nasal deformity with periorbital ecchymosis in 92 (76.65%) feeling of crepitus between bone fragments in 88 (73.30%) and swollen nasal bridge in 65 (54.15%) cases. Septal hematoma in 24 (20%) and septal abscess in six (5%) were complications of simple nasal bone fractures. Persistent postoperative nasal deviation was a complication in seven (5.80%) patients with closed reduction for simple nasal bone fractures.

DISCUSSION

Nose is located prominently in the face and it is its prominent location that it suffers trauma on many occasions. Several different causes have been reported in literature like road traffic accidents interpersonal violence sports injuries and falls. Much controversy exists as to the ideal treatment to properly address acute nasal fractures. A successful management algorithm should provide each patient with an aesthetically and functionally acceptable nose.

Majority of the patients in the present study were in the second decade of their life. Almost similar results were also reported in a local study by Afshin in which age of the patients ranged between 10-70 years.112 In another study by Cannon CR14 the commonest age group affected was 11-20 years. Contrary to these reports in another study13 the age group mostly involved was 21-40 years. While results of Yilmiz17 showed that the maximum number of patients (68.75 %) was in pediatric age group.

Males receive more nasal trauma as compared to females probably due to more involvement in physical activities. In our series males were more affected i.e in 90 cases as compared to females in 30 cases with a ratio of 3:1. This is in accordance with other studies.1115 Sang HK5 also reported a male preponderance over females with a ratio of 5.7:1 in his series of 741 patients. Yakup C13 reported a male to female ratio of 4:1. Javad Rashid6 found 31 males with 9 females in his series of 40 patients. In Afshin Muhammad1 study the male to female ratio was 2:1. Nardis15 reported male to female ratio of 1.8:1.

Road traffic accident was the most frequent cause of nasal trauma in our study. This may be due to young drivers with over speeding no licensing and not observance of traffic rules. Smith H4 reported motor vehicle crash as the most common cause for nasal trauma in 47% of patients. Interpersonal violence was the next common reason for nasal trauma in our study which is probably due to lack of tolerance anxiety and other psychological reasons in the terrorism affected area. Sang HK5 found interpersonal violence in 38% of his series followed by fallings in 31% and sports injuries in 17% of cases. Yakup C13 also reported violence as the most frequent cause of nasal trauma in his series in 60% cases fallings in 30% cases accidents in 4.5% cases and sports injuries in 4.5% cases in his study on pure nasal fractures.

The symptoms in descending order of frequency were nasal obstruction epistaxis and headache in patients with simple nasal bone fractures as supported by findings of the other studies.1516

Nasal obstruction was probably due to edema and associated complication like septal hematoma.

Septal hematoma was the most common complication of nasal trauma in our study as also reported in literature.7911 The picture of septal hematoma is emerged when a patient with nasal trauma develops bilateral nasal obstruction and open mouth breathing during sleep especially in children.

In our study all patients were treated by closed reduction. Tremendous satisfaction with closed reduction has been reported in literature with this mode of treatment for simple nasal bone fractures.1718 In our series 5.8% of the patients complained of persistent nasal deviation. Contrary to our results the post-reduction incidence of nasal deformities have been shown to be as high as 40% to 62% independent of the surgeon's experience when simple closed manipulation was employed.1920 Our better results

could be due to either more adequate reduction of the fracture or complete management of a component of the fracture at the time of the treatment.

Family physicians as well as public at large should be made aware of the seriousness of nasal trauma as this accounts for a high rate of morbidity in our country. Our study is limited by a rather small sample size.

CONCLUSIONS

Road traffic accident is the most common cause of nasal trauma. Closed reduction for simple nasal bone fracture generally produces acceptable cosmetic results. By knowing the etiology of nasal trauma the risk of nasal injuries can be reduced by taking safety measures and precautions.

REFRENCES

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2. Liau JY Woodlief J van Aalst JA. Pediatric naso-orbito-ethmoid fractures. J Craniofac Surg 2011; 22:1834-8.

3. Kittle CP Verret AJ Wu J Mellus DE Hale RG Chan RK. Characterization of mid-face fractures incurred in recent wars. J Craniofac Surg 2012; 23:1587-91.

4. Smith HL Chrischilles E Janus TJ Sidwell RA Ramirez M Peek-Asa C et al. Clinical indicators of mid-face fracture in patients with trauma. Dent Traumatol 2013; 29:313-8.

5. Sang HK Soo HL Pil DC. Analysis of 809 facial bone fractures in a pediatric and adolescent population. Arch Plast Surg 2012; 39:606-11.

6. Javadrashid R Khatoonabad M Shams N Esmaeili F Jabbari KH. Comparision of ultrasonography with computed tomography in the diagnosis of nasal bone fractures. Dentomaxillofac Radiol 2011; 40:48691.

7. Batista AM Ferreira FO Marques LS Ramos-Jorge ML Ferreira MC. Risk factors associated with facial fractures. Dental Press J Ortod 2012; 17:1-8.

8. Kang SJ Kim JW. Proposed method for closed reduction of impacted nasal bone fractures using a Kirschner wire and a C-arm. J Oro Maxilofac Surg 12; 70:1393-7.

9. Wright RJ Murakami CS Ambro BT. Pediatric nasal injuries and management. Facial Plast Surg 2011; 27:483-90.

10. Baliqa SD Uroloqin SB. Transnasal fixation of nose fracture: minimally invasive approach. J Maxillofac Oral Surg 2012; 11:34-7.

11. Konstantindis L Malliari H Metaxas S. Nasal trauma: primary reconstruction with open rhinoplasty. Can J Plast Surg 2011; 19:108-10.

12. Kim SH Lee SH Cho PD. Analysis of 809 facial bone fractures in a pediatric and adolescent population. Arc Plast Surg 2012; 39:606-11.

13. Khwaja S Pahade AV Luff D Green MW Green KM Nasal fracture reduction: local versus general anaesthesia. Rhinology 2007; 45:83-8.

14. Cannon CR Cannon R Young K Replogle W Stringer S Gasson E. Charactreistics of nasal injuries incurred during sports activities: analysis of 91 patients. Ear Nose Throat J 2011; 90:8-12.

15. Nardis AC Costa SA Silva RA Kaba SC. Patterns of pediatric facial fractures in a hospital of Sao Paulo Brazil: A retrospective study of 3 years. J Cranio Maxillo Face Surg 2013; 41:226-29.

16. Raja K. Management of maxillofacial injuries in Iraq. J Craniofac Surg 2011; 22:1561-6.

17. Yilmaz MS Guven MVarli AF .Nasal fractures: Is closed reduction satisfying .J Craniofac Surg 2013; 24:36-8.

18. Ridder GJ Boedeker CC Fradis M Schipper J: Technique and timing for closed reduction of isolated nasal fractures: A retrospective study. Ear Nose Throat J 2002; 81:49.

19. Murray JA Maran AG. The treatment of nasal injuries by manipulation. J Laryngol Otol 1980; 94: 1405-10.

20. Fernandes SV. Nasal fractures: the taming of the shrewd. Laryngoscope 2004; 114: 587-92.
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Publication:Gomal Journal of Medical Sciences
Article Type:Report
Geographic Code:9PAKI
Date:Mar 31, 2014
Words:2355
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