Ear, Nose & Throat
Question 56 of 300
A 19 year old rugby player presents to the Emergency Department 3 days after injuring his nose during a game. He tells you he received a knee to his face during a tackle, he had epistaxis at the time but this resolved after first aid measures. Since then he has noticed a persistent clear nasal discharge. What complication of nasal fracture is causing this patient's symptoms?
Answer:
- In patients with nasal injury and persisting discharge from the nose, it can be difficult to differentiate between nasal secretion and cerebrospinal fluid (CSF) arising from a nasoethmoidal fracture.
- Although often advocated, testing for the presence of glucose, which is present in CSF but not normally in nasal secretion, may be falsely positive due to contamination of nasal secretions by blood or tears.
- Beta-2 transferrin (also known as the Tau protein) is almost exclusively found in CSF and is a highly sensitive and specific test for the presence of CSF.
Nasal Fracture
Ear, Nose & Throat / Maxillofacial & Dental
Last Updated: 12th February 2021
Assessment
For nasal injury, the history must include:
- Previous nasal injury/deformity – often a perceived nasal deformity is pre-existing
- Epistaxis – this may be extensive with nasal trauma but a history of epistaxis alone is not predictive of a new nasal deformity
- Anticoagulant medication – may complicate the management of post-traumatic epistaxis
- Any persistent nasal discharge since the injury – this symptom may indicate a nasoethmoid injury with CSF leak
Investigation
- Imaging for nasal fracture
- It is now universally recognised that x-rays of the nasal bones are unnecessary as they do not alter management of the injury.
- CSF rhinorrhea
- In patients with nasal injury and persisting discharge from the nose, it can be difficult to differentiate between nasal secretion and cerebrospinal fluid (CSF) arising from a nasoethmoidal fracture.
- Although often advocated, testing for the presence of glucose, which is present in CSF but not normally in nasal secretion, may be falsely positive due to contamination of nasal secretions by blood or tears.
- Beta-2 transferrin (also known as the Tau protein) is almost exclusively found in CSF and is a highly sensitive and specific test for the presence of CSF.
Management
- Nasal fracture
- Nasal fracture is a clinical diagnosis and there is no evidence that immediate reduction of a displaced fracture, practiced in some centres, is any better than delayed assessment and reduction. However, displaced fractures must be reduced before 14 days as attempted closed reduction beyond this time may be impossible.
- In patients with obvious new deformity or new septal deviation (but no significant complications), patients can be discharged home with otolaryngology review within 7 - 10 days of injury.
- In patients with a nondisplaced fracture and no septal deviation, patients can be discharged home. Ensure arrangement is in place for otolaryngology review at 7 - 10 days if: patient remains unhappy with cosmetic appearance once swelling has settled or is unable to breathe normally through each nostril.
- Septal haematoma
- Septal haematoma is a rare problem but is more common in children due to the relative lack of bone in the nose which is softer, and therefore more easily deformed.
- Septal haematoma can result in avascular necrosis of the cartilage and possible formation of a septal abscess through secondary infection.
- Loss of a substantial amount of septal cartilage can lead to a permanent septal perforation, and/or saddle nose deformity. Rarely, a septal abscess can spread intracranially via the venous drainage of the mid-face, leading to cavernous sinus thrombosis.
- Septal haematomas most commonly occur in the anterior portion of the septum and appear as a red, usually bilateral swelling.
- If identified, a patient with a septal haematoma must be referred urgently to an otolaryngologist for incision and drainage of the haematoma, +/- nasal packing to prevent accumulation of the haematoma +/- intravenous antibiotics. A septal haematoma should ideally be drained within hours of presentation, as necrosis can occur within 24 hours.
- Traumatic epistaxis
- Traumatic epistaxis is common in nasal fracture and, although occasionally severe, is usually self-limiting.
- It can be managed in a similar way to a non-traumatic nosebleed.
- CSF rhinorrhoea
- If CSF rhinorrhoea is confirmed, the patient should be referred immediately to an otolaryngologist for further assessment.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
