Nasal trauma and fractures in children and adolescents

INTRODUCTION — This topic will discuss evaluation, diagnosis, and management of nasal trauma and fractures in children. Epistaxis and other facial fractures are discussed separately:

●(See "Evaluation of epistaxis in children" and "Causes of epistaxis in children" and "Management of epistaxis in children".)

●(See "Orbital fractures".)

●(See "Mandibular (jaw) fractures in children".)

●(See "Initial evaluation and management of facial trauma in adults".)

EPIDEMIOLOGY — Nasal trauma results in nasal fracture in up to one-third of children seeking emergency care and, with high-force mechanisms, is often associated with midfacial, sinus, or frontobasal fractures [1,2]. Nasal fractures are one of the most common facial fractures in children [1,3,4]. Etiologies vary by age, with falls accounting for most fractures in children younger than five years; falls and sports in older schoolchildren; and sports, physical assaults, and motor vehicle crashes in adolescents [1,2,4].

DEVELOPMENTAL ANATOMY — In children, most of the nasal support structures consist of cartilage, and the nose does not protrude forward to the same degree as adults [5]. In infants and younger children, the developing nasal bone has a midline suture, and the septum is composed almost entirely of cartilage. The pediatric nose is subject to two major growth spurts at two to five years of age and then again at puberty [3]. The dorsal and frontal projection of the nose typically reaches adult size by 18 years in females and 20 years in males. However, the nasal septum may continue to grow in both males and females up to 25 years of age.

Due to this developmental anatomy, nasal injuries occur more commonly in children older than five years of age as the nose becomes more prominent and projects forward to a greater degree from the face. However, injury to important cartilaginous structures may not initially be apparent. As a result, serious pediatric nasal trauma can be missed in young children and cause progressive nasal deformity, septal deviation, and nasal airway obstruction over time [3]. Finally, because cartilage heals more rapidly than bone, children with suspected nasal fractures warrant more rapid follow-up and treatment than adults [5].

Once fully developed, the upper one-third of the nose is supported by the paired nasal bones and the frontal processes of the maxilla; the lower two-thirds of the nose is maintained by cartilaginous structures (figure 1) [5]. The superior portion of the nasal bones is thick and relatively resistant to fracture. By contrast, the inferior portion is thin and weak. The bony nasal septum articulates with the undersurface of the nasal bones to provide support to the nasal dorsum (figure 2). A paired cartilaginous framework, separated in the midline by attachments to the quadrangular septal cartilage, provides support to the lower two-thirds of the nose. The upper lateral cartilages attach to the undersurface of the nasal bones and support the middle one-third (figure 1). The lower lateral cartilages consist of medial and lateral crura, which join in the midline to form the tip of the nose and provide further support to the lower one-third of the nose [5].

The rich blood supply of the nose, derived from the internal and external carotid arteries, accounts for the frequency and intensity of epistaxis and swelling in patients with nasal trauma. The Kiesselbach plexus, the vascular watershed area of the anteroinferior nasal septum, is the site of origin of most nosebleeds (figure 3). (See "Causes of epistaxis in children".)

TYPES OF INJURIES — Direct blows to the nose can cause a variety of serious nasal injuries:

●Nasal fractures – Nasal fractures may involve the nasal bones, septum, or both. Specific fracture patterns depend upon whether the injury force is lateral or midline [3]:

•Lateral forces are associated with a simple linear fracture without displacement or a lateral fracture with inward displacement on the side of the trauma and outward displacement on the opposite side (picture 1); a greenstick fracture (fracture of the bone with periosteum still intact) may also be evident. Greenstick fractures occur in children because of the unfused midline suture of the nasal bones (figure 1) and the increased proportion of cartilaginous nasal structures.

•High forces directed to the midface are associated with complicated fractures such as naso-orbito-ethmoid fractures and, in young children, "open-book" fractures, which are discussed below.

•Both lateral and midline forces may be associated with septal fractures that cause deviation of cartilage and/or bone. In neonates, septal deviation or dislocation may occur during labor and delivery and cause total nasal airway obstruction (picture 2) [6-8].

●Naso-orbito-ethmoid fractures – Naso-orbito-ethmoid fractures occur with high impact to the central midface and involve complete separation of the nasal bones and the medial walls of the orbits from the frontal bone and the infraorbital rim. The bones typically are fragmented and displaced posteriorly into the ethmoid region. The medial canthal tendons, which are attached to the medial walls of the orbits, are shifted laterally with the fracture segments, resulting in increased inner canthal distance (traumatic telecanthus) [9]. In young children, high-impact midface forces can cause open-book fractures in which the unfused nasal bones are splayed laterally and leave a central depression [3]. Frontal fractures may also occur with extension of the fracture line into the ethmoid and lacrimal bones. (See "Orbital fractures", section on 'Nasoethmoid fracture'.)

●Septal hematomas – Septal hematomas are uncommon but important injuries to identify, especially in young children [1,2]. Trauma to the nasal septum can tear the blood vessels that are adjacent to the septal cartilage (figure 3) [10]. Hematomas form when blood collects in the space between the cartilage and the overlying mucoperichondrium. Expansion of the hematoma separates the cartilage from the mucoperichondrium, which obstructs blood flow to the nasal cartilage. If not rapidly evacuated, pressure-induced avascular necrosis of the nasal cartilage may occur with septal perforation and irreversible damage possible as soon as 24 hours after injury [11]. The accumulated blood and necrotic tissue also form a nidus for infection with bacteria that colonize the nasal mucosa [12].

Once necrosis and/or septal abscess occur, the replacement of necrotic tissue by fibrous tissue, retraction of scar tissue, and loss of support to the lower nose may lead to facial deformity, including saddle nose, displacement of the maxilla, retraction of the anterior nasal septum (columella), widening of the nasal base, and diminished size of the nasal cavity [10,11].

STABILIZATION — Most children with isolated nasal trauma have a minor injury that does not require emergency stabilization.

Children with nasal trauma in association with high-force multiple trauma should undergo initial stabilization according to the principles of Advanced Trauma Life Support (table 1). (See "Trauma management: Approach to the unstable child", section on 'Primary survey'.)

Key interventions for these patients include:

●Patients with neck pain or a high-risk mechanism (eg, diving accident, high-risk motor vehicle collision, serious head or face injury, or multiple trauma) warrant institution of spinal motion restriction and evaluation for cervical spine injury. (See "Pediatric cervical spinal motion restriction" and "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Evaluation'.)

●Supine trauma patients with heavy nasopharyngeal bleeding or oral debris from associated jaw injuries are at risk of aspiration and airway compromise. While an assistant provides manual in-line cervical spine motion restriction, the patient should be log-rolled onto their side (figure 4) and the nasal passages and oropharynx cleared of all blood and secretions using two large-bore Yankauer or wide-bore tonsil tip suction catheters. For patients at risk for spinal column injury, the backboard or trauma stretcher may be tilted in a manner that reduces the risk of aspiration after initial suctioning. Nasal bleeding can usually be controlled with external pressure and nasal decongestants (eg, topical oxymetazoline spray). If packing is necessary to control bleeding, the septum should be evaluated first for the presence of a septal hematoma or deviation [3]. (See "Management of epistaxis in children", section on 'Acute management'.)

●Nasogastric and nasotracheal intubation are contraindicated in general for all trauma patients but are particularly dangerous in patients with persistent nasal bleeding or nasal drainage because of the risk of placing the tube through a fractured cribriform plate and into the cranial vault.

EVALUATION

History — Important historical information after nasal trauma includes [3,4]:

●What is the mechanism of injury?

Isolated nasal injury (eg, direct blow to the nose) helps to focus the evaluation on the presence of a nasal fracture or septal hematoma. In addition to nasal fracture and/or septal hematoma, high midline forces are more likely to cause naso-orbito-ethmoid fractures and to involve associated and potentially serious intracranial, orbital, or mandibular injury that requires emergency stabilization. In young children, midline forces may cause an open-book fracture with lateral splaying of the unfused nasal bones and a central depression (See 'Stabilization' above.)

In children, lateral nasal forces are more commonly associated with simple linear or greenstick nasal fractures and, in adolescents, ipsilateral inward and contralateral outward nasal fractures with associated septal injury. (See 'Types of injuries' above.)

●When did the injury occur?

Patients who present for care soon after injury with obvious nasal deformities and limited swelling may undergo immediate fracture reduction by an otolaryngologist with good cosmetic outcomes. By contrast, children who come for evaluation once swelling has developed require delayed evaluation by an otolaryngologist three to five days later to permit swelling to recede prior to reduction. Successful fracture reduction is difficult if more than 14 days elapse between injury and surgery.

●Has the appearance of the nose changed?

Whether the nose looks different and the specific changes in appearance are important historical elements to help identify the presence of specific types of fractures (eg, increased inner canthal distance [traumatic telecanthus] seen in patients with naso-orbito-ethmoid fractures). Pre-injury photographs can be especially helpful.

●Is epistaxis present?

Epistaxis can occur from isolated soft tissue trauma but is almost always present in patients with nasal fractures or septal disruption. Nasal fractures are uncommon in children who do not have epistaxis. Bilateral epistaxis suggests more severe trauma or more extensive nasal fractures.

●Is there clear nasal drainage?

Clear nasal drainage suggests basilar skull fracture with disruption of the cribriform plate and cerebrospinal fluid leakage.

●Does the patient describe nasal obstruction?

After clearance of secretions or blood, nasal obstruction during acute evaluation points to deviation of the septum or a septal hematoma. For patients who present a day or more after injury, typical symptoms of nasal septal hematoma and/or abscess include progressive nasal obstruction (95 percent), persistent or worsening pain (50 percent), rhinorrhea (25 percent), and fever (25 percent) [12-14].

●Any vision changes?

Patients with vision change (eg, decreased visual acuity or diplopia) are likely to have serious eye or orbital injuries that warrant ophthalmologic evaluation and treatment. (See "Approach to diagnosis and initial treatment of eye injuries in the emergency department" and "Orbital fractures".)

●Has the patient had prior nasal injuries or surgeries?

Prior nasal injury or surgery increases the likelihood that current deformity is chronic rather than acute. Comparison with pre-injury photographs is particularly helpful in this setting.

Physical examination — In patients with multiple trauma, evaluation for nasal injury is performed as part of the secondary survey and after all serious, life-threatening injuries have been identified and addressed. (See "Trauma management: Approach to the unstable child", section on 'Primary survey'.)

Examination of the nose in children may be hampered by lack of cooperation because of pain or anxiety. Pain control prior to examination may permit a better examination. Sedation appropriate for minimally painful procedures may also be helpful in selected patients to ensure an adequate examination. (See 'Initial treatment' below and "Procedural sedation in children: Selection of medications", section on 'Minimally painful procedures'.)

In addition, nasal bleeding and swelling, which occur soon after trauma, can impair the assessment. Measures to control epistaxis and limit further swelling should be provided. (See 'Initial treatment' below.)

The examination of children with nasal trauma should include inspection and palpation of the nose, internal examination of the nasal cavity, and assessment for adjacent injuries [3]:

●Inspection – Inspection should identify the location and presence of external nasal deformity. Epistaxis, edema, and ecchymosis suggest septal injury [15]. Nasal deformity may be obscured by swelling (figure 5). A flattened, broad nose with increased inner canthal distance and vertical orbital displacement suggests a naso-orbito-ethmoid fracture [16,17]. Although there is some ethnic variation, the normal mean inner canthal distance is 16 mm at birth and increases to 25 or 27 mm in the mature female and male face, respectively [18,19].

●Palpation – Palpation of the nasal bones and cartilage should assess for signs of a nasal fracture including mobility, stepoff, or crepitus [3]. Tenderness over specific sites identify specific injuries:

•Frontal sinus – Frontal sinus fractures

•Tip of the nose – Septal hematoma [12]

•Anterior nasal spine from beneath the upper lip – Septal fracture

●Examination of the nasal cavity – The intranasal cavity should be evaluated using a nasal speculum and appropriate lighting in all children with nasal trauma because septal injury (eg, septal hematoma (picture 3)) can occur in the absence of the external findings [3,12-15]. In addition, the signs and symptoms of nasal septal injury may evolve during the 24 to 72 hours after injury. Children with nasal trauma should have close follow-up and re-examination soon after the injury occurs. (See 'Management' below.)

Mucosal laceration with bleeding is suggestive of underlying cartilaginous injury. The septum should be examined for fracture, displacement, laceration, discoloration, and abnormal swelling [3,4]. The nasal septum usually is between 2 and 4 mm thick [20].

Findings suggestive of septal hematoma include [12,13,15]:

•Asymmetry of the septum with a blue or red discoloration

•Swelling of the nasal mucosa that obstructs the nasal passage

•The size of the mass does not change with the application of topical vasoconstricting agents

Nasal septal abscesses typically are larger and more painful than are uncomplicated septal hematomas; the overlying mucosa may be inflamed and have an inflammatory exudate [12].

Apparent septal deviation may be explained by a previous septal deviation or may be caused by a hematoma or abscess [3]. Thus, the area of the septum that appears to be deviated should be palpated with a cotton-tipped applicator to determine whether it is compressible. Immediate consultation with an otorhinolaryngologist is warranted for children who have compressible lesions.

The presence of clear fluid in the nasal cavity may indicate a cerebrospinal fluid leak as a result of an associated skull fracture, usually through the cribriform plate. The evaluation of clear nasal drainage is discussed separately. (See "Evaluation and management of middle ear trauma", section on 'Evaluation of otorrhea' and "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fracture'.)

●Adjacent injuries – Common adjacent traumatic injuries involve the orbit, dentition, and mandible. The evaluation and management of these injuries are discussed in detail separately. (See "Orbital fractures" and "Evaluation and management of dental injuries in children" and "Mandibular (jaw) fractures in children".)

Imaging — Imaging is not necessary for most children with isolated nasal trauma. The physical examination is usually sufficient to diagnose displaced nasal fractures in children [3,4,21,22]. Nondisplaced fractures do not require surgical reduction; thus, radiographs are only needed for medical-legal documentation or when the diagnosis of a displaced fracture is in doubt (image 1). Small observational studies suggest that ultrasonography has better sensitivity for detecting nasal fractures than plain radiographs in children [23]. However, the reported sensitivity for ultrasound ranges from about 25 to 75 percent. Based on this evidence, it is unclear that ultrasonography adds significantly to clinical assessment when diagnosing isolated nasal fractures.

After high-force nasal injury, computed tomography of the maxillofacial bones, orbits, and the base of the skull with 1- to 2-mm slices and axial, coronal, sagittal, and three-dimensional reconstruction images is indicated if any of the following injuries are suspected [3,4,24]:

●Naso-orbito-ethmoid or, in young children, open-book fracture (suggested by flattening of the nasal dorsum and increased inner canthal distance)

●Frontal sinus fracture (suggested by tenderness over the frontal sinus)

●LeFort fracture (suggested by malocclusion and instability of the palate)

●Cerebrospinal fluid leak (suggested by clear rhinorrhea)

DIAGNOSIS — Plain radiographs and computed tomography are not needed to make the diagnosis of isolated nasal fractures in children [3,4]. In children or adolescents with nasal trauma, a careful history and physical examination usually can establish the presence of a displaced nasal fracture or septal hematoma based upon the following clinical findings [3,4] (see 'History' above and 'Physical examination' above):

●Nasal fracture (any of the following):

•Grossly apparent nasal deformity or malposition

•Local nasal tenderness with stepoff and/or crepitus

•No nasal deformity but at least two of the following:

-Periorbital swelling or ecchymoses

-Epistaxis

-Localized nasal tenderness

●Septal hematoma (all of the following):

•Epistaxis

•Blue or red swelling with asymmetry of the nasal septum

•Obstructive, boggy (compressible) swelling of the nasal passage

•The size of the mass does not change with the application of topical vasoconstricting agents

For patients with midline, high-force nasal trauma and clinician concern for nasal fracture with associated orbital, frontal sinus, and/or intracranial injury, computed tomography of the maxillofacial bones, orbits, and the base of the skull with 1- to 2-mm slices and axial, coronal, sagittal, and three-dimensional reconstruction images is the study of choice [3,4,24].

MANAGEMENT — The management of nasal trauma in children and adolescents depends upon patient age, the degree of nasal obstruction, and associated injuries.

Indications for emergency specialty consultation — Emergency consultation with an otolaryngologist should occur for patients with the following conditions [3,8]:

●Septal hematoma or abscess

●High-force midline nasal trauma with concern for associated orbital or frontal sinus fracture (eg, naso-orbito-ethmoid or open-book fractures)

●Newborn infant with septal deviation or dislocation and nasal airway obstruction

In addition, prompt consultation with an otolaryngologist for children with isolated nasal fractures who present within a few hours of injury permits timely closed reduction before swelling obscures cosmetic landmarks [4]. However, most pediatric patients have significant swelling at initial evaluation and can be referred for evaluation by an otolaryngologist three to five days after the injury. (See 'Isolated nasal fracture' below.)

Initial treatment — Initial emergency care of all nasal injuries consists of pain management, control of epistaxis, limitation of soft tissue swelling, and management of open wounds:

●Pain management – Children with minor or moderate pain can receive oral analgesia with acetaminophen or oral nonsteroidal noninflammatory drugs (NSAIDs; eg, ibuprofen) as needed, which is usually sufficient for isolated nasal fractures. For hemodynamically stable patients with severe nasal fractures (eg, open-book or naso-orbito-ethmoid fractures), intranasal fentanyl can be used as long as epistaxis is first controlled. Alternatively, intravenous opioids (eg, fentanyl or morphine) combined with NSAIDs (eg, ketorolac) are an effective approach that may decrease total opioid medication requirements and decrease pain. The combination of opioids and NSAIDs has been shown to decrease opioid requirements and decrease pain in children without increased blood loss or need for transfusion after orthopedic surgery [25-27].

●Control of epistaxis – Most epistaxis can be controlled by compressing the nasal alae together for three to five minutes (figure 6). Topical vasoconstrictors (eg, oxymetazoline) may be used if bleeding is not easily controlled. Other techniques for managing epistaxis are discussed in detail separately. (See "Management of epistaxis in children", section on 'Acute management'.)

●Limit swelling – All patients should have cold therapy applied to the nose. The patient should also be kept in a head-up position to prevent the formation and/or facilitate the resolution of edema and hematoma [3,28]:

•Children with high-force nasal trauma in association with other injuries should have the head elevated approximately 30 degrees during stabilization and while maintaining spinal motion restriction as needed pending further diagnostic imaging and specialty evaluation.

•Children with isolated nasal trauma and those cleared after major trauma should sit upright.

●Open wounds – Open wounds should be carefully evaluated and tetanus prophylaxis provided, as needed (table 2). Lacerations that involve the nasal cartilage, ala, or columella warrant specialty consultation. Repair of nasal lacerations is discussed in detail separately. (See "Assessment and management of facial lacerations", section on 'Indications for subspecialty consultation or referral' and "Assessment and management of facial lacerations", section on 'Nose'.)

Management of specific injuries — In addition to the general measures described above, further care is provided based upon specific injuries.

Soft tissue injury with swelling — Because septal cartilaginous injuries can be difficult to detect in children, the clinician should have a low threshold for referral of a pediatric patient with nasal trauma and swelling to an otolaryngologist, especially if swelling is asymmetric or obscures the contours of the nasal bridge [3].

Selected pediatric patients who have no symptoms of airway obstruction; minimal swelling without epistaxis; and no signs of nasal fracture, septal hematoma, or septal deviation on a complete external and internal nasal examination may be discharged home with the following instructions:

●Oral analgesia as needed for mild pain (eg, acetaminophen or ibuprofen)

●Limitation of swelling with cold therapy for the first 24 hours after injury and elevation of the head of the bed while sleeping for two to three days

●Promptly return for emergency evaluation if the child develops obstruction of nasal breathing, intranasal mass, epistaxis, or clear drainage from the nose

Isolated nasal fracture — Pediatric patients with suspected isolated nasal fractures and no septal hematoma at initial evaluation warrant referral to the otorhinolaryngologist within three to five days for definitive management [3,28]. This brief delay in evaluation permits resolution of the edema and permits visualization of the nasal structures during reduction.

These patients should be discharged with caregiver instructions to perform cold therapy for at least 24 hours for swelling and to keep the head of the bed elevated until their follow-up visit. Pain control with NSAIDs (eg, ibuprofen) may be provided. In addition, the clinician should instruct the parents or primary caregiver to bring a recent photograph of the child to the appointment so that the otorhinolaryngologist can compare the nasal contours before and after the trauma.

An isolated nasal fracture with the attendant deviation of the nasal septum is typically reduced by the otorhinolaryngologist within seven days of injury. The short delay in definitive treatment has little adverse effect on outcome [1,3-5]. However, delay beyond seven days may render reduction of nasal fractures more difficult or cause permanent displacement because the active growth centers in the child's nasal bones promote rapid healing [3,28]. The fractured elements become difficult to mobilize after 7 to 10 days [5].

Most nasal fractures in children can be managed with closed reduction [3,4,28]. Fractures with splayed nasal bones and no impactions can be reduced with bilateral digital compression on the dorsum for 10 to 15 minutes. Nasal deviation to one side often can be reduced by digital compression on the side of the deviation. The end-point of reduction in children is difficult to appreciate because the cartilaginous elements neither move into place as readily as the ossified elements do in adults, nor do the elements "snap" into place [3]. Use of intranasal instrumentation may be necessary if digital compression alone is not successful (picture 4 and picture 5). Open reduction may need to be performed if significant dislocations are present, the injury is more than two weeks old, or closed and intranasal instrumentation fail [3,28]. In prepubertal children, open reduction may be delayed to avoid injury to growth centers [3].

Naso-orbito-ethmoid fractures — Pediatric patients with naso-orbito-ethmoid or open-book fractures should undergo computed tomography of the maxillofacial bones, orbits, and the base of the skull with 1- to 2-mm slices and axial, coronal, sagittal, and three-dimensional reconstruction images to define the full extent of injury. The timing of repair is frequently delayed to permit swelling to subside but is generally completed by two weeks after the injury. The timing for individual patients is determined by patient condition and the preference of the surgical specialist (plastic, otolaryngology, or oro-maxillo-facial surgeon). Management of these complicated injuries is discussed in greater detail in the references [9,16,17].

Septal hematoma or abscess — Management of septal hematoma (picture 3) or abscess should be carried out urgently by an otorhinolaryngologist. Needle aspiration confirms the diagnosis of hematoma or abscess but is not sufficient to drain the collection. Aspirated material should be sent for Gram stain and aerobic and anaerobic cultures [12,14].

Management of septal hematomas involves drainage by intranasal incision under general anesthesia. Approximation of the mucoperichondrial flaps to the cartilaginous septum with a through-and-through suture decreases the risk of recurrence and complications [14]. Septal abscesses are treated with incision, drainage, and nasal packing.

Children who undergo drainage of either septal hematoma or abscess should be treated with systemic antibiotics [14]. Antibiotics should be chosen to cover anaerobes, Staphylococcus aureus, Streptococcus pneumoniae, group A beta-hemolytic Streptococcus, and Haemophilus influenzae (type B and nontypeable), similar to what is recommended for acute bacterial rhinosinusitis as provided in the table (table 3).

Children who have had nasal trauma complicated by septal hematoma should be examined periodically by an otolaryngologist for evidence of cosmetic deformities for at least 12 to 18 months after the injury [29].

Neonatal septal deviation — Septal deviations that cause nasal airway obstruction in newborn infants (picture 2) should be reduced promptly by a pediatric otolaryngologist because newborns are preferential nose breathers, and nasal obstruction can significantly impair breathing [6-8].

RETURN TO PLAY — After fracture reduction, the nasal bones remain mobile for approximately two weeks and can be depressed by force for up to six weeks. Thus, most children with isolated nasal fractures should avoid all sports activities for two weeks and not play contact sports (eg, American football, lacrosse, or wrestling) for six weeks. Most athletes successfully return to their sport after a nasal fracture [30].

COMPLICATIONS — Childhood nasal fracture may be complicated by structural or cosmetic deformity. In one study, 57 children with nasal fractures who had reached nasal maturity were compared with 50 individuals without history of nasal trauma [31]. Functional complaints occurred with equal frequency in both groups. However, deviations of the osseous and cartilaginous pyramid, humps and saddle formations, and deviations of the septum were found more frequently in the fracture group.

In addition to the cosmetic complications, nasal fractures may be complicated by:

●Septal abscess and, rarely, intracranial infection caused by direct spread to the cavernous sinus [32,33] (see "Septic dural sinus thrombosis")

●Lacrimal duct obstruction [34] (see "Approach to the child with persistent tearing")

●Maxillary hypoplasia and atrophic rhinosinusitis [35] (see "Atrophic rhinosinusitis", section on 'Secondary atrophic rhinosinusitis')

●Toxic shock syndrome [36] (see "Staphylococcal toxic shock syndrome" and "Invasive group A streptococcal infection and toxic shock syndrome: Epidemiology, clinical manifestations, and diagnosis")

●Naso-oral-fistula [37]

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of acute fracture management".)

●(See "General principles of definitive fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Upper extremity, thoracic, and facial fractures in children" and "Society guideline links: Acute pain management" and "Society guideline links: Pediatric trauma".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Nose fracture (The Basics)" and "Patient education: Facial fractures (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Anatomy – In children, most of the nasal support structures consist of cartilage (figure 1 and figure 2), and the nose does not protrude forward to the same degree as adults. Due to this developmental anatomy, nasal injuries occur more commonly in children older than five years of age because the nose is more prominent and projects forward to a greater degree from the face. However, because injury to important cartilaginous structures may not initially be apparent, serious pediatric nasal trauma can be missed in young children and cause progressive nasal deformity, septal deviation, and nasal airway obstruction over time. (See 'Developmental anatomy' above.)

●Types of injuries – Direct blows to the nose can cause a variety of serious nasal injuries (see 'Types of injuries' above):

•Simple linear fracture – Lateral forces are associated with a simple linear fracture without displacement or a lateral fracture with inward displacement on the side of the trauma and outward displacement on the opposite side (picture 1).

•Naso-orbito-ethmoid fractures – High forces directed to the midface are associated with complicated fractures such as naso-orbito-ethmoid fractures and, in young children, open-book fractures.

•Septal fractures or dislocation – Both lateral and midline forces may be associated with septal fractures that cause deviation of cartilage and/or bone. In neonates, septal dislocation may occur during labor and delivery and cause total nasal airway obstruction.

●Stabilization – Most children with isolated nasal trauma have a minor injury that does not require emergency stabilization. Children with nasal trauma in association with high-force multiple trauma should undergo initial stabilization according to the principles of Advanced Trauma Life Support (table 1). Key interventions for patients with nasal trauma include spinal motion restriction for patients with neck pain or a high-risk mechanism, positioning and suctioning to prevent aspiration of blood, and control of epistaxis. (See 'Stabilization' above.)

●Clinical findings and diagnosis – In children or adolescents with nasal trauma, a careful history and physical examination can usually establish the presence of a nasal fracture or septal hematoma based upon the following clinical findings (see 'Evaluation' above and 'Diagnosis' above):

•Nasal fracture (any of the following):

-Grossly apparent nasal deformity or malposition

-Local nasal tenderness with stepoff and/or crepitus

-No nasal deformity but at least two of the following: periorbital swelling or ecchymoses, epistaxis, or localized nasal tenderness

•Septal hematoma (all of the following) (picture 3):

-Epistaxis

-Blue or red swelling with asymmetry of the nasal septum

-Obstructive, boggy (compressible) swelling of the nasal passage

-The size of the mass does not change with the application of topical vasoconstricting agents

●Imaging – Imaging is not necessary for most children with isolated nasal trauma. After high-force nasal injury, computed tomography of the maxillofacial bones, orbits, and the base of the skull with 1- to 2-mm slices and axial, coronal, sagittal, and three-dimensional reconstruction images is indicated if any of the following injuries are suspected (see 'Imaging' above):

•Naso-orbito-ethmoid or, in young children, open-book fracture (suggested by flattening of the nasal dorsum and increased inner canthal distance)

•Frontal sinus fracture (suggested by tenderness over the frontal sinus)

•LeFort fracture (suggested by malocclusion and instability of the palate)

•Cerebrospinal fluid leak (suggested by clear rhinorrhea)

●Initial treatment – Initial emergency care of all nasal injuries consists of pain management, control of epistaxis (see "Management of epistaxis in children"), limitation of soft tissue swelling, and management of open wounds. (See 'Initial treatment' above.)

●Specific injuries – Further care depends upon the severity and type of injury:

•Emergency otolaryngology consultation – Emergency consultation with an otolaryngologist should occur for patients with (see 'Indications for emergency specialty consultation' above):

-Septal hematoma or abscess (see 'Septal hematoma or abscess' above)

-High-force midline nasal trauma with concern for associated orbital or frontal sinus fracture (eg, naso-orbito-ethmoid or open-book fractures) (see 'Naso-orbito-ethmoid fractures' above)

-Newborn infant with septal deviation or dislocation and nasal airway obstruction (see 'Neonatal septal deviation' above)

In addition, prompt consultation with an otolaryngologist for children with isolated nasal fractures who present within a few hours of injury permits timely closed reduction before swelling obscures cosmetic landmarks.

•Soft tissue injury with swelling – Because septal cartilaginous injuries can be difficult to detect in children, the clinician should have a low threshold for referral of a pediatric patient with nasal trauma and swelling to an otolaryngologist, especially if swelling is asymmetric or obscures the contours of the nasal bridge.

•Isolated nasal fractures without a septal hematoma – Treatment includes (see 'Isolated nasal fracture' above):

-Cold therapy for at least 24 hours for swelling.

-Keep the head of the bed elevated until their follow-up visit.

-Pain control with nonsteroidal anti-inflammatory drugs (NSAIDs; eg, ibuprofen) as needed.

-Referral to the otorhinolaryngologist within three to five days for definitive management; parents or the primary caregiver should bring a recent photograph of the child to the appointment.