© Borgis - New Medicine 2/2005, s. 28-32
Eliza Brożek-Mądry, Mieczysław Chmielik, Anna Bielicka, Lechosław P. Chmielik, Małgorzata Dębska, Lidia Zawadzka-Głos
Post-traumatic nasal deformations in children
Department of Paediatric Otorhinolaryngology, Medical Academy of Warsaw, Poland
Head: Prof. Mieczysław Chmielik MD, PhD
Objective: Epidemiology and physiopathology analysis of post-traumatic nasal deformations in children.
Methods: The study materials included documentation of patients of the Paediatric Otolaryngology Department of the Medical University in Warsaw as well as information researched in literature, concerning recent or past post-traumatic nasal deformations in children. The consequences of trauma were classified according to the type of lesions they were followed by i.e.: a) soft tissues damage b) fractures with or without dislocation, c) septum haematoma or abscess formation. Nasal deformations included nasal dorsum deformations, septum cartilaginous or osseous deformations and nasal septum cartilage loss.
Results: In 2003-2005, 944 were followed up after past nasal trauma at the Outpatient Clinic. Among them, 77 children were admitted due to complications of recent nasal trauma. These children underwent closed reduction and/or closed septum reduction and/or incision and drainage of the septum haematoma or abscess. Five children were diagnosed with septum haematoma/abscess. Seventy eight children were admitted to the Department because of septum deviation. They were analysed for past nasal trauma and type of deformation. These patients underwent either septoplasty or septoplasty with osteotomy. The analysis also included 44 patients who underwent surgical reconstructions of the nasal septum performed with preserved cartilage or autogenous costal cartilage.
Conclusions: Every nasal trauma in a child should be properly and thoroughly evaluated and followed up in order to prevent late complications including osseous or cartilaginous skeleton deformations. Establishing and initiating appropriate management schemes together with professional otolaryngological medical training may decrease the incidence of these deformations.
Nasal trauma is the most common type of facial trauma in children (1). From the beginning i.e. the foetal period, throughout following stages of motor evolution and sports training, the nose, being the most prominent part of the face, is particularly subject to trauma. It has been shown in the literature that the incidence of nasal fractures in children amounts 23 to 63% of all fractures (2, 3, 4). In developmental age, trauma of the nasal skeleton can adversely influence nasal growth. The shape of the deformed nose and septum deteriorates with time due to hyperstimulation of the perichondrial regeneration mechanisms (5). Yet we are still witnessing cases where nose surgical treatment is being postponed until 17-18 years of age. The fractures called "green stick” fractures, i.e. without periosteum disruption, do not influence the nasal growth but can lead to deformities like humps or callosities.
Nasal trauma and its consequences
Nasal trauma can be divided into prenatal, perinatal and postnatal. All these types can lead to deformations of various types:
1) Soft tissues injury,
2) Chondral/osseous skeleton fractures
– With or without dislocation,
3) Septum haematoma
– Abscess formation.
We have distinguished prenatal and perinatal nasal trauma for their specific character and further management. Prenatal nasal trauma occurs presumably due to a prolonged intra-uterine positional pressure (1), whilst perinatal nasal trauma is connected with prolonged or rapid labour and passage through the osseous birth canal (6). The most frequent deformity after birth is nasal tip deformation (1). Typically, one can observe nasal tip flattening on one side with the septum tilted up in the same direction. In most cases these changes tend to set straight without any further consequences. Still, the fact is that a child in its first weeks of life cannot breathe through the mouth and nasal patency disorders may lead to sleep apnoea, hypoxia and respiratory failure. Such cases require surgical management.
Nasal deformations involving soft tissues have a natural tendency to heel and resolve without any further consequences unless other types of post-traumatic changes accompany them.
Nasal fractures involve mainly nasal bones and occur with or without dislocation. Usually fractures require closed reduction. Periorbital haematoma and damage in the vicinity of ethmoid cells should lead to more cautious proceeding (7). In teenagers, fractures start to resemble adult types of lesions.
All the above-mentioned injuries can be accompanied by septum haematoma formation. Untreated haematoma usually leads to abscess formation and consequent partial or total septal cartilage damage. The first symptoms of septum abscess are nasal patency disorders and fever. Damage to the septum cartilage results in an external deformation of the nose. Lack of proper support in the area of columella and nasal dorsum impairs respiratory function and results in a saddle nose deformity. Immediate cartilage implantation at the site of septal defect, before atrophy sets in, enables regeneration of autogenic cartilage (8). Further development depends on the extent of necrosis and on damage to the surrounding tissues. It was also noticed that allogenic cartilage implantation in septum abscess may prevent septal perforation, however, it does not stimulate normal growth in the middle third of the nose and maxilla (9).
Neglected old fractures with dislocation may lead to chondrous skeletal deformations or loss or osseous skeletal deformations. Changes in the nasal septum present different forms, among them:
– Concave, convex, S-shaped or C-shaped deviations (described sometimes as crests)
– Lists running horizontally
– Spines formed by coexisting list and crest
– Anterior septum cartilage dislocation
There are reports in the literature classifying nasal septum deviations into groups, as prof. Mladina´s classification. It distinguishes 7 types of deviations depending on the combination of lesions. Mladina et al. stated that types 1, 2 and 7 constitute the most frequent post-traumatic deviations in the normal maxilla. Types 5 and 6 occur more frequently in cases of any asymmetry between nasal floor levels (10).
Surgical techniques in post-traumatic reconstruction in children require relevant modifications when compared to adult techniques, depending on the age and healing patterns. Deformations impairing normal breathing in a newborn should be reduced unless they reposition themselves. Closed reduction of nasal fractures is performed with plastic, stiff catheters. To keep the skeleton in position, nasal packing is required for 5 to 7 days (6). The child is hospitalised until nasal packing is removed.
A nasal septum haematoma or abscess requires antibiotics and drainage through a wide incision with a careful evaluation of the skeleton. Large or total cartilaginous skeleton loss should be reconstructed to avoid complications. Reconstruction techniques are based on a modified Cottle method that may be performed in children. The principle of this method includes avoiding the septal mucosa, incisions with a principle of symmetric proceeding without cartilage resection.
In case of septum deviations, a septoplasty should be performed. In case of co-existing deformations of the osseous pyramid of the nose, septoplasty alone may not be sufficient to restore nasal patency. Then Cottle proposed osteotomy in adults. Formerly, osteotomies in children were not performed to avoid any developmental disorders. These concerns were not confirmed in the works by Huizig or Pirsig. A long period of observation performed at our Department allows us to assume that osteotomies in children may and should be performed when the nasal pyramid deformity significantly impairs nasal patency. However, the indications should be carefully considered.
MATERIAL AND METHOD
The study involved children consulted between 2003 and 2005 at the outpatient clinic directly after nasal trauma. In this group, we have distinguished a group of children admitted to the Department for further surgical treatment. The analysis included nose lesions and management.
The study also involved children admitted to the Department between 2003 and 2005 due to septum deviation. We analysed this group, the history of trauma and the types of deformations.
We also completed the data with patients who underwent surgical reconstruction of the nose with cartilage implantation between 1985 and 2005.
In the years 2003-2005, 944 children visited the Outpatient Clinic (544 boys and 400 girls) for recent nasal trauma. Figure 1 presents the number of children consulted depending on age. The number of children requiring surgical treatment and therefore admitted to hospital was marked in Figure 1. The group consisted of 77 children (8% of all children consulted). Histories of 65 patients (31 girls and 34 boys) between the 1st and 18th year of age (mean age 5) were located and analysed. The most common posttraumatic lesions were displacement of the axis of the nasal dorsum on either right or left side depending on the trauma force vector (oblique or arch-shaped) with intussusceptions of the bones on one side and/or prominence on the other. In three children we have observed "open book” fractures. Radiograms of nasal bones were performed in 41 patients and did not show any lesions in 18 of them (44%).
Fig. 1. Children (total number) after nasal trauma followed up at the Outpatient Clinic (girls/boys) and children admitted to hospital after nasal trauma.
Fig. 2. Nasal dorsum deformations.
Table 1. Also summarises the type of necessary surgical treatment in admitted children.
Table 1.Surgical procedures in children after nasal trauma.
|Nasal bones reduction (closed reduction)||55||71,4|
|Nasal septum reduction (closed reduction)||4||5,2|
|Incision and drainage of the septal haematoma/abscess||3||3,9|
|Nasal bones and septum reduction||2||2,6|
|Nasal bones reduction and septal haematoma /abscess drainage ||2||2,6|
|Lack of parental consent for surgical treatment||2||2,6|
|Lack of data||9||11,7|
We analysed children admitted to the Department between 2003 and 2005 because of septum deviation. Patient histories of 78 children (20 girls and 58 boys) were collected. Children in this group were between 3 and 18 years old (mean age 12 years and 8 months). In 40 of them, i.e. in more than a half, we did not find any obvious or remembered trauma in their history. Major and secondary symptoms are collected in Table 2. In this group, 68 out of 78 children were surgically treated (87.2% of the admitted children). Sixty-one patients underwent septoplasty, 4 – septoplasty with osteotomy and 3 children were qualified for other surgical procedures (two for functional sinus surgery and 1 for adenoidectomy). The remaining children were not operated due to their poor general condition. Concurrent diseases were diagnoses in 35 out of 65 admitted children (53.8%) and were as follows: bronchial asthma, hypertension, bleeding disorders, epilepsy and others.
Table 2 presents the range of deformities of the nasal dorsum. The most frequent deformations in the chondral skeleton were:
– Dislocation of the septum cartilage in the columella region (64 patients)
– A list on one or both sides (49 patients)
– A spine and/or crest (23 patients)
– Fractures and fragmentation of the nasal septum (11 patients – 8 without any history of trauma)
Table 2.Symptoms in children with septum deviation.
|Nasal patency impairment||75||96.1|
|Recurrent upper respiratory infections||32||41,0|
|Sleep apnoea episodes||7||9,0|
Osseous skeleton deformations were described in 40 patients:
– Bony list (19 patients)
– Oblique vomer (14 patients)
– Anterior nasal spine deformation (7 patients)
– Vertical lamina of the ethmoid bone deviation (2 patients)
Between 1985 and 2005, we have performed 44 reconstructive surgeries of the nasal septum with implantation of preserved cartilage or autogenic cartilage from the patient´s rib. Seventeen surgeries were performed because of cartilage damage due to abscess formation in an early period, during active inflammation. The following nine reconstructions were performed in patients who had a history of posttraumatic nasal abscess. In three cases surgery was performed after a following trauma. Twelve re-operations were conducted with 7 preserved cartilage implantations and 5 autogenic cartilage implantations from the rib.
The above-mentioned data shows that nasal trauma occurs most frequently in children 1-2 years old. Such a significant incidence of trauma in the first year of life is probably connected with parental vigilance being put to sleep when children start to move around. Younger children are also more frequently consulted than older ones especially when they are the first and only child of their parents. If we look at children admitted to hospital for further treatment, we will notice that the highest admission rates concern children aged 4-5 years and later 8-9 years. The most frequent trauma, in this group, depending on the direction, was lateral trauma – only three children underwent central trauma that resulted in "open book” fractures, which are elsewhere described as more frequent in children (11). X-ray is of minor usefulness as a diagnostic tool in nasal fractures (44% of false negative results).
Considering children admitted with a recent trauma history and children with septum deviation, similar lesions were observed in the shape of the nasal dorsum (oblique or arch-shaped), a potential starting point for further studies.
Nasal skeleton abnormalities in children with septum deviation, described during surgery, show posttraumatic changes in children without history of nasal trauma.
Reconstructive surgery with cartilage implantation has given good results in patients operated no longer than four years before the study and in a group of patients re-operated 3-4 years after initial surgery. The disadvantage of implanted cartilage is its inability to grow and its gradual absorption. Therefore, after 3 to 4 years, the functional and aesthetic results of surgery deteriorated. Degradation of functional and aesthetic results obviously increased if any trauma occurred after reconstruction (12).
1. Young children (1-2 years old) get more often consulted after nasal trauma, while most children admitted to hospital after a nasal trauma are either 4-5 years old or 8-9 years old.
2. Radiography appears to be lesser of a diagnostic tool in nasal fractures.
3. A cartilage implanted in the nasal septum to restore proper support for the nasal dorsum makes nasal patency possible and ensures normal functioning for 3 to 4 years after surgery.
4. Three to four years after cartilage implantation the implant needs to be replaced.
5. Nasal septum reconstruction enables physiologic functioning of the nose and prevents consequences of disturbed breathing.
6. Establishing and initiating appropriate management schemes together with professional otolaryngological medical training may decrease the incidence of these deformations.
7. Long-term experience yielded an algorithm of management in nasal trauma in children (9).
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