© Borgis - New Medicine 3/1999, s. 12-15
Mieczysław Chmielik, Stanisław Betlejewski
Management of deviation of the nasal septum in children
Department of Paediatric Otolrhinolaryngology, Warsaw Medical School, Poland
Head: Prof. Mieczyslaw Chmielik, M.D.
Department of Otolaryngology, University of Medical Sciences, Bydgoszcz, Poland
Head: Prof. Stanislaw Betlejewski, A.M.
In this study we investigated the optimal treatment of nasal fractures and nasal deformations in children. An algorithm for the menagament of nasal fractures by children is publicated.
Disorders affecting nasal patency, especially in children, can seriously impair the development of hearing, speech intelligence, and physical development. Therefore, the ability to foresee the possible audiological consequences caused by deformations of the nose, and the evaluation of the possibilities of surgical correction, is very important.
Childhood, the most important period of life, consists of several stages, and the possibilities of nasal injury vary from stage to stage. During delivery, the child is exposed to injuries of the nose because the birth canal has bony walls, and its diameter is usually smaller than that of the head; nasal trauma always occurs during the birth process. The majority of these traumas do not require repositioning, as in the new-born there are mechanisms which can repair deformations spontaneously. This phenomenon, recorded over a long period, is presented in detail by P.Spiewak in this doctoral thesis.
Delivery by Caesarean section can also cause nasal injury, especially if the child is removed rapidly.
Deformations of the nasal endoskeleton in the new-born require surgical intervention if they fail to reposition spontaneously within the first seven days of life. These deformations may cause breathing difficulties in the infant or small child, particularly during feeding and sleep. This apparent coryza may cause the family doctor to prescribe anti-inflammatory, antibacterial, anti-allergic, or anti-oedematous treatment. This is, of course, ineffective. Examination of the nasal cavities in infants is outside the competency of most family doctors, and therefore every infant with persistent coryza should be examined by a laryngologist.
In cases of perinatal fracture of the nasal septum, repositioning of the deformation is necessary. Stiff plastic catheters are introduced into both nasal cavities, and the repositioning is achieved by bringing the catheters close together. To keep the elements in a fixed position, the nose should be packed for 5 to 7 days. Tamponing of the cavities in an infant requires constant observation, and the child should therefore be hospitalised. After removal of the tampons, nasal breathing usually returns to normal.
Nasal traumas do not usually occur in infants, who are normally at home. This type of trauma appears when the child begins to walk. They are very frequent, but the force causing them is usually small. The skeleton of the child´s nose consists mainly of elastic chondral elements, and injuries rarely have a permanent effect. As the child grows, the range of its penetration increases, and the probability of nasal injuries involving larger forces also increases. The child may, for example, be struck by a swing, kicked by a horse, or suffer a traffic accident. In such cases, the physician should, first of all, evaluate the patient´s general condition. It should be remembered that nasal trauma is a cranial trauma, and that dangerous intracranial complications requiring immediate intervention may occur. If this happens, the child should be admitted to a medical centre to ensure proper care.
In the child, the periosteum is relatively strong, and this is why bone fractures without rupture of the periosteum occur. These are called greenstick fractures. Dislocation does not occur very often.
These fractures do not require repositioning, but can sometimes cause a subperichondral or subperiosteal haematoma. Fractures without dislocation in childhood can result in external deformations of the nose - e.g: humps or thickenings. This is why it is very important for parents to be informed of this possible complication immediately after the trauma. In patients with a lateral wall haematoma, the retained blood may suppurate. This is particularly dangerous in haematomas of the septum, because the untreated septal abscess leads to permanent cosmetic deformations and impairment of nasal breathing.
Therefore, in cases of distension of the nasal septum where there is retention of blood or pus, evacuation of the skeletal elements is essential. This is done by a wide semi-transverse incision. Losses in the column or dorsum of the nose should be reconstructed simultaneously by a preserved cartilage implant.
Haematoma or abscess of the nasal septum always requires systemic antibiotic therapy, and compact nasal packing with an antibiotic.
Fractures with dislocation due to nasal trauma in children must be repositioned within 7 days. This is necessary because metabolic mechanisms, including the healing of wounds, occur much more rapidly in the child than in the adult. Within 7 days from the trauma adhesion appears, usually being elastic in this period. A repositioning performed at this stage may seem effective, but within a short time the adhesion can pull the repositioned fragments of bone to the earlier bad position. Thus, the period of up to three weeks after the trauma which some handbooks recommend as being suitable for repositioning seems to be too long for patients at a developmental age.
Repositioning of the nose in children should always be done under general anaesthesia. For safe anaesthesia, basic laboratory investigation is essential. Thus, the repositioning cannot be done in the period immediately after the accident, when it will be too early for oedema to appear. Post-traumatic oedema usually disappears within 4 to 6 days after the trauma, leaving only one day for the repositioning. For this reason, basic laboratory tests should be ordered immediately after the accident, and an appointment with the anaesthetist should be made for the sixth day after the fracture.
Nasal repositioning in post-infancy is analogous to the procedure in the adult patient. The invaginated elements are lifted, and the externally dislocated skeletal fragments are simultaneously pushed into the correct position. After fixing bones and cartilage in the right position, the nose should be filled with an inexpansible material, such as gauze. The nasal packing should remain in place for 7 to 10 days. Materials such as polyurethane sponge or merocel should not be used. These materials are useful in cases of an isolated fracture of the nasal septum, where the bony skeleton of the lateral walls and dorsum of the nose are preserved.
There are not usually any serious contraindications for ambulatory treatment in post-infant children after this procedure. It will be obvious that the nasal repositioning and removal of the tamponade must be done by a laryngologist. Unsatisfactory results after a properly conducted reposition procedure may indicate a fracture in the deeper cranio-facial structures. Computer tomography of the affected region is then essential, and in the case of a lesion of the deep skeletal craniofacial structure, the patient should be under the care of a maxillofacial surgeon. If tomography shows no pathology within the mandibulo-facial complex, the nose repositioning procedure should be repeated.
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1. Chmielik M. et al.: Functional and cosmetic long term results after reconstructive operations of the nose in children using preserved homologous cartilage graft. Otolaryng. Pol., 1998, suppl. 27:49-53. 2. Chmielik M., Witkowska A.: Rhinosurgery in children. Otolaryng. Pol., 1993, 47:138-143. 3. Huizing E.: Septum surgery in children, invications. Surgical technique and long-term results. Rhinology 1979, 17:91-93.