List of Abbreviations
BP – blood pressure
IV – intravenous administration
IM – intramuscular administration
PSD – primary surgical debridement [Note: Russian VKhO can mean secondary too depending on context, but standard is secondary/primary; keeping standard surgical terms]
CT – computed tomography
NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs
NBF – nasal bone fracture
NS – nasal septum
RR – respiratory rate
TBI – traumatic brain injury
HR – heart rate
ECG – electrocardiogram.
Terms and Definitions
Level of evidence, LoE – ranking of research designs based primarily on their internal validity.
Note 1: this method is used to determine the persuasiveness of a study.
Note 2: various hierarchies of evidence are used to assess health technologies.
Level of clinical evidence (LCE) – the degree of certainty in the validity of the intervention's effect and in the fact that following the recommendations will bring more benefit than harm in a specific clinical situation.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Nasal trauma – an injury to the nose resulting from the direct or indirect action of a traumatic factor acting from the outside and inside, leading to a disruption of the integrity of tissues and structures of the external nose, nasal cavity, and impaired nasal functions [6, 7].
Superficial nasal injury is an injury to the external nose without damage to the skin, nasal bones, or nasal mucosa in the absence of neurological symptoms.
Nasal bruise is a closed mechanical injury to the tissues and structures of the nose without visible disruption of the integrity of the skin and mucous membranes, occurring under the influence of a blunt object from the outside or inside, accompanied by rupture of small vessels followed by hemorrhage.
Nasal bruise (contusion) is a nasal injury characterized by blood impregnation of the soft tissues of the external nose due to vascular disruption in the injury zone, unlike a hematoma, which represents an accumulation of blood in confined cavities
Nasal abrasion is damage to the superficial layer of the skin of the external nose, in which the focus of crushed skin vessels is visible to the naked eye.
Nasal bone fracture (NBF) – partial or complete disruption of the integrity of its constituent bone anatomical structures (nasal bones, frontal processes of the maxilla, nasal septum, nasal spine) as a result of mechanical injury. An NBF is classified as closed if the integrity of the nasal skin is preserved, and open if there is communication between the bone fragments and the external environment through an open nasal wound.
Nasal wound – a type of nasal injury involving full-thickness damage to the skin of the external nose, often with exposure of cartilaginous and bony structures and deeper anatomical formations of the nasal cavity, sometimes with avulsion of the ala and apex (tip) of the nose.
Open nasal wound – a local disruption of the integrity of all layers of the skin and soft tissues in the nasal region resulting from external impact.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Nasal trauma occurs as a result of the direct or indirect action of a damaging factor, such as mechanical, thermal, or chemical.
As a result of the impact of a traumatic factor (externally and/or internally), there is a disruption of the integrity of the skin of the external nose or the mucous membrane of the cavity, and damage to the blood and lymphatic vessels and nerves located in the injury zone.
The degree of damage to the soft tissues, bone, and cartilage skeleton of the nose is determined by the nature of the injury, and in mechanical trauma, it depends on the direction and force of the impact. Trauma is often accompanied by damage to the nasal bones in the form of a fracture and displacement of the nasal septum resulting from a subluxation of the quadrangular cartilage or a fracture of the bone structures.
Trauma leading to a nasal bone fracture can be domestic, occupational, sports-related, combat-related, etc. NBFs are often diagnosed in patients with catatrauma (injury sustained from a fall from a height), as well as resulting from road traffic accidents.
A crucial condition for the correct diagnosis and adequate treatment of NBFs is a clear understanding of their traumatogenesis.
When mechanical force is applied in the frontal plane, a fracture of the nasal bones occurs with depression (flattening) of the nasal dorsum. At the same time, separation of the nasal bones is recorded only with a fairly strong impact. A lateral direction of the acting force vector can lead to the separation of the synostosis between the nasal bone and the frontal process of the maxilla with the formation of external nasal scoliosis, but more often the fracture line passes above the suture between the frontal process of the maxilla and the nasal bone [8, 9]. As a rule, a fracture of the nasal septum (NS) with the displacement of its fragments along the sutures is observed simultaneously. In NBFs, the cartilaginous part of the nasal septum is most often damaged [10]. At the same time, displacement of the nasal bones cannot occur without disrupting the integrity of the perpendicular plate of the ethmoid bone upon which they rest. With severe traumatic impact, pronounced compression of the external nose occurs with the formation of bone shards and cartilage fragments.
In young children, due to the elasticity of the bony framework of the external nose, NBFs are rare; hematoma and abscess of the nasal septum occur more frequently. As the child grows older, the frequency of greenstick fractures, "open book" fractures, and fractures along the bone and cartilage suture lines increases. Comminuted fractures are less common in children than in adults [11].
Deformity of the external nose due to NBF is determined in 43% of cases, while lateral deviation of the nasal dorsum is detected in 25%, slope depression in 40%, flattening of the nasal dorsum in 10%, and combined deformity in 25% of patients.
In most cases, edema of the nasal soft tissues rapidly develops after trauma, which in childhood is associated with their increased hydrophilicity, often making it difficult to assess the presence of deformity. In addition, NBF is often accompanied by epistaxis and reactive edema of the nasal mucosa. Frequently, NBFs involve rupture and detachment of the perichondrium or periosteum of the nasal septum, displacement of the quadrangular cartilage, with blood accumulating between it and the perichondrium – a septal hematoma. When the hematoma becomes infected, a nasal septal abscess forms, resulting in lysis of the quadrangular cartilage, which in turn is accompanied by nasal deformity and impaired functions.
Along with aesthetic facial impairment, a feature of NBFs is significant functional disorders – post-traumatic nasal breathing impairment, which negatively affects the respiratory, cardiovascular, and other body systems. Post-traumatic changes in the structures of the external nose and nasal cavity worsen the aerodynamics of nasal breathing and affect endurance and working capacity [12, 13, 14].
Nasal trauma can be isolated or combined with damage to the paranasal sinuses and adjacent organs – the eye, zygomatic region, mandible, oral cavity, auricle, or brain in the form of a concussion or brain contusion [6].
1.3 Epidemiology of the Disease or Condition
Nasal bone fractures are one of the urgent problems of traumatic facial injuries not only due to their incidence, but also due to their functional, aesthetic, and social significance. Superficial nasal injuries rarely become the reason for seeking medical care. Most frequently in the early period after trauma, nasal bone fractures and nasal injuries accompanied by epistaxis and marked deformity of the external nose are recorded.
In the structure of ENT organ injuries, NBFs in adults account for up to 90%, and among facial skeleton injuries, about 54%. In children, NBFs account for an average of 0.16% of total traumatic injuries. NBFs are most frequently observed in males aged 15 to 25 years [15, 16, 17, 18]. About 85% of patients seeking rhinoplasty attribute their condition to a previous nasal injury [14, 19]. NBFs are more common in boys (63.3%), and the mean patient age is 11.5 ± 1.2 years. 18% of newborns sustain external nasal trauma during delivery [20]. Domestic or street injuries predominate in children (66.8%), injuries in childcare facilities account for 17.2%, road traffic accidents account for 10.5%, and sports injuries account for 5.5% [21].
1.4 Features of Coding the Disease or Condition
S00.3 – Superficial injury of nose
S01.2 – Open wound of nose
S02.2 – Fracture of nasal bones
S02.20 – Closed fracture of nasal bones
S02.21 – Open fracture of nasal bones
1.5 Classification of the disease or condition
There is currently no universally accepted classification of NBFs. In practice, the classifications of nasal bone fractures by Yu.N. Volkov [22] (Table 1), S.B. Besshapochny [23], and A.S. Lopatin [24] are most frequently used.
Table 1.
Classification of nasal bone fractures (Volkov Yu.N., 1958) [22]
Open | Bone Fractures of the nose | Without deformity of the external nose |
|---|---|---|
Closed | With deformity of the external nose |
Classification of NBFs (Besshapochny S.B., 1984) [23]
Nasal bone fractures:
I. without deformity of the external nose
II. with deformity of the external nose:
1. unilateral
2. bilateral
- with lateral displacement of bone fragments
- with posterior displacement of fragments
- with lateral displacement combined with posterior displacement of fragments.
Classification of NBFs (Lopatin A.S., 2019) [24]
1.1 Isolated
1.2. Combined
2.1. Open
2.2. Closed
3. With displacement:
3.1. with a lateral direction of impact;
3.2. with a frontal direction of impact;
3.3. with a frontolateral impact;
3.4. with a basal impact.
In addition, taking into account the extent of the zone of traumatic damage to surrounding anatomical structures, NBFs are divided into:
1. Isolated NBFs:
1.1. with deformity of the external nose
1.2. without deformity of the external nose
2. Combined NBFs:
2.1 with facial skin trauma
2.2 with trauma to intranasal structures
2.3 with trauma to the paranasal sinuses
3. Associated nasal bone fractures:
3.1 with maxillofacial trauma
3.2 with traumatic brain injury
3.3 with trauma to the extremities, torso, and internal organs.
At the same time, isolated nasal bone fractures account for 27.8%, while combined and associated fractures account for 52.6% and 19.6%, respectively [21].
Depending on the duration of the post-injury period, the feasibility of mobilizing bone fragments, and their reposition, three stages of the clinical course of displaced nasal bone fractures are distinguished [25].
I – acute: the first fourteen days after the injury. At this stage, standard nasal bone reposition is performed.
II – malunited (antiquated) fracture: from two weeks to two months. Reposition is possible only with simultaneous septoplasty.
III – persistent deformation: more than two months. Reposition of bone fragments is possible with osteotomy.
1.6 Clinical presentation of the disease or condition
Clinical manifestations of superficial nasal trauma are mild: pain in the injury area, slight swelling, and moderate skin redness without damage to the superficial layer.
In other types of nasal trauma, the following may be observed: visible external nasal deformity in the form of a significant increase in the nasal pyramid and smoothing of its contours due to soft tissue edema in nasal contusion, as well as changes in the color and integrity of the external nasal skin in nasal bruising and abrasion, lateral displacement or depression of the nasal pyramid in nasal bone fracture, thickening of the nasal septum and narrowing of the nasal passages in nasal septal hematoma, epistaxis, pain and tenderness upon palpation in the area of damaged external nasal structures, impaired breathing and olfaction. In associated nasal injuries, clinical symptoms corresponding to the injury zones are recorded: edema, bruising, hematomas, wounds, visual impairment, altered consciousness, and impaired brain activity.
Clinical symptoms of nasal bone fractures include edema, pain, external nasal deformity, crepitus and mobility of bone fragments, epistaxis, and nasal breathing difficulty.
External nasal deformity in children with a nasal bone fracture is detected in only 57.5% of cases due to pronounced soft tissue edema. It should also be taken into account that in 7.4% of pediatric patients, the external nasal deformity is unrelated to the recent trauma and was present previously [19].
Nasal bone fractures are frequently accompanied by damage to the skin of the external nose, tears of the nasal mucosa, soft tissue emphysema of the nose and face, and ecchymosis. Epistaxis is a common manifestation of nasal bone fractures, but in uncomplicated isolated fractures, it is rarely intense and recurrent [26].
Nasal bone fractures are often accompanied by subcutaneous hemorrhage into the eyelids and orbital soft tissues ("spectacle hematoma" sign); however, this sign may also be a manifestation of an anterior skull base fracture or cavernous sinus injury.
Crepitus and mobility of bone fragments are observed in less than half of the cases; therefore, their absence does not rule out a nasal bone fracture. Pain in the nasal area is also not a pathognomonic symptom of nasal bone fractures, as it can occur with contusions and inflammatory diseases of the nose [27].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnosis of nasal trauma involves determining the nature and severity of injuries to the external nose, nasal cavity structures, and main nasal functions based on patient complaints, clinical manifestations, physical examination, palpation, rhinoscopy, and, if necessary, additional diagnostic methods.
Criteria for establishing the diagnosis/condition:
1) anamnestic data indicating the fact of trauma based on the victim's or eyewitnesses' description;
2) characteristic complaints after sustaining trauma regarding pain, nasal deformity, nasal breathing difficulty, epistaxis, and olfactory impairment;
3) physical examination findings — presence of skin lesions of the external nose (bruises, abrasions, wounds), external nasal deformity, crepitus and mobility of bone fragments, epistaxis, impaired breathing, and olfaction;
4) additional examination findings — detection of signs of nasal bone fracture based on facial skull radiography (if contraindicated, nasal bone ultrasound (ultrasonography)), as well as, in case of polytrauma, signs of damage to the walls of the paranasal sinuses, orbit, zygomatic bone, maxilla, and cranial bones based on skull radiography, facial CT, or brain CT.
2.1 Complaints and Anamnesis
When taking the medical history and recording complaints, the circumstances and mechanism of trauma, direction of the impact, and loss of consciousness are clarified. It is specified whether the injury is primary or if the external nose was previously traumatized with resulting deformity, and whether prior surgical treatment for nasal diseases was performed. Information regarding tetanus vaccination is recorded in combined injuries involving a breach of skin integrity [29, 30]. Hemodynamic parameters (BP, HR, RR) are evaluated during the general examination.
2.2 Physical Examination
It is recommended to perform an initial examination (consultation) by an otorhinolaryngologist for all patients with nasal trauma in order to identify key symptoms and determine the nature and severity of nasal injuries (see Section 1.6 "Clinical Presentation") [11, 13, 20, 21, 28].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
It is recommended to perform palpation of the maxillofacial region in all patients with nasal trauma to clarify the nature of the trauma and the severity of injuries [6, 11, 26, 29, 31].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: during the examination of the external nose, record the presence of edema, hematomas, abrasions, and wounds. Visually assess the presence and severity of external nasal deformity. Palpation should determine the presence of bone fragment crepitus, subcutaneous emphysema, and hematoma. Assess the nasal valve area, the condition and mobility of the alae nasi, and the mobile part of the nasal septum. Photographic documentation is essential for medical and forensic examination [14].
2.3 Laboratory Diagnostics
It is recommended to perform a coagulogram (screening hemostasis test) in patients with nasal trauma accompanied by bleeding to assess the hemostatic system, the volume of blood loss, diagnose potential anemia, and prepare for surgical intervention if required [7].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.4 Instrumental Diagnostics
It is recommended to perform facial skull radiography in adult patients with nasal trauma, and in children with nasal trauma starting from 3 years of age, to detect bone and traumatic changes [8, 13, 36].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: In nasal bone fractures, lateral facial skull radiography has high diagnostic and legal significance, as in the majority of cases (70.2%) it allows for the detection of a fracture and determination of the nature of bone fragment displacement [8, 13, 36].
In nasal bone fractures, both nasal bones are typically injured, with common fracture lines passing through them, although single and multiple fractures may occur [37]. To clarify the side of the fracture, it is recommended to perform radiography of the facial skeleton in the lateral projection with the patient's head positioned on the left and right sides.
Radiological presentation of nasal bone fractures is quite diverse: fracture lines and displacement of bone fragments relative to each other and surrounding areas of the facial skeleton in the sagittal plane are identified [9, 37].
However, overall, the sensitivity of radiography of the facial skeleton in nasal bone fractures does not exceed 70%, which is explained by the complex skialogy of the facial skull bones on lateral radiographs; furthermore, this projection does not allow for registering the displacement of bone fragments in the frontal plane.
In children under the age of 3, assessment using nasal bone radiography has low informativity due to the absence or poor development of the cortical bone component, incomplete ossification, and the predominance of cartilage and soft tissues.
Thus, a negative result of a standard radiographic examination of the nasal bones does not exclude the presence of a nasal bone fracture [39].
It is recommended to perform radiography of the paranasal sinuses in adults and children from 3 years of age with nasal trauma when displacement of bone fragments in the anteroposterior direction is suspected and there is no evidence of bone-traumatic changes on lateral facial skull radiography [39].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: to detect fragment displacement from outside inwards, which may not be visualized on lateral views, it is necessary to perform radiography of the paranasal sinuses in the occipitomental projection [8, 36].
It is recommended to perform facial CT or CT of the maxillofacial region, and/or brain CT in patients with nasal bone fractures in cases of combined and polytrauma of the skull for differential diagnosis [40].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Computed tomography (CT) is indicated in cases of combined and multiple nasal bone fractures, clinical manifestations of traumatic brain injury (TBI), low diagnostic value of facial bone radiography in the presence of clinical signs of nasal bone trauma, planning for extended surgical treatment, suspected nasal cerebrospinal fluid leak, severe patient condition, and ongoing or recurrent post-traumatic epistaxis [9, 21, 38, 40]. The choice of the scanning area depends on concomitant pathology.
At the present stage of otolaryngology development, CT is widely used in the diagnostic process. The sensitivity of the method for nasal bone trauma approaches 100%. CT is performed using spiral scanning with a slice thickness of 3 mm. This method allows for detailed visualization of the injury site, assessment of bone fragment position, and the topography of damaged structures relative to surrounding tissues and organs. CT makes it possible to evaluate the condition of the nasal septum, determine the presence of associated injuries to the paranasal sinuses, orbits, and cranium, as well as assess the state of soft tissues and the brain, enabling timely interventions in cases of craniofacial trauma and zygomatico-orbital complex injuries [41, 42]. 3D CT visualization is recommended when planning surgical intervention.
It is recommended to perform an ultrasound examination (ultrasound) of the nasal bones in all patients with nasal trauma when there are contraindications to radiological diagnostic methods in order to clarify the diagnosis [14, 43].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: Ultrasound of the (nasal) bones is characterized by simplicity, non-invasiveness, the absence of ionizing radiation exposure to the patient, and the possibility of repeated use to monitor reduction and the dynamics of fragment consolidation [43]. The examination is performed in four projections: anterior longitudinal, anterior transverse, right lateral, and left lateral.
2.5 Other Procedures
It is recommended to perform an initial consultation (examination) by an ophthalmologist for all patients with nasal trauma when damage to the visual organ is suspected, in order to ensure timely diagnosis of concomitant pathology and treatment [7, 29].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform an initial consultation (examination) by a neurologist for all patients with nasal trauma for the timely diagnosis of concomitant pathology and treatment [7, 29].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform an electrocardiogram (ECG) in patients with nasal trauma and concomitant massive bleeding, or combined nasal trauma, to assess the cardiovascular system and plan treatment [7, 33, 34, 35].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
Conservative treatment aims to reduce pain severity and edema, prevent the development of bacterial inflammation in the injury area, and stimulate repair processes and accelerate the recovery of nasal functions [21, 26, 29, 45].
It is recommended for all patients with nasal trauma to be prescribed analgesics for symptomatic pain management in the absence of contraindications [21, 26].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Severe pain, as well as neuro-psychological stress associated with trauma, plays a role in the development or aggravation of traumatic shock [26].
To reduce pain severity, drugs from the other analgesics and antipyretics group (ATC: N02B) and the non-steroidal anti-inflammatory and antirheumatic drugs group (ATC: M01A) are used, either alone or in combination [46, 47].
It is recommended to use a combination of non-steroidal anti-inflammatory drugs (NSAIDs) (ATC: M01A non-steroidal anti-inflammatory and antirheumatic drugs) and anilides (paracetamol** (ATC: N02BE01)), as well as pyrazolones (metamizole sodium (ATC: N02BB02)) for pain relief in adults and children, including the postoperative period (Tables 2, 3) [46, 47]. In children, the use of NSAIDs (ATC: M01A non-steroidal anti-inflammatory and antirheumatic drugs) is limited to ibuprofen** (ATC: M01AE01) from 3 months of age, ketoprofen** (ATC: M01AE03) from 15 years of age, and ketoprofen** (ATC: M01AE03) in the dosage form of granules for oral solution from 6 years of age. In outpatient practice when treating children, the use of metamizole sodium preparations (ATC: N02BB02) should be avoided, and in inpatient practice, they should be used only if other analgesics (ATC code: N02) approved for use in children are unavailable, due to the risks of developing serious adverse events.
Table 2. Recommended doses and regimens of analgesic therapy in adults with nasal injuries.
Drug | Single dose | Dosing interval | Maximum daily dose | Maximum duration of administration |
|---|---|---|---|---|
Paracetamol** (ATC: N02BE01) | 1 g, IV infusion over 15 min | 4 h | 4 g | 5–7 days |
Diclofenac** (ATC: M01AB05) | 75 mg IM | 12 h | 150 mg | 2 days |
Ketorolac** (ATC: M01AB15) | 30 mg IV, IM | 6 h | 60–90 mg | 2 days |
Ketoprofen** (ATC: M01AE03) | 100 mg IV, IM | 12 h | 200 mg | no more than 2 days |
Lornoxicam (ATC: M01AC05) | 8 mg IV, IM | 12 h | 16 mg | 1–7 days |
Dexketoprofen** (ATC: M01AE17) | 50 mg IV, IM | 8–12 h | 150 mg | 2 days |
Metamizole sodium (ATC: N02BB02) | 500–1000 mg IV, IM | 8–12 h | 2 g | 1–5 days |
Table 3. Recommended doses and regimens of analgesic therapy in children with nasal injuries.
Drug | Single dose | Dosing interval | Maximum daily dose | Maximum duration of administration |
Paracetamol** (IV) (ATX: N02BE01) | IV infusion over 15 minutes: 10–50 kg – 15 mg/kg; <10 kg – 7.5 mg/kg >50 kg – 1000 mg | 4 h | 33–50 kg – <60 mg/kg, but not more than 3 g; 10–50 kg – <60 mg/kg, but not more than 2 g; <10 kg – <30 mg/kg >50 kg – 4 g | 5–7 days |
Paracetamol** (per os) (ATX: N02BE01) | 10–15 mg/kg | 6 h | no more than 60 mg/kg | 3–5 days |
Paracetamol** (suppositories rectally) (ATX: N02BE01) | 10-14 years – 350-500 mg 5-10 years – 250-350 mg 3-5 years – 150-200 mg 1-3 years – 100-150 mg 3-12 months – 50-100 mg | 6 h | <60 mg/kg | up to 5 days |
Ibuprofen** (per os) (ATX: M01AE01) | >6 years – 200-400 mg; 4-6 years – 150 mg; 1-3 years – 100 mg; 6-12 months – 50 mg 3-6 months – 50 mg | 6-8 h 8 h | 12-17 years – 1 g; 6-12 years – 800 mg; 4-6 years – 450 mg; 1-3 years – 300 mg; 6-12 months – 200 mg; 3-6 months – 150 mg | 4 days |
Ibuprofen** (rectal suppositories) (ATC: M01AE01) | 3-9 months – 60 mg 9-24 months – 60 mg | 8 h 6 h | 3-9 months – 180 mg 9-24 months – 240 mg | no more than 3 days |
Metamizole sodium (ATC: N02BB02) | from 15 years – 500-1000 mg IV, IM; 2-14 years – 50-100 mg/kg IM, IV; 3 months - 1 year – 50-100 mg/10 kg IM | 8–12 h | from 15 years – 2 g | 1–5 days 3 days |
It is recommended to administer tetanus toxoid vaccines (ATC code: J07AM) to patients with nasal trauma involving compromised skin and mucous membranes caused by impact with the ground or soil particles entering the wound [29].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Emergency tetanus immunoprophylaxis should be performed as early as possible and up to 20 days from the moment of injury, taking into account the incubation period of tetanus. Emergency tetanus prophylaxis consists of primary surgical debridement of the wound and simultaneous specific immunoprophylaxis with tetanus toxoid** (ATC: J07AM01), human tetanus immunoglobulin** (ATC: J06BB02), or tetanus antitoxin (ATC: J06AA02) in accordance with the instructions for use.
It is not recommended to routinely prescribe systemic antibacterial therapy to patients with isolated nasal bone fractures (including open fractures) in the pre- and postoperative periods [48, 49].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
Comments: Prophylactic use of systemic antibacterial therapy does not reduce the risk of postoperative infectious and inflammatory complications after nasal bone reduction in adults and children.
It is recommended to prescribe systemic antibacterial drugs to patients with nasal trauma accompanied by contaminated and purulent wounds of the skin and mucous membranes, with pronounced edema-toxic syndrome or complicated nasal septum hematoma/abscess, with combined and polytrauma, as well as with severe comorbid somatic pathology in order to manage bacterial infection [6, 28, 45, 48, 50, 51, 52, 53, 54].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: In the clear presence of a bacterial inflammatory process or a high probability of its development, antibacterial therapy with broad-spectrum antimicrobial drugs is prescribed. Beta-lactam antibacterial drugs are used (ATC: J01CR penicillin combinations, including combinations with beta-lactamase inhibitors, J01D other beta-lactam antibacterial drugs) – cefazolin** (ATC: J01DB04), ceftriaxone** (ATC: J01DD04), ampicillin+[sulbactam]** (ATC: J01CR01), amoxicillin+[clavulanic acid]**3 (ATC: J01CR02), and in case of allergy to beta-lactam antibacterial drugs, drugs from the lincosamide group (J01FF) – clindamycin** (ATC: J01FF01) are used.
Penicillin combinations, including combinations with beta-lactamase inhibitors (ampicillin+[sulbactam]** (ATC: J01CR01), amoxicillin+[clavulanic acid]**3 (ATC: J01CR02)) provide a broader coverage of Gram-negative and anaerobic bacteria than cefazolin**. Ampicillin+[sulbactam]** (ATC: J01CR01) is used IM and IV, in adults depending on the severity of the infection 3-12 g/day in 3 doses, in children – 150 mg/kg/day in 3 doses (in newborns – in 2 doses) for 5-14 days. Amoxicillin+[Clavulanic acid]**3 (ATC: J01CR02) is used IV in adults and children over 12 years of age at 1 g (calculated as amoxicillin) 3 times a day, in children under 12 years of age at 25 mg/kg 3 times a day for 5-14 days.
It is recommended to prescribe angioprotectors to adults and children over 15 years of age with nasal trauma and pronounced edema syndrome in order to accelerate the timing of bone fragment reduction and prevent potential complications [6, 21, 55].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: For post-traumatic edema syndrome in the nasal dorsum area, angioprotector drugs are applied topically (troxerutin (ATC: C05CA04) for adults and children over 15 years old), sodium heparin** (C05BA03), in the form of a gel to undamaged skin areas 2 times a day until the edema resolves [56].
It is recommended to prescribe hemostatic agents to all patients with nasal trauma accompanied by profuse bleeding, as well as for the prevention of perioperative bleeding [21, 26, 50].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Bleeding in nasal injuries can originate from both the nasal cavity and damaged soft tissues in open nasal wounds. Mechanical methods of stopping bleeding usually require therapeutic support in the form of prescribing hemostatic agents [62]. For this purpose, drugs from the groups of other systemic hemostatic agents (etamsylate** (ATC: B02BX01)) and antifibrinolytic agents (tranexamic acid** (ATC: B02AA02), aminocaproic acid** (ATC: B02AA01)) are used.
Etamsylate** (ATC: B02BX01) is administered IV or IM to adults at 250–500 mg to stop bleeding, followed by 250 mg every 4-6 hours; to children at 10-15 mg/kg/day in 3-4 doses for 5-10 days. During nasal bone reduction, adults are administered the drug IV or IM 1 hour before surgery at a dose of 250–500 mg, if necessary during surgery at a dose of 250-500 mg, and prophylactically at 500-750 mg IV or IM evenly throughout the day after surgery. Children are administered the drug IV during surgery at 8–10 mg/kg body weight, followed by 10-15 mg/kg throughout the day.
Tranexamic acid** (ATC: B02AA02) is administered as an IV drip or slow IV push at an administration rate of 1 ml/min (50 mg/min). It is prescribed at a dose of 10-15 mg/kg every 6-8 hours in adults and 20 mg/kg/day in children over 1 year of age until bleeding stops.
Aminocaproic acid** (ATC: B02AA01) is used as an IV drip. Adults are administered 4-5 g of the drug during the first hour; in case of ongoing bleeding – 1 g/hour for no more than 8 hours until bleeding stops; if necessary, infusions are repeated every 4 hours; maximum daily dose is 30 g. Children – 100 mg/kg body weight in the first hour, then – 33 mg/kg/h; maximum daily dose – 18.0 g/m2 of body surface area (up to 1 year – 3 g; 2-6 years – 3-6 g; 7-10 years – 6-9 g; from 10 years – same as for adults). For acute blood loss: children under 1 year – 6 g; 2-4 years – 6-9 g; 5-8 years – 9-12 g; 9-10 years – 18 g. Duration of therapy is 3-14 days.
It is recommended to prescribe decongestants and other topical nasal preparations to all patients with nasal trauma to facilitate nasal breathing [29, 50].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: To reduce reactive post-traumatic edema of the nasal mucosa, as well as to facilitate nasal breathing in the postoperative period, patients with nasal trauma are recommended to use drugs from the adrenomimetic group, including sympathomimetic combinations (ATC: R01AA) and sympathomimetics in combination with other agents, excluding corticosteroids R01AB) in the form of sprays and drops [56].
Phenylephrine (ATC: R01AA04, R01AB01) at a concentration of 0.125% intranasally: <1 year – 1 drop, 1-6 years – 1-2 drops, >6 years – 3-4 drops up to 3 times a day for up to 7 days; Oxymetazoline (ATC: R01AA05, R01AB07) at concentrations: <1 year – 0.01%, 1-6 years – 0.025%, >6 years – 0.05%, intranasally 1-2 drops 2-3 times a day for up to 5 days.
Xylometazoline** (ATC: R01AA07, R01AB06) 2-6 years – 0.05%, >6 years – 0.1%, intranasally as a spray, 1 actuation 2-3 times a day for up to 5 days.
It is recommended to prescribe topical antiseptics and disinfectants (local antiseptic preparations) to all patients with nasal trauma in case of damage to the skin or mucous membranes with signs of wound infection or a high risk of its infection in order to prevent complications [29, 50, 57].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Quaternary ammonium compounds (ATC D08AJ) (benzyldimethyl[3-(myristoylamino)propyl]ammonium chloride monohydrate (except for sprays for children under 3 years of age), iodine preparations (povidone-iodine** (D08AG02)), and biguanides and amidines (chlorhexidine** (D08AC02)) possess pronounced antimicrobial properties. The frequency of wound treatment depends on the severity of inflammation and the nature of the exudate. The wound is treated until the infection resolves or healing begins [57].
It is recommended to use local irrigation therapy in all patients with nasal trauma to improve the processes of repair and regeneration of the nasal mucosa [21, 50, 58, 59].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
Comments: In the post-traumatic and postoperative periods, adequate nasal cavity care helps accelerate the healing of the damaged mucosa, restore its normal function, and prevent potential complications, such as synechia formation [61].
Irrigation therapy is carried out using sterile isotonic sea water solutions (Other drugs (ATC: R01AX10)) 2–3 times a day until epithelialization of damaged tissues and subsidence of inflammatory phenomena.
3.2 Surgical Treatment
Emergency surgical interventions for nasal trauma are aimed at the prompt arrest of epistaxis and primary surgical debridement (PSD) of open nasal wounds.
Surgical treatment for nasal trauma is performed to restore the impaired shape of the external nose and eliminate the displacement of intranasal structures resulting from the injury, as well as to restore nasal functions, primarily respiratory and cosmetic.
It is recommended to perform surgical debridement of the wound and infected tissue, and apply a cosmetic suture in all patients with open nasal wounds and open nasal bone fractures [68].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: prior to suturing, it is necessary to thoroughly inspect the wound, remove foreign bodies, and probe the tissues along the wound tract.
It is recommended to perform surgical arrest of epistaxis in case of ineffectiveness of hemostatic therapy and nasal packing in all patients with nasal trauma [62].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: The determining factor in choosing surgical methods for arresting bleeding is the localization of the bleeding source.
In case of ongoing bleeding from the anterior nasal cavity, the following techniques are used: elevation of the mucoperichondrial flap followed by packing, curettage of the enlarged bleeding vessel, cryocoagulation, and electrocautery [62, 63].
For heavy epistaxis, the following are used: ligation of the external carotid artery, endoscopic clipping of bleeding vessels, and endovascular vessel embolization [63, 65].
To stop epistaxis from the ethmoid arteries, ethmoidectomy [64] is also used, which can be performed via external, internal, and endonasal approaches [65].
It is recommended to perform incision and drainage of a nasal septal hematoma/abscess, if present, in all patients with nasal trauma in order to prevent complications [66].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: Surgical treatment of a nasal septum hematoma and abscess consists of incision and drainage of the contents followed by anterior nasal packing. Subsequently, daily dressings are performed until discharge ceases.
It is recommended to perform reposition of the nasal bones with fixation of bone fragments in the correct position in all patients with nasal trauma resulting in external nasal deformity, in order to restore the shape of the external nose and restore nasal breathing function [28, 50, 51, 52].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: The goal of surgical intervention is to restore the anatomical architectonics of the external nose and nasal cavity, as well as to restore nasal functions.
Depending on the timing, surgical treatment can be early—within the first 7 days from the moment of injury, delayed—on days 8–15, and elective—6 months after the injury and later [21, 50].
Early surgical treatment is performed in patients with nasal bone fractures with minimal or moderate manifestations of traumatic edema syndrome, as well as in cases of combined injuries of the external nose with damage to intranasal structures, paranasal sinuses, and in the presence of a nasal septal hematoma. Early surgical treatment helps avoid septic complications and the formation of synechiae in the nasal cavity.
In severe condition of a patient with nasal trauma, in the presence of pronounced edematous-traumatic syndrome, as well as in combined fractures of the nasal bones, nasal septum, and facial wounds, surgical treatment may be postponed for up to 15 days from the moment of trauma.
Elective surgical treatment of nasal bone fractures (rhinoseptoplasty) is performed in cases of concomitant injuries with skull base fractures and nasal liquorrhea, as well as those proceeding with severe functional impairments.
To eliminate external nasal deformity, external (digital), endonasal (instrumental), and extranasal (open) methods of nasal bone reposition are used.
In pediatric practice, the efficacy of the external method is low (22%) due to the age-related characteristics of tissue structure. In children, it is advisable to use the endonasal method of nasal bone reposition using ENT elevators for endonasal reduction of nasal bones designed by M.F. Manakov, Yu.N. Volkov, followed by anterior nasal packing to fix the correct position of the fragments [21, 29, 50, 52]. The extranasal method of nasal bone reposition is used in case of simultaneous surgical interventions for intracranial trauma or trauma of the frontal sinuses and maxilla.
In combined nasoseptal fractures, simultaneous reposition of the nasal bones and septoplasty in the acute period of trauma is indicated [67].
In concomitant fractures of the nasal bones with other traumatic injuries, it is advisable to perform reposition simultaneously with a team of surgeons if they are performing any intervention under general anesthesia [50].
If traumatic brain injury is suspected, the reduction of fragments should be postponed until the primary consultation (examination) by a neurologist/neurosurgeon and the necessary additional examinations are performed.
3.3 Other Treatment
For the effective treatment of nasal injuries, the patient is recommended to limit physical activity, avoid actions that could lead to the displacement of nasal bone fragments, as well as during sleep; a full-value, vitamin-rich, easily digestible diet is recommended; do not take a hot bath, shower, sauna, or visit a swimming pool throughout the entire treatment period.
It is recommended to perform anesthesia of the external nose and nasal cavity when performing surgical treatment in patients with nasal trauma – open and closed fractures of the external nasal bones, trauma and displacement of intranasal structures for the purpose of analgesia [68, 69].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: when performing surgical care in adults with isolated nasal injuries, local anesthesia is used in the form of applications of local anesthetic solutions (C05AD) to the nasal mucosa in combination with the administration of analgesics (N02) intramuscularly or using regional block anesthesia with amides (N01BB) (Articaine) [70]. In childhood, if it is necessary to perform a surgical intervention for nasal bone fractures, it is recommended to use combined anesthesia [68, 69].
It is recommended to perform anterior nasal packing in all patients with fractures of the external nasal bones and intranasal structures, to fix the repositioned nasal bone fragments, as well as a measure to stop epistaxis in case of trauma to the nasal mucosa [13, 50, 68, 69].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: The pack is inserted on the side of the deformity and removed on the 2nd–3rd day after surgery. The duration of packing is determined by the mobility of the bone fragments. The efficacy of prolonged anterior packing (more than 3–5 days) after nasal bone reposition has not been proven [71].
It is recommended to apply a sling bandage to the nose in case of fractures, complex injuries, and after surgeries to ensure better preservation of the position of the aligned fragments [29].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: External splinting after closed reposition of nasal bone fractures should not be used routinely, but only in patients with severe comminuted fractures [72].
It is recommended to conduct a primary consultation (examination, consultation) by a physical therapist for all patients with pronounced reactive inflammatory phenomena in order to accelerate the relief of reactive inflammatory phenomena [21, 29, 50].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Laser physiotherapy of the maxillofacial region and exposure to magnetic fields (magnetotherapy) exert anti-inflammatory, decongestant, and wound-healing effects [21, 29, 50].
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended to conduct a follow-up dispensary consultation (examination, consultation) by an otorhinolaryngologist within a year (with mandatory examinations at 1 month, 3 months, 6 months, and one year after surgical intervention) for all patients after surgical interventions for nasal trauma that led to a deformity of the external nose and/or intranasal structures of the nasal cavity – nasal septum deformity, for the prevention of deformity recurrence and potential complications [21, 29, 50].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
5. Prevention and Dispensary Observation
It is recommended to implement a general set of social measures for the prevention of traumatism [21, 27, 29, 45, 73].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: The general complex of social measures for injury prevention includes measures to ensure compliance with safety regulations in educational and upbringing institutions, at work and in everyday life, as well as explanatory work with parents in preschool and general educational institutions, and the promotion of a healthy lifestyle for injury prevention, including the prevention of nasal injuries.
6. Organization of Medical Care
Indications for hospitalization in a medical organization:
1) severe condition of a patient with a nasal injury;
2) presence of pronounced edema-traumatic syndrome;
3) nasal injury accompanied by bleeding;
4) nasal injury with severe pain syndrome;
5) combined fractures of the nasal bones and nasal septum with damage to the paranasal sinuses and facial wounds;
6) traumatic deformity of the external nose with damage/displacement of the nasal septum;
7) traumatic deformity/displacement of the nasal septum leading to impaired nasal breathing;
8) nasal injury in patients with severe concomitant somatic pathology (risk of complicated course of the injury);
9) nasal injury in patients taking anticoagulants or antiplatelet agents due to cardiovascular diseases;
10) complications resulting from nasal injury (hematoma, nasal septal abscess, inflammatory diseases of the paranasal sinuses and surrounding areas);
11) need for closed reduction of the nasal bones.
Indications for patient discharge from a medical organization
1) satisfactory condition of the patient, normalization of clinical parameters;
2) improvement of the external nose shape;
3) improvement of nasal breathing function;
4) absence of complications.
7. Additional Information
The prognosis is favorable subject to compliance with the recommended methods of treatment for nasal injuries and patient adherence to medical recommendations [based on the clinical guidelines "Nasal injury"]
Criteria for Evaluating the Quality of Medical Care
Criteria for assessing the quality of primary health care in patients with nasal injury (ICD-10 S00.3; S01.2; S02.2; S02.20; S02.21)
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1. | Otorhinolaryngologist appointment (examination, consultation) performed | Yes/no |
2. | Radiography of the facial skeleton bones and/or computed tomography of the facial skull bones performed | Yes/no |
3. | Referral for hospitalization issued in the presence of indications | Yes/no |
Criteria for assessing the quality of specialized medical care in patients with nasal injury (ICD-10 S00.3; S01.2; S02.2; S02.20; S02.21)
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1. | Otorhinolaryngologist appointment (examination, consultation) performed | Yes/no |
2. | Radiography of the facial skeleton bones and/or computed tomography of the facial skull bones performed | Yes/no |
3. | Reduction of the nasal bones performed | Yes/no |
4. | Surgical debridement of an open nasal wound performed | Yes/No |
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Appendix A1. Working Group Composition
Artyushkin, S.A., MD, Professor, Honored Doctor of the Russian Federation, is a member of a professional association. There is no conflict of interest.
Golovanov, A.E., MD, Associate Professor, is a member of a professional association. There is no conflict of interest.
Yunusov, A.S., MD, Professor, is a member of a professional association. There is no conflict of interest.
Eremina, N.V., MD, Professor, is a member of a professional association. There is no conflict of interest.
Alekseenko, S.I., MD, Associate Professor, is a member of a professional association. There is no conflict of interest.
Tkachuk, I.V., PhD, is a member of a professional association. There is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
otorhinolaryngologists;
otorhinolaryngologist-audiologists;
emergency medicine physicians;
general practitioners (family doctors);
pediatricians;
general practitioners (internal medicine);
infectious disease specialists.
Table 1. Scale for assessing levels of reliable evidence (LRE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing levels of evidence (LE) for methods of prevention, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Procedure for the provision of medical care in the profile «otorhinolaryngology»: Order of the Ministry of Health of the Russian Federation No. 905n dated November 12, 2012, «On approval of the Procedure for the provision of medical care to the population in the profile „otorhinolaryngology“».
CR337. Pain syndrome (PS) in children in need of palliative medical care (http://cr.rosminzdrav.ru/#!/schema/886).
Ministry of Health of the Russian Federation Order No. 174 of May 17, 1999, On measures for the further improvement of tetanus prevention. – M., 1999. – 18 p.
Federal Law No. 323-FZ of November 21, 2011 "On the Fundamentals of Protecting Public Health in the Russian Federation"
Appendix A3.1 Explanation of Notes
** – a medicinal product included in the List of Vital and Essential Drugs for medical use for 2020 (Decree of the Government of the Russian Federation No. 2406-r dated October 12, 2019)
# – off-label use outside the indications registered in the medicine's instructions is carried out by decision of the medical commission, with the permission of the Local Ethics Committee of the medical organization (if any), subject to the signed informed consent of the parents (legal representative) and the patient over 15 years of age.
Appendix B. Physician Action Algorithms
Diagram
Appendix C. Patient Information
If a patient has a nasal injury resulting in pronounced facial edema, external nasal deformity, soft tissue damage of the external nose, epistaxis, or nasal breathing impairment, this patient requires an emergency otolaryngologist consultation. Delayed diagnosis and treatment of a nasal injury can lead to the development of various diseases and life-threatening complications.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Absent