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PEDIATRIC NASAL TRAUMA, EVALUATION AND TREATMENT
Lawrence Martin, M.D.

“The infant, child and teen are all subject to nasal trauma and nasal deformities requiring possible surgery. The early recognition, precise diagnosis and treatment of these injuries and deformities is important to prevent later disfigurement, self-consciousness and impaired nasal function. A discussion of four conditions peculiar to the pediatric population is presented.

NASAL FRACTURES
One-half of all nasal fractures occur in children and, as one might expect, many of these injuries go unrecognized. The child’s nose is primarily cartilage and it responds differently to trauma than does an adult’s nose, which has bony as well as cartilage support. In children, no matter how small the injury to the nasal cartilage and bone, the resultant deformity may only become exaggerated rather than less noticeable as the child grows older.

Diagnosis can be a difficult problem in pediatric nasal trauma. The history may be unobtainable, and the child may not cooperate with the examination. Frequently, the parent’s information regarding the child’s appearance can be biased and misleading. A prior recent photo is helpful, but it does not always confirm the diagnosis.

In most young children, the nose and septum are straight and any deviation or deflection should be regarded as significant. In order of frequency, the most common findings of nasal fracture in children are epistaxis, swelling of the nasal dorsum, ecchymoses of the eyes, tenderness of the dorsum, x-ray evidence of fracture, and crepitus of the nasal bones. X-ray examination of the nasal bones is frequently done in the emergency department, but the x-ray has been found to be diagnostic in only one-half of the patients. CT scans can be considered for evaluation especially when there are other known or suspect facial fractures.

Examination of the child by an Otolaryngologist and/or Facial Plastic Surgeon should be done as soon as possible after injury because some fractures can be reduced immediately and associated facial lacerations and other fractures can be repaired. In general, fractures should be reduced at five to seven days after the injury when the edema has subsided and a more accurate reduction can be obtained. Occasionally, general anesthesia is required for the nasal examination of a child in order to make the diagnosis and rule out the existence of hematoma; the fracture could then be reduced at the time of examination. Hematoma, either small or large, can be devastating for they can cause abcess formation, dissolution of cartilage and bone, and later deformity.

Treatment of nasal fractures is usually accomplished by the closed technique, using digital palpation and special blunt instruments with the child under general anesthesia. At times, open operative reduction is required when the nasal bones have to be stabilized and hematomas have to be evacuated. Antibiotics should be be used when an intranasal dressing is used for support or to aid in hemostasis. The child’s parents should be informed that later deformities may develop due to disturbed growth patterns caused by the injury; these deformities can occur whether the child or teenager has surgery or not.

NASAL SEPTUM SURGERY IN CHILDREN
(Nasal Airway Reconstruction)
Most often, the deviated nasal septum is caused by developmental factors or by recognized or unrecognized nasal trauma. It has long been taught that the septum should not be operated upon in children because disturbances of the growth pattern may lead to subsequent nasal deformity. However, when a child has severe nasal obstruction secondary to a deviated septum with mouth breathing and its attendant problems of poor physical and intellectual development, septal surgery should be considered. Poor occlusion, snoring and sleep apnea, sinusitis and throat infections are well known conditions associated with nasal obstruction. The key at surgery is to manipulate and align the cartilage without removing it in the classic submucous resection (SMR) technique. Established techniques using sutures can provide a patent airway without distorting the future growth of the nose.

DISLOCATION OF THE NASAL SEPTUM IN THE NEWBORN
This deformity may occur during intrauterine life or during delivery. It most commonly occurs at delivery with a cephalic presentation in which the occiput is in the left anterior position. This condition needs to be differentiated from the temporary deformity or flattening of the nose seen at birth which corrects itself and needs no treatment. Diagnosis of the dislocated septum is made by noting the obvious outward deviation of the nose to one side accompanied by leaning of the columella, loss of tip stability, flattening of the nostril on the side of dislocation, and decreased movement of the ala on the same side during inspiration. Treatment of this condition is done at one to two days after birth in the nursery without an anesthetic. The septal cartilage is gently replaced in the septal groove with small blunt instruments. The cartilage usually stays in place without packing or splints.

RHINOPLASTY IN CHILDREN AND TEENAGERS
Although uncommon, isolated congenital deformities of the external nose of a child can be corrected early for the child’s appearance and self image. Nasal reshaping (rhinoplasty) is frequently combined with septal surgery (septorhinoplasty). Aesthetic rhinoplasty, especially with boys, has traditionally been delayed until age 17 or 18 when maturation of the nasal architecture is achieved. However, many girls are as physically mature at age 14 or 15 as they would be at 17 or 18. Rhinoplasty can be considered in these patients, especially when there is self-consciousness, peer ridicule and airway obstruction. Unfortunately, not all physically mature girls are mature enough emotionally to undergo the surgery and to cooperate and comply with the postoperative instructions required in rhinoplasty. For these teens, it is advisable to wait until they are older.”

AMAZING TRANSFORMATIONS
Nasal Surgery With Results That Last A Lifetime
(From Northwest Community Hospital Newsletter 2005)

“YOUR NOSE
It is the most defining feature of your face. Its shape and size can have a tremendous impact on your confidence and self-image – even on your health.

According to the American Academy of Facial Plastic Surgery, each year a half million people seek consultation with facial plastic surgeons about rhinoplasty, or cosmetic surgery, to reshape or repair the nose. Many undergo rhinoplasty for cosmetic reasons while others have the procedure done to simultaneously correct a breathing problem or repair a birth defect or injury. Rhinoplasty is suitable for most ages, from teens to people in their 60s.

“The perception is that it’s only for appearance, but I would say it is done to simultaneously improve breathing for half of the patients nationwide,” says Lawrence Martin, MD, FACS, board certified Otolaryngologist and Facial Plastic Surgeon.

Rhinoplasty has been around for decades, but today’s surgeries produce much better results due to:

• More thorough doctor/patient consultations.
  
• Better diagnostic capabilities.
  
• Advances in surgical techniques.
  

Getting the right doctor is very important, too. And at Northwest Community Hospital, specialists such as Dr. Martin have the experience and surgical skills to improve the look and function of the nose.

RESULTS THAT LAST
Thirty years ago, most rhinoplasties focused on reducing the size of the nose by removing cartilage and bone. Many good, early results later developed deformities and breathing problems. Today it is a much more meticulous procedure that not only reshapes the nose but reinforces its new shape so the results can last a lifetime, even for young people who have surgery.

Traditionally, surgeons have used a closed (or endonasal) approach for rhinoplasty, in which the surgery is performed through the nostril. Now in many cases, specially trained surgeons, such as Dr. Martin, employ what is called an open (or external) approach, involving a small incision on the skin between the nostrils. “The biggest advancement in rhinoplasty is the use of the external approach to lift up the skin and look at the anatomy to operate on both sides at once to achieve symmetry,” Dr. Martin says.

The surgeon then fortifies the reshaped nose with cartilage sutures – and the patient’s own cartilage when necessary – so the results will last. Reinforcing the tissues and structure of the nose during the procedure is crucial to avoiding problems later.

Recovery is rapid even with the open approach, and discomfort is minimized with only an overnight internal dressing.

Throughout Dr. Martin's nearly 30 years of performing rhinoplasty, he has witnessed countless amazing transformations in the confidence and mental well-being of his patients.

“The improvement I see in their confidence is remarkable, especially in younger patients,” he says.

Most facial plastic surgeries are performed at Northwest Community Hospital’s Day Surgery Center, which has recently been expanded and remodeled. “It’s top-notch care with all board certified anesthesiologists,” Dr. Martin says. “It’s a very comfortable environment.”