Patient Presentation
A 2-year-old male came to clinic after a witnessed fall at daycare. What the daycare professional told the mother was that he was jostled by another child and fell striking his face on the side of a plastic kitchen set. He cried immediately and was consoled within a reasonable time frame. He did not lose consciousness and had had normal mentation since the episode 3 hours previously. He had slept at his normal nap time but was awoken early from his nap to come to the appointment. He had a cut lip that had bled for a short time and resolved with pressure and some ice. He had been given some acetaminophen and drunk fluids without emesis. There was no reported drainage from nose or ears. The daycare had not commented on his head, eyes or neck or other body problems. The mother said he was acting normally but she was concerned about the swelling of his lip and also a small abrasion and redness on his nose. She was concerned that he had broken his nose.
The pertinent physical exam had normal vital signs and growth.
Head had no abnormalities. His face showed a small abrasion from the tip upward for about 1/3 of the nose. It was clean and dry without erythema and no edema. There was also a 2-4 mm abrasion on his chin. His eyes revealed extra ocular movements to be intact. External structures were without abrasions and gross visual acuity was normal. His ears had no fluid behind the tympanic membranes. His nose showed no evidence of external deformity without any malpositioning or pain with palpation. There was no abnormal bleeding or masses. His nasal septum appeared intact. His mouth showed a small 5 mm laceration on the lower lingual surface with good hemostatis and localized edema. The same area on the external surface also had some mild edema. There was no other evidence of oral trauma. His neck was without pain and had normal ROM. He had normal mental status throughout the visit.
The diagnosis of a small lip laceration and facial abrasions after a witnessed fall was made. The mother was counseled about how to manage the lip laceration, and was relieved to hear that a nasal fracture was very unlikely in his case. The mother was given head injury instructions and asked to monitor for any additional problems that arose for his nose or mouth too.
Discussion
Facial trauma is common and accounts for about 11% of all pediatric emergency room visits. Nasal fractures are fewer in younger ages but increase in incidence as children age because of increased opportunity for trauma (e.g. playing, sports, car accidents, etc.). Anatomy also plays a part as young children have more cartilaginous structures and the nose does not protrude as much as an older child or adult who also have more osseous structures. The nasal structures have 2 bigger growth phases from 2-5 years and also at puberty. Adult size is reached in 16-18 years for females and about 2 years later for males (18-20 years). Fractures in children could cause problems with ability to breath and altered growth.
History should include the mechanism of injury, its intensity and timing, along with other potential associated problems such as head and neck, dental or ocular injuries of the head and neck, or other body parts. As with all trauma, ABCs should be carried out and investigating for additional injuries is important. Head and neck structures should be evaluated for any trauma. The neck should be examined for pain, masses and range of motion (if appropriate). Eyes should be examined for symmetry, pupillary reflexes, extra ocular movements and acuity. Racoon eyes or other ecchymosis around the eyes may indicate basilar skull or other cranial fractures. Ear examination showing any trauma including hemotympanum should be evaluated for cranial fractures. Dental examination should look for any loose teeth or intraoral trauma, including the temporomandibular junction. Neurological examination should evaluate the cranial nerves, gait, balance etc. Other body structures should be evaluated based on the history.
With nasal trauma the airway patency and nasal airflow are important to determine as the airway is more collapsible and also narrower in the pediatric patient. The external nose should be inspected for obvious deformations, edema, erythema, and bruising. Internally, the nasal septum should be evaluated to make sure there is no septal hematoma that needs to be addressed emergently. Septal hematomas are rare but more common in children. Other nasal structures should be evaluated using adequate lighting and nasal speculum. Airflow in both nares should be determined but can be difficult to do in children. Epistaxis is common but not for every injury. Nasal fractures generally occur with epistaxis, but are not specific for it. Blood clots may make the internal examination difficult to complete as well. Other drainage should be asked about and inspected for. Cerebrospinal fluid leaks should try to be discerned but can be difficult to discern, especially in children who often have concomitant upper respiratory infections.
Learning Point
In general, low impact, limited acute nasal trauma, without significant signs or symptoms for the patient (especially possible septal hematoma and/or airway obstruction), and no evidence of significant additional trauma usually, but not always, are self limited and are not because of a nasal fracture. These patients are usually treated symptomatically with ice, pain medications and return precautions for any nasal/airflow obstruction, additional bleeding or nasal discharge and head injury precautions. Sometimes subtle deviation or obstruction only becomes apparent in the next several days after the trauma as the edema may distort the structures.
Patients who cannot be effectively examined by a primary care or emergency room physician or if there is concern for additional or more significant injuries should consult an otolaryngologist for further evaluation and treatment. This could include head and facial imaging. Patient with acute nasal fracture ( 3 months) are treated with open reduction and possible septoplasty if airway flow is compromised. Timing of the surgery depends on the clinical circumstances. Septoplasty is used sometimes for various bony deformities in chronic/delayed cases.
Questions for Further Discussion
1. What are indications for head imaging after a traumatic injury?
2. How is epistaxis treated?
3. How is dental trauma treated?
4. What causes facial pain? A review can be found here
Related Cases
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- Disease: Lip Laceration and Facial Abrasions |
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To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Nose Injuries and Disorders and Facial Injuries and Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Landeen KC, Kimura K, Stephan SJ. Nasal Fractures. Facial Plast Surg Clin N Am. 2022;30(1):23-30. doi:10.1016/j.fsc.2021.08.002
Tolley PD, Massenburg BB, Manning S, Lu GN, Bly RA. Pediatric Nasal and Septal Fractures. Oral Maxillofac Surg Clin N Am. 2023;35(4):577-584. doi:10.1016/j.coms.2023.04.005
Trujillo O, Lee C. Nasal Fractures: Acute, Subacute, and Delayed Management. Otolaryngol Clin North Am. 2023;56(6):1089-1099. doi:10.1016/j.otc.2023.05.004
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 