Nasal fractures in children and adolescents: Mechanisms of injury and efficacy of closed reduction

Pediatric Craniomaxillofacial Fractures: A Review

Pediatric facial fractures constitute a small portion of all facial fractures. The frequency of pediatric facial fractures by location, and mechanism of injury, changes over time associated with craniofacial growth and activity. Pediatric patients have protective anatomic features, such as increased soft tissue, excess adipose tissue, and more flexible bone. Conservative management is often sufficient. Surgical intervention can often be conservative. Follow-up monitoring is valuable for concerns of growth disruption from either the trauma itself or surgical interventions. Older teenage patients may often be treated similar to adults. Postoperative management varies by fracture type without a defined long-term follow-up course.

Clinical characteristics of pediatric nasal bone fractures by age group

BACKGROUND

The clinical characteristics of pediatric nasal fractures can vary depending on the child's age, social activities, and environment. Therefore, this study aimed to analyze these characteristics in different age groups.

METHODS

We retrospectively reviewed of a series of patients aged under 12 years who received treatment between 2013 and 2021. The initial study design involved dividing the patients into four age groups, corresponding to different developmental ages, but there were no cases in infants aged 0 to 1 year. Therefore, the patients were divided into three groups: group I, between 2 and 5; group II, between 6 and 9; and group III, between 10 and 12 years of age. The following parameters were evaluated: sex, age, etiology, fracture type and severity, and the incidence of septal injuries.

RESULTS

In total, 98 patients were included in this study. In group III, the ratio of boys to girls was 3.88:1, exceeding the overall ratio of 1.97:1. The most common cause varied with age: slipping down in group I, bumping accidents in group II, and sports accidents in group III. Concomitant septal injuries were present in 4.17% of patients in group I, 5.71% of patients in group II, and 28.21% of patients in group III.

CONCLUSION

Increasing age was accompanied by a greater tendency for male predominance and a higher prevalence of sports-related causes and septal injuries. Violence was infrequent but started to become a contributing factor during school age. These varying environmental factors across age groups can offer valuable insights into the epidemiology and clinical characteristics of pediatric nasal bone fractures.

Clinical characteristics of adolescent nasal bone fractures

Background

There have been many reports of nasal bone fractures in adults, but there are few clinical reports of them in adolescents, although adolescence is the main growth period of the nasal bone. In addition, previous studies have tended to classify and describe child and adolescent nasal fractures in the same category. The aim of this study was to identify the clinical aspects of nasal fractures in adolescents, and to evaluate the characteristics of nasal fractures in the growth period.

Methods

Our institution’s database was reviewed to extract data on adolescent patients between the age of 13 to 18 who had isolated nasal bone fractures from March 2012 to February 2020. The study excluded patients with other facial fractures, previous facial fractures, or congenital deformities.

Results

This study included 243 boys and 26 girls. Interpersonal violence and sports-related accidents accounted for 85 and 79 cases, respectively. There were 128 frontal impact injuries and 132 lateral impact injuries, and 97 patients had accompanying septal fractures. An accompanying septal fracture was present in 36.06% of all patients, but in 51.20% of those who underwent surgery.

Conclusion

The prevalence of adolescent nasal fractures was significantly higher in boys, to a greater extent than observed for pediatric or adult fractures. The main causes of fractures were interpersonal violence and sports-related accidents. An explanation for these results is that adolescent boys are more prone to have violent accidents or companionship with active sports than other age or sex groups, leading to substantially more fractures.

Etiology, pattern, and treatment of nose fractures: A 10-year cross-sectional cohort retrospective study

Background

Determining the etiology, epidemiology, pattern, and treatment of nasal bone fractures and the associated soft tissue injuries in a population will be beneficial for the prevention, rapid and correct diagnosis, and adequate management of this pathology in order to minimize postoperative complications.

Patients and Methods

This study retrospectively evaluated the patients admitted and treated for nasal bone fractures in a university clinic of oral and maxillofacial surgery in Romania over a 10-year period. Following statistical analysis, evaluation and correlation of the monitored variables, a P value < 0.05 was considered statistically significant.

Results

Nasal bone fractures had the highest incidence among men (88.30%), aged 20-29 years (33.33%), with no education (33.33%), interpersonal violence being the main cause in this category of patients (P = 0.004; P = 0.005; P = 0.005). In urban environment (55.9%), nasal bone fractures through aggression and road traffic accidents were predominant, while in rural areas (44.10%), those caused by domestic accidents and animal attacks prevailed (P = 0.551). Nondisplaced (81.10%), closed (85.60%) and involving the nasal septum fractures (51.35%) were preponderant. Hematoma was the most frequent associated soft tissue injury (86.49%), its incidence being increased in the case of displaced (P = 1.000) and open fractures (P = 0.692). The most frequent treatment method was close nasal reduction (CNR) + closed septoplasty (51.35%). The most frequent complication was malunion (7.2%), secondary to CNR without septoplasty (P = 0.037).

Conclusions

The main etiology of nasal bone fractures was interpersonal violence, which mainly affected men, aged 20-39 years, with a low level of education, living in urban areas. Implementing laws to fight interpersonal aggression and increase the education level of the population would lead to a considerable reduction in the incidence of this pathology. Patients treated by CNR + closed septoplasty and ORIF had the best postoperative evolution. Immediate septoplasty in the case of associated septal fractures significantly decreased the rate of postoperative complications.

A Single Center Review of Pediatric Nasal Bone Fractures - An Analysis of Concomitant Injuries, Management, and Outcomes

BACKGROUND

Pediatric nasal bone fractures presenting as isolated fractures or with concomitant facial injuries are rare and not well documented. Analysis of treatment at an urban, level-one trauma center provides insight into their management.

METHODS

Data were collected for pediatric nasal bone fractures diagnosed between January 2000 and December 2014. Patients were divided into groups based on presence or absence of isolated nasal bone fractures. Groups were compared using Chi-squared analysis, and a Bonferroni correction was used for a more conservative alpha (a = .004).

RESULTS

Assault was the most common etiology presenting in 46 of 122 pediatric nasal bone fractures. There was no significant difference in surgical versus non-surgical management of isolated and non-isolated nasal bone fractures (P = 0.98). Treatment for both was predominantly watchful waiting in 91% to 95% of the cases followed by closed reduction in 3.2% to 3.3%. In the patients with isolated fractures, 11.5% sustained intracranial hemorrhage, compared to 35.6% of multifracture cases (P = .002); 15.0% of isolated fractures sustained a traumatic brain injury, compared to 55.9% of multifracture cases (P = .000003). No significant difference in fatality existed between groups (P = 0.53).

CONCLUSIONS

Multi-facial fracture cases were more likely to present with traumatic brain injuries and be admitted to the intensive care unit than isolated nasal bone fractures. Rates of surgical and non-surgical management were not significantly different between the 2 groups. Watchful waiting of pediatric nasal bone fractures was the management approach selected 92% to 95% of the time regardless of the presence or absence of concomitant facial fractures.

Comparison of postoperative outcomes between early and delayed surgery for pediatric nasal fractures

Background

Pediatric nasal fractures, unlike adult nasal fractures, are treated surgically as early as 7 days after the initial trauma. However, in some cases, a week or more elapses before surgery, and few studies have investigated the consequences of delayed surgery for pediatric nasal fractures. The purpose of this study was to evaluate the postoperative outcomes of pediatric nasal fractures according to the time interval between the initial trauma and surgery.

Methods

The records of pediatric patients under 12 years old who underwent closed reduction of nasal bone fracture from March 2012 to February 2020 were reviewed. The interval between trauma and surgery was divided into within 7 days (early reduction) and more than 7 days (delayed reduction). Postoperative results were classified into five grades (excellent, good, moderate, poor, and very poor) based on the degree of reduction shown on computed tomography.

Results

Ninety-eight patients were analyzed, of whom 51 underwent early reduction and 47 underwent delayed reduction. Forty-two (82.4%) of the 51 patients in the early reduction group showed excellent results, and nine (17.6%) showed good results. Thirty-nine (83.0%) of the 47 patients in the delayed reduction group showed excellent results and eight (17.0%) showed good results. No statistically significant difference in outcomes was found between the two groups (chi-square test p=0.937). However, patients without septal injury were significantly more likely to have excellent postoperative outcomes (chi-square test p<0.01).

Conclusion

No statistically significant difference was found in the outcomes of pediatric nasal fractures between the early and delayed reduction groups. Successful surgical results were found even in patients who received delayed reduction (more than 7 days after trauma).

Does pediatric septoplasty compromise midfacial growth? A systematic review

OBJECTIVE

Septal deviation is an important cause of impaired nasal breathing among pediatric patients. A widespread solution to septal deviation is septoplasty. However, there are certain controversies surrounding the effect of this technique on pediatric patients and its influence on the growth centers of the nose. The objective of this review is to study if there is a strong and valid evidence in the literature that supports a detrimental effect of pediatric septo- and rhinoseptoplasty in facial growth DATA SOURCES: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database.

REVIEW METHODS

The outcome assessed was the midfacial growth after pediatric septoplasty.

RESULTS

Eight publications met the inclusion criteria. None found major disturbances in facial growth. Only minor nasal anomalies were reported by 4 authors.

CONCLUSION

Septoplasty in pediatric patients does not seem to affect midfacial growth according to available evidence. However, due to their design, the degree of recommendation of these studies was not superior to level C.

Closed and Open Reduction of Nasal Fractures

AIM

The objective of this review was to determine the different types of surgical intervention in the management of nasal bone fractures, the outcomes, and complications associated with each intervention.

METHODS

A search was conducted using the PubMed and Cochrane Database of Systematic Review databases from January 1, 1997 until September 9, 2017. The search strategy was constructed using the Population Intervention Comparison Outcome framework with keywords related to nasal fracture and its treatment. Two sets of independent researchers performed the analysis. Qualitative analysis was performed using the Methodological Index for Non-Randomized Studies and National Institute for Clinical Excellence methodology for randomized controlled trial checklists.

RESULTS

The 4276 titles were obtained from PubMed database alone. Exclusion was made based on the title, abstract and full-text analysis. Finally, 23 papers were included and analyzed. Of the 23 papers, 13 (56.5%) were retrospective record review, 2 (8.7%) were randomized clinical trial or a randomized study and 8 case series (34.8%). 16 (69.6%) studies addressed closed reduction, 3 studies (13%) on open reduction and 4 studies (17.4%) addressed both open and closed reduction. The main focus in the outcome in all studies was accuracy of the anatomical reduction of the nasal bones. Three studies (13.0%) reported restoration of function such as breathing comfort or release in respiratory obstruction and another 3 (13.0%) addressed both cosmetic and breathing outcomes. Residual deformity was the most described complications in the studies (30.4%). In general, most of the studies were not of high quality as they lacked in some key elements in the Methodological Index for Non-Randomized Studies checklist.

CONCLUSION

Both closed and open reduction provided good outcomes in cosmetic and breathing. Septoplasty is recommended to be performed simultaneously with fracture reduction.

Rattled: Analysis of Facial Trauma Among Toddlers

OBJECTIVE

The aim of this study was to determine the national incidence of facial trauma among toddlers and delineate patterns of injury and their causes.

METHODS

A retrospective review was designed to explore patterns of maxillofacial trauma within toddler-aged children using the National Electronic Injury Surveillance System from the Consumer Product Safety Commission. The database was searched for emergency department visits involving facial trauma sustained by children 12 months through 3 years of age from 2010 through 2014 and analyzed for patient demographics, primary diagnosis, and associated products/activities. Subset analyses were performed between age groups to determine the relationship between causes of injury and age using extrapolated national incidences.

RESULTS

A sample of 45,249 patients extrapolated to an estimated 1.3 million emergency department visits for facial trauma in toddlers from 2010 to 2014, averaging 260,000 annually. Injuries involving foreign bodies and fractures had a higher incidence in toddlers 2 years or older, and fractures comprised fewer than 1% of facial injuries in any age group. Furniture was the most common source of trauma overall, with a higher frequency among toddlers aged 12 to 17 months. Trauma in the setting of sports was more common in toddlers aged 3 years.

CONCLUSIONS

The low incidence of facial fractures further supports recommendations against routine imaging in toddler facial trauma and suggests that more focus should be placed on investigating for concurrent traumas and soft tissue injuries where fractures are involved. Our findings highlight prevention opportunities, particularly in furniture-related injuries for toddlers aged 12 to 17 months and sports-related traumas in toddlers aged 3 years. Our study also suggests restricting certain toys from 3-year-old toddlers to decrease the risk of aspiration.

Epidemiology of violence in pediatric and adolescent nasal fracture compared with adult nasal fracture: An 8-year study

Background

The epidemiology of nasal fractures varies according to factors such as the era and area of the study, as well as the age of the patient. We compared the characteristics and causes of pediatric nasal fractures.

Methods

A total of 2,321 patients with nasal fractures from 2010 to 2017 were examined. The patients were divided into age groups using the Korean school system of age classification. The causes of injury were divided into five groups: violence, fall or slip down, sports, road traffic accidents, and others. Fractures were classified using the Stranc and Robertson standard: vector of force and plane of fracture.

Results

Violence was the most common cause of nasal fracture in patients older than 12 years. Violence was a significantly less frequent cause among patients younger than 12 years old than among adolescent and adult patients. Nasal fractures due to violence were not observed in patients younger than 10 years. Plane 2 and lateral force fractures were the most common; however, in patients younger than 12 years, frontal force fractures were significantly more frequent than were lateral force fractures.

Conclusion

As children may simply be injured due to a fall or slip down, it is important for the parents and guardians to ensure their safety. As they become older, children should abstain from violence and be monitored. It is therefore very important to ensure that the environment is free of violence in order to prevent such injuries.

Trend analysis of nasal bone fracture

Background

Nasal bone fractures occur frequently because the nasal bone is located at the forefront of the face. The goal of this study was to examine the cause, change in severity, change in incidence, and demographics of nasal bone fracture according to today’s lifestyle.

Methods

A total of 2,092 patients diagnosed as having nasal bone fractures at our department between 2002 and 2017 were included in this study. We retrospectively examined patients’ medical records to extract information regarding age, sex, cause of injury, combined facial bone fractures, and related injuries such as skull base fracture, spinal cord injury, brain hemorrhage, and other bone fractures. Fracture severity was classified by nasal bone fracture type.

Results

No statistically significant difference was found in annual number of patients treated for nasal bone fracture. The proportion of patients who underwent closed reduction was significantly decreased over time for those with nasal bone fractures caused by traffic accidents. However, it was not significantly changed for those with nasal bone fractures due to other causes. The number of patients with combined facial bone fractures increased over time. Incidences of severe nasal bone fracture also increased over time.

Conclusion

The study suggested that there is a decrease in the frequency and increase in the severity of nasal bone fracture due to traffic accident. Many protective devices prevent nasal bone fractures caused by a small amount of external force; however, these devices are not effective against higher amounts of external force. This study highlights the importance of preoperative thorough evaluation to manage patients with nasal bone fractures due to traffic accident.

Blunt nasal trauma in children: a frequent diagnostic challenge

OBJECTIVE

The clinical challenge in blunt nasal trauma in children, is to identify cases requiring specialized care among frequently encountered banalities, whilst trying to minimize the exposure to diagnostic procedures. We aim to evaluate the related diagnostic and therapeutic pathways and its outcome during follow-up.

METHODS

This retrospective cohort study includes children up to 16 years presenting at the emergency department with blunt nasal trauma of our tertiary reference center.

RESULTS

The incidence of blunt nasal injuries was estimated 1750 cases in 7 years. A total of 459 consecutive cases with suspected complications were enrolled. Univariate comparison between age groups revealed a statistically significant diminution of downfall related injuries with growing up, whereas blows (including violence) significantly increased with age (p < 0.001 each). The logistic regression model identified male sex as an independent risk factor for soft tissue lesions (OR 1.699, p = 0.017) and for frontobasal fractures (OR 2.415, p = 0.050). Age was not identified to play a significant role regarding localization of injuries. Delayed septorhinoplasties became necessary in 2 cases only (0.4%). The logistic regression model identified nasal bone fracture (OR 17.038, p < 0.001) and mandibular fracture (OR 4.753, p = 0.004) as independent risk factor for a surgical intervention.

CONCLUSIONS

Blunt trauma to the nose is frequent in children. Trauma mechanisms differ significantly between age groups, whereas localization and concomitant injuries do not. Male sex was identified as an independent risk factor for soft tissue lesions and frontobasal fractures. In our experience, initial triage by the pediatric department with consecutive involvement of the ENT specialists in case of suspected complications is safe and effective and may help to reduce unnecessary diagnostic procedures/irradiation to the young patients.

Influence of nasal septum deformity on nasal obstruction, disease severity, and medical treatment response among children and adolescents with persistent allergic rhinitis

OBJECTIVE

To evaluate the impact of different types of nasal septum deformity (NSD) on nasal obstruction, rhinitis severity and response to medical treatment among pediatric persistent allergic rhinitis (PER) patients.

METHODS

In a prospective, real-life study, 150 children and adolescents (mean age 13 ± 2.8 years, females 32.6%) diagnosed with PER according to ARIA guidelines were assessed by nasal endoscopy for NSD according to Mladina's classification, their response to medical treatment (intranasal steroids and antihistamines or antileucotriens), the presence of comorbidities, rhinitis severity (modified-ARIA criterion) and nasal obstruction visual analog scale score (VAS).

RESULTS

Most patients (87%) had 1 of the 7 types of septal deformities. There was a high prevalence of bilateral (types 4 and 6; 46%) and anterior unilateral (types 1 and 2; 25%) NSD in patients not responding to medical treatment. Type 4 (OR = 6.4; p = 0.005) or type 6 (OR = 4.4; p = 0.03) NSD increased the risk of lack of improvement with medical treatment. Coexistence of anterior unilateral or bilateral NSD with severe turbinate enlargement increased >20-fold the risk of lack of improvement. Patients with bilateral NSD presented greater rhinitis severity. Non-responder adolescents displayed higher prevalence of bilateral NSD than children (53% vs. 23%; p = 0.02). Nasal obstruction VAS was higher for patients with anterior than posterior NSD, and greater for patients with bilateral NSD than any other type of septal morphology.

CONCLUSION

Nasal endoscopy shows that bilateral and unilateral anterior nasal septum deformities are strongly associated with a poor response to medical treatment, greater rhinitis severity and higher nasal obstruction VAS. Consequently, nasal endoscopy is necessary in the PER patients to understand the disease severity as well as to plan a specific surgical treatment in order to improve nasal obstruction, disease severity, and patient's quality of life.

Management of Pediatric Nasal Surgery (Rhinoplasty)

Nasal surgery in children, most often performed after trauma, can be performed safely in selected patients with articulate, deliberate, and conscientious operative plan. All nasal surgery in children seeks to avoid disruption of the growth centers, preserving and optimizing nasal growth while improving the form and function of the nose. A solid appreciation of long-term outcomes and effects on growth remain elusive.

Use of radiography and ultrasonography for nasal fracture identification in children under 18 years of age presenting to the ED

PURPOSE

To compare the diagnostic value of ultrasonography (USG), which is rapid, inexpensive, simple, and does not involve radiation, with that of direct radiography for identifying fractures in the nasal bones of pediatric patients presenting in the emergency department with nasal trauma.

EQUIPMENT AND METHODS

Patients under 18years old presenting with nasal trauma at the emergency department included prospectively. The patients' age and sex distribution, trauma type, GCS, physical examination findings, direct radiography, and USG results were recorded. The physical examination made by the emergency medicine specialist on arrival was accepted as the gold standard for diagnosis.

FINDINGS

In total, 133 patients, 34.6% female and 65.4% male, were included in this study. The average patient age was 7.44±5.05years, with the greatest proportion (21.8%, n=29) of patients in the age ranges of 0-2 and 6-8years. The most frequently observed finding on physical examinations was swelling (51.1%, n=68). In total, 50 (37.6%) patients had nasal fractures according to their first physical examination, which was performed by emergency medicine specialists. That is, fractures were detected by direct radiography in only 11 of the 34 cases who were diagnosed with fractures by USG.

CONCLUSIONS

We consider that USG should be preferred over direct radiography for use at the bedside of pediatric patients who present at emergency department with nasal trauma, because of its superior diagnostic ability and the lack of a requirement for radiation.