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While motor vehicle accidents used to account for the majority of facial trauma, increased use of safety belts and the prevalence of air bags have made interpersonal violence the most common cause of facial injuries. After assessing for airway compromise, the care of facial trauma is focused on identifying threats to vision and optimizing function and cosmesis. Traditional teaching has shown correlation between facial fractures and associated injuries (10% incidence of associated cervical spine injury); however, newer data show that intracranial and spinal injuries should be evaluated outside the influence of facial trauma.
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Nasal fracture is the most common maxillofacial fracture (mandibular fracture is second) and generally occurs in the setting of blunt trauma.
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Examine for swelling, tenderness, mobility, crepitus, deformity, and step-offs.
Look for septal hematoma, appearing as a dark purple/blue mass coming off of the septum (Figure 14.1).
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Clinical diagnosis; radiographs are insensitive and computed tomography (CT) is unnecessary unless concerned for additional facial fractures.
If alignment is acceptable, epistaxis is controlled, there is no septal hematoma, and the patient can breathe out of each individual naris, no further management is required.
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Ice to reduce swelling
If markedly displaced can attempt reduction using scalpel handles in each nare with anterior and midline pressure.
Follow-up with plastic surgery, ENT, or oral and maxillofacial surgery (OMS) in 3-5 days for further reduction, only if alignment is unacceptable once swelling decreases.
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Septal hematoma = Blood accumulation separating the septal cartilage from the perichondrial blood supply; requires recognition and prompt drainage as follows:
Anesthetize the septum with topical, atomized, or injectable anesthetic.
Make an elliptical incision in the mucosa overlying the hematoma, being careful not to incise the cartilage.
Evacuate the clot with pressure and/or suction.
Place a small Penrose drain into the incision.
Pack both nostrils as in anterior epistaxis to reapproximate perichondrium and septal cartilage.
Follow-up with ENT in 48 hours.
Untreated septal hematomas can lead to abscess, necrosis, and septal perforation.
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KEY FACT
Evaluate all patients with nasal trauma for septal hematoma. Drain septal hematoma to prevent abscess formation and cartilage necrosis.
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Orbital floor or “blowout” fractures are the most common and are often isolated. They result from a direct blunt force to the globe, usually from a fist or a ball, increasing intraocular pressure enough ...