Sinus and Airway: Broken Nose

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The Topic

Broken nose. Describe the bones and cartilages that make up the nose and nasal cavity. Discuss the bones that usually break in a broken nose and what the drainage pathway is that can be compromised if not repaired.

Bony Anatomy Walls

Superior Nasal Ethmoid Frontal Inferior Maxillae Palatine Lateral Lacrimal Ethmoid Maxillae Inferior nasal conchae Nasal Septum Perpendicular plate of ethmoid Vomer Sphenoid + maxillae + palatine (small extent)

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Fig 1. 1

Bony Anatomy

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Fig 2. 1

Bony Anatomy
3 turbinates/conchae: Superior Middle Inferior -Have corresponding meatuses which drain from paranasal sinuses - Increase surface area = promote warming & humidification of inspired air.

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Fig 3. 1

Bony Anatomy

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Fig 4. 1

Bony Anatomy

Inferior meatus - Nasolacrimal duct opens into the anterosuperior aspect of the inferior meatus Middle meatus -Ethmoidal bulla (projection on meatus) formed by middle ethmoidal air cells. Underneath, is unciate process (thin, arched bone length). In between, is the semilunar hiatus which connects ethmoidal infundibulum with middle meatus. - Anterior ethmoidal air cells, maxillary sinus & frontal sinus opens into the infundibulum to drain. Superior meatus - Anterior region of superior meatus opens to posterior ethmoidal air cells -Sphenoethmoidal recess Superior to superior conchae & anterior to sphenoid bone body Opens into sphenoidal sinus

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Bony Anatomy

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Fig 5. 1

Cartilages of the Nose

Lateral wall: 1. Septal cartilage 2. Lateral nasal cartilage 3. Greater alar cartilage 4. Lesser alar cartilages Medial wall: 1. Septal Cartilage 2. Vomeronasal cartilage 3. Alar cartilages Roof: 1. Septal cartilage 2. Greater alar cartilage

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Second Outline Level

Third Outline Level

Fig 6. 4

Fourth Outline Level Fifth Outline Level Sixth Outline Level Seventh Outline Level Eighth Outline

Nasal Fractures

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Septal and bony nasal fractures occur as midfacial fractures or isolated fractures 5 (79)
Children are more likely to have greenstick fractures (displacement does not occur in the fracture injury) 6,5 (80)

More cartilage Bones have greater elasticity 6

Nasal fracture categorization according to impact type 5 (80)

Nasal Fractures Categories 5(80)

Type Type I - Lateral Type II - Frontolateral - Lateral surface of the nose appears depressed - Cartilaginous nasal skeleton unaffected -Nose appears crooked -Nasal pyramid inclines towards opposite side of localised trauma - Septum can fracture with varying severity -Septum fractures - Impact is frontal and localised - Indirect indication is that at the top of the pyriform aperature, the turbinate has undergone avulsion at its head - Localised caudal trauma - Septal hematoma -Quadrangular cartilage of septum undergoes small fractures that are incomplete 5 (80)

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Type III - Frontal

Type IV - Caudal

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Second Outline Level

Third Outline Level

Fourth Outline Level Fifth Outline Level Fig 8. Above is a CT scan Sixth Outline Fig 7. Above is a showing nasal bones that have Level posteroanterior image. The fractured in their weaker region nasal root is pushed towards Seventh (their lower region). The nasal the right side of the patient. The Outline Level root has deviated to the septum is displaced. 7 Eighth Outline patients right side. 7

Nasal involvement in Midface Fractures

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The nose is also part of the midface, which has weaker points 5 (69) The most common midface fracture classification is the Le Fort classification 5 (70)
Le Fort I, II affect the central midface

Separation from facial skeleton Wedging, displacement 5 (71)

Le Fort Fractures

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Fig 9. Le Fort Fractures. 8

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Le Fort Fractures
Category Le Fort I Involvement of Nasal Structures - Nasal wall of maxillary sinus fractures - Damage to the vomer - Can have dislocation of septal cartilage 5 (71) - Midface separation like a pyramid - Possible fracture of nasal bones, vomer bone, septal bone, perpendicular plate of ethmoid - Dislocated septum - Lacrimal bone affected - Comminuted nasal bone 5 (73) - Lacrimal bones affected by fracture line 5 (75) - Paranasal sinus walls, septal bone can fracture 5 (75-76)

Le Fort II

Le Fort III

All three Le Fort Fractures occur due to blunt force. 5 (71,73,75)

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Nasoethmoidal Complex Fractures

Impact occurs from the front, breaking the nasal bones and maxillary frontal processes at typical locations 5 (76) Fractures occur in the interorbital space 5 (77)

Comminution of nasal bones, ethmoid and lacrimal lamellar bone can take place 5 (76,77)

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Nose and Paranasal Sinuses

Chronic sinusitis can result if improper healing impedes ventilation

Occluded ostia impedes paranasal sinus discharge into the nasal cavity Negative impact of injury on ventilation can damage ciliated epithelial lining of the nose and paranasal sinuses

The lining aids paranasal sinus discharge 5 (69)

CSF Rhinorrhea

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Definition: CSF Rhinorrhea refers to the drainage of cerebrospinal fluid through the nasal cavity 10

Fig 11. An axial CT scan of a patient with a spontaneous CSF leak revealing a defect in the posterior table of the left frontal sinus. 10

References
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Schuenke M, Schulte E, Ross L, Lamperti ED, Schumacher U. Thieme Atlas of Anatomy: Head and Neuroanatomy Thieme Medical Publishers Inc.: New York/US, 2010. Hiatt, J.L., Gartner, L.P., Textbook of head & neck anatomy. 4th edn. Philadelphia: Lippincott Williams & Wilkins, 2010. Martini, F.H., Nath, J.L., Fundamentals of anatomy & physiology. 8th ed. Pearson Benjamin Cummings. 2009. p224, 225, 228, 229 Wikipedia. Nasal cartilages Wikipedia, the free encyclopedia. URL: 'http://en.wikipedia.org/wiki/File:Gray852.png. Accessed May 2012. Ernst A, Herzog M, Seidl RO. Head and neck trauma. Stuttgart, Germany: Georg Thieme Verlag, 2006. Haraldson SJ. Nasal Fracture Sport-specific biomechanics. Medscape Reference, 2011. URL: http://emedicine.medscape.com/article/84829-overview#a0107. Accessed May 2012. Smith JE. Nasal Fracture Imaging - Overview. Medscape Reference, 2011. URL: http://emedicine.medscape.com/article/391863-overview . Accessed May 2012. Department of Radiology (University of Washington). Facial and Mandibular Fractures. Department of Radiology (University of Washington). URL: http://www.rad.washington.edu/academics/academic-sections/msk/teachingmaterials/online-musculoskeletal-radiology-book/facial-and-mandibular-fractures. Accessed May 2012.

References
9. 10. 11.

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Dalton J. Sinonasal Cavities. St Lucia, Qld: The University of Queensland, 2012. Lecture. Welch, K. et.al. CSF Rhinorrhea, Medscape. URL: http://emedicine.medscape.com/article/861126-overview#a05. Accessed May 2012. Kerr JT, Chu FWK, and Bayles SW. Cerebrospinal Fluid Rhinorrhea: Diagnosis and Management. Otolaryngologic clinics of North America 1 August 2005 (volume 38 issue 4) Pages 597-611. Merriam Webster Medical Dictionary. Comminuted. MedlinePlus. URL: http://www.merriam-webster.com/medlineplus/comminuted. Accessed May 2012.