Inevitably cause considerable soft-tissue swelling. This becomes marked very

quickly and resolves about 10 days after the injury. This soft-tissue swelling

may well mask the underlying bony deformity, and if there is initial doubt about

whether surgical manipulation is necessary, patients should be examined again

after this interval. Radiography should be carried out. Both a lateral and an

anteroposterior view should be taken. In a lateral X-ray it can be difficult to

differentiate between an undisplaced fracture of the nasal tip and the vascular

markings on a normal nasal bone, hence the importance of taking an

anteroposterior view as well. It can also be difficult to ascertain whether the

fracture line is new, or related to a previous injury.

Clinical examination. In looking for a deviated fracture of the nasal bones, the

examiner should stand behind the patient with the latter's head thrown back,

when asymmetry is more easily demonstrated. The patient's profile should also be

examined for evidence of depression or hump formation. Anterior rhinoscopy

should be carried out to ascertain the patency of the airways and to note any

damage to the septum such as dislocation, haematoma or abscess formation. As

nasal injuries may be associated with facial fractures, the eyes should be

routinely examined for diplopia, the orbital rim palpated for step deformity,

and sensation tested over the area of skin supplied by the infra-orbital nerve.

Palpation of the nasal bones themselves should be done very gently, and pain

will be evoked, if a fracture is present, up to 3 weeks from the original

injury.

Treatment. Treatment of fractured nasal bones with cosmetic deformity is

manipulation. This can be done immediately, before the swelling occurs, as on

the sports field, when firm pressure may be enough to reduce the fracture. The

next optimum period for manipulation is about 10 days after the injury, when the

soft-tissue swelling will have resolved, but the nasal bones are still mobile.

After 3 weeks, the callus formation is sufficient to make manipulation

impossible, and the patient should be reviewed in 6 month, when, if active

treatment is still required, a formal rhinoplasty is carried out.

The nasal bones are disimpacted and manipulated with special forceps, and, of

equal importance, an attempt should be made to reposition the septal cartilage

in the midline. If there is instability in the corrected position, a plaster of

Paris cast or tin splint should be applied for a period of 10 days. Anterior

nasal packing is introduced.

Epistaxis associated with nasal injures is usually short-lived and settles with

simple pressure. Occasionally it may be troublesome and recurrent, especially if

there is an associated fracture of the ethmoidal area.

If the fracture is compound to the skin, the wound should be cleaned and

sutured, and the patient given systemic antibiotics and antitetanus prophylaxis.

Nasal septal haematoma and abscess

A haematoma of the nasal septum may be secondary to trauma or may follow septal

surgery. The blood collects in the subperichondrial layers and is bilateral.

This results in a smooth firm swelling of the septum causing bilateral nasal

obstruction. Infection frequently supervenes, and an abscess occurs. This is

associated with considerable pain in the region of the nasal tip, which becomes

excruciating on manipulation of the nose. If an abscess forms the patient

complains of headache and fever.

A septal haematoma should be evacuated with an adequate incision on both sides

of the cartilage, and removal of all blood clot. The nose is thereafter packed

for 24 hours to prevent reaccumulation of blood. If an abscess is encountered,