1. Anatomy Relevant to Nasal Trauma (ENT Ultra-High Yield)

Trauma to the external nose is one of the most common ENT emergencies. To manage it correctly, ENT surgeons must know the anatomy with surgical precision, because small anatomical differences determine deformity, airway compromise, bleeding, and cosmetic outcomes.

1.1 Osteocartilaginous Framework

The nose consists of:

A. Bony Upper Third

Nasal bones (paired)
Frontal process of maxilla
Nasal part of frontal bone

These bones determine dorsal height, nasal bridge shape, and fracture displacement patterns.

B. Cartilaginous Lower Two-Thirds

Upper lateral cartilages (ULC)
Lower lateral cartilages (LLC) – medial, middle, lateral crura
Septal cartilage

The cartilaginous framework is flexible, but fractures and dislocations here create airway obstruction and long-term deformity.

1.2 Nasal Septum Anatomy

Formed by septal cartilage, vomer, perpendicular plate of ethmoid
Provides central support to entire nose
Septal fractures → external deformity + obstruction
Hematoma risk due to subperichondrial vessels

1.3 Soft Tissue Envelope

Thin skin dorsally
Sebaceous thick skin near tip
Easily bruised
Prone to edema masking fracture
Lacerations risk underlying cartilage exposure

1.4 Blood Supply

From both internal and external carotid systems:

Kiesselbach plexus anteriorly
Woodruff plexus posteriorly

Nasal trauma → epistaxis is common.

1.5 Nerve Supply

Infraorbital nerve
External nasal nerve
Anterior ethmoidal nerve

In trauma, numbness over nasal tip suggests infraorbital nerve involvement.

2. Mechanisms of Nasal Trauma (ENT Expanded)

Different mechanisms cause specific fracture patterns.

2.1 Blunt Trauma

Most common (fights, falls, sports)
Causes nasal bone displacement, septal fractures

2.2 Lateral Impact

Depression of one nasal bone
Outward displacement of opposite nasal bone
Classic “C-shaped” deformity

2.3 Frontal Impact

Flattening of dorsum
Bilateral nasal bone comminution
Severe edema

2.4 High-Velocity Trauma

Motor vehicle crashes
May involve:
- Ethmoid fractures
- Cribriform plate injuries → CSF rhinorrhea
- Orbital fractures
- Midface fractures (Le Fort patterns)

2.5 Penetrating Trauma

Cuts, stabs
Avulsion injuries
Septal perforation risk

2.6 Iatrogenic Trauma

Aggressive nasal intubation
Improper nasal packing
Endoscopic surgery complications

3. Types of Nasal Injuries (ENT Structure)

3.1 Soft Tissue Injuries

Contusion
Abrasion
Laceration
Degloving injuries
Skin loss
Bruising/hematoma

These need early repair to prevent scar deformities.

3.2 Fractures

A. Nasal Bone Fracture

Most common facial fracture
May be linear, depressed, or comminuted

B. Septal Fracture

Often missed
Can cause permanent airway obstruction
Deviated septum long-term

C. Septal Dislocation

Severe obstruction
Saddle nose if untreated

D. Combined Septal + Nasal Bone Injury

Most deforming
Needs careful reduction

3.3 Septal Hematoma

One of the MOST IMPORTANT ENT EMERGENCIES.

Caused by rupture of submucosal vessels
Blood collects between perichondrium and cartilage
Cartilage loses nutrition → necrosis → saddle nose deformity

Must be drained immediately.

3.4 Cartilage Fractures

Upper lateral cartilage
Lower lateral cartilage
Alar cartilage
Can cause persistent asymmetry

3.5 Internal Nasal Valve Collapse

Trauma causes:

Septal deviation
Upper lateral cartilage collapse
→ breathing obstruction.

4. Clinical Features (ENT Ultra-Expanded)

4.1 Symptoms

Pain
Nasal obstruction
Epistaxis
Swelling
Nasal deformity
Bruising around eyes (“raccoon eyes” → skull base injury suspicion)
Nasal tip numbness
CSF rhinorrhea

4.2 Signs

A. External Findings

Edema
Bruising
Deviation
Depression of nasal bone
Widening of nasal dorsum

B. Internal Findings

Septal deviation
Septal hematoma (boggy, bluish swelling)
Mucosal laceration
Turbinate injury

4.3 Features Suggesting Complicated Trauma

CSF rhinorrhea
Periorbital hematoma
Telecanthus
Epiphora
Vision loss
Diplopia
Malocclusion (midface fracture)

5. CSF Rhinorrhea in Nasal Trauma (ENT Emergency)

Trauma may fracture the cribriform plate, causing leak of CSF.

Features:

Watery discharge
Worsens on bending forward
Glucose positive
β2-transferrin positive

Risks:

Meningitis
Brain abscess

Management:

Immediate neurosurgical consultation
Bed rest, head elevation
Avoid nasal packing unless posterior bleed
Definitive repair of skull base defect

6. Septal Hematoma (MANDATORY ENT EMERGENCY SECTION)

If untreated within 24–48 hours → cartilage necrosis → saddle nose deformity.

6.1 Clinical Features

Bilateral soft, fluctuant swelling on septum
Obstruction out of proportion to trauma
Pain
Fever (in infected hematoma)

6.2 Management

Immediate incision & drainage
Remove clots
Bilateral packing
Antibiotics

6.3 Complication of Delay

Septal abscess
Cartilage necrosis
Saddle nose deformity
Intracranial complications (rare)

7. Investigations in Nasal Trauma

7.1 Clinical Examination (Primary Tool)

Look for deformity
Palpate crepitus
Check septum
Rule out hematoma

7.2 X-Ray

Rarely useful
Not recommended in modern ENT practice

7.3 CT Scan

Indications:

Suspected skull-base fracture
Suspected midface fractures
CSF leak
Orbital involvement
Severe comminuted fractures

7.4 Nasal Endoscopy

To assess mucosal tears
Septum
Turbinates

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

8. Management of Nasal Trauma (ENT Gold-Standard Approach)

8.1 Initial Steps

Control bleeding
Ice compression
Analgesics
Elevate head
Inspect for septal hematoma

8.2 Timing of Fracture Reduction

Swelling initially masks deformities
Ideal timing: 5–10 days after injury (adults)
Earlier in children: 3–7 days
After 2–3 weeks, bones heal → require open surgery

8.3 Closed Reduction (Standard ENT Approach)

Indicated for:

Simple displaced nasal fractures
Septal dislocation
Lateral or frontal nasal bone shift

Steps:

Local or general anesthesia
Elevate depressed bone fragment
Reposition nasal bones
Reduce septal deviation
External nasal splint

Advantages:

Quick
No incision
Good cosmetic outcomes if done timely

8.4 Open Reduction (When closed reduction fails)

Indications:

Comminuted fractures
Old fractures (>3 weeks)
Severe deformity
Associated septal perforation
Combined rhinoplasty requirement

Surgical approach:

External rhinoplasty incision
Direct visualization of bones + cartilage
Osteotomies + reconstruction

9. Septal Injuries in Nasal Trauma (Deep ENT Expansion)

Septal trauma determines whether the nose heals normally or becomes permanently deformed. ENT surgeons must treat septal injuries with absolute precision.

9.1 Septal Deviation (Traumatic DNS)

Mechanism

Impact causes buckling or displacement of septal cartilage
Often associated with fracture lines through bony septum
May coexist with nasal bone fractures

Clinical Consequences

Persistent unilateral obstruction
Recurrent sinusitis
Snoring
External deformity (crooked nose)

Findings on Examination

C-shaped deviation
S-shaped deviation
Spur formation

Management

During acute phase: reduction when feasible
Definitive surgery: septoplasty after 3–6 months once healing stabilizes

9.2 Septal Dislocation

More severe than deviation.

Mechanism

Whole septal cartilage displaced from midline
Often at the junction with maxillary crest

Clinical Signs

Gross nasal obstruction
Asymmetry of external nose
Airway collapse

Management

Immediate repositioning
Internal packing
Splints (if required)

9.3 Septal Fracture

Features

Crepitus
Step deformity
Hematoma risk higher

Management

Reduction with or without sutures
Address associated hematoma

9.4 Septal Abscess

Occurs when septal hematoma becomes infected.

Clinical Presentation

Fever
Severe pain
Tender swelling
Pus under mucoperichondrium
Threat to cartilage viability

Management

Incision & drainage
Culture
Broad-spectrum antibiotics
Monitor for deformity

Complications

Saddle nose deformity
Cavernous sinus thrombosis (rare)

10. Saddle Nose Deformity (The Most Feared Post-Trauma Outcome)

10.1 Mechanism

Necrosis of septal cartilage (usually due to hematoma or abscess)
Loss of support → collapse of mid-nasal dorsum

10.2 Clinical Features

Depressed dorsal profile
Widened nasal bridge
Supratip dip
Nasal obstruction
Poor aesthetic appearance

10.3 Management

Non-Surgical

Not effective; deformity is structural

Surgical Reconstruction

Septal cartilage graft
Costal cartilage graft (for severe loss)
Onlay dorsal graft
Spreader grafts
Osteotomies for realignment

Reconstruction typically done months after trauma when edema resolves.

11. Lacerations and Soft Tissue Trauma (ENT Plastic Principles)

11.1 Types of Lacerations

Horizontal
Vertical
Avulsion
Degloving injuries
Cartilage exposure

11.2 Management Principles

A. Clean, irrigate, debride

Remove foreign bodies
Betadine irrigation

B. Alignment is key

Reapproximate skin edges PERFECTLY
Misalignment → lifelong scarring

C. Cartilage repair

Use absorbable sutures
Recreate normal contour

D. Suturing technique

Fine non-absorbable sutures (6-0 or 5-0 nylon) for skin
Deep layers with absorbable sutures

E. Tetanus prophylaxis

11.3 Nasal Tip Trauma

The nasal tip has thick skin and is prone to bulky scars.

Management:

Conservative trimming
Minimal tension
Avoid excessive suturing
Ensure alar rim integrity

11.4 Degloving Injuries

Severe injuries where skin is peeled back.

Management

Early vascular assessment
Reapproximation
Debridement only if non-viable
Consider local flaps
Reconstructive surgery

12. Pediatric Nasal Trauma (ENT Expanded Section)

Children’s noses behave differently due to anatomy:

12.1 Differences in Children

More cartilage, less bone
Higher elasticity
Easier green-stick fractures
Higher risk of septal hematoma
Deviations easily missed
Nasal growth centers may be affected

12.2 Clinical Features

Tenderness
Edema masking deformity
Epistaxis
Irritability

12.3 Why Trauma Is More Serious in Children

Damage to septal cartilage disrupts nasal growth
Leads to nasal deformity + midface hypoplasia

12.4 Management Principles

ENT evaluation within 3–7 days
Septal hematoma MUST be ruled out
Gentle closed reduction
Avoid open surgery unless absolutely necessary
Long-term follow-up for developing deformity

13. Complications of Nasal Trauma (Full Surgical Detail)

13.1 Early Complications

A. Epistaxis

Anterior bleeds most common
Posterior bleeds rare but dangerous

B. Septal Hematoma

Emergency
Risk of necrosis

C. Airway Obstruction

Deviated septum
Mucosal edema
Clots

D. CSF Rhinorrhea

Cribriform plate fracture

E. Soft Tissue Infection

Cellulitis
Abscess

13.2 Late Complications

A. Cosmetic Deformities

Saddle nose
Crooked nose
Broad nose
Depressed nasal bone
Tip asymmetry

B. Functional Problems

Persistent obstruction
Internal valve collapse
Snoring
Mouth breathing

C. Chronic Sinusitis

From altered nasal airflow.

D. Anosmia

From cribriform plate injury.

E. Septal Perforation

From mucosal damage + infection.

14. Management Algorithm (ENT Gold Flowchart)

Step 1 — Stabilize

ABC assessment
Control bleeding
Look for airway compromise

Step 2 — Examine

Inspect external deformity
Palpate bones
Check septum for hematoma
Assess eyes (to rule out orbital involvement)

Step 3 — Identify Red Flags

CSF leak
Diplopia
Vision changes
Malocclusion
Telecanthus
Signs of midface fracture

Step 4 — Decide on Imaging

Uncomplicated fracture → no imaging
Complex → CT scan

Step 5 — Management

A. Closed Reduction

For simple displaced fractures

B. Open Reduction

For comminuted, old, or complex fractures

C. Drain Hematoma

EMERGENCY

Step 6 — Splinting

External splint for 7–10 days
Internal packing if needed

Step 7 — Follow-up

Check airway
Monitor for infection
Evaluate cosmetic outcome

15. OSCE / OSPE Checklist for Nasal Trauma

Station: External Nose Injury

History

Mechanism of injury
Time since trauma
Epistaxis
Obstruction
CSF leak suspicion
Visual symptoms

Examination

Inspect from all angles
Palpate nasal bones
Assess septum
Check mucosa
Rule out hematoma

Red Flags Examiner Wants You to Say

CSF leak
Septal hematoma
Orbital injury
Midface fractures

Immediate Management Answer Should Include

Ice
Analgesics
Elevation
Drain hematoma
Plan for reduction after swelling subsides

16. Case Scenarios (Exam Scoring Section)

Case 1: Lateral Impact Injury

A 22-year-old develops unilateral depression.

Points to mention:

Likely lateral fracture
Closed reduction between days 5–10
Check for septal injury

Case 2: Child With Swelling and Bilateral Obstruction

Boggy swelling on exam.

Diagnosis:

Septal hematoma

Immediate action:

Drain NOW

Case 3: Clear Watery Discharge After Trauma

Suspect:

CSF rhinorrhea

Management:

No nasal packing
Neurosurgery consult
CT skull base

Case 4: Old Untreated Trauma

Fracture 1 month old.

Management:

Requires open rhinoplasty approach
Osteotomies
Septoplasty

17. MCQs (15 ENT-Level Questions)

MCQ 1

Most important emergency in nasal trauma:
A. Epistaxis
B. Soft tissue swelling
C. Septal hematoma
D. Edema
Correct Answer: C

MCQ 2

Best timing for closed reduction:
A. Day 1
B. Day 3
C. Day 5–10
D. After 1 month
Correct Answer: C

MCQ 3

Septal hematoma appears as:
A. Hard swelling
B. Fluctuant, bilateral swelling
C. Blue discoloration only
D. Non-tender swelling
Correct Answer: B

MCQ 4

Not a late complication:
A. Saddle nose
B. CSF rhinorrhea
C. Crooked nose
D. Nasal obstruction
Correct Answer: B

MCQ 5

CSF rhinorrhea occurs due to fracture of:
A. Maxilla
B. Nasal bone
C. Cribriform plate
D. Septum
Correct Answer: C

18. Advanced Reconstructive Principles in Nasal Trauma

Nasal reconstruction following trauma is one of the most technically demanding areas of ENT because the nose is both a functional airway and a central aesthetic unit. Trauma disrupts cartilage, bone, mucosa, and soft tissue, all of which must be restored in harmony.

18.1 Principles of Nasal Reconstruction

1. Restore Structure

Upper third → bony correction (nasal bones)
Middle third → cartilaginous correction (upper lateral cartilages, septum)
Lower third → alar cartilages + tip

2. Restore Function

Correcting the nasal valve angle (15°–20°)
Rebuilding septal support
Preventing collapse during inspiration

3. Maintain Symmetry

Symmetry is more important than perfection
Even minor asymmetries are visible due to central facial location

4. Respect Growth in Children

Avoid aggressive septal surgery
Growth centers lie in septovomeral region
Damage → midface hypoplasia

5. staged Approach

Acute phase → preserve tissue, drain hematoma, reduce fractures
Secondary phase → definitive correction after 3–6 months

18.2 Timing of Nasal Reconstruction

Immediate (Within 24 Hours)

Complex lacerations
Avulsion injuries
Exposed cartilage or bone

Early (3–7 Days)

Closed reduction of fractures once swelling settles

Delayed (3–6 Months)

Secondary deformity correction
Septorhinoplasty
Grafting procedures

18.3 Graft Materials in ENT Trauma Reconstruction

1. Septal Cartilage

First choice
Straight, strong, easy to harvest
Used for spreader grafts, dorsal support, columellar struts

2. Conchal Cartilage (Ear)

Curved
Suitable for alar reconstruction

3. Costal Cartilage

For severe saddle nose deformity
Very strong, but risk of warping

4. Alloplastic Materials (rarely used)

Silicone
Medpor
Higher risk of infection

19. Common Post-Traumatic Nasal Deformities (ENT Textbook Expansion)

19.1 Deviated Nose Deformity

Causes:

Asymmetric fracture
Untreated septal deviation
Cartilage memory

Features:

Crooked dorsum
Tip deviation
Nasal obstruction

Management:

Septorhinoplasty
Osteotomies + spreader grafts

19.2 Saddle Nose Deformity (Detailed Reconstruction)

Pathophysiology:

Loss of septal cartilage → collapse of dorsal support

Reconstruction:

Septal reconstruction
Onlay dorsal graft
Spreader grafts to widen internal nasal valve
Tip repositioning

Costal cartilage used for severe cases.

19.3 Open Roof Deformity

Occurs after inadequate reduction of displaced nasal bones.

Correction:

Bilateral osteotomies
Reapproximation of nasal bones
Dorsal onlay graft (if needed)

19.4 Inverted V Deformity

Failure to support upper lateral cartilage after trauma.

Treatment:

Spreader grafts between septum and upper lateral cartilages

20. Rhinoplasty Principles in Post-Trauma Nose

ENT surgeons performing trauma rhinoplasty must balance:

Aesthetics
Airway function
Septal stability

20.1 Key Surgical Steps

Elevate skin–soft tissue envelope carefully
Correct fractures with osteotomies
Straighten septum (L-strut preserved)
Build dorsal aesthetic lines
Reconstruct nasal valve

20.2 Internal Nasal Valve Correction

Use spreader grafts
Maintain proper angle
Prevent future obstruction

20.3 External Nasal Valve Support

Alar batten graft
Rim graft

21. CT Scan Findings in Nasal Trauma (Radiology Expansion)

Useful in:

Complex fractures
Orbital involvement
Cribriform plate injury
Midface fractures

Features Seen:

Depressed nasal bone segments
Comminuted fractures
Septal deviation / fracture lines
Air–fluid levels in sinuses
Cribriform plate disruption → risk of CSF leak

22. CSF Rhinorrhea in Nasal Trauma

Mechanism:

Cribriform plate fracture
Dural tear → CSF leak into nasal cavity

Signs:

Clear watery discharge
Glucose positive (not reliable)
Beta-2 transferrin: gold standard
Increased leak during bending forward

Management:

No nasal packing
Head elevation
Avoid nose blowing
Neurosurgical referral
Endoscopic repair if persistent

23. Major ENT Emergencies Associated With Nasal Trauma

23.1 Septal Hematoma

Already discussed as top priority.

23.2 Orbital Complications

Diplopia
Restricted eyeball movement
Infraorbital nerve anesthesia

Requires urgent CT.

23.3 Airway Compromise

Deviated septum
Edema
Clots

23.4 Uncontrolled Epistaxis (Posterior)

Sphenopalatine artery injury

24. Detailed Stepwise Management Protocol

STEP 1 – Immediate Evaluation

Airway
Breathing
Circulation

STEP 2 – ENT Examination

Inspect externally
Palpate bones
Assess septum
Look for hematoma
Check eyes and teeth for associated fractures

STEP 3 – Identify Red Flags

CSF rhinorrhea
Diplopia
Telecanthus (medial canthal tendon injury)
Severe epistaxis

STEP 4 – Imaging if Required

CT face
CT skull base for CSF leak

STEP 5 – Treatment

Drain hematoma
Reduce fractures
External splinting
Internal nasal packing (if needed)

STEP 6 – Follow-Up

Evaluate in 1 week
Consider secondary reconstruction after 3–6 months

25. Complications – Expanded (Tables + Explanations)

Early Complications Table

Complication	Mechanism	Symptoms	Management
Septal hematoma	Bleeding under mucoperichondrium	Bilateral obstruction, swelling	Drain immediately
Infection	Contamination of wound	Fever, pain	Antibiotics + drainage
CSF Rhinorrhea	Skull base fracture	Clear watery discharge	Neurosurgical management
Airway obstruction	Septal deviation, edema	Mouth breathing	Decongestants, surgery

Late Complications Table

Complication	Cause	Features	Treatment
Saddle nose	Cartilage necrosis	Depressed dorsum	Costal cartilage graft
Crooked nose	Misaligned bones	Asymmetry	Osteotomies
Nasal obstruction	Internal valve collapse	Difficulty breathing	Spreader grafts
Chronic sinusitis	Disturbed airflow	Headache, discharge	Medical + surgical

26. OSCE: Full Trauma Station Model Answer

History

Mechanism
Time since injury
Bleeding
Nasal blockage
Vision changes

Physical Examination

Inspect from front, profile, basal view
Palpate nasal bones
Check septum
Look for hematoma
Examine eyes and bite

Give Examiner These Points (High-yield)

“I will rule out septal hematoma first.”
“I will check for CSF leak.”
“I will schedule reduction after swelling resolves.”

Management Answer

Ice, elevation
Closed reduction 5–10 days
Drain hematoma
Splinting
Follow-up

27. Additional High-Yield MCQs (Exam-Level)

MCQ 6

Saddle nose deformity results from:
A. Nasal bone fracture
B. Septal cartilage necrosis
C. Turbinate injury
D. Persistent edema
Correct Answer: B

MCQ 7

The safest and strongest graft for major reconstruction is:
A. Septal cartilage
B. Conchal cartilage
C. Silicone implant
D. Costal cartilage
Correct Answer: D

MCQ 8

CSF leak after nasal trauma indicates:
A. Turbinate fracture
B. Cribriform plate fracture
C. Septal spur
D. Hematoma
Correct Answer: B

MCQ 9

Best imaging for complex nasal trauma:
A. MRI
B. X-ray
C. Ultrasound
D. CT scan
Correct Answer: D

MCQ 10

Timing for secondary septorhinoplasty is:
A. Immediately
B. 1 week
C. 1 month
D. 3–6 months
Correct Answer: D