On the subject of nasal trauma, Hippocrates (460–377 BC) wrote in his book “Joints” that its treatment does not require any particular skill on the part of the doctor. Although his writings on how to treat fresh nasal injuries contain several recommendations that are still valid, he was certainly mistaken on this point. On the contrary, taking good care of a fresh nasal injury is a difficult art. Both correct diagnosis and adequate treatment require great skill.

Deviation of the nose and compression of the lobule are frequently observed in the newborn. About 30% of all newborns exhibit some flattening of the lobule immediately after birth. This flattening disappears quickly in most cases, though in some a deformity remains. Although individual cases of nasal deformity at birth were described long ago, the study of its incidence, causes, and treatment only started in the 1970s (e.g., Lindsay Gray, Jazbi, Jeppesen, Pirsig). In describing neonatal nasal deformities, we should distinguish between nasal deformities due to birth trauma and those occurring in utero.

Nasal deformity in the newborn following vaginal birth is rather common. The incidence reported varies from 1%–23%. This variation is very likely due to differences in definition, time lapse between examination and birth, and ethnic factors. The majority of these deformities correct the mselves in a few days. The tissues are apparently flattened or pushed during birth, later returning to their original position due to their elasticity. In a minority of cases, however, the deviation remains and nasal breathing may be impaired (Jeppesen 1977, 3.2 %; Jazbi 1977, 1.9 %; Collo 1978, 1.6 %; Podoshin et al. 1991, 0.93 %; Hughes et al. 1999, 0.6 %). Concern about disturbed nasal growth is then justified.

Nasal trauma due to vaginal birth is characterized by a deviation of the cartilaginous pyramid and lobule to one side and dislocation of the cartilaginous septum from its base to the opposite side. The columella is deviated, while the shape of the nostrils and alae is distorted and asymmetrical. Sometimes, bulging instead of a luxation of the anterior septum is found. Jeppesen and Windfield (1976) postulated that presentation of the child in left occipito-anterior position would lead to a luxation of the septal base to the right whereas presentation in right occipito-posterior position would cause a luxation to the left. Other authors (e.g. Kent et al. 1998) havenot been able to confirm this hypothesis, however.

A proper diagnosis of these fresh birth trauma deformities is of paramount importance. The most important questions are:

• Is the septum dislocated?
  
• Is the nose obstructed?
  
• Are there other congenital anomalies (e.g., choanal atresia)?

• The nasal mucosa is decongested and slightly anesthetized by putting a few drops of xylometazoline 0.025% and xylocaine 1% in the nasal cavity.
  
• The pyramid and lobule are inspected and palpated. The following aspects are investigated: Is the nose deviating? Is the lobule compressable? Are the nostrils equal in size and shape? Is the columella symmetrical? Is there loss of support of the cartilaginous dorsum and tip, indicating a septal dislocation?
  
• The vestibule, valve, and nasal cavity are inspected using a straight small-diameter endoscope or electric otoscope. The septum is palpated with a cotton-wool applicator. The following questions are answered: 1) Is the caudal septal in the midline? 2) Has the septal base slipped off the premaxilla? 3) Is there a septal hematoma? 4) Are the choanae open?
  
• When a septal dislocation is found, the cartilaginous septum is gently grasped and examined for abnormal mobility using a straight anatomical forceps with protected legs (e.g., with a piece of silicone tube cut from a narrow suction tube).

A septal dislocation is corrected as soon as possible.

Steps

• If the septum is found to be displaced and mobile, it is gently lifted up with the anatomical forceps (see preceding text) and replaced in the midline.
  
• If it is immobile, no further action is taken. A watchful waiting policy is adopted, and the child is followed up.
  
• In babies with breathing obstruction, isotonic saline or decongestive nose drops are put into the nose prior to feeding.

Nasal trauma is one of the most common injuries during childhood. No child reaches puberty without having suffered several minor and major falls and bumps on the nose. The majority of these accidents do not need special attention. However, some eventually lead to a nasal deformity.

Fig. 9.1a Deviation of pyramid and septum in a neonate delivered by cesarean section; the septum appeared to be immobile.

Fig. 9.1b Spontaneous correction of the deformity after 18 months.

Fig. 9.3 Scarring of the ala and atrophy of the triangular cartilage on the left due to an untreated dorsal hematoma.

Septal and pyramid deformities may gradually develop in later life when the septum becomes dislocated from its base by an accident with a frontolateral or basolateral impact. Even a minor trauma may have this effect. A frontal injury may cause a disruption of the cartilaginous pyramid from the bony pyramid. In these cases, sagging of the cartilaginous dorsum occurs. It is generally assumed that a high percentage of the nasal deformities in adults originate in minor injuries during childhood.

Fig. 9.4a, b Untreated nasal injury with a slight deviation of the bony pyramid to the right in a 6-year-old girl(a). At age 17, a severe deformity had occurred (b). The external pyramid is underdeveloped (“child’s nose”); the maxilla shows retrusion; the bony pyramid deviates markedly to the right, while the cartilaginous pyramid deviates to the left (C-shape deformity). There is a severe saddling of the cartilaginous dorsum with a step at the junction between the cartilaginous and the bony pyramid (Pirsig 1992).

Hematomas, especially septal and dorsal, should not be overlooked. In infants and children, septal hematomas occur rather frequently. They pose a major threat as they usually lead to a septal abscess and destruction of the septum.

Soft-tissue lesions such as avulsion of the alae, columella, or the head of the inferior turbinate have to betreated as soon as possible. This also applies to dog and monkey bites and to lesions of the columella caused by intubation.

The external nose, septum, and nasal cavity are inspected and palpated after mucosal decongestion in general or local anesthesia. Special attention is paid to the septum. A septal hematoma is to be excluded by palpating the septum with a cotton-wool applicator.

Examining the nose in a child with a fresh injury puts quite a strain on the child, its parents, the doctor, and the hospital staff. Therefore, the appropriate intranasal inspection is often omitted. This may be acceptable in some cases, but in other cases such negligence may have grave consequences. Navigating in the gray area between doing too much and too little requires experience. Plain radiographs have almost no value in diagnosing fresh nasal injuries in children. CT scans may provide important information but cannot be performed routinely.

Depending on the findings, we have to decide whether it is best to wait and see what happens or arrange for surgery.

When we decide to follow a wait-and-see policy, the parents are asked to watch out for the following developments over the next days:

• Is nasal breathing possible, or does the nose remain obstructed?
  
• Is the swelling of the external nose decreasing?
  
• Is there improvement in the child’s general condition (no fever)? The signs and symptoms of a septal abscess are briefly described.

Surgical treatment is indicated under the following circumstances:

Nasal trauma is one of the most common injuries in adults. It is usually caused by sports, traffic accidents, and fights. Males are most frequently affected, especially young males between 15 and 25 years of age. A nasal trauma may be an isolated injury or part of a major maxillofacial and/or skull trauma. If it is part of a larger trauma, a completely different approach to diagnosis and treatment is required.

Nasal injuries may involve the bony-cartilaginous skeleton, the soft tissues, or both.

Depending on the impact of the trauma and the resulting fractures and dislocations, we may distinguish five types of trauma: those with a lateral, frontal, frontolateral, basal, or basolateral impact. In special circumstances, a combination of these main types may occur.

This is another very frequent type of trauma. It is usually caused by a traffic accident, fall, or sport injury. The bony and/or cartilaginous pyramid will be impressed. The dorsal skin may be lacerated. In patients who received a severe impact on the bony bridge, the result may be a bony saddle nose with multiple fracturing of the nasal bones, skin lesions, and a septal fracture. In cases where the force has hit the cartilaginous pyramid, the triangular cartilages may be disconnected from the bony pyramid, resulting in a saddling nose and a vertical septal fracture. Lobular soft-tissue injuries may also occur (e.g., of the ala and the head of the inferior turbinate).

Some injuries are caused by both lateral and frontal forces. Usually, one of the deformities previously described will result.

This is another common type of trauma. It is caused by a fist blow, traffic accident or sport injury, or fall. The most common sequelae are a horizontal fracture of cartilaginous septum and soft-tissue lesions such as avulsion of the columella, alae, and the head of the inferior turbinate.

It is not as simple to make the correct diagnosis in fresh nasal injuries as is usually thought. Edema, hematoma, bleeding, pain, and anxiety of the patient make it difficult to determine precisely what has been fractured, dislocated, or bruised.

For a correct diagnosis of the nasal injury, we first need to obtain a full history of the cause and the angle of impact. Furthermore, information is needed about preexisting nasal complaints and deformities, previous surgery, and earlier injuries.

Color photographs of the nose and face are required for documentation. They are particularly important in legal cases when another party is involved.

Depending on the type and severity of the trauma and the general condition of the patient, we may have to arrange for an ophthalmologic, maxillofacial, and neurological examination.

First of all, treatment depends on whether we are dealing with an isolated nasal injury or with an injury as part of a major maxillofacial and/or skull trauma.

Primary general care to secure the airways, bleeding, and circulation is provided first. The airway is secured by intubation or tracheotomy; bleeding is controlled as much as possible by anterior nasal tamponade or anterior and posterior nasal tamponade (Bellocq type); and circulation is assured.

There is no doubt that the best way to treat a fresh septal and pyramid fracture is by surgical repositioning and reconstruction. Nevertheless, “closed reduction” is more commonly practiced. It is less invasive and takes less time to perform. Those who defend closed reduction also argue that the results are not too bad and that most patients are satisfied with the outcome. Finally, if complaints remain or reoccur, functional and/or aesthetic surgery can always be performed later. All these arguments are certainly valid. However, they do not dispel the evidence that surgical reconstruction in the acute or semi-acute phase produces the best results. Thus the question is when to choose closed reduction and when to prefer surgical correction? As many factors are involved, this decision has to be made for each patient individually. Some of the factors to take into account are the extent and type of the injury, the cause of the trauma, the wishes of the patient, the skill of the surgeon, and the hospital facilities.

Injuries that may be treated by a so-called closed reduction are uncomplicated septum–pyramid fractures.

The following injuries require immediate surgical reconstruction:

• Open skin lesions, avulsions, bites.
  
• Septal hematomas and pronounced paranasal or dorsal hematomas.
  
• Nasal bleeding that does not stop in spite of repeated intranasal tamponade.
  
• Bony fractures with severe dislocation, open fractures, and multiple fractures.
  
• Severe depression of the bony and/or cartilaginous pyramid.
  
• Septal fractures obstructing nasal breathing.

Injuries that may be treated conservatively by internal dressings, taping, and stents are limited hematomas and ecchymoses.

The best timing for surgical treatment of nasal injuries is within hours after the injury. Skin lesions and avulsions are taken care of as soon as possible. A septal hematoma is evacuated the same day. Repositioning of septal and pyramid fractures is also performed the same day. When indicated, this may be postponed, however. It has often been stated that injuries to the septum and pyramid should be addressed either within hours or after 3–5 days when the post-traumatic edema has subsided. Although it is certainly true that surgery in swollen and hyperemic tissues is more difficult, there are, in our opinion, no strong arguments against performing surgery during the first days after the trauma.

For many surgeons, closed reduction is the preferred treatment in the majority of cases. The reason is that if the attempt proves unsuccessful, surgical correction can always follow at a later stage. In many cases, however, the effect of a closed reduction is limited for two main reasons. First of all, it is difficult and sometimes impossible to reposition the dislocated bones, as the traumatic fracture is usually incomplete. Secondly, it is impossible to redress the bony pyramid without repositioning the deviated or fractured septum.

Steps

• Local anesthesia is applied to the mucosa and paranasally as required.
  
• Bimanual repositioning with the thumb and the forefinger may be attempted first. It sometimes works when the pyramid is deviated without impression of one of the lateral walls.
  
• In cases with impression of the lateral bony wall, a Walsham or Asch forceps is used. One leg is introduced in the nasal cavity and positioned under the impressed bone. The impressed bone is then out-fractured while the pyramid is simultaneously rotated towards the midline. Care is taken not to damage the mucosa.
  
• The repositioned pyramid is supported by internal dressings and protected by external tapes and a stent for several days.

Avulsions of the columella or alae are closed in four layers: 1) vestibular skin; 2) connective-tissue layer;3) subcutis; and 4) external skin. Lesions of the head of the inferior turbinate may be closed by one or two resorbable sutures. In most cases, adjusting the tissues with Merocel, gelfoam, or a dressing with ointment usually suffices.

In some cases with severe nasofacial trauma, the nose may have to be completely rebuilt.

Steps

• The septum is rebuilt first. The anterior septum is reconstructed by one or two plates. The posterior septum is repaired by several smaller plates mosaic style.
  
• An internal dressing with ointment is applied to fix the septum and provide support for the pyramid and lobule.
  
• The bony pyramid is reconstructed. Dislocated parts are repositioned. Loose fragments may be used. Miniplates may have to be applied.
  
• The triangular cartilages are reconstructed and fixed to the bony pyramid and the septum. The cartilaginous pyramid is rebuilt working from the inside to the outside in four layers: 1) mucosa (resorbable sutures); 2) cartilage (slowly resorbable sutures); 3) subcutaneous layers (continuous resorbable suture); and 4) skin (nonresorbable monofilament sutures). Special care is taken to recreate a functioning valve area.
  
• The lobule is reconstructed working from inside to outside. Usually, internal dressings are applied first. The lobule is then reconstructed over it in the following sequence: 1) vestibular skin (resorbable sutures); 2) lobular cartilages (slowly resorbable sutures); 3) connective-tissue layer (continuous resorbable sutures); and 4) external skin (5–0 or 6–0 nonresorbable monofilament sutures).

Nasal surgery in children differs from that in adults; neither the indications nor the surgical techniques are the same. The root cause of this difference is that surgery influences further growth of the nose and the midface. The effects of surgery may be similar to those of other injuries. This applies in particular to surgery of the septum and the triangular cartilages (in other words, the septolateral cartilage) and to a lesser extent to surgery of the bony pyramid. This has become evident in many ways. First, it was reported in follow-up studies in children following submucous septal resection (Ombrédanne 1942). In later years, it was convincingly shown by various studies on identical twins (Huizing 1966, Pirsig 1992, Grymer 1997). Finally, it was systematically investigated in a large number of animal studies (Sarnat and Wechsler, Verwoerd and collaborators).

The conclusions drawn from the information gathered so far may be summarized as follows:

The present status of nasal surgery in childhood can be summarized as follows:

• In spite of our increased knowledge, the late effects of nasal surgery in childhood are still unpredictable in an individual case. The amount of damage to the septolateral cartilage dictates future growth of the nose and midface.
  
• The later in life surgery is carried out, the less negative the effects will be on further development of the nose and midface. This applies in particular to surgery of the cartilaginous septum and triangular cartilages.
  
• The old notion that nasal surgery should be postponed until after puberty is basically still valid.
  
• Deviations of the septum and pyramid are the exception to this rule. Early repositioning of the septum and cartilaginous pyramid, whereby resections are avoided as much as possible, may prevent development of a severely deviated and obstructed nose during further growth.
  
• It is the task of the rhinological surgeon to weigh in each individual case the likely advantages of surgery against the disadvantages.

Rehabilitation of cleft-lip patients requires close cooperation between a number of specialists. Nowadays, all large medical centers have a so-called “Schizis team.” In such a team specialists of the following disciplines work together: plastic surgery, maxillofacial surgery, otorhinolaryngology, orthodontics, and speech therapy. Usually, a general pediatrician completes the team.

In this chapter we only deal with the rhinological aspects of rehabilitation of cleft-lip patients. Here, we discuss only the specific surgery of the septum, pyramid, and lobule in these cases. As to the surgery of the lip, maxilla, and palate as well as the various orthodontic options, we refer the reader to other textbooks.

Lobular surgery is always performed in the final phase of rehabilitation. Usually the lobule is reconstructed in a separate procedure 1 year after correction of the septum and the bony pyramid. Reconstructing the nasal lobule in cleft-lip patients is one of the most difficult surgical procedures in nasal surgery, requiring great skill and experience. Several techniques have been developed. Over the last decades, Tajima (1977), Millard (1982), Gubisch (1990), and Farrior (1993), among others, have made important contributions. Here, we limit ourselves to a description of the method used by Rettinger (Rettinger and O’Connel 2001).

This technique comprises the following main phases:

• Exposure of the anterior part of the septum, cartilaginous dorsum, and both lobular cartilages using the external approach. The lateral crus on the CS side is freed with the vestibular skin attached.
  
• Correction of the anterior septum and reinforcement of the medial crura.
  
• Advancement of the malpositioned dome and lateral crus with the vestibular skin attached to the CS in a medial and upward direction to create a more symmetrical and a more narrow and projecting tip.
  
• Reconstruction of the resulting cartilaginous and skin defect at the lateral wall of the vestibule with a composite graft.
  
• Lengthening of the columella, if required.

Steps

Fig. 9.7b The lobular cartilages, anterior septum, and cartilaginous dorsum are completely exposed. On the CS the vestibular skin remains attached to the cartilage.

Fig. 9.8a, b The anterior septum is corrected and fixed in the midline.

The medical profession has long ignored sleep-related breathing disorders and snoring, which were perceived as a social rather than a medical issue. In the late 1970s and the 1980s, however, greater interest was shown in disorders of sleep and snoring. Surgery of the soft palate and pharynx (uvulopalatopharyngoplasty) was introduced by Ikematsu (1964), followed by Fujita (1981), and further developed by others. Nasal masks for positive-pressure ventilation were developed to avoid pharyngeal collapse during sleep (Sullivan et al. 1981). A new subspecialty called “rhonchology” appeared. More recently, an effort has been made to start classifying and standardizing symptoms, diagnosis, and treatment.

Nowadays, three different types of sleep-related breathing disorders are distinguished: primary or nonapneic snoring; upper airway resistance syndrome (URAS); and obstructive sleep apnea (OSA).

• Primary or nonapneic snoring (previously called “benign snoring,” “social snoring,” or “habitual snoring”) is a relatively harmless condition. The intensity of snoring is less than 70 dB, and apnea is absent or rare.
  
• URAS is characterized by chronic daytime sleepiness in the absence of distinct apneas/hypopneas. A higher upper-airway resistance, which is recognized by oesophageal pressure measurement, causes respiratory arousals and sleep fragmentation.
  
• OSA is characterized by episodes of partial or complete obstruction of the upper airways leading to snoring and episodes of apnea with a minimum duration of 10 seconds and oxygen desaturation. It is mostly associated with daytime fatigue and may cause cardiopulmonary and neurological disorders.

The borderlines between these three types are still rather vague. Changes in definitions and terminology may therefore be expected in the near future.

Snoring noises are produced at the level of the pharynx. Apneas are caused by temporary collapse of a pharyngeal segment. A major causative role is played by the dimensions of the nasopharynx, palate, oropharynx, tongue base, and hypopharynx. Other important factors are the condition of the soft tissues, in particular of the mucosa, the musculature of these areas, and the size of the tonsils. Secondary causative factors are obesity, alcohol intake, use of certain medications, and sleeping position. Impaired nasal breathing may play a role, but recent studies have demonstrated that this factor is less important than previously thought.

In former decades, obstruction of nasal breathing was widely believed to be one of the main causes of snoring. Patients were sent to the ENT surgeon to have their septum straightened or their nasal polyps removed. The restoration of nasal breathing turned out to have considerably less effect on snoring than expected, however. In some cases, complaints of snoring and apnea have even been found to increase after improving nasal breathing. Unfortunately, we do not yet have methods to predict the effects of nasal surgery on snoring in an individual case. Nevertheless, it is advisable to treat nasal obstruction in patients suffering from snoring and apneas. In cases with allergic rhinitis, antiallergic treatment is given. In patients with polyposis or septal-pyramid deformities, surgery is performed. This is done primarily because most patients report a (considerable) improvement in their quality of life after improvement of nasal breathing. Secondly, nasal surgery can reduce pressure in nasal positive pressure ventilation treatment and thus increase the compliance to use nasal positive pressure ventilation.

In general, snoring is decreased or abolished in only 25% of patients when normal nasal breathing is restored. In OSA patients, this figure is even lower, lying between 15% and 20%. Generally speaking, any treatment will be successful if it leads to enlargement of the pharyngeal lumen.

In brief, the main options are:

• Weight loss, change in life style, and change in sleeping position.
  
• Nasal continuous positive pressure ventilation (nCPAP).
  
• Internal and external nasal dilatators.
  
• Progenic oral devices.
  
• Nasal surgery in cases with obstructed nasal breathing.
  
• Uvulopalatopharyngoplasty with or without tonsillectomy (or other types of velar surgery such as laser-assisted uvuloplasty (LAUP).
  
• Pharyngeal and tongue-base surgery.
  
• Maxillomandibular advancement surgery.
  
• Tracheotomy.

In patients with impaired nasal breathing, surgery (or conservative treatment) must always be considered. However, the main reason for nasal surgery should be diminishing nasal complaints. Only in a limited number of patients has a beneficial effect on snoring and apneas been reported. This applies particularly to OSA patients (e.g., Pirsig and Verse 2000).