leading with the nose

Monday, March 3, 2014

We lead with our noses. The protuberance in the front of our face falls victim to tripping on the sidewalk, bumping into walls and other assorted misadventures. And then there is the danger of sports, where an inadvertent elbow and head butt can turn a player like LeBron James into the masked avenger. We lead with other noses and they are prone to break, accounting for almost 40% of facial injuries. Most of the time a fractured nose (remember that broken, fractured and cracked all mean the same thing and one term does not imply a more or less serious injury) is an inconvenience.

For all its simplicity, the nose performs a variety of functions as air gets inhaled and exhaled. There are the olfactory, or sense of smell receptors, that are also closely associated and needed for taste and why food is less appealing when we’re stuffed up. There are the tiny nasal hairs that trap large particles before they get into our lungs. Air is also warmed and humidified by the nose and is especially important for those who live in the frozen tundra of Wisconsin. The bony spine makes up the bridge of the nose and holds the cartilage in place, but it is the cartilage that makes most of its shape and length and separates the nostrils from each other.

As with any other injury, pain and swelling are the result of a nose injury but anytime the nose bleeds, it is likely that the cartilage may be broken. There is also the potential of whether the nose has become deformed. The initial care of a broken nose has little to do with the cosmetic issue and a lot to do with looking for the complications associated with the break. This is less than satisfying for the patient, since they often leave looking the same way they arrived and have been told that time will decide what happens. Those complications include a septal hematoma, a maxillary fracture and a cribriform plate leak. And not to forget that the face provides frontal protection of the face: a concussion is always a possibility with any injury to the face.

When injured, the blood rich septum will bleed but the nosebleed will usually resolve quickly with holding direct pressure on the nose. This can be painful because you have to squeeze something that is broken. But the doctor is more interested in looking inside the nostril at the septal wall, looking for a hematoma or clot that is trapped under the cartilage lining. Left there, its pressure will increase, damaging and potentially causing a sepal perforation or a hole that would connect the two nostrils. This can lead to infection, recurrent nosebleed and permanent changes to the appearance of the nose.

The cribriform plate is part of the ethmoid bone located at the base of the nose where it attaches to the skull. On the brain side of this bone are the meninges or the lining of brain tissue. Damage to the cribriform area can cause CSF, cerebrospinal fluid that bathes the brain with nutrients, to leak and more importantly allow the outside world, full of infection, into the brain. CSF leak from the nose appears thin and clear, and is definitely different than snot. Cribriform plate injuries with CSF leaks become a medical  priority.

While it is common to have an isolated nose injury, the maxilla or cheek bone can also be damaged. This is the bone that holds the upper teeth and is also the bone that supports the orbit and eye, and the doctor will want to check out not only the maxilla but also the mandible.

Once the complications are ruled out, there is little to be done right away. Even if the nose is obviously deformed, x-rays aren’t usually required and neither is an emergency visit to an ENT specialist or plastic surgeon. Waiting for a few days for an office allows the swelling to resolve and allow a better assessment of the way the nose looks. Ice, elevation and some pain medication is all that is usually required. After a few days, if the nose needs to be realigned, that procedure can happen using local anesthetic in the specialists’ office.

Broken noses hurt and the injury can make a dent in daily routines. Rolling over in bed and hitting the nose against a pillow is not pleasant. Habits like rubbing the nose, sniffing or blowing it will cause pain. Fortunately, the healing is relatively quick, though the badge of a broken nose may last much longer. Protective masks that form fit, like that worn by Mr. James, are not often worn by “normal” people but of course most of us also don’t have elbows flying around our heads as we rebound under the basket.

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