Lateral nasal wall abscess following manipulation of fractured nasal bones

Abstract

Nasal fracture accounts for over 50% of facial fractures and is a frequent presentation to ear, nose and throat emergency clinics. Optimal management of nasal injuries with deformity is by manipulation under anaesthetic and should be offered when appropriate. A healthy 27-year-old woman presented with a lateral nasal wall mass with purulent discharge 1 month following manipulation. CT imaging revealed a mass arising from fragments of the nasal bone, consistent with an abscess. Bone fragments and purulent material were initially debrided, with a subsequent formal excision of a persistent granuloma performed with an excellent cosmetic outcome. This appears to be the first description of a granuloma resulting from a closed reduction—manipulation of a nasal fracture.

Background

Nasal injury is a common presentation to emergency departments following sporting injury.^{1 2} In total, nasal fractures account for over 50% of all maxillofacial fractures.^{3 4}

These typically cause significant paranasal swelling; however, it is important to assess for associated injuries, including orbital rim fracture and visual disturbance, in the acute phase. If the fracture is uncomplicated, assessment for nasal deviation should be undertaken approximately 5 days following the injury.^{5 6} This delayed assessment allows time for paranasal swelling to decrease and if there is a significant cosmetic deformity, a manipulation under anaesthetic (MUA) of nasal bones may be offered within the following 2 weeks.^{5 6}

The risks of MUA are well-documented. The most common adverse event is persistent nasal deformity, occurring in over 10% of procedures, followed by septal deviation, nasal obstruction and less commonly epiphora, visual disturbance and olfactory disturbance.¹

This case demonstrates the unusual complication of a nasal granuloma following instrumental reduction manipulation of fractured nasal bones. It indicates the need for care when performing instrumental as opposed to digital manipulation in such cases.

Case presentation

A 27-year-old woman presented to the emergency department following a horse-riding accident which involved a collision with a low-hanging tree branch. Despite wearing a helmet, her face collided directly with the tree branch resulting in nasal injury and minor facial wounds.

Following an initial assessment in the emergency department, she was referred to ear, nose and throat (ENT), who reviewed the patient 5 days after the initial injury. During this assessment, the injury was felt to be consistent with a deviated nasal fracture and the patient underwent nasal MUA 10 days following the initial injury to good cosmetic effect. Two days following the MUA, the patient developed a mass on the right lateral nasal wall. The swelling was associated with intermittent purulent discharge, erythema and visual obstruction to the patient due to its locale and proximity to the medial canthus. This failed to respond to a course of oral antibiotics.

Approximately 1 month after the MUA, the patient was referred for an ophthalmic opinion because of the possibility of a nasolacrimal abscess. This was excluded and the patient referred for a second ENT opinion in a tertiary unit.

On examination, the patient had a mild deviation of the nasal pyramid associated with a saddle nose deformity. Overlying the right bony pyramid of the nasal wall was a 1×1 cm raised, tender and erythematous mass which expressed purulent material from a skin punctum when palpated, which was consistent with an underlying abscess (figure 1). Endonasally, the patient had a marked right septal deviation, but did not volunteer any complaints of nasal obstruction, restriction or mucopurulent nasal discharge. This presented an aesthetic defect for the patient and she was displeased with the cosmetic outcome following MUA.

Figure 1.

Granuloma on initial presentation.

Investigations

CT sinuses were requested to rule out bony migration and subsequent intraorbital or nasolacrimal involvement (figures 2 and 3). CT reported ‘a small abscess and localised haematoma in the right paranasal region in association with multiple non-united fracture segments of the nasal bone. No intraorbital or intracranial abnormal findings were reported’.

Figure 2.

CT scan of nose and paranasal sinuses—bone.

Figure 3.

CT scan of nose and paranasal sinuses—soft tissue.

Differential diagnosis

• Abscess or haematoma secondary to necrotic fragments of the fractured nasal bone.

• Dacryocystitis.

Treatment

Prior to the presentation at our unit, the patient was treated with a course of oral flucloxacillin by her general practitioner (GP) which did not improve her symptoms.

Aspiration of the mass and limited debridement was attempted under local anaesthetic with the removal of two large shards of necrotic bone, a small volume of organised haematoma and purulent material (figure 4).

Figure 4.

Necrotic bone material removed from the lesion.

The lesion persisted despite this and due to ongoing cosmetic concerns, the patient underwent formal open debridement and excision under general anaesthesia. Intraoperatively, necrotic, granulation tissue was noted superficial to nasal periosteum. This was excised with close margins and the wound left to heal by secondary intention.

Outcome and follow-up

The patient was seen in the outpatient clinic 2 weeks and 3 months following the procedure. Gratifyingly, the patient was satisfied with the cosmetic result (figure 5).

Figure 5.

Three months postoperatively of formal debridement under general anaesthetic.

Discussion

Nasal fracture is a common presenting complaint to emergency departments and frequently referred to the ENT casualty clinic.^{1 2} In the UK, ENT casualty clinic is frequently led by senior house officers (SHOs), and thus, SHOs are often the responsible clinicians for assessing and listing patients for MUA. Likewise, the SHO may consent the patient for the procedure and should be aware of the relevant risks and adverse outcomes.^{6 7}

The mechanism of nasal injury is key to understanding the underlying pathology. Likewise, knowledge of the relevant anatomy is essential when assessing the nasal injury and the potential repair. Identification of nasal fracture is based on clinical examination, which should include endonasal and external nasal examination, assessment for orbital-ethmoid fractures, visual disturbance, basal skull fracture, septal haematoma and nasolacrimal involvement.

Nasal fracture can be classed from Murray type 1–5 (table 1). Type 4 represents a closed, fragmented nasal fracture resulting from a crush injury secondary to head-on, frontal trauma (as presented in this case).^{8 9}

Table 1.

Summary of Murray’s classification of nasal fracture (type 1–5)^{8 9}

Type 1	Soft tissue injury, no fracture
Type 2	Simple, non-displaced fracture
Type 3	Simple, displaced fracture
Type 4	Closed, comminuted fracture
Type 5	Open, comminuted fracture

Ultimately, the goal of MUA is an improved aesthetic outcome and improve nasal airflow. Closed reduction achieves a satisfactory outcome in a majority of nasal fractures; however, current evidence states that persistent nasal deformity can be as high as 50% in comminuted fractures.¹⁰ It has been suggested that the type of nasal fracture should be accounted for when planning definitive management. Radiological imaging is not used routinely in the assessment of nasal fractures since the immediate management is dependent on clinical appearance. However, CT scanning is helpful in identifying complicating or characterising fractures.¹¹

Haematoma and abscess arising from the nasal septum or alar cartilage secondary to nasal trauma have been described in the literature which similarly present with nasal pain and swelling.^12–14 Prompt management of haematoma or abscess reduces the risk of intraorbital and intracranial infective complications. In addition, the complications of haematoma and abscess may compromise the structural integrity of the nose and result in nasal structural collapse, avascular necrosis and saddle-nose deformity.^11–13

This is the first case known to the authors to present an external abscess involving fragments of the nasal bone.

Prophylactic antibiotics are not prescribed routinely for patients with a nasal fracture or those undergoing MUA. Evidence has suggested a little benefit of prophylactic antibiotics in facial fractures overall, save for mandibular fractures.¹⁵ Likewise, the use of prophylactic antibiotics in nasal surgery is controversial, and typically only recommended if endonasal packing has been applied.¹⁶ Despite the rare complication described in this case study, the authors do not recommend that prophylactic antibiotics are given to all nasal MUA patients as this has implications for antibiotic resistance and associated Clostridium d ifficile rates.

However, had a swab of the purulent discharge been taken at the initial presentation of the patient to her GP, the GP could have exhibited antimicrobial stewardship and tailored prescription to the relevant sensitivities. And subsequently, if there had been no improvement with oral antibiotics, this may have triggered an earlier referral to ENT for consideration of surgical intervention, before the abscess had presented such a cosmetic concern for the patient.

The authors believe that all nasal injuries should be assessed on an individual basis for consideration of closed reduction MUA, and specifically, manipulation that involves instrumental rather than digital reduction.⁶ Particular consideration should be given to patterns of injury that are consistent with comminuted fracture and imaging to rule out potential bony migration, nasolacrimal involvement and intracranial spread.

In this case, it appears that manipulation has complicated the existing nasal fracture, producing further trauma and comminution which has perpetuated both cosmetic deformity and granuloma formation. The authors encourage individual assessment of nasal injuries at the time of fracture reduction to determine the choice of technique. Judicial use of instrumental reduction by experienced clinicians is advised to avoid more serious complications, such as those illustrated by this case.

Learning points.

• Ensure patients are consented appropriately to include the risk of further cosmetic defect and nasal deformity.

• The mechanism of nasal injury is key to understanding the potential underlying pathology, and thus appropriate patient selection for manipulation under anaesthetic (MUA).

• Consider mechanism and grade of nasal fracture, and if comminuted, whether closed MUA is appropriate definitive management.

• Consider follow-up of patients with complicated or potentially comminuted nasal fractures for adverse cosmetic outcomes.

• Ensure that consideration is given to potential bony migration, nasolacrimal and orbital involvement in all nasal fractures prior to surgery.