AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 11

rims to ascertain whether a malar (tripod) fracture has occurred . Check the patient for trismus. Make sure the patient is not experiencing double vision or if the patient’s extra- ocular movements are compromised in any direction, which may occur when an orbital blowout fracture happens and the inferior rectus or medial rectus becomes entrapped (Figure 11.2). Make sure that there is no infraorbital nerve hypoes- thesia , which can also occur with a blowout fracture, a tripod fracture, or a simple anterior maxillary sinus fracture.

64

Figure 11.2. Coronal CT scan demonstrating a blowout fracture of the right orbital floor. This fracture often results in entrapment of the inferior rectus muscle, limiting upward gaze and causing diplopia (double vision).

Next, evaluate the nose. In general, isolated nasal fractures can be reduced up to 14 days after the fracture, if they cause a cosmetic defor- mity or airway obstruction (Figure 11.3). It is easier to do when there is

less swelling, and usually the swelling goes down by five to seven days. If the septum has been fractured, you must rule out a septal hematoma —the formation of a blood clot between the perichondrium and cartilage that disrupts the nourish- ment of the cartilage. This can result in septal necrosis , with subsequent perfora- tion as a result of either a loss of nutrition from the perichondrium or a secondary infection of the hematoma, generally with Staphylococcus aureus . These conditions are treated by incision, drainage, and packing to ensure that the blood and bacteria do not accumulate. Radiographs are not particularly helpful in cases of a broken nose, because old fractures cannot be distinguished from acute ones.

Figure 11.3. Nasal fracture. Note that the bony nasal pyramid has been shifted toward the patient’s left. Most commonly a right-handed individual will strike a patient’s nose and shift the bony pyramid toward the patient’s right. Repair is straightforward, but should be completed within 5–7 days to ensure optimal outcome.

Primary Care Otolaryngology