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SECTION II — Diseases of Nose and Paranasal Sinuses
Figure 32.4. An endoscopic view of multiple nasal polypi.
Surgical
Endoscopic sinus surgery. These days, ethmoidal polypi
are removed by endoscopic sinus surgery more popularly
called functional endoscopic sinus surgery (FESS). It is done
with various endoscopes of 0°, 30° and 70° angulation.
Polypi can be removed more accurately when ethmoid
cells are removed, and drainage and ventilation provided
to the other involved sinuses such as maxillary, sphenoidal or frontal.
Prior to the advent of endoscopic sinus surgery, follow-
ing operations were commonly done:
1. Polypectomy. One or two polyps which are peduncu-
lated can be removed with snare. Multiple and sessile
polypi require special forceps.
2. Intranasal ethmoidectomy. When polypi are multiple and sessile, they require uncapping of the ethmoidal air cells by intranasal route, a procedure called
intranasal ethmoidectomy.
3. Extranasal ethmoidectomy. This is indicated when
polypi recur after intranasal procedures and surgical
landmarks are ill-defined due to previous surgery. Approach is through the medial wall of the orbit by an
external incision, medial to medial canthus.
4. Transantral ethmoidectomy. This is indicated when
infection and polypoidal changes are also seen in the
maxillary antrum. In this case, antrum is opened by
Caldwell–Luc approach and the ethmoid air cell approached through the medial wall of the antrum.
This procedure is also superceded by endoscopic sinus
surgery.
Figure 32.5. A polyp protruding from the left nostril in a patient with
bilateral ethmoidal polypi.
Scan to play Nasal Polypi.
TREATMENT
Conservative
1. Early polypoidal changes with oedematous mucosa
may revert to normal with antihistaminics and control
of allergy.
2. A short course of steroids may prove useful in case of
people who cannot tolerate antihistaminics and/or in
those with asthma and polypoidal nasal mucosa. They
may also be used to prevent recurrence after surgery.
Contraindications to use of steroids, e.g. hypertension,
peptic ulcer, diabetes, pregnancy and tuberculosis
should be excluded.
SOME IMPORTANT POINTS TO
REMEMBER IN A CASE OF NASAL POLYPI
1. If a polypus is red and fleshy, friable and has granular surface, especially in older patients, think of malignancy.
2. Simple nasal polyp may masquerade a malignancy
underneath. Hence all polypi should be subjected to
histology.
3. A simple polyp in a child may be a glioma, an encephalocele or a meningoencephalocele. It should always be
aspirated and fluid examined for CSF. Careless removal
of such polyp would result in CSF rhinorrhoea and
meningitis.
4. Multiple nasal polypi in children may be associated
with mucoviscidosis (cystic fibrosis).
5. Epistaxis and orbital symptoms associated with a polyp should always arouse the suspicion of malignancy.
Chapter 33
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Epistaxis
Bleeding from inside the nose is called epistaxis. It is fairly
common and is seen in all age groups-children, adults and
older people. It often presents as an emergency. Epistaxis
is a sign and not a disease per se and an attempt should
always be made to find any local or constitutional cause.
BLOOD SUPPLY OF NOSE (FIGURES 33.1
AND 33.2)
Nose is richly supplied by both the external and internal
carotid systems, both on the septum and the lateral walls.
NASAL SEPTUM
Internal Carotid System
1. Anterior ethmoidal artery
2. Posterior ethmoidal artery
Branches of ophthalmic
artery
External Carotid System
1. Sphenopalatine artery (branch of maxillary artery) gives
nasopalatine and posterior medial nasal branches.
2. Septal branch of greater palatine artery (branch of
maxillary artery).
3. Septal branch of superior labial artery (branch of facial
artery).
LATERAL WALL
Internal Carotid System
1. Anterior ethmoidal
2. Posterior ethmoidal
Branches of ophthalmic artery
External Carotid System
1. Posterior lateral nasal
branches
2. Greater palatine artery From maxillary artery
3. Nasal branch of anterior
superior dental
4. Branches of facial artery
to nasal vestibule
From sphenopalatine
artery
From infraorbital branch
of maxillary artery
LITTLE’S AREA
It is situated in the anterior inferior part of nasal septum,
just above the vestibule. Four arteries-anterior ethmoidal, septal branch of superior labial, septal branch of
sphenopalatine and the greater palatine, anastomose here
to form a vascular plexus called “Kiesselbach’s plexus.”
This area is exposed to the drying effect of inspiratory
current and to finger nail trauma, and is the usual site for
epistaxis in children and young adults.
retrocolumellar Vein. This vein runs vertically downwards just behind the columella, crosses the floor of nose
and joins venous plexus on the lateral nasal wall. This is a
common site of venous bleeding in young people.
WOODRUFF’S PLEXUS
It is a plexus of veins situated inferior to posterior end
of inferior turbinate. It is a site of posterior epistaxis in
adults.
CAUSES OF EPISTAXIS
They may be divided into:
1. Local, in the nose or nasopharynx.
2. General.
3. Idiopathic.
A. LOCAL CAUSES
Nose
1. Trauma. Finger nail trauma, injuries of nose, intrana-
sal surgery, fractures of middle third of face and base of
skull, hard-blowing of nose, violent sneeze.
2. Infections
(a) Acute: Viral rhinitis, nasal diphtheria, acute sinusitis.
(b) Chronic: All crust-forming diseases, e.g. atrophic
rhinitis, rhinitis sicca, tuberculosis, syphilis septal
perforation, granulomatous lesion of the nose, e.g.
rhinosporidiosis.
3. Foreign bodies
(a) Nonliving: Any neglected foreign body, rhinolith.
(b) Living: Maggots, leeches.
4. Neoplasms of nose and paranasal sinuses.
(a) Benign: Haemangioma, papilloma.
(b) Malignant: Carcinoma or sarcoma.
5. Atmospheric changes. High altitudes, sudden decompression (Caisson disease).
6. Deviated nasal septum.
Nasopharynx
1. Adenoiditis.
2. Juvenile angiofibroma.
3. Malignant tumours.
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SECTION II — Diseases of Nose and Paranasal Sinuses
B. GENERAL CAUSES
1. Cardiovascular system. Hypertension, arteriosclerosis, mitral stenosis, pregnancy (hypertension and hormonal).
2. Disorders of blood and blood vessels. Aplastic
anaemia, leukaemia, thrombocytopenic and vascular
purpura, haemophilia, Christmas disease, scurvy, vitamin K deficiency and hereditary haemorrhagic telangectasia.
3. Liver disease. Hepatic cirrhosis (deficiency of factor II,
VII, IX and X).
4. Kidney disease. Chronic nephritis.
5. Drugs. Excessive use of salicylates and other analgesics
(as for joint pains or headaches), anticoagulant therapy (for heart disease).
6. Mediastinal compression. Tumours of mediastinum
(raised venous pressure in the nose).
7. Acute general infection. Influenza, measles, chickenpox, whooping cough, rheumatic fever, infectious
mononucleosis, typhoid, pneumonia, malaria and
dengue fever.
8. Vicarious menstruation (epistaxis occurring at the
time of menstruation).
Figure 33.1. Blood supply of the nasal septum.
Scan to play External and Internal Carotid Artery.
C. IDIOPATHIC
Many times the cause of epistaxis is not clear.
SITES OF EPISTAXIS
1. Little’s area. In 90% cases of epistaxis, bleeding occurs
from this site.
2. Above the level of middle turbinate. Bleeding from
above the middle turbinate and corresponding area on
the septum is often from the anterior and posterior
ethmoidal vessels (internal carotid system).
3. Below the level of middle turbinate. Here bleeding
is from the branches of sphenopalatine artery. It may
be hidden, lying lateral to middle or inferior turbinate
and may require infrastructure of these turbinates
for localization of the bleeding site and placement of
packing to control it.
4. Posterior part of nasal cavity. Here blood flows di-
rectly into the pharynx.
5. Diffuse. Both from septum and lateral nasal wall. This
is often seen in general systemic disorders and blood
dyscrasias.
6. Nasopharynx.
Chapter 33 — Epistaxis
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CLASSIFICATION OF EPISTAXIS
Anterior Epistaxis
When blood flows out from the front of nose with the
patient in sitting position.
Posterior Epistaxis
Mainly the blood flows back into the throat. Patient may
swallow it and later have a “coffee-coloured” vomitus.
This may erroneously be diagnosed as haematemesis.
The differences between the two types of epistaxis are
tabulated herewith (Table 33.1).
MANAGEMENT
In any case of epistaxis, it is important to know:
1. Mode of onset. Spontaneous or finger nail trauma.
2. Duration and frequency of bleeding.
3. Amount of blood loss.
4. Side of nose from where bleeding is occurring.
5. Whether bleeding is of anterior or posterior type.
6. Any known bleeding tendency in the patient or family.
7. History of known medical ailment (hypertension, leukaemia, mitral valve disease, cirrhosis and nephritis).
8. History of drug intake (analgesics, anticoagulants, etc.).
Figure 33.2. Blood supply of the lateral wall of the nose.
TABLE 33.1 DIFFERENCES BETWEEN ANTERIOR
AND POSTERIOR EPISTAXIS
Anterior epistaxis Posterior epistaxis
Incidence More common Less common
Site Mostly from Little’s
area or anterior part
of lateral wall
Age Mostly occurs in
children or young
adults
Cause Mostly trauma Spontaneous; often due
Bleeding Usually mild, can be
easily controlled by
local pressure or
anterior pack
FIRST AID
Most of the time, bleeding occurs from the Little’s area
and can be easily controlled by pinching the nose with
thumb and index finger for about 5 min. This compresses
the vessels of the Little’s area. In Trotter’s method patient
is made to sit, leaning a little forward over a basin to spit
any blood and breathe quietly from the mouth. Cold
Mostly from posterosuperior
part of nasal cavity; often
difficult to localize the
bleeding point
After 40 years of age
to hypertension or
arteriosclerosis
Bleeding is severe, requires
hospitalization; postnasal
pack often required
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SECTION II — Diseases of Nose and Paranasal Sinuses
compresses should be applied to the nose to cause reflex
vasoconstriction.
CAUTERIZATION
This is useful in anterior epistaxis when bleeding point
has been located. The area is first topically anaesthetized
and the bleeding point cauterized with a bead of silver
nitrate or coagulated with electrocautery.
ANTERIOR NASAL PACKING
In cases of active anterior epistaxis, nose is cleared of
blood clots by suction and attempt is made to localize the
bleeding site. In minor bleeds, from the accessible sites,
cauterization of the bleeding area can be done. If bleeding
is profuse and/or the site of bleeding is difficult to localize, anterior packing should be done. For this, use a ribbon gauze soaked with liquid paraffin. About 1 m gauze
(2.5 cm wide in adults and 12 mm in children) is required
for each nasal cavity. First, few centimetres of gauze are
folded upon itself and inserted along the floor and then
the whole nasal cavity is packed tightly by layering the
gauze from floor to the roof and from before backwards.
Packing can also be done in vertical layers from back to
the front (Figure 33.3). One or both cavities may need to
be packed. Pack can be removed after 24 h, if bleeding
has stopped. Sometimes, it has to be kept for 2-3 days; in
that case, systemic antibiotics should be given to prevent
sinus infection and toxic shock syndrome.
POSTERIOR NASAL PACKING
It is required for patients bleeding posteriorly into the
throat. A postnasal pack is first prepared by tying three
silk ties to a piece of gauze rolled into the shape of a cone.
A rubber catheter is passed through the nose and its end
brought out from the mouth (Figure 33.4). Ends of the
silk threads are tied to it and catheter withdrawn from
nose. Pack, which follows the silk thread, is now guided
into the nasopharynx with the index finger. Anterior nasal cavity is now packed and silk threads tied over a dental
roll. The third silk thread is cut short and allowed to hang
in the oropharynx. It helps in easy removal of the pack
Figure 33.3. Methods of anterior nasal packing. (A) Packing in vertical layers. (B) Packing in horizontal layers.
Figure 33.4. Technique of postnasal pack.
Figure 33.5. Epistaxis balloon for posterior epistaxis. Posterior bal-
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loon (A) is inflated with 10 mL and anterior balloon (B) with 30 mL.
Catheter provides nasal airway.
later. Patients requiring postnasal pack should always be
hospitalized. Instead of postnasal pack, a Foley’s catheter
size 12-14 F can also be used. After insertion balloon is
inflated with 5-10 mL of saline. The bulb is inflated with
saline and pulled forward so that choana is blocked and
then an anterior nasal pack is kept in the usual manner.
These days nasal balloons are also available (Figure 33.5).
A nasal balloon has two bulbs, one for the postnasal space
and the other for nasal cavity.
ENDOSCOPIC CAUTERIZATION
Using topical or general anaesthesia, bleeding point is localized with a rigid endoscope. It is then cauterized with
a malleable unipolar suction cautery or a bipolar cautery. The procedure is effective with less morbidity and
decreased hospital stay. The procedure has a limitation
when profuse bleeding does not permit localization of
the bleeding point.
ELEVATION OF MUCOPERICHONDRIAL
FLAP AND SUBMUCOUS RESECTION (SMR)
OPERATION
In case of persistent or recurrent bleeds from the septum,
just elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood
vessels. SMR operation can be done to achieve the same
result or remove any septal spur which is sometimes the
cause of epistaxis.
LIGATION OF VESSELS
1. External carotid. When bleeding is from the external
carotid system and the conservative measures have
failed, ligation of external carotid artery above the
origin of superior thyroid artery should be done. It is
avoided these days in favour of embolization or ligation of more peripheral branches of sphenopalatine
artery.
2. Maxillary artery. Ligation of this artery is done in
uncontrollable posterior epistaxis. Approach is via
Chapter 33 — Epistaxis
Caldwell-Luc operation. Posterior wall of maxillary sinus is removed and the maxillary artery or its branches
are blocked by applying clips. This procedure is now
superceded by transnasal endoscopic sphenopalatine
artery ligation.
3. Ethmoidal arteries. In anterosuperior bleeding above
the middle turbinate, not controlled by packing, anterior and posterior ethmoidal arteries, which supply
this area, can be ligated. The vessels are exposed in
the medial wall of the orbit by an external ethmoid
(Lynch) incision.
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Transnasal Endoscopic Sphenopalatine
Artery Ligation (TESPAL)
The procedure can be done with rigid endoscopes under
topical anaesthesia with sedation or under a general anaesthesia. A mucosal flap is lifted in posterior part of lateral nasal wall, sphenopalatine artery (SPA)is localized as
it exits the foramen and closed with a vascular clip. Distal
branches of the artery can be additionally cauterized and
the flap then reposited. Anterior ethmoidal artery can
also be ligated by Lynch incision as an adjunctive procedure. SPA ligation gives high success in control of refractory posterior bleed.
Embolization
It is done by an interventional radiologist through femoral artery catheterization. Internal maxillary artery is localized and the embolization is performed with absorbable gelfoam and/or polyvinyl alcohol or coils. Both
ipsilateral or bilateral embolizations may be required for
unilateral epistaxis because of cross circulation. Embolization is generally a safe procedure but may have potential
risks like cerebral thromboembolism, haematoma at local
site. Ethmoidal arteries cannot be embolized.
GENERAL MEASURES IN EPISTAXIS
1. Make the patient sit up with a back rest and record
any blood loss taking place through spitting or vomiting.
2. Reassure the patient. Mild sedation should be given.
3. Keep check on pulse, BP and respiration.
4. Maintain haemodynamics. Blood transfusion may be
required.
5. Antibiotics may be given to prevent sinusitis, if pack is
to be kept beyond 24 h.
6. Intermittent oxygen may be required in patients with
bilateral packs because of increased pulmonary resistance from nasopulmonary reflex.
7. Investigate and treat the patient for any underlying local or general cause.
hereditary haemorrhagic telangiectasia. It occurs
on the anterior part of nasal septum and is the cause of recurrent bleeding. It can be treated by using Argon, KTP or
Nd: YAG laser. The procedure may require to be repeated
several times in a year as telangectasia recurs in the surrounding mucosa. Some cases require septodermoplasty
where anterior part of septal mucosa is excised and replaced by a split-skin graft.
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Chapter 34
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Trauma to the Face
Injuries of face may involve soft tissues, bones or both.
The majority of facial injuries are caused by automobile
accidents. Others result from sports, personal accidents,
assaults and fights. The management of facial trauma can
be divided into:
1. General management.
2. Soft tissue injuries and their management.
3. Bone injuries and their management.
GENERAL MANAGEMENT
1. Airway. Maintenance of airway should receive the
highest priority. Airway is obstructed by loss of skeletal
support, aspiration of foreign bodies, blood or gastric
contents or swelling of tissues. Airway is secured by
intubation or the tracheostomy.
2. Haemorrhage. Injuries of face may bleed profusely.
Bleeding should be stopped by pressure or ligation of
vessels.
3. Associated injuries. Facial injuries may be associated
with injuries of head, chest, abdomen, neck, larynx,
cervical spine or limbs and should be attended too.
SOFT TISSUE INJURIES AND THEIR
MANAGEMENT
FACIAL LACERATIONS
Wound is thoroughly cleaned of any dirt, grease or foreign matter. The lacerations are closed by accurate approximation of each layer.
PAROTID GLAND AND DUCT
Parotid tissue, if exposed, is repaired by suturing. Injuries
of parotid duct are more serious. Both ends of the duct are
identified and sutured over a polyethylene tube with fine
suture. The tube is left for 3 days to 2 weeks.
2. Middle third. Between the supraorbital ridge and the
upper teeth.
3. Lower third. Mandible and the lower teeth.
The various fractures encountered in these regions are
listed in Table 34.1.
I. FRACTURES OF UPPER THIRD OF FACE
A. FRONTAL SINUS
Frontal sinus fractures may involve anterior wall, posterior wall or the nasofrontal duct.
1. Anterior wall fractures may be depressed or comminuted. Defect is mainly cosmetic. Sinus is approached
through a wound in the skin if that is present, or
through a brow incision. The bone fragments are elevated, taking care not to strip them from the periosteum. The interior of the sinus is always inspected to
rule out fracture of the posterior wall.
2. Posterior wall fractures may be accompanied by dural
tears, brain injury and CSF rhinorrhoea. They may
require neurosurgical consultation. Dural tears can
be covered by temporalis fascia. Small sinuses can be
obliterated with fat.
3. Injury to nasofrontal duct causes obstruction to sinus
drainage and may later be complicated by a mucocele.
In such cases, make a large communication between
the sinus and the nose. Small sinuses can be obliterated
with fat after removing the sinus mucosa completely.
B. SUPRAORBITAL RIDGE
Ridge fractures often cause periorbital ecchymosis, flattening of the eyebrow, proptosis or downward displacement of eye. Fragment of bone may also be pushed into
the orbit and get impacted. Ridge fractures require open
reduction through an incision in the brow or transverse
skin line of the forehead.
FACIAL NERVE
If severed, the facial nerve is exposed by superficial parotidectomy and cut ends are approximated with 8–0 or
10–0 silk under magnification.
BONE INJURIES AND THEIR
MANAGEMENT
The face can be divided into three regions:
1. Upper third. Above the level of supraorbital ridge.
C. FRACTURES OF FRONTAL BONE
They may be depressed or linear, with or without separation. They often extend into the orbit. Brain injury and
cerebral oedema are commonly associated with each other and require neurosurgical consultation.
II. FRACTURES OF MIDDLE THIRD OF FACE
A. NASAL BONES AND SEPTUM
Fractures of nasal bones are the most common because of
the projection of nose on the face. Traumatic forces may
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SECTION II — Diseases of Nose and Paranasal Sinuses
TABLE 34.1 FRACTURES OF THE FACE
Upper third Middle third Lower third
Frontal sinuses Nasal bones and septum Alveolar process
Supraorbital
ridge
Frontal bone • Zygoma
Naso-orbital area Symphysis
• Body
• Zygomaticarch
• Orbitaloor
• Maxilla
• Le Fort I (transverse)
• Le Fort II (pyramidal)
• Le Fort III (craniofacial
dysjunction)
• Angle
• Ascending
ramus
• Condyle
• Temporoman-
dibular joint
act from the front or side. Magnitude of force will determine the depth of injury.
Types of Nasal Fractures (Figures 34.1
and 34.2)
1. depressed. They are due to frontal blow. Lower part
of nasal bones which is thinner, easily gives way. A severe
frontal blow will cause “open-book fracture” in which nasal septum is collapsed and nasal bones splayed out. Still,
greater forces will cause comminution of nasal bones and
even the frontal processes of maxillae with flattening and
widening of nasal dorsum.
2. angulated. A lateral blow may cause unilateral depression of nasal bone on the same side or may fracture
both the nasal bones and the septum with deviation of
nasal bridge.
Nasal fractures are often accompanied by injuries of
nasal septum which may be simply buckled, dislocated
or fractured into several pieces. Septal haematoma may
form.
Clinical Features
1. Swelling of nose. Appears within few hours and may
obscure details of examination.
2. Periorbital ecchymosis.
3. Tenderness.
4. Nasal deformity. Nose may be depressed from the front
or side, or the whole of the nasal pyramid deviated to
one side (Figure 34.2).
5. Crepitus and mobility of fractured fragments.
6. Epistaxis.
7. Nasal obstruction due to septal injury or haematoma.
8. Lacerations of the nasal skin with exposure of na-
sal bones and cartilage may be seen in compound
fractures.
Diagnosis
Diagnosis is best made on physical examination. X-rays
may or may not show fracture (Figure 34.3). Patient
should not be dismissed as having no fracture because
X-rays did not reveal it.
X-rays should include Waters’ view, right and left lateral views and occlusal view.
Figure 34.1. Types of fractures. (A) Normal. (B) Frontal blow causing
depressed fracture or open-book fracture. (C) Lateral blow causing
deviation of the nasal bridge or depression of one nasal bone.
Treatment
Simple fractures without displacement need no treatment; others may require closed or open reduction. Presence of oedema interferes with accurate reduction by
closed methods. Therefore, the best time to reduce a fracture is before the appearance of oedema, or after it has
subsided, which is usually in 5–7 days. It is difficult to
reduce a nasal fracture after 2 weeks because it heals by
that time. Healing is faster in children and therefore earlier reduction is imperative.
1. closed reduction. Depressed fractures of nasal
bones sustained by either frontal or lateral blow can be
reduced by a straight blunt elevator guided by digital manipulation from outside.
Laterally, displaced nasal bridge can be reduced by firm
digital pressure in the opposite direction. Impacted fragments sometimes require disimpaction with Walsham
or Asch’s forceps before realignment. Septal fractures are
also reduced by Asch’s forceps. Septal haematoma, if present, must be drained.
Simple fractures may not require intranasal packing.
Unstable fractures require intranasal packing and external splintage.
2. open reduction. Early open reduction in nasal fractures is rarely required. This is indicated when closed
methods fail. Certain septal injuries can be better reduced
by open methods. Healed nasal deformities resulting
from nasal trauma can be corrected by rhinoplasty or
septorhinoplasty.
Chapter 34 — Trauma to the Face
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Figure 34.2. (A) Fracture of the nasal bones with displacement of the bridge to the right. (B) Fracture after manual correction.
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B. NASO-ORBITAL FRACTURES
Direct force over the nasion fractures nasal bones and displaces them posteriorly. Perpendicular plate of ethmoid,
ethmoidal air cells and medial orbital wall are fractured
and driven posteriorly. Injury may involve cribriform
plate, frontal sinus, frontonasal duct, extraocular muscles, eyeball and the lacrimal apparatus. Medial canthal
ligament may be avulsed.
Clinical Features
1. Telecanthus, due to lateral displacement of medial orbital wall.
2. Pug nose. Bridge of nose is depressed and tip turned
up.
3. Periorbital ecchymosis.
4. Orbital haematoma due to bleeding from anterior and
posterior ethmoidal arteries.
5. CSF leakage due to fracture of cribriform plate and
dura.
6. Displacement of eyeball.
Diagnosis
Various facial films will be required to assess the extent
of fracture and injury to other facial bones. Computed
tomography (CT) scans are more useful.
Treatment
1. closed reduction. In uncomplicated cases, fracture
is reduced with Asch’s forceps and stabilized by a wire
passed through fractured bony fragments and septum
and then tied over the lead plates. Intranasal packing is
given. Splinting is kept for 10 days or so.
2. open reduction. This is required in cases with extensive comminution of nasal and orbital bones, and
those complicated by other injuries to lacrimal apparatus,
medial canthal ligaments, frontal sinus, etc.
An H-type incision gives adequate exposure of the fractured area. This can be extended to the eyebrows if access
to frontal sinuses is also required.
Nasal bones are reduced under vision and bridge height
is achieved. Medial orbital walls can be reduced. Medial canthal ligaments, if avulsed, are restored with a through and
through wire. Intranasal packing may be required to restore
the contour. When bone comminution is severe, restoration
of medial canthal ligaments and lacrimal apparatus should
receive preference over reconstruction of nasal contour.
Figure 34.3. Fractured nasal bone (arrow) as seen in a radiograph.
C. FRACTURES OF ZYGOMA (TRIPOD
FRACTURE)
After nasal bones, zygoma is the second most frequently
fractured bone. Usually, the cause is direct trauma. Lower
segment of zygoma is pushed medially and posteriorly resulting in flattening of the malar prominence and a step
deformity at the infraorbital margin. Zygoma is separated
at its three processes (Figure 34.4). Fracture line passes
through zygomaticofrontal suture, orbital floor, infraorbital margin and foramen, anterior wall of maxillary sinus and the zygomaticotemporal suture. Orbital contents
may herniate into the maxillary sinus.
Clinical Features
1. Flattening of malar prominence.
2. Step deformity of infraorbital margin.
3. Anaesthesia in the distribution of infraorbital nerve.
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