SIGNS AND SYMPTOMS 
- Nasal deformity, asymmetry, swelling, or ecchymosis
- Epistaxis
- Periorbital ecchymosis ("raccoon eyes") from damage to branches of ethmoidal artery:
- May indicate nasofrontoethmoid complex injury
- Palpable sharp edges, depressions, or other irregularities suggest nasal fracture.
- Crepitus or mobility of skeletal parts on palpation
- Septal hematoma:
- Bluish fluid-filled sac overlying nasal septum
- Critical to detect because it must be drained
- Failure to drain can result in necrosis of the septum
- Flattening of nasal root and widening of intercanthal distance (telecanthus):
- Indicative of serious nasofrontoethmoid complex injury
- Clear rhinorrhea indicates possible CSF leak:
- Rhinorrhea may be delayed.
- Loss of sense of smell suggests significant injury.
- Tear duct injuries may be present with abnormal tearing.
- Associated eye injuries:
History
- Direct blow
- Associated injuries or symptoms
- Presence of epistaxis
- Changes in vision or smell
Physical Exam
- Thorough physical exam with visual inspection and palpation is vital.
- It is critical to identify a septal hematoma:
- Bluish bulging mass on nasal septum
- Septal deviation
- Epistaxis or intranasal laceration
- Examine closely for telecanthus:
- Intercanthal width > 30–35 mm
- Wider than width of 1 eye
- May indicate nasofrontoethmoid fracture
- Usually associated with depressed nasal bridge
- CSF rhinorrhea:
- Indicates more serious underlying facial bone or skull fracture
- CSF mixed with blood will often cause double ring sign when placed on filter paper, although this sign is not 100% reliable.
ESSENTIAL WORKUP
If concern for anything other than a simple nasal fracture:
- Evaluate nasolacrimal duct for patency:
- Instill fluorescein into eye and look for it in nasopharynx under inferior turbinate.
- Absence implies duct injury.
- Eyelash traction test:
- Grasp eyelashes on eyelid and pull laterally:
- If eyelid margin does not become taut or "bow string," then medial portion of tendon has been disrupted.
- This test is performed on both upper and lower eyelids.
- Possible for only 1 portion of tendon to be selectively injured
DIAGNOSIS TESTS & INTERPRETATION
Lab
Coagulation studies if on anticoagulants with uncontrolled epistaxis
Imaging
- Nasal radiographs are rarely indicated:
- Normally do not alter initial or subsequent management
- Gross deformities will need referral.
- Fractures without deformity will be treated conservatively regardless of radiographic findings.
- Patients with associated facial bone deformity, crepitus, or tenderness may require radiographs.
- CT is test of choice if facial bone, nasofrontoethmoid, or depressed skull fractures are suspected; have low threshold for ordering CT if other injuries are suspected.
DIFFERENTIAL DIAGNOSIS
- Other facial injuries such as orbital, frontal sinus, maxillary sinus, or cribriform plate fractures
- Nasofrontoethmoid fracture
[Outline]
PRE-HOSPITAL
- Management of airway takes precedence.
- Nasotracheal intubation is contraindicated.
- Consider orotracheal intubation or cricothyroidotomy if definitive airway control is needed.
- Cervical spine precautions are indicated if there is associated trauma.
- Epistaxis can normally be controlled with direct pressure; pinch nares together.
INITIAL STABILIZATION/THERAPY
- Airway management with orotracheal intubation or cricothyroidotomy:
- Nasotracheal intubation is contraindicated.
- Cervical spine precautions
- Other injuries take precedence.
ED TREATMENT/PROCEDURES
- Abrasions and lacerations:
- Proper cleansing of facial wounds is essential.
- Lacerations may be sutured.
- Epistaxis must be controlled if it does not stop spontaneously:
- Anesthetize/vasoconstrict with topical cocaine, lidocaine, or neosynephrine spray.
- Identify bleeding source; cauterize anterior source if necessary.
- Pack nares with petroleum jelly, impregnated gauze, or any number of commercial packs.
- Posterior packs are rarely needed.
- Prophylactic antibiotics to prevent sinus infection are indicated if packed: Amoxicillin, amoxicillin/clavulanate, or trimethoprim–sulfamethoxazole or azithromycin in penicillin allergic patients.
- Displaced fractures do not need reduction in ED unless airway is compromised.
- Generally recommended to allow swelling to abate and reduce fracture in 3–5 days, although there are many specialists who recommend local anesthesia and immediate reduction.
- Septal hematoma must be drained immediately in ED:
- Anesthetize with topical cocaine or lidocaine and vascular constriction with neosynephrine.
- Attempt to aspirate with 18G to 20G needle on 3-mL syringe.
- Rolling cotton swab down septum may facilitate drainage.
- Holding mucosa down against cartilage must be done to prevent reaccumulation.
- This can be done with petroleum jelly gauze packing.
- Both nares should be packed to ensure adequate pressure:
- Packing is left in place for 3–5 days or until follow-up with ear, nose, and throat (ENT).
- Prophylactic antibiotics are prescribed.
MEDICATION
- Amoxicillin: 500 mg PO TID (peds: 40 mg/kg PO div. TID)
- Amoxicillin/clavulanate: 500/125–875/125 mg PO BID (peds: 40 mg/kg/d of amoxicillin PO BID)
- Azithromycin: 500 mg PO day 1 followed by 250 mg PO daily for 4 additional days (peds: 10 mg/kg PO day 1, followed by 5 mg/kg PO days 2–4)
- Cocaine: Topical 4%
- Lidocaine: 1–2% without epinephrine
- Neosynephrine nasal spray
- Trimethoprim–sulfamethoxazole: Double strength (DS) PO BID (peds: 40 mg/kg/d sulfamethoxazole PO BID)
IN-PATIENT-CONSIDERATIONS
Admission Criteria
- Most nasal fractures do not require admission.
- Admit patients with nasoethmoid fractures or more significant craniofacial injuries.
Discharge Criteria
- No evidence of significant head, neck, or other injuries.
- Epistaxis controlled
- Reliable companion or caregiver
Pediatric Considerations
- Follow up with specialist sooner because fibrous union begins in only 3–4 days
- Consider contacting child protective services if any suspicion of nonaccidental trauma:
- History does not fit injury.
- Always consider nonaccidental trauma as potential mechanism of injury.
- Fractures are rare in children; nasal injuries in children are more likely to be cartilaginous.
- Significant injuries in children are not always fully appreciated.
[Outline]
FOLLOW-UP RECOMMENDATIONS
- Follow up with ENT, plastic surgery, or oral maxillofacial (OMF) surgeon in 3–5 days for management:
- Patients with septal hematoma should follow up in 24 hr for re-evaluation after drainage.
- Return for signs of clear rhinorrhea, difficulty breathing, fever, or signs associated with head injury.
- Atighechi S, Baradaranfar MH, Akbari SA. Reduction of nasal bone fractures: A comparative study of general, local, and topical anesthesia techniques. J Craniofac Surg. 2009;20(2):382–384.
- Ondik MP, Lipinski L, Dezfoli S, et al. The treatment of nasal fractures: A changing paradigm. Arch Facial Plast Surg. 2009;11(5):296–302.
- Repanos C, Carswell AJ, Chadha NK. Manipulation of nasal fractures under local anaesthetic: A convenient method for the Emergency Department and ENT clinic. Emerg Med J. 2010;27(6):473–474.
- Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries and management. Facial Plast Surg. 2011;27(5):483–490.
- Ziccardi VB, Braidy H. Management of nasal fractures. Oral Maxillofac Surg Clin North Am. 2009;21(2):203–208.
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