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:
- Subconjunctival hemorrhage
- Hyphema
- Retinal detachments
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
Diagnostic 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
- US can be used to detect fractures and is as sensitive as plain films
- 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
Prehospital
- 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 may be indicated if posterior packs are placed, most evidence suggests they are not needed for anterior packing:
- Displaced fractures do not need reduction in ED unless airway is compromised
- Generally recommended to allow swelling to abate and reduce fracture in 3-7 d, although there are some 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 18-20G 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 d or until follow-up with ear, nose, and throat (ENT)
- Prophylactic antibiotics are prescribed
Medication
- Amoxicillin: 500 mg PO t.i.d (peds: 40 mg/kg PO div t.i.d)
- Amoxicillin/clavulanate: 500/125-875/125 mg PO b.i.d (peds: 40 mg/kg/d of amoxicillin PO b.i.d)
- 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 b.i.d (peds: 40 mg/kg/d sulfamethoxazole PO b.i.d)
Admission, Inpatient, and Nursing 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 d
- 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
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Follow-up Recommendations
- Follow up with ENT, plastic, or oral maxillofacial (OMF) surgeon in 3-7 d 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
- American Family Physician Web Resource. Management of acute nasal fractures . Am Fam Physician. 2004. http://www.aafp.org/afp/2004/1001/p1315.html.
- HwangK, KiSJ, KoSH. Etiology of nasal bone fractures . J Craniofac Surg. 2017;28(3):785-788.
- HwangK, YeomSH, HwangSH. Complications of nasal bone fractures . J Craniofac Surg. 2017;28(3):803-805.
- Land isBN, BornerU. Septal hematoma: Always think about it . J Pediatr. 2013;163(4):1223.
- RicciG, D'AscanioL. Antibiotics in septoplasty: Evidence or habit ? Am J Rhinol Allergy. 2012;26(3):194-196.
- ZiccardiVB, BraidyH. Management of nasal fractures . Oral Maxillofac Surg Clin North Am. 2009;21(2):203-208.
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