Nasal fractures that require intervention are almost always evident with deformity, swelling, laceration, and ecchymosis. Fractures to adjacent bony structures, including the orbit, frontal sinus, or cribriform plate, often occur. Epistaxis may be due to a septal or turbinate laceration but can also be seen with fractures of adjacent bones, including the cribriform plate. Septal hematoma is a rare but important complication that, if untreated, may result in necrosis of the septal cartilage and a resultant “saddle nose” deformity. A frontonasoethmoid fracture has nasal or frontal crepitus and may have telecanthus or obstruction of the nasolacrimal duct.
Management and Disposition
Identify and treat life-threatening injuries first. Patients with associated facial bone deformity or tenderness require CT to rule out facial fractures. Isolated nasal fractures rarely require radiographs. Refer obvious deformities within 2 to 5 days for reduction, after the swelling has subsided. Nasal fractures with mild angulation and without displacement may be reduced in the ED. Nasal injuries without deformity need only conservative therapy with an analgesic and a nasal decongestant. Immediately drain septal hematomas, with packing placed to prevent reaccumulation. Uncontrolled epistaxis may require nasal packing. Vigorously irrigate and suture lacerations overlying a simple nasal fracture and place the patient on antibiotic coverage. Complex nasal lacerations with underlying fractures should be repaired by a facial surgeon.
Control epistaxis to perform a good intranasal examination. If obvious deformity is present, including a new septal deviation or deformity, treat with ice and analgesics and provide ENT referral in 2 to 5 days for reduction.
Bilateral nasal bleeding requires evaluation of each nostril individually, as bilateral nasal packing requires inpatient observation for oxygenation and apnea monitoring.
For patients who are anticoagulated, consider local application of liquid thrombin or tranexamic acid in conjunction with nasal packing. Check prothrombin time and international normalized ratio if on warfarin or if patient has unexplained bleeding.
Although the effectiveness of prophylactic antibiotics to prevent toxic shock syndrome is unproven, providers continue to often prescribe antistaphylococcal antibiotics to patients discharged with nasal packing.
Consider cribriform plate fractures in patients with clear rhinorrhea after nasal injury, as this finding may be delayed.
Patients with facial trauma should be examined for a septal hematoma.
Nasal Fracture. Deformity is evident on examination. Note periocular ecchymosis indicating the possibility of other facial fractures (or injuries). The decision to obtain radiographs is based on clinical findings. (Photo contributor: David W. Munter, MD.)
Septal Hematoma. A bluish, grapelike mass on the nasal septum. If untreated, this can result in septal necrosis and a saddle nose deformity. An incision, drainage, and packing are indicated. (Photo contributor: Lawrence B. Stack, MD.)