After a direct blow to the nose from a fight, fall, sports injury, or motor vehicle crash, the patient usually arrives at the ED or clinic concerned that his nose is broken. There is usually minimal continued hemorrhage. There may be tender ecchymotic swelling over the nasal bones or the anterior maxillary spine, and inspection and palpation may or may not disclose a nasal deformity. Alcohol consumption is an important contributing factor in many cases.
What To Do:
To help determine the nature and extent of the injury, obtain a history of the mechanism of injury. A direct frontal blow can cause fractured bones to telescope posteriorly. A laterally directed injury can cause a depression on the side of the impact, often with a corresponding outward displacement on the opposite side of the nose.
Additional history should include information regarding previous surgeries and injuries, as well as a subjective assessment of baseline nasal function and appearance.
Examine the patient for any associated injuries (e.g., blow-out fractures, zygoma fractures, mandible fractures, and eye injuries). A general screening exam should include special attention to the cervical spine.
A deformity of the nose usually will be evident when a nasal fracture has occurred. Edema and ecchymosis of the nose and periorbital structures ordinarily will be present. Palpation of the nasal structures should be done to elicit crepitus, indentation, or irregularity of the nasal bone. Bony crepitus and nasal segment mobility are both diagnostic for nasal fracture.
If a facial or mandibular fracture is suspected, assessment with a CT scan is indicated. Uncommon findings, such as a cerebrospinal fluid leak posing as clear rhinorrhea, subcutaneous emphysema, mental status changes, new malocclusion, or limited extraocular movement, also require CT evaluation and subspecialty consultation.
An internal nasal examination should be conducted with good lighting, suction, and vasoconstriction with topical anesthesia. A nasal speculum and a headlamp will improve visualization. Clots should be removed with Frazier tip suction and cotton-tipped applicators. With swelling and/or continued bleeding, instill cotton pledgets soaked in 4% cocaine or, alternatively, 2% tetracaine (Pontocaine) or 4% lidocaine (Xylocaine) mixed 1:1 with 1% phenylephrine (Neo-Synephrine) or oxymetazoline (Afrin).
After removing these pledgets, inspect for nasal airway patency, ongoing epistaxis, septal deformities, and, most important, septal hematomas, which may appear as slightly white or purple areas of fluctuance lying on one or both sides of the nasal septum. Bimanual palpation of the septum with cotton-tipped applicators helps to differentiate hematoma, which tends to be more compressible from tissue edema. Areas of increased mobility are suggestive of septal fracture. If bleeding continues, treat this epistaxis as described in Chapter 27.
When an uncomplicated nasal fracture is suspected, plain radiography rarely is indicated. In fact, because of poor sensitivity and specificity, plain radiographs may serve only to confuse the clinical picture.
Explain to the patient that for minor injuries, radiographic examinations are not routinely used. They expose him to unnecessary radiation and usually are not helpful because all therapeutic decisions are made on the basis of the physical examination. If there is a fracture, but it is stable and in a good position clinically, the nose need not be reset. Conversely, a broken and displaced cartilage may obstruct breathing and require operation but may never show up on the film.
Patients with suspected or possible nondisplaced fractures and no nasal deformity should be sent home with analgesics, cold packs, and instructions to keep the head elevated and avoid contact sports and related activities for 6 weeks. When nasal deformity cannot be visualized or palpated because of marked swelling, have the patient seen in follow-up within 3 to 5 days when the swelling has subsided.
Patients with suspected displaced fractures, nasal deformity, or both should be referred for otolaryngologic or plastic surgery consultation to discuss immediate or delayed reduction. Patients can be instructed that reduction is more accurate after the swelling subsides and that there is no greater difficulty if it is done between the 5th and 10th day after the injury.
Septal hematomas should be drained immediately to prevent septal necrosis and the development of a saddle-nose deformity. If improperly managed, a septal hematoma may still result in this disastrous outcome; therefore otolaryngologic consultation is advisable.
A minor isolated fracture of the anterior nasal spine (in the columella of the nose) does not necessitate restriction of activities. Such fractures hurt only when the patient smiles.
A laceration over a nasal fracture should probably be closed with antibiotic prophylaxis, such as cephalexin (Keflex), 500 mg qid, or cefadroxil (Duricef), 500 mg bid for 3 to 5 days.
Physical abuse should be considered in children and women and should be appropriately ruled out and managed.
What Not To Do:
Do not focus solely on the obviously traumatized nose. Consider cervical spine injury as well as other facial injuries and other remote trauma.
Do not automatically obtain radiographs of every injured nose. Patients may expect this because it used to be standard practice (and they are still regularly obtained), but routine films have turned out to be mostly useless.
When a deformity is apparent, do not assume that a normal radiographic examination means that there is no fracture. Radiographs can often be inaccurate in determining the presence and nature of a nasal fracture. Rely on the clinical assessment. If there is swelling, arrange for reexamination in 3 to 5 days when the swelling has subsided, and then look for subtle deformities.
Do not pack an injured nose that does not continue to bleed. Packing is generally unnecessary and will only add to the patient’s discomfort.
The nose is easily exposed to trauma, because it is the most prominent and anterior feature of the face. The nose is supported by cartilage, anteriorly and inferiorly, and by bone, posteriorly and superiorly. Although most of the nasal structures are cartilaginous, the nasal bones usually are fractured in an injury.
Fights and sports injuries account for most nasal fractures in adults, followed by falls and vehicle crashes.
The two most common indications for reducing a nasal fracture are an unacceptable appearance and the patient’s inability to breathe through the nose. Regardless of radiographic findings, if neither breathing nor cosmesis is a concern, it is not necessary to reduce the fracture.
Nasal fractures are uncommon in young children, because their noses are composed of mostly pliable cartilage. For this reason, radiographic examination has even less accuracy than in an adult.
It should be noted, however, that with significant trauma to the face, children may develop devastating growth retardation of the nose and midface. Refer all young children with posttraumatic nasal asymmetry, bony crepitus, epistaxis, periorbital ecchymosis, significant edema, or overlying skin lacerations to an otolaryngologist for reexamination within 2 to 4 days. Because of faster rates of bone healing, realignment in children should ideally be performed within 4 days of injury.
Suspect septal hematoma when a patient’s nasal airway is completely occluded. Within 48 to 72 hours, a hematoma can compromise the blood supply to the cartilage and cause irreversible damage.