3.10 Nasal Fracture

agk’s Library of Common Simple Emergencies

Presentation

After a direct blow to the nose the patient usually arives at the emergency department with minimal continued hemorrhage. There is usually tender ecchymotic swelling over the nasal bones or the anterior maxillary spine; inspection and palpation may (or may not) disclose a nasal deformity.

What to do:

Examine for any associated injuries (i.e., blowout fractures, zygoma fractures).
With minor injuries, explain that x rays are not routinely used or useful, because all therapeutic decisions are made on the basis of the physical examination. If there is a fracture, but it is stable and in good position clinically, it need not be reset. Conversely, a broken and displaced cartilage may obstruct breathing and require operation, but never show up on the film. Send the patient for x rays of the nasal bones only if there is a good reason.
If bleeding continues, instill cotton pledgets soaked in 4% cocaine or 2% tetracaine (Pontocaine) mixed 1:1 with 1% Neo-Synephrine or epinephrine 1:1000 into both nasal cavities.
After removing the.cotton pledgets, inspect the nasal mucosa for large lacerations or a septal hematoma.
Patients with nondisplaced fractures without deformity should be sent home with analgesics, cold packs, and instructions to avoid contact sports and related activities for six weeks.
Patients with displaced fractures and/or nasal deformity should have otolaryngologic or plastic surgery consultation for immediate or delayed reduction. Patients can be instructed that reduction is more accurate after the swelling subsides and there is no greater difficulty if it is done within six days of the injury.
Septal hematomas should be drained to prevent septal necrosis and the development of a saddle nose deformity. Otolaryngologic consultation is advisable.
An isolated fracture of the anterior nasal spine (in the columella of the nose), does not necessitate restricting activities. It only hurts when you smile.

What not to do:

Do not automatically x ray every injured nose. Patients may expect this, because it is the old practice, but routine films have turned out not to help.
Do not assume a negative x ray means no fracture when a deformity is apparent. X rays can often be inaccurate in determining the presence and nature of a nasal fracture. Rely on your clinical assessment. When there is swelling, arrange for re-examination in 3-4 days when the swelling subsides, to 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.

Discussion

The two most common indications for reducing a nasal fracture are an unacceptable appearance and inability of the patient to breathe through the nose. Regardless of x-ray 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 mostly pliable cartilage. 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 irreversable damage.

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