What imaging and laboratory studies should be ordered for a patient who fell on their nose?

Imaging for Nasal Trauma

For a patient who fell on their nose, order CT maxillofacial (without contrast) if there are signs of complex injury, displaced fracture, or associated facial trauma; otherwise, clinical examination alone is sufficient for isolated nasal injuries, as imaging rarely changes management.

Primary Recommendation

The 2022 ACR Appropriateness Criteria clearly establishes that CT maxillofacial is the gold standard imaging modality for nasal trauma when imaging is indicated 1. MDCT provides superior sensitivity compared to plain radiographs (CT is more sensitive in confirming nasal bone fractures), offers multiplanar and 3D reconstructions critical for surgical planning, and can detect subtle nondisplaced fractures that other modalities miss 1.

However, imaging is often unnecessary for isolated nasal trauma. Recent evidence shows that substantial numbers of patients undergo imaging without requiring surgical intervention 2.

Clinical Decision Algorithm

When to Order Imaging:

Order CT maxillofacial if ANY of the following are present:

• Complex nasal injuries with suspected associated facial fractures
• Signs of midface injury (malocclusion, facial asymmetry, infraorbital nerve paresthesia)
• Severe displacement requiring surgical planning
• Penetrating trauma or foreign body
• History of previous nasal fracture or rhinoplasty (these significantly complicate radiological diagnosis) 3
• Concomitant facial bone fractures 3

Clinical examination alone is sufficient when:

• Isolated, simple nasal trauma
• No significant displacement
• No associated facial injuries
• Patient will be managed conservatively regardless of imaging findings

Imaging Modalities: Evidence-Based Hierarchy

CT Maxillofacial (First-Line When Imaging Indicated)

• Sensitivity superior to plain radiographs for detecting nasal bone fractures 1
• Detects subtle nondisplaced fractures with thin-section acquisitions
• Provides multiplanar and 3D reconstructions essential for surgical planning 1
• Can identify associated facial injuries in complex trauma 1
• No contrast needed - IV contrast does not aid in fracture detection 1

Plain Radiography (NOT Recommended)

The ACR guidelines are explicit: nasal radiographs have limited diagnostic value 1. Diagnostic accuracy ranges only 53-82%, and radiographs do not considerably alter diagnosis or management of nasal fractures 1. Recent pediatric data confirms nasal X-rays may be of limited use after facial trauma 2.

Ultrasound (Emerging Alternative)

While not first-line per ACR guidelines 1, recent research (2024-2026) shows ultrasound has:

• Sensitivity 88.57-90-100% and specificity 98-100% 4, 5, 6
• Particular utility for isolated nasal bone fractures 1
• Better detection of nondepressed fractures and anterior septal cartilage deviation than CT 1
• Radiation-free, making it suitable for pediatric patients and pregnant women 5
• Operator-dependent limitation 4

Ultrasound may be considered for initial assessment in appropriate clinical contexts, particularly for displaced fractures where sensitivity matches CT 4, but CT remains superior for undisplaced fractures 4.

Laboratory Studies

No routine laboratory studies are indicated for isolated nasal trauma. Consider labs only if:

• Significant bleeding raises concern for coagulopathy
• Patient requires procedural sedation for reduction
• Polytrauma with other systemic injuries

Critical Pitfalls to Avoid

1. Don't order plain radiographs - they have poor diagnostic accuracy (53-82%) and don't change management 1

2. Don't order CT head for isolated nasal injury - there is no relevant literature supporting this 1

3. Be cautious with patients who have:

   • Previous nasal fractures (OR=5.197 for diagnostic discrepancy) 3
   • History of rhinoplasty (OR=6.114 for diagnostic discrepancy) 3
   • Concomitant facial fractures (OR=3.765 for diagnostic discrepancy) 3

   These patients require prompt CT scan for accurate diagnosis 3

4. Consider chest X-ray only if tooth is missing - to exclude aspiration, as avulsed teeth in the airway risk obstructive pneumonia 1

Special Considerations

High-energy mechanism (motor vehicle collision, significant fall): Lower threshold for CT imaging as these mechanisms increase risk of complex fractures and associated injuries 1.

Pediatric patients: Imaging may be reduced given that many undergo X-ray or CT without requiring surgical intervention 2. Clinical examination is particularly important in this population.

Surgical planning: If surgical intervention is anticipated, CT maxillofacial is mandatory as surgeons rely on 3D reformations for preoperative planning 1.