What is the best pain control for a nasal fracture?

Pain Management for Nasal Fracture

For nasal fracture pain control, a multimodal approach starting with acetaminophen as first-line treatment, supplemented by NSAIDs if needed, and reserving opioids for severe breakthrough pain is strongly recommended. 1

First-Line Pain Management

• Acetaminophen (Paracetamol):

  • Regular administration every 6 hours (500-1000 mg)
  • Maximum daily dose: 4000-6000 mg
  • Provides effective pain control with minimal side effects 2
  • Can be given intravenously initially for faster onset if severe pain

• NSAIDs:

  • Consider for moderate pain not controlled by acetaminophen alone
  • Options include:
    • Ibuprofen: 400-600 mg every 6-8 hours (maximum 3200 mg/day)
    • Naproxen: 250-500 mg every 12 hours (maximum 1500 mg/day)
    • Diclofenac: Available in various formulations
  • Use with caution due to potential GI and renal toxicity 2
  • Consider co-prescription of proton pump inhibitors in high-risk patients 1

Second-Line Pain Management

• Tramadol:

  • Preferred over other opioids if additional analgesia needed
  • Starting dose: 50-100 mg every 4-6 hours
  • Maximum daily dose: 400 mg
  • Lower risk of respiratory depression than traditional opioids 1

• Stronger Opioids (for severe breakthrough pain only):

  • Oxycodone: 5-15 mg every 4-6 hours as needed 3
  • Use the lowest effective dose for the shortest duration
  • Monitor closely for respiratory depression, especially within first 24-72 hours
  • Titrate based on individual response 3

Local Anesthesia for Nasal Fracture Reduction

If reduction of the nasal fracture is required:

• Topical anesthesia has been shown to be effective and well-tolerated:

  • Topical tetracaine gel applied to nasal dorsum combined with intranasal cocaine solution is the least painful method 4
  • Success rates comparable to general anesthesia (84.6% patient satisfaction with topical anesthesia vs. 91.7% with general anesthesia) 5
  • Minimal adverse events reported with local anesthesia 4

• Local anesthesia is a safe and effective alternative to general anesthesia for pain relief during nasal fracture manipulation 4

Non-Pharmacological Interventions

• Ice packs applied to the affected area to reduce swelling and inflammation 1
• Immobilization with appropriate nasal splinting as directed by the treating physician 1
• Elevation of the head while sleeping to minimize swelling

Special Considerations

• Avoid NSAIDs in patients with:

  • History of GI bleeding
  • Renal impairment
  • Concurrent anticoagulant therapy
  • Significant cardiovascular disease

• Use opioids cautiously in:

  • Elderly patients (increased risk of delirium, falls)
  • Patients with sleep apnea
  • Those with history of substance abuse

• Monitor for complications such as:

  • Septal hematoma (requires urgent drainage)
  • Cerebrospinal fluid leak (suggests more serious injury)
  • Concurrent orbital or other facial fractures

The evidence strongly supports that most patients with nasal fractures can be effectively managed with acetaminophen and NSAIDs, with opioids reserved only for severe breakthrough pain that doesn't respond to first-line treatments 2, 1.