What is the recommended treatment for a nose fracture in the emergency department (ED)?

Management of Nasal Fractures in the Emergency Department

The recommended first-line treatment for nasal fractures in the emergency department is closed reduction with firm sustained compression to the lower third of the nose for 10-15 minutes, potentially combined with vasoconstrictor spray such as oxymetazoline to help control bleeding. 1

Initial Assessment and Management

• Clinical Evaluation:

  • Assess for tenderness, contusion, edema over nasal bones
  • Check for nasal deformity, facial asymmetry, or malocclusion
  • Evaluate for septal hematoma (requires immediate drainage if present)
  • Rule out associated injuries (orbital, midface, or skull base fractures)

• Bleeding Control:

  • Apply firm pressure to the lower third of the nose for 10-15 minutes
  • Use vasoconstrictor spray (oxymetazoline/Afrin) to constrict blood vessels
  • Have patient lean forward slightly to prevent blood from flowing down throat
  • Consider topical tranexamic acid for persistent bleeding, especially in patients on antiplatelet therapy 1

Timing of Reduction

• Immediate reduction is indicated for:

  • Grossly displaced fractures
  • Open fractures
  • Septal hematomas (require immediate drainage)

• Delayed reduction (3-10 days after injury) is preferred for most cases:

  • Allows edema to resolve for better assessment and reduction 2
  • Improves accuracy of reduction and cosmetic outcomes 3

Anesthesia Options

• Local anesthesia is effective for simple nasal fractures 4

  • Topical cocaine or lidocaine with epinephrine
  • Consider procedural sedation for patient comfort 5

• General anesthesia may be necessary for:

  • Complex fractures with septal involvement
  • Pediatric patients
  • Patients unable to tolerate local anesthesia

Reduction Techniques

• Closed reduction:

  • External manipulation using elevator or forceps
  • Internal manipulation with Asch or Walsham forceps for septal realignment
  • Success rate is highest when performed after edema resolves (3-10 days) 3

• Open reduction:

  • Reserved for complex fractures with significant septal involvement
  • Indicated when closed reduction fails or for secondary deformities
  • Provides direct visualization and more precise correction 3

Special Considerations

• Basal skull fractures: Avoid nasopharyngeal airways; use oropharyngeal airways instead 5

• Septal hematoma:

  • Requires immediate drainage to prevent septal necrosis and saddle nose deformity
  • Incise and drain, then place septal quilting sutures or nasal packing

• Associated injuries:

  • Assess for midface fractures (zygoma, maxilla) 5
  • Consider CT imaging if multiple facial fractures are suspected 5

Post-Reduction Care

• External nasal splint for 7-10 days
• Nasal saline irrigation to prevent crusting
• Avoid digital trauma (nose picking) and vigorous nose blowing
• Regular nasal moisturization with saline gel or spray 1-3 times daily 1
• Humidification in dry environments to reduce risk of epistaxis 1

Follow-up and Complications

• Follow-up within 5-7 days to assess alignment and function

• Potential complications include:

  • Nasal deformity (occurs in 14-50% of cases) 3
  • Nasal obstruction due to septal deviation
  • Septal perforation
  • Synechiae formation

• Consider referral to otolaryngology for:

  • Failed reduction
  • Persistent nasal deformity
  • Chronic nasal obstruction

Early and appropriate management of nasal fractures in the ED significantly reduces the need for secondary surgical interventions, lowers healthcare costs, and improves patient satisfaction 6.