What are the proper steps for evaluating and managing a nose injury?

Evaluating and Managing a Nose Injury

The proper evaluation of a nose injury requires a systematic approach starting with firm sustained compression to the lower third of the nose for 5-15 minutes for active bleeding, followed by anterior rhinoscopy to identify the source of bleeding after removing any blood clots. 1

Initial Assessment and Triage

Determining Severity

1. Assess for signs requiring prompt management:

   • Active bleeding duration >30 minutes
   • History of hospitalization for nosebleed
   • Prior blood transfusion for nosebleeds

   • 3 recent episodes of nasal bleeding

   • Signs of hypovolemia (tachycardia, syncope, orthostatic hypotension)
   • Bleeding from both sides of the nose or from the mouth 1

2. Evaluate risk factors that increase frequency or severity:

   • Personal or family history of bleeding disorders
   • Use of anticoagulant or antiplatelet medications
   • Intranasal drug use
   • Prior nasal/sinus surgery
   • Nasal/facial trauma
   • Nasal cannula oxygen use
   • CPAP use
   • Chronic kidney or liver disease 1, 2

Initial Management of Active Bleeding

1. Apply firm sustained compression to the lower third of the nose for 5 minutes or longer 1

   • This is the simplest and most effective first-line treatment
   • Compression should be directed to the soft part of the nose

2. Consider using vasoconstrictor spray such as oxymetazoline to help constrict blood vessels 2

3. Perform anterior rhinoscopy after removing any blood clots to identify the bleeding site 1

Diagnostic Evaluation

Physical Examination

1. Nasal examination should include:

   • Assessment of nasal patency and valve function (Cottle maneuver)
   • Evaluation for septal deviation or deformity
   • Inspection for signs of trauma (saddle nose deformity)
   • Examination of turbinates for hypertrophy 1

2. Advanced visualization:

   • Perform nasal endoscopy to identify the site of bleeding and detect any underlying pathology
   • Endoscopy allows better visualization of the middle meatus, posterior septum, sinus ostia, posterior choanae, and nasopharynx 1, 2

Imaging (when indicated)

1. CT maxillofacial is the preferred imaging modality for suspected fractures:

   • Provides high-resolution images for detection of subtle nondisplaced fractures
   • Allows multiplanar and 3D reconstructions for characterization of complex fractures
   • More sensitive than radiographs for confirming nasal bone fractures 1

2. Radiographs have limited diagnostic value (53-82% accuracy) and rarely alter management 1

Treatment Approaches

For Active Bleeding

1. Nasal cautery:

   • Preferred over packing if a specific bleeding site can be identified
   • Anesthetize the bleeding site before cauterization
   • Restrict application only to the active or suspected site(s) of bleeding 1, 2

2. Nasal packing:

   • Use for ongoing active bleeding not controlled by compression or cautery
   • Consider resorbable packing for patients with bleeding disorders or those on anticoagulant/antiplatelet medications 1
   • Be aware of potential complications including infection, decreased blood flow, septal perforations, and worsening of obstructive sleep apnea 2

For Persistent or Recurrent Bleeding

1. Refer for endoscopic evaluation and possible arterial ligation:

   • Endoscopic arterial ligation (particularly sphenopalatine artery) has a 97% success rate
   • Consider for persistent bleeding not controlled by packing or cauterization 2

2. Embolization may be considered for intractable cases:

   • Success rate of approximately 80%
   • Higher risk of serious complications including stroke (0.9-1.6%) 2

Post-Treatment Care and Prevention

1. Patient education:

   • Explain the type of packing placed and plan for removal
   • Provide instructions on post-procedure care
   • Advise on warning signs requiring medical attention 1

2. Prevention of recurrence:

   • Regular nasal moisturization with saline gel or spray 1-3 times daily
   • Humidification in dry environments
   • Avoidance of digital trauma (nose picking) and vigorous nose blowing 2

3. Activity restrictions:

   • Avoid straining, lifting over 10 pounds, bending over, and exercising
   • Sleep with head slightly elevated
   • Avoid medications that may increase bleeding (aspirin, ibuprofen) unless medically necessary 1

Warning Signs Requiring Immediate Attention

• Return of blood from nose or mouth
• Fever over 101°F
• Increasing pain
• Vision changes
• Shortness of breath or labored breathing
• Loss of color around the skin of the nose
• Swelling of the face
• Diffuse skin rash 1, 2

By following this systematic approach to evaluating and managing nose injuries, clinicians can effectively control bleeding, identify underlying causes, and prevent complications while providing appropriate patient education for ongoing care.