Management of Nasal Fractures
Nasal fractures should be suspected based on clinical examination findings of external deformity, nasal airway obstruction, point tenderness, mobility/crepitus, and evaluated for septal hematoma, with referral to an otolaryngologist or plastic surgeon within 1-2 weeks for optimal outcomes. 1
When to Suspect a Nasal Fracture
Clinical Assessment
- External deformity: Visible asymmetry or deviation of the nasal bones
- Nasal airway patency: Assess for obstruction or breathing difficulties
- Point tenderness: Pain on palpation over nasal bones
- Mobility/crepitus: Abnormal movement or grinding sensation of nasal bones
- Septal hematoma: Requires immediate evacuation if present 1
Red Flags Requiring Urgent Attention
- Septal hematoma (requires immediate drainage)
- Signs of orbital involvement (diplopia, periorbital ecchymosis)
- Neurological symptoms
- Cerebrospinal fluid leakage
- Multiple facial fractures 1
Diagnostic Imaging
Recommended Imaging
- Ultrasound: Excellent radiation-free option with 90-100% sensitivity and 98-100% specificity for isolated nasal fractures 1
- Maxillofacial CT: Preferred for suspected complex fractures or when additional facial bone involvement is suspected 1
Not Recommended
- Plain radiographs: Limited diagnostic value (53-82% accuracy) and do not significantly alter management 1
Management Approach
Immediate Management
- Assess airway patency: Ensure breathing is not compromised
- Control bleeding: Apply pressure, cold compresses
- Evaluate for septal hematoma: Requires immediate drainage if present
- Pain management: Analgesics as appropriate
Referral Guidelines
- Timing: Early intervention within 1-2 weeks is critical for optimal outcomes 1
- Specialist selection:
- Otolaryngologist: For nasal airway obstruction, functional breathing concerns, septal involvement, or sinus involvement
- Plastic surgeon: For primary cosmetic concerns or complex facial trauma involving multiple facial bones
- Pediatric otolaryngologist: For infants and children, especially with congenital malformations 1
Treatment Options
- Closed reduction: For simple displaced fractures, often performed under local anesthesia in outpatient setting
- Open reduction: For complex fractures or those with significant septal involvement
- Specialized techniques: For cartilaginous injuries, including mobilization, trimming/thinning, and reconstruction 1
Special Considerations
Pediatric Patients
- Consider child abuse as possible etiology in children younger than 5 years with inconsistent history or injuries incompatible with reported mechanism 1
- Referral to pediatric otolaryngologist may be necessary 1
Sports-Related Injuries
- Athletes with isolated nasal fractures may return to play with appropriate protection
- Face mask protection recommended for 6 weeks after injury 2
Potential Complications
- Persistent nasal deformity
- Nasal airway obstruction
- Breathing difficulties
- Septal perforation
- Long-term functional and cosmetic complications 1
Prevention of Secondary Deformities
- Complete nasal assessment (bony and septal structures)
- Primary septal reconstruction in cases with severe septal fracture dislocation
- Appropriate follow-up to monitor healing 3
The management of nasal fractures requires prompt recognition and appropriate specialist referral. Failure to identify and properly treat these fractures can lead to significant functional and cosmetic complications. The choice between otolaryngology and plastic surgery referral should be based on the primary concerns (functional vs. cosmetic), though both specialties show similar outcomes in managing these injuries 1.