CT is the Preferred Imaging Modality for Evaluating Nasal Fractures
CT maxillofacial without IV contrast is the preferred imaging modality for evaluating nasal fractures over plain radiographs due to its superior diagnostic accuracy and ability to detect associated injuries. 1, 2
Evidence-Based Rationale
The American College of Radiology (ACR) Appropriateness Criteria explicitly states that CT maxillofacial without IV contrast is "usually appropriate" for the initial imaging of patients with suspected nasal injury presenting with visible nasal deformity, palpable nasal deformity, tenderness to palpation of the nose, or epistaxis 1. This recommendation represents the highest level of guideline evidence available.
CT imaging offers several advantages over plain radiographs:
- Higher sensitivity for detecting nasal fractures (plain radiographs have only 53-82% sensitivity) 2
- Ability to create multiplanar and 3D reconstructions for better characterization of complex fractures 2
- Capacity to identify associated injuries that may be missed on plain films
- Better visualization of the nasal septum, which is involved in 56.1% of nasal trauma cases 3
Diagnostic Accuracy Comparison
| Imaging Modality | Sensitivity | Specificity | PPV | NPV |
|---|---|---|---|---|
| CT Scan | Superior reference standard | Reference standard | Reference standard | Reference standard |
| Plain Radiographs | 53-82% | Lower than CT | Lower than CT | Lower than CT |
Research has demonstrated that plain film radiographs have limited reliability, with one study showing only 82% reliability in diagnosing nasal bone fractures 4. Another study found that while X-rays could identify bilateral nasal fractures, they frequently missed unilateral fractures, fractures of the frontal process of the maxilla, and fractures of the perpendicular plate of the ethmoid bone 5.
Clinical Applications and Benefits of CT
CT scanning provides several clinical advantages:
- Fracture classification: Enables precise classification of nasal fractures (Types I-III with subtypes), which guides treatment planning 4
- Associated injury detection: Can identify concomitant facial fractures and septal involvement that may alter management 3
- Surgical planning: Provides detailed information about fracture location, fracture line shape, and fragment number/position 3
- Head injury assessment: Important since 68% of facial fracture patients have associated head injuries 2
When X-rays Might Be Considered
While CT is clearly superior, there may be limited scenarios where plain radiographs could be considered:
- Settings with limited access to CT technology
- Cases where radiation exposure is a significant concern (though the benefit of accurate diagnosis typically outweighs this risk)
- Simple, obvious nasal fractures in stable patients without suspicion of other injuries
Important Clinical Caveat
It's worth noting that despite advances in imaging, clinical examination remains fundamental in determining the need for surgical intervention. One study found similar rates of surgery (41% vs 37%) regardless of whether the fracture was diagnosed by CT or plain radiographs 6. This suggests that while CT provides superior diagnostic information, the decision for surgical intervention should be guided by clinical findings in conjunction with imaging results.
Practical Algorithm for Nasal Fracture Imaging
For patients with suspected nasal fracture (visible deformity, palpable deformity, tenderness, epistaxis):
- First-line imaging: CT maxillofacial without IV contrast
- Consider concurrent CT head if head injury is suspected
If CT is unavailable or contraindicated:
- Consider plain radiographs with the understanding of their limitations
- Supplement with clinical examination findings
For complex cases or when septal involvement is suspected:
- CT is essential for proper evaluation and surgical planning