What is the initial assessment and management for a patient with a head-butted nose?

Initial Assessment and Management of Nasal Trauma from Head-Butt Injury

For a patient presenting with a head-butted nose, immediately assess for active epistaxis and airway compromise, then perform a systematic examination to identify nasal fractures, septal hematoma, and associated injuries that require urgent intervention.

Immediate Priorities

Airway and Bleeding Assessment

• First, assess for active bleeding and potential airway compromise from blood entering the oropharynx, as these are the most urgent concerns requiring immediate management 1.
• Position the patient sitting upright with head slightly tilted forward to prevent blood from entering the airway or stomach 2.
• If active epistaxis is present, apply firm sustained compression to the lower third of the nose for at least 5-10 minutes without checking if bleeding has stopped 3, 4.
• Apply topical vasoconstrictors (oxymetazoline or phenylephrine) if bleeding persists after initial compression, which resolves 65-75% of nosebleeds 3, 4.

Critical Examination Components

External Nasal Examination:

• Inspect for obvious deformity, deviation, or asymmetry of the nasal dorsum and sidewalls 1.
• Palpate the nasal bones and cartilages for crepitus, step-offs, or mobile fracture segments 1.
• Assess for saddle nose deformity which may indicate septal injury 1.
• Check for periorbital ecchymosis ("raccoon eyes") or subcutaneous emphysema suggesting more extensive facial trauma 1.

Anterior Rhinoscopy (Essential):

• After controlling any active bleeding and removing blood clots, perform anterior rhinoscopy with a nasal speculum and adequate lighting 1.
• Specifically look for septal hematoma—a bluish, fluctuant swelling of the nasal septum that requires urgent drainage to prevent septal necrosis and saddle nose deformity 1.
• Assess for septal deviation or fracture 1.
• Evaluate the inferior turbinates and nasal valve patency 1.
• Identify any lacerations of the nasal mucosa 1.

Associated Injury Assessment:

• Examine for signs of orbital injury including visual changes, diplopia, or periorbital swelling 1.
• Assess for dental malocclusion or mandibular injury 1.
• Check for cerebrospinal fluid rhinorrhea (clear watery discharge) suggesting skull base fracture 1.
• Palpate facial bones for tenderness or instability suggesting midface fractures 1.

Management Based on Findings

If Septal Hematoma is Present:

• This requires urgent incision and drainage to prevent cartilage necrosis—refer immediately to ENT or perform drainage if trained 1.

If Active Bleeding Continues:

• Perform anterior rhinoscopy after removing clots to identify the bleeding site 1, 3.
• Consider nasal cautery (chemical or electrical) for localized bleeding sites 3, 4.
• Apply nasal packing if bleeding cannot be controlled with compression and cautery 1, 3.
• Use resorbable packing if the patient is on anticoagulants or has a bleeding disorder 1.

For Nasal Fractures:

• Most simple nasal fractures can be managed conservatively initially with ice, analgesia, and elevation of the head 1.
• Definitive reduction should be performed within 7-10 days before significant healing occurs, or delayed 2-3 weeks after swelling subsides 1.
• Complex fractures with significant deviation or functional impairment may require ENT referral 1.

Documentation Requirements

• Document the mechanism of injury, time of injury, and any immediate complications 1.
• Record factors that increase bleeding risk including anticoagulant use, hypertension, or bleeding disorders 3.
• Note all physical examination findings including presence or absence of septal hematoma 1.

Common Pitfalls to Avoid

• Insufficient compression time: Maintain pressure for at least 5-10 minutes without checking if bleeding has stopped 3, 4.
• Missing septal hematoma: This is the most critical time-sensitive finding that can lead to permanent nasal deformity if not drained urgently 1.
• Premature imaging: Radiographic imaging is not required for most simple nasal fractures and should be reserved for suspected complications or complex injuries 1, 3.
• Overlooking associated injuries: Always assess for orbital, dental, and intracranial injuries in facial trauma 1.

When to Refer or Seek Specialist Consultation

• Septal hematoma requiring drainage 1.
• Persistent epistaxis not controlled by standard measures 1, 3.
• Complex nasal fractures with significant deviation or functional impairment 1.
• Suspected orbital or skull base fractures 1.
• Cerebrospinal fluid leak 1.

Patient Education

• Apply ice to reduce swelling for the first 48 hours 1.
• Avoid nose blowing and strenuous activity for 24-48 hours 4.
• Use saline nasal sprays and humidification to prevent recurrent bleeding 3, 4.
• Return immediately if bleeding recurs and cannot be controlled, or if signs of infection develop 3, 4.