Nasal Trauma with Persistent Tenderness at Two Weeks
This patient requires immediate evaluation for a missed nasal fracture or septal hematoma, as persistent tenderness two weeks post-trauma is abnormal and suggests inadequate initial assessment or an evolving complication. 1
Immediate Assessment Required
Critical Examination Steps
Perform anterior rhinoscopy immediately to identify structural injury, septal deviation, or delayed complications 2. This examination must include:
- Visual inspection for septal hematoma - the most critical missed diagnosis that can lead to septal perforation and saddle nose deformity if untreated 3, 1
- Assessment of nasal airway patency bilaterally to detect functional obstruction 1
- Palpation of nasal bones for crepitus, step-offs, or mobility indicating fracture 1
- Evaluation for mucosal lacerations or ongoing bleeding 2
- Documentation of any nasal deformity compared to pre-injury appearance 1
Red Flags Requiring Subspecialist Referral
Refer immediately to ENT or facial plastic surgery if any of the following are present 1:
- Septal hematoma (fluctuant, bluish septal swelling)
- Persistent nasal obstruction
- Visible nasal deformity or deviation
- Cerebrospinal fluid rhinorrhea (clear watery discharge)
- Extraocular movement defects
- Malocclusion
Management Based on Findings
If Nasal Fracture is Confirmed
Closed reduction must be performed within 3-5 days of injury for optimal results, but can be attempted up to 2-3 weeks post-trauma 1, 4. At two weeks post-injury, this patient is at the outer limit of the window for closed reduction. The bones may have already begun healing in a displaced position, which occurs in up to 50% of inadequately managed nasal fractures 4.
- Immediate referral to ENT or facial plastic surgery is warranted if fracture displacement is present, as closed reduction becomes increasingly difficult after 7-10 days 1, 4
- If closed reduction window has passed, the patient may require formal septorhinoplasty 3-6 months after injury once all swelling has resolved 4
If Septal Hematoma is Present
This is a surgical emergency requiring immediate drainage to prevent cartilage necrosis, septal perforation, and saddle nose deformity 3, 1. The two-week timeframe makes this diagnosis less likely but still possible if it developed after initial injury assessment.
If Examination is Normal
Persistent tenderness without structural abnormality suggests soft tissue injury or periosteal contusion 5. Management includes:
- Analgesics: NSAIDs (ibuprofen 400-600mg every 6-8 hours) or acetaminophen for pain control 6
- Cold compresses for the first 48-72 hours if not already done, warm compresses after 72 hours to promote healing 5
- Avoidance of contact sports or re-injury risk until tenderness resolves 7
- Follow-up in 1 week if tenderness persists beyond 3 weeks total 1
Common Pitfalls to Avoid
The most critical error is missing a septal hematoma, which can develop hours to days after initial trauma and may not be present on initial evaluation 3, 1. At two weeks, if a hematoma was missed initially, the patient is at high risk for septal abscess, cartilage necrosis, and permanent deformity.
The second major pitfall is delayed referral of displaced nasal fractures 3. After 2-3 weeks, closed reduction becomes technically difficult or impossible, necessitating formal rhinoplasty months later with significantly increased morbidity and cost 4.
Imaging (plain radiographs or CT) is generally not indicated for isolated nasal trauma unless there is concern for facial fractures beyond the nasal bones, orbital involvement, or mandibular injury 1. Clinical examination is more accurate than plain films for nasal fracture diagnosis.
Follow-Up Plan
- Re-examine in 3-5 days if conservative management is initiated 1
- Refer to ENT/facial plastics within 24-48 hours if any structural abnormality is identified 1
- Educate patient that persistent symptoms beyond 3-4 weeks total warrant subspecialist evaluation even if initial examination appears normal 4
- Document baseline nasal appearance and function for medicolegal purposes and future comparison 1