What imaging study would you order for nasal trauma?

Imaging for Nasal Trauma

CT maxillofacial without IV contrast is the preferred imaging modality for nasal trauma when imaging is indicated, offering superior fracture detection and characterization compared to plain radiographs. 1, 2

When to Order Imaging

Imaging is indicated for nasal trauma when any of the following are present:

• Visible or palpable nasal deformity 1
• Tenderness to palpation of the nose 1
• Epistaxis 1
• Suspected complex injuries or associated facial fractures 1, 2
• Deep lacerations with exposed cartilage 3

However, clinical examination remains the gold standard for determining need for surgical intervention in isolated nasal trauma, and imaging findings do not necessarily dictate management. 4

Imaging Modality Selection

CT Maxillofacial (First-Line When Imaging Needed)

CT maxillofacial without IV contrast is the recommended imaging study according to the American College of Radiology. 1, 2

CT provides several advantages:

• Superior sensitivity for detecting nasal bone fractures compared to radiographs (CT vs. radiographs: higher detection rates) 1
• High-resolution thin-section acquisitions detect subtle nondisplaced fractures 1
• Multiplanar and 3D reconstructions allow better characterization of complex fractures and are critical for surgical planning 1
• Fully characterizes extent of injuries and detects additional facial fractures in complex cases 1
• Essential for classification systems that rely on CT to determine degree of septal deviation 1
• Faster acquisition time and less reliant on patient positioning than radiography 1

Plain Radiographs (Not Recommended)

Nasal radiographs have limited diagnostic value and should not be routinely ordered. 1, 2

The evidence against plain films is compelling:

• Diagnostic accuracy ranges only 53-82% 1, 2
• Do not considerably alter diagnosis or management of nasal fractures 1
• X-rays are not helpful for assessment of traumatic nasal injuries 5

Ultrasound (Alternative in Select Cases)

Ultrasound may be considered as an alternative for isolated nasal bone fractures, though it is not first-line:

• Very high accuracy with sensitivity 90-100% and specificity 98-100% 1, 2
• Particularly accurate for isolated nasal bone fractures 1
• Better detects nondepressed fractures of the nasal bridge and anterior septal cartilage deviation than CT 1, 2
• One study showed 100% sensitivity, 89% specificity, 96% positive predictive value, and 100% negative predictive value 1

However, ultrasound is typically not first-line and requires operator expertise. 1

Additional Imaging Considerations

CT Head

• Not indicated for isolated nasal bone injury 1
• May be warranted if there are signs of intracranial injury or other associated facial fractures 1

Chest Radiograph

• Only indicated if a tooth is absent to exclude aspiration 1

Clinical Pitfalls

The most important pitfall is over-reliance on imaging to determine surgical need. Experienced clinical examination determines the need for surgery in isolated nasal trauma, regardless of CT findings—studies show similar surgery rates whether diagnosed by CT or radiographs (41% vs. 37%). 4

For simple isolated nasal trauma without complex features, imaging may not be necessary at all if clinical examination is adequate. 5 CT is primarily indicated when there are suspected orbital, maxillary, frontal, or zygomatic fractures. 5