Diagnosis of Nasal Fractures
CT maxillofacial without IV contrast is the recommended imaging modality for diagnosing nasal fractures, offering superior fracture detection and characterization compared to plain radiographs. 1, 2
Clinical Diagnosis
The diagnosis of a nasal fracture begins with clinical assessment, which remains the gold standard for determining the need for surgical intervention regardless of imaging findings 3. Key clinical indicators include:
- Visible or palpable nasal deformity 2
- Tenderness to palpation of the nose 2
- Epistaxis 2
- Deep lacerations with exposed cartilage 2, 4
Imaging Recommendations
First-Line Imaging: CT Maxillofacial
CT maxillofacial without IV contrast is the preferred imaging modality for the following reasons 1, 2, 5:
- Superior sensitivity for detecting nasal bone fractures compared to plain radiographs 1, 2
- High-resolution thin-section acquisitions that detect subtle nondisplaced fractures 1
- Multiplanar and 3D reconstructions that better characterize complex fractures and aid in surgical planning 1
- Faster acquisition time than radiography and less reliant on patient positioning 1
- Ability to detect associated facial fractures and fully characterize the extent of injuries 1
CT is particularly valuable when complex nasal injuries or associated facial fractures are suspected 1, 2. Several classification systems for nasal fractures rely on CT findings, including the Rhee classification system that uses CT to determine the degree of septal deviation 1.
Alternative Imaging: Ultrasound
Ultrasound may be considered for isolated nasal bone fractures with excellent diagnostic performance 1, 2, 5:
- Sensitivity: 90-100% 1, 2, 5
- Specificity: 98-100% 1, 2, 5
- Superior detection of nondepressed fractures of the nasal bridge and anterior septal cartilage deviation compared to CT 1, 5
One study using conductor-assisted nasal ultrasound technique demonstrated 100% sensitivity, 89% specificity, 96% positive predictive value, and 100% negative predictive value 1.
Imaging NOT Recommended
Plain radiographs have limited diagnostic value and are not recommended 4, 5:
- Low accuracy: only 53-82% 4, 5
- Do not significantly alter diagnosis or management decisions 4, 5
- Inferior to CT in confirming clinical suspicion of nasal bone fracture 1
CT head is not indicated for isolated nasal bone injury 1, 2, though it may be warranted if signs of intracranial injury or other associated facial fractures are present 2.
When to Image
Imaging is specifically indicated when 2:
- Suspected complex injuries are present
- Associated facial fractures are suspected
- There is visible or palpable nasal deformity
- Deep lacerations with exposed cartilage are present
Important Clinical Caveat
Experienced clinical examination remains the gold standard for determining the need for surgery in isolated nasal trauma 3. A retrospective review of 232 patients found similar rates of surgery (41% for CT diagnosis vs 37% for radiograph diagnosis), suggesting that imaging findings alone should not drive surgical decision-making without clinical correlation 3.
Additional Considerations
Chest radiograph is only indicated if a tooth is absent to exclude aspiration 1, 2. An avulsed tooth in the airway should be removed by a physician or surgeon due to risk of obstructive pneumonia 1.
Assess for septal involvement, as septal deviation must be corrected before nasal bone realignment 5. CT is valuable for detecting the degree of comminution and septal involvement, which significantly impacts treatment outcomes 1, 6.