What is the best course of treatment for a patient with a history of intermittent nasal congestion and sinus issues, who has a history of a nasal fracture (broken nose) and denies recent nasal congestion or sinus infection?

Management of Intermittent Nasal Congestion and Sinus Issues with History of Nasal Fracture

This patient requires CT imaging of the paranasal sinuses to evaluate for anatomic obstruction from the prior nasal fracture, followed by otolaryngology referral if structural abnormalities are identified, particularly if there is septal deviation compressing the middle turbinate or ostiomeatal complex obstruction. 1

Diagnostic Approach

Initial Assessment Requirements

• Document symptom duration and pattern: The intermittent nature over "a couple years" suggests chronic rhinosinusitis (CRS) if symptoms have been present ≥8-12 weeks cumulatively, or recurrent acute rhinosinusitis if there are ≥3-4 discrete episodes per year with complete resolution between episodes 1

• Perform nasal airway examination: Look specifically for nasal septal deviation (from the prior fracture), middle turbinate abnormalities, nasal polyps, purulent discharge in the middle meatus, and mucosal edema 1, 2

• Obtain coronal CT scan with cuts through the ostiomeatal complex: This is strongly recommended for any patient with chronic or recurrent symptoms to define anatomic abnormalities, assess for ostiomeatal obstruction, and evaluate the extent of mucosal disease 1, 2

Key Diagnostic Considerations

The history of nasal fracture is particularly relevant because:

• Traumatic septal deviation can compress the middle turbinate into the ostiomeatal complex, creating mechanical obstruction that predisposes to recurrent sinus infections 1

• Post-traumatic anatomic changes may include middle turbinate deformities or accessory structures blocking sinus drainage 1

• CT imaging is essential to differentiate between inflammatory disease and structural problems that require surgical correction 1, 2

Treatment Algorithm

If CT Shows Anatomic Obstruction from Prior Fracture

• Refer to otolaryngology for surgical evaluation: Significant nasal septal deviation compressing the middle turbinate, obstruction of sinus outflow tracts, or ostiomeatal complex blockage are indications for functional endoscopic sinus surgery (FESS) 1, 3

• Maximize medical therapy first: Every effort should be made to optimize medical treatment before proceeding with surgery, including intranasal corticosteroids and management of any underlying allergic rhinitis 1, 3

• Expect continued medical therapy post-operatively: Most patients benefit from individualized medical management even after surgical correction 1, 3

If CT Shows Mucosal Disease Without Significant Anatomic Obstruction

• Initiate intranasal corticosteroids: These reduce inflammation and improve sinus drainage 3

• Consider allergy testing: Allergic rhinitis is a common predisposing factor for CRS and should be evaluated and treated if present 1

• Evaluate for other predisposing conditions: Including immunodeficiency (particularly if there is history of recurrent otitis media, bronchitis, or pneumonia), ciliary dysfunction, or gastroesophageal reflux 1, 4

If Symptoms Suggest Active Infection

• Start amoxicillin-clavulanate if purulent discharge is present on examination, as post-traumatic anatomic changes often harbor resistant organisms 3

• Add intranasal corticosteroids as adjunctive therapy 3

• Reassess after 7-10 days: If no improvement, switch to respiratory fluoroquinolones (levofloxacin or moxifloxacin) 3

Critical Pitfalls to Avoid

• Do not rely on plain radiographs: They have significant false-positive and false-negative rates and cannot adequately assess the ostiomeatal complex or define anatomic abnormalities from trauma 3, 5

• Do not overlook the structural component: A history of nasal fracture makes anatomic obstruction highly likely, and treating with antibiotics alone without addressing the underlying mechanical problem will lead to recurrent symptoms 1

• Do not delay CT imaging: In patients with recurrent or chronic symptoms and a history of facial trauma, CT is necessary to guide appropriate management and avoid unnecessary repeated courses of antibiotics 1, 2

• Avoid prolonged nasal decongestants: These can cause rhinitis medicamentosa and worsen the underlying problem 1, 3

Specialist Referral Indications

Refer to otolaryngology when: 1, 3

• CT demonstrates septal deviation compressing the middle turbinate
• Ostiomeatal complex obstruction is present
• Nasal polyps are identified
• Symptoms persist despite aggressive medical management
• Recurrent infections continue despite appropriate antibiotic therapy

Consider allergist-immunologist referral when: 1

• Chronic or recurrent sinusitis is associated with other recurrent infections (otitis media, bronchitis, pneumonia)
• Prior surgical procedures have been performed but symptoms persist
• Evaluation for immunodeficiency or specific antibody deficiency is needed