Best Imaging for Possible Nasal Fracture
CT maxillofacial without IV contrast is the preferred imaging modality for suspected nasal fractures, offering superior fracture detection, characterization of complex injuries, and surgical planning capabilities compared to plain radiographs. 1, 2
When to Image
Imaging is indicated when any of the following are present: 2
- Visible or palpable nasal deformity
- Tenderness to palpation of the nose
- Epistaxis
- Suspected complex injuries or associated facial fractures
- Deep lacerations with exposed cartilage
Primary Imaging Recommendation: CT Maxillofacial
CT maxillofacial provides the highest diagnostic accuracy for nasal trauma. 1, 2 This modality offers several critical advantages:
- Detects subtle nondisplaced fractures through high-resolution thin-section acquisitions that plain radiographs miss 1
- Provides multiplanar and 3D reconstructions that surgeons find critical for preoperative planning 1
- Characterizes complex nasal injuries and detects associated facial fractures that commonly occur together 1
- Superior sensitivity compared to radiographs in confirming clinical suspicion of nasal bone fracture 1
Important Caveat About CT Limitations
While CT is the gold standard imaging modality, clinical examination remains paramount for determining need for surgery. 3 A 2013 study found similar surgical rates (41% vs 37%) whether fractures were diagnosed by CT or plain radiographs, confirming that experienced clinical examination is the ultimate determinant of surgical necessity regardless of imaging findings. 3
Additionally, CT cannot accurately predict septal fracture severity, which is crucial since 96% of simple nasal bone fractures involve septal fractures. 4 The correlation between CT septal grading and intraoperative findings is only 33.5%, meaning CT cannot definitively determine if septoplasty is needed. 4
Alternative Imaging: Ultrasound
Ultrasound is a highly accurate alternative for isolated nasal bone fractures, particularly when CT is unavailable or radiation exposure is a concern. 2, 5, 6
Performance characteristics include:
- Sensitivity: 90-100% 1, 2, 5
- Specificity: 98-100% 1, 2, 5
- Superior detection of nondepressed nasal bridge fractures and anterior septal cartilage deviation compared to CT 1
Technical Considerations for Ultrasound
- Use high-frequency linear transducer (10-15 MHz) for optimal resolution 5, 6
- Hockey-stick probe (L15-7 MHz) shows closer agreement with intraoperative findings for both lateral nasal walls and midline 6
- Higher specificity for midline nasal bone fractures compared to CT 6
What NOT to Use
Plain Radiographs: Limited Value
Conventional nasal radiographs have poor diagnostic accuracy (53-82%) and generally do not alter management decisions. 7, 8 They are inferior to both CT and ultrasound for fracture detection. 1, 5, 6
CT Head: Not Indicated for Isolated Nasal Injury
CT head has no role in evaluating isolated nasal bone injury. 1, 2 However, it may be warranted if signs of intracranial injury or other associated facial fractures are present. 2
Chest Radiograph: Only for Tooth Aspiration
Chest X-ray is only indicated if a tooth is absent to exclude aspiration into the airway. 1, 2
Clinical Algorithm
- Perform thorough clinical examination looking for deformity, tenderness, epistaxis, or exposed cartilage
- If imaging indicated: Order CT maxillofacial without IV contrast as first-line 1, 2
- If CT unavailable or isolated simple fracture suspected: Consider ultrasound with high-frequency probe 2, 5, 6
- Avoid plain radiographs as they rarely change management 7, 8
- Remember: Base surgical decision primarily on clinical findings, not imaging alone 3