Imaging for Nasal Fracture from Trauma
CT maxillofacial without IV contrast is the preferred imaging modality for nasal trauma, as it provides superior fracture detection and characterization compared to plain radiographs, which have limited diagnostic value with accuracy of only 53-82%. 1, 2
Why CT is Superior
CT maxillofacial is the gold standard because:
- It offers high-resolution thin-section acquisitions that detect subtle nondisplaced fractures that plain films miss 3, 1
- It provides multiplanar and 3D reconstructions for better characterization of complex fractures, which surgeons find critical for preoperative planning 3, 1
- It accurately identifies septal involvement, which occurs in 96% of nasal bone fractures and must be addressed for successful treatment 4
- It detects associated injuries including naso-orbital-ethmoid fractures, which require subspecialist management 2
The Problem with Plain Radiographs
Plain X-rays (nasal bone series) are not recommended as they:
- Have poor accuracy of only 53-82% and rarely alter management decisions 2
- Show positive findings in only 82% of actual fractures, with 9.5% false negatives 5
- Cannot reliably predict septal fracture severity, which is critical for treatment planning 4
- Fail to adequately visualize the complex three-dimensional anatomy of nasal fractures 5
Alternative: Ultrasound for Isolated Fractures
Ultrasound may be considered for isolated nasal bone fractures as:
- It demonstrates very high accuracy with sensitivity of 90-100% and specificity of 98-100% 1
- It is particularly helpful for evaluating midline nasal bone fractures, showing higher specificity than CT 6
- A hockey-stick probe (L15-7 MHz) provides better agreement with intraoperative findings than standard linear probes 6
However, ultrasound has limitations for lateral nasal wall fractures where CT remains superior 6
When to Image
Obtain imaging when any of these findings 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
- Deep lacerations with exposed cartilage 1
- Mucosal tearing on physical examination (statistically significant predictor of septal fracture) 4
Additional Imaging Considerations
CT head is not indicated for isolated nasal bone injury but should be obtained if signs of intracranial injury or other facial fractures are present, as 68% of maxillofacial trauma patients have associated head injury 1, 2
Chest radiograph is only indicated if a tooth is absent to exclude aspiration 1
Common Pitfalls
- Do not rely on plain radiographs alone—they miss significant fractures and septal involvement that will lead to treatment failure 2, 5, 4
- Do not assume isolated nasal bone fracture without imaging—56% have associated traumatic septal deviation requiring additional surgical intervention 7
- CT findings may underestimate septal fracture severity compared to intraoperative findings, so direct visualization may still be needed during reduction 4