What is the immediate treatment for an acute nondisplaced nasal fracture?

Immediate Treatment for Acute Nondisplaced Nasal Fracture

For an acute nondisplaced nasal fracture, conservative management with pain control, ice application, nasal decongestants for epistaxis if present, and patient education is the appropriate initial treatment—imaging and surgical intervention are not indicated. 1

Initial Assessment Priorities

Before initiating treatment, you must exclude critical complications that would change management:

• Rule out septal hematoma by examining the nasal septum for bluish, fluctuant swelling—this requires urgent drainage to prevent cartilage necrosis 1
• Check for cerebrospinal fluid leak (clear rhinorrhea, halo sign) which necessitates immediate specialist referral 1
• Assess for exposed cartilage or open wounds that would require surgical management 1
• Evaluate for associated facial fractures (zygomatic, maxillary, frontal) through clinical examination 1

Conservative Treatment Protocol

Pain Management

• Prescribe regular acetaminophen (paracetamol) as first-line analgesia unless contraindicated 1
• Use opioids cautiously, particularly in elderly patients or those with renal dysfunction 1
• Avoid NSAIDs in patients with renal impairment 1

Epistaxis Control (if present)

• Apply topical vasoconstrictors (oxymetazoline nasal spray) which achieves 65-75% resolution of bleeding 1
• Instruct the patient to lean forward and pinch the soft part of the nose for at least 5 minutes, continuing for a full 15 minutes if bleeding slows 2
• If bleeding persists despite these measures, spray 2 sprays of oxymetazoline in the bleeding nostril and continue holding for 5 minutes 2

Symptomatic Measures

• Apply ice to the nose for the first 48-72 hours to reduce swelling 1
• Use humidification and saline nasal spray to maintain moisture and promote healing 1

Patient Education and Restrictions

Provide clear instructions on:

• Avoid further trauma: no vigorous nose-blowing, avoid contact sports, and do not touch or manipulate the nose 1
• Preventive measures: eliminate digital trauma (nose picking) and use proper nasal hygiene 2
• When to seek urgent care: persistent epistaxis despite conservative measures, development of nasal deformity, or signs of septal hematoma 1

Imaging Considerations

Routine imaging is NOT indicated for isolated nondisplaced nasal fractures without clinical deformity. 2 The diagnosis is clinical, and imaging does not alter management in straightforward cases.

However, obtain CT maxillofacial without IV contrast if:

• Visible or palpable nasal deformity is present 3
• You suspect complex injuries or associated facial fractures 3
• Deep lacerations with exposed cartilage exist 3

Plain radiographs have limited diagnostic value with only 53-82% accuracy and should not be used 2

Red Flags Requiring Immediate Specialist Referral

Refer urgently to otolaryngology if any of the following develop:

• Septal hematoma (requires drainage within 24-48 hours) 1
• Open fracture with exposed cartilage 1
• Significant nasal deformity 1
• Persistent epistaxis despite conservative measures 1
• Suspected cerebrospinal fluid leak 1

Common Pitfalls to Avoid

The most critical error is missing a septal hematoma, which can lead to septal necrosis, saddle nose deformity, and abscess formation if not drained promptly. Always perform anterior rhinoscopy or nasal endoscopy to visualize the septum directly. 4

Another pitfall is attempting immediate closed reduction without proper experience or in the acute setting when significant edema is present—this often leads to suboptimal results and secondary deformities. 5 For nondisplaced fractures, reduction is not indicated.

Do not tell patients on anticoagulation to stop their medications without consulting the prescribing physician, as these are typically prescribed for serious medical conditions. 2 However, if epistaxis is severe, advise not taking additional doses until evaluated urgently. 2

Follow-Up

Document the outcome of intervention or transition of care within 30 days for quality assurance and to identify any delayed complications requiring further management. 2