What is the appropriate evaluation and management for a patient presenting with a suspected broken nose?

Evaluation and Management of Suspected Nasal Fracture

For a patient with suspected nasal fracture, immediately assess for active bleeding and septal hematoma, control any epistaxis with firm compression for 10-15 minutes, perform anterior rhinoscopy after bleeding control to identify septal hematoma (which requires urgent drainage), and defer imaging as CT is not routinely indicated for simple nasal fractures. 1

Immediate Priorities

Airway and Bleeding Control

• Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 1
• Apply firm sustained compression to the lower third of the nose for at least 10-15 minutes without checking if bleeding has stopped 1, 2
• If bleeding persists after compression, apply topical vasoconstrictors (oxymetazoline or phenylephrine) which resolve 65-75% of nosebleeds 1, 2
• Perform anterior rhinoscopy after controlling bleeding and removing blood clots to identify the bleeding site 3, 1

Critical Examination for Septal Hematoma

The single most important examination finding to identify is septal hematoma, as missing this diagnosis leads to cartilage necrosis and permanent saddle nose deformity. 1

• Perform anterior rhinoscopy after bleeding control to visualize the nasal septum 1
• Look for a bluish, fluctuant swelling on the septum that obscures normal septal landmarks 1
• If septal hematoma is identified, arrange urgent incision and drainage by an ENT specialist 1

Physical Examination Components

External Nasal Assessment

• Inspect for obvious deformity, deviation, or asymmetry of the nasal dorsum and sidewalls 1
• Palpate the nasal bones and cartilages for crepitus, step-offs, or mobile fracture segments 1
• Assess for saddle nose deformity which indicates septal injury 1
• Check for periorbital ecchymosis or subcutaneous emphysema suggesting more extensive facial trauma 1

Internal Nasal Examination

• Perform anterior rhinoscopy after controlling active bleeding and removing blood clots 3, 1
• Identify septal hematoma, septal deviation, or visible fracture lines 1
• If bleeding persists and anterior rhinoscopy fails to identify the source, nasal endoscopy should be performed or the patient referred to someone who can perform it 3

Imaging Decisions

Imaging is NOT routinely indicated for simple nasal fractures and should be reserved for suspected complications or complex injuries. 3, 1

When CT Maxillofacial IS Indicated

• Suspected orbital fractures (periorbital ecchymosis, diplopia, enophthalmos) 3
• Suspected skull base fractures (CSF rhinorrhea, Battle's sign) 3
• Complex nasal fractures with significant deviation requiring surgical planning 3
• Associated midface or mandibular trauma 3

When Imaging is NOT Needed

• Simple isolated nasal fractures with minimal deviation 3, 1
• Nasal radiographs have limited diagnostic value with accuracy ranging only 53-82% and do not alter management 3
• CT head alone is not useful for evaluating nasal bone injury 3

Initial Management Based on Findings

For Simple Nasal Fractures Without Complications

• Apply ice to reduce swelling for the first 48 hours 1
• Provide adequate analgesia 4
• Elevate the head of the bed 1
• Avoid nose blowing and strenuous activity for 24-48 hours 1

For Active Bleeding That Persists

• Anesthetize the bleeding site if cautery is planned 3
• Restrict cautery application only to the active or suspected bleeding site 3
• If bleeding continues despite compression and cautery, treat with nasal packing 3

For Septal Hematoma

Urgent incision and drainage is required to prevent cartilage necrosis. 1

• Refer immediately to ENT specialist 1
• This is a true emergency that cannot be delayed 1

Documentation Requirements

• Document mechanism of injury, time of injury, and any immediate complications 1
• Record factors that increase bleeding risk: anticoagulant use, hypertension, bleeding disorders 1
• Note all physical examination findings, specifically documenting presence or absence of septal hematoma 1

Timing of Definitive Fracture Management

Most simple nasal fractures can be managed conservatively initially, with definitive reduction (if needed) performed within 5-14 days after swelling subsides. 4, 5

• Early intervention (<14 days) with closed reduction is cost-effective and minimizes need for secondary surgeries 5
• Manipulation under local anesthesia is effective first-line treatment for simple nasal fractures 4
• However, fractures with significant septal involvement have measurably high rates of requiring subsequent open treatment 5

Common Pitfalls to Avoid

• Insufficient compression time (checking before 10-15 minutes) leads to uncontrolled bleeding 1, 2
• Missing septal hematoma results in permanent nasal deformity if not drained urgently 1
• Premature imaging wastes resources as most simple nasal fractures don't require CT 3, 1
• Bilateral simultaneous septal cautery increases risk of septal perforation 2

When to Refer to ENT Specialist

• Septal hematoma requiring drainage (urgent) 1
• Persistent epistaxis not controlled by standard measures 1, 2
• Complex nasal fractures with significant deviation or functional impairment 1
• Suspected orbital or skull base fractures (immediate) 1
• Recurrent bleeding despite appropriate treatment 2

Prevention of Recurrent Bleeding

• Apply petroleum jelly or other moisturizing agents to the anterior nasal septum 3, 1, 2
• Use saline nasal sprays regularly to keep nasal mucosa moist 1, 2
• Use humidification in the home environment 1, 2