What is the recommended treatment for an adult patient with no significant medical history who has suffered blunt trauma to the nose?

Management of Blunt Nasal Trauma in Adults

For an adult patient with blunt nasal trauma, immediately assess for septal hematoma and active epistaxis, control any bleeding, drain any septal hematoma within 24-48 hours to prevent cartilage necrosis, and perform closed reduction of nasal fractures within 5-10 days if present.

Immediate Assessment Priorities

The initial evaluation must focus on identifying time-sensitive complications that can lead to permanent deformity or functional impairment:

• Examine for septal hematoma by inspecting the nasal septum for a boggy, bluish swelling that obstructs the nasal airway—this is a surgical emergency requiring immediate drainage to prevent avascular necrosis of the septal cartilage and subsequent saddle nose deformity 1, 2
• Control active epistaxis using direct pressure, topical vasoconstrictors, or anterior nasal packing as needed 1
• Assess for open wounds or lacerations requiring immediate repair, particularly those involving the nasal mucosa or through-and-through injuries 3
• Evaluate for associated facial fractures by palpating the nasal bones, orbital rims, and maxilla for step-offs or crepitus 4

Septal Hematoma Management

This is the most critical time-sensitive complication:

• Drain any identified septal hematoma immediately through incision and drainage, as delays beyond 24-48 hours significantly increase the risk of cartilage necrosis and permanent deformity 2
• Prescribe antimicrobial therapy with clindamycin as initial coverage if secondary abscess formation is suspected, pending culture results 2
• Place nasal packing after drainage to prevent reaccumulation 2

Nasal Fracture Management

For patients with suspected or confirmed nasal fractures:

• Perform closed reduction within 5-10 days of injury, as this window allows for optimal manipulation before significant callus formation while swelling has subsided enough for accurate assessment 1, 5, 4
• Delay reduction beyond the first 2-3 days if significant edema prevents accurate assessment of alignment, but do not wait beyond 10-14 days when bony healing makes closed reduction difficult 4
• Consider open reduction only for complex fractures with significant displacement, comminution, or when closed reduction fails to restore acceptable form and function 5

Soft Tissue Injury Management

For lacerations and abrasions:

• Repair lacerations immediately when possible rather than delaying, as most sources indicate immediate reconstruction optimizes outcomes 3
• Thoroughly irrigate and debride contaminated wounds to prevent infection 3
• Use layered closure for through-and-through lacerations, repairing the nasal mucosa first, then the deeper tissues, and finally the skin 3

Common Pitfalls to Avoid

• Do not miss a septal hematoma—failure to drain within 24-48 hours leads to irreversible cartilage necrosis and saddle nose deformity that requires complex reconstruction 2, 4
• Do not attempt closed reduction too early—excessive edema in the first 2-3 days prevents accurate assessment and increases the risk of suboptimal alignment 4
• Do not delay reduction beyond 10-14 days—bony healing makes closed reduction increasingly difficult and may necessitate formal septorhinoplasty 4
• Do not dismiss "minor" nasal trauma—up to 50% of inadequately managed nasal fractures result in posttraumatic deformity requiring subsequent rhinoplasty 4

Follow-Up Considerations

• Counsel patients that even with optimal acute management, secondary nasal deformities requiring subsequent rhinoplasty occur in up to 50% of cases 4
• Schedule reassessment at 5-7 days to evaluate for delayed complications and determine if closed reduction is indicated 1, 4
• Refer to otolaryngology or facial plastic surgery for complex injuries, failed closed reduction, or significant cosmetic/functional concerns 5, 4