What is the recommended imaging study for an adult patient with blunt nasal trauma and no significant medical history?

Imaging for Blunt Nasal Trauma

For an adult patient with isolated blunt nasal trauma and no significant medical history, clinical examination alone is sufficient to determine management, and routine imaging is not indicated.

Clinical Examination is the Gold Standard

• Clinical examination remains the gold standard for determining the need for surgical intervention in isolated nasal trauma, regardless of imaging findings 1.
• Physical examination should focus on identifying nasal deformity, septal hematoma (which requires urgent drainage), and functional symptoms such as nasal obstruction 2.
• The decision for surgical reduction is based on clinical findings of displacement and functional impairment, not on radiographic confirmation of fracture 1.

When Imaging is NOT Indicated

• Plain radiographs (X-rays) are not helpful for the assessment of traumatic nasal injuries and should not be obtained 2.
• X-rays have poor sensitivity (72%) and specificity (73%) for nasal fractures compared to clinical examination 3.
• For isolated nasal trauma without concerning features for other facial injuries, no imaging is required 2.

When CT Imaging IS Indicated

CT scans are only indicated if there is suspected orbital, maxillary, frontal, or zygomatic fractures 2.

Specific indications for facial CT include:

• Suspected midface fractures involving paranasal sinus walls 4
• Orbital involvement (periorbital ecchymosis, diplopia, enophthalmos, or restricted extraocular movements) 2
• Suspected complex facial fractures beyond isolated nasal injury 2
• Polytrauma patients requiring evaluation of multiple body regions 5

The "Clear Sinus" Sign

• If CT is performed for other reasons, the absence of free fluid in paranasal sinuses reliably excludes fractures involving sinus walls (P < .001) 4.
• However, isolated nasal fractures and zygomatic arch fractures can still occur with clear sinuses 4.

Common Pitfalls to Avoid

• Ordering routine X-rays or CT scans for isolated nasal trauma wastes resources and does not change management, as clinical examination determines the need for reduction 1, 2.
• Failing to examine for septal hematoma is a critical error, as this requires urgent drainage regardless of fracture presence 2.
• Delaying referral for displaced fractures beyond two weeks, as nasal bones begin uniting and reduction becomes more difficult 2.
• Obtaining CT for isolated nasal trauma exposes patients to unnecessary radiation without clinical benefit 1.

Management Algorithm

For isolated nasal trauma:

1. Perform thorough clinical examination for deformity, septal hematoma, and functional symptoms 2
2. If undisplaced without functional symptoms: conservative management 2
3. If displaced: refer for reduction within two weeks 2
4. No imaging required unless suspicion for associated facial fractures 2

If polytrauma or concern for other facial injuries:

• CT of the face is appropriate to evaluate for complex fractures 5, 2
• Clinical judgment should guide imaging decisions in the context of overall injury pattern 5