What are the clinical indications for ordering an X-ray (radiograph) or computed tomography (CT) scan to diagnose a suspected nasal fracture in a patient presenting with nasal trauma?

Clinical Assessment and Imaging for Suspected Nasal Fractures

When to Order Imaging

Routine imaging is NOT indicated for isolated, non-displaced nasal fractures without clinical deformity. 1, 2 The decision to image should be based entirely on clinical findings at presentation.

Order Imaging When These Clinical Features Are Present:

• Visible or palpable nasal deformity 2
• Significant tenderness to palpation of the nasal bones 2
• Persistent epistaxis despite conservative measures 2
• Deep lacerations with exposed cartilage 2
• Suspected complex injuries or associated facial fractures (zygomatic, maxillary, frontal, or orbital involvement) 2, 3

Do NOT Order Imaging When:

• No clinical deformity is present on examination 1
• Isolated soft tissue swelling without bony tenderness 4
• Minor trauma with normal nasal appearance and function 1

Patients without clinical features at initial presentation are significantly less likely to require surgical intervention and should be given a contact number for rapid ENT access if deformity develops over the subsequent 3 weeks. 4

Clinical Examination Essentials

Critical Findings Requiring Urgent Referral (Regardless of Imaging):

• Septal hematoma - requires immediate drainage to prevent cartilage necrosis 1, 3
• Open fracture with exposed cartilage 1
• Suspected cerebrospinal fluid leak (clear rhinorrhea after trauma) 1
• Significant nasal deformity 1

Physical Examination Technique:

• Palpate the entire nasal dorsum for step-offs, crepitus, or focal tenderness 2
• Perform anterior rhinoscopy to exclude septal hematoma (bluish, fluctuant septal swelling) 3
• Assess for associated facial fractures by palpating orbital rims, zygoma, and maxilla 2
• Check for malocclusion suggesting mandibular or maxillary involvement 5

Imaging Modality Selection

First-Line Imaging: CT Maxillofacial Without IV Contrast

CT is the preferred imaging modality when imaging is indicated. 2 It provides superior fracture detection compared to plain radiographs, with higher sensitivity for nasal bone fractures. 5, 2

Advantages of CT: 5, 2

• High-resolution thin-section acquisitions detect subtle non-displaced fractures
• Multiplanar and 3D reconstructions characterize complex fractures
• Essential for surgical planning in comminuted fractures
• Identifies associated facial fractures in up to 75% of cases 5

Plain Radiographs: NOT Recommended

Nasal radiographs should NOT be ordered - they have limited diagnostic value with only 53-82% accuracy and do not alter management. 5, 1, 3 Plain films are unreliable, with negative findings in 9.5% of actual fractures and suspicious findings requiring further imaging in 8.5%. 6

Alternative: Point-of-Care Ultrasound

Ultrasound may be considered for isolated nasal bone fractures when available and the clinician is experienced. 2 It demonstrates very high accuracy with 90-100% sensitivity and 98-100% specificity. 5, 2, 7

Ultrasound advantages: 5, 8

• Better detects non-displaced fractures of the nasal bridge
• Superior for anterior septal cartilage deviation compared to CT
• Higher specificity for midline nasal bone fractures than CT
• No radiation exposure

Technical considerations: A hockey-stick probe (15-7 MHz) or linear array transducer (17-5 MHz) provides optimal visualization. 8

Additional Imaging Considerations

When to Add CT Head:

Order CT head in addition to maxillofacial CT when: 5

• High-energy mechanism (motor vehicle collision, significant fall)
• Frontal bone involvement (one-third have intracranial injury) 5
• Altered mental status or neurological symptoms 5
• Suspected posterior table frontal sinus fracture 5

CT head is NOT indicated for isolated nasal bone injury without these features. 5

Chest Radiograph:

Only indicated if a tooth is absent to exclude aspiration. 5, 2

Common Pitfalls to Avoid

• Do not reflexively order nasal X-rays - they waste resources and provide no clinical benefit 5, 1, 3
• Do not miss septal hematomas - always perform anterior rhinoscopy, as this requires urgent drainage regardless of imaging 1, 3
• Do not image non-displaced fractures without deformity - clinical examination alone guides conservative management 1
• Do not delay reduction beyond 2 weeks - nasal bones begin uniting, making closed reduction difficult 3
• Do not forget to assess for associated injuries - 75% of high-energy nasal fractures have other facial fractures 5