Nasal Bone Fracture: Referral and Treatment Algorithm
Refer isolated nasal bone fractures to ENT/Otolaryngology for closed reduction with or without septal correction, but immediately refer to maxillofacial surgery if there are associated complex midface fractures (naso-orbital-ethmoid, Le Fort, or zygomaticomaxillary complex injuries). 1, 2
Immediate Assessment for Urgent Referral Indications
Before determining the appropriate specialist, evaluate for these conditions requiring immediate subspecialist referral:
- Septal hematoma → Urgent ENT referral for drainage to prevent septal necrosis 3, 4
- Open fracture with exposed cartilage → Urgent ENT referral 3
- Cerebrospinal fluid leak (suggests cribriform plate involvement) → Urgent neurosurgical consultation 3, 2
- Persistent epistaxis despite conservative measures → Urgent ENT referral 3
- Malocclusion or extraocular movement defects → Urgent subspecialist referral 4
Determining the Appropriate Specialist
Refer to ENT/Otolaryngology for:
- Isolated nasal bone fractures (including bilateral comminuted patterns) requiring closed reduction 2
- Nasal fractures with septal deviation requiring septal correction before or during nasal bone realignment 1, 2
- Displaced nasal fractures with clinical deformity requiring reduction within 2 weeks 2
Key principle: ENT specialists routinely manage isolated nasal bone fractures and perform closed reduction with or without septoplasty 2. Septal correction must precede nasal bone realignment when septal deviation is present 1.
Refer to Maxillofacial Surgery for:
- Naso-orbital-ethmoid (NOE) complex fractures involving medial orbital walls, nasal septum, and naso-frontal junction (prevents enophthalmos, telecanthus, lacrimal obstruction, ptosis) 2
- Le Fort II or III fractures where nasal bones are part of pyramidal midface injuries involving orbital rims, maxillary sinuses, and pterygoid plates 2
- Zygomaticomaxillary complex fractures with nasal involvement requiring open reduction and internal fixation 2
Critical distinction: The American College of Radiology emphasizes that complex midface fractures require subspecialist management due to involvement of multiple facial bones and potential for severe functional and cosmetic complications 5, 2.
Clinical Features Warranting ENT Referral
Only refer patients showing clinical features at presentation, as these patients are significantly more likely to require surgical correction (P < 0.001) 6:
- Visible nasal deformity or deviation 3, 6
- Significant septal deviation (96.2% of simple nasal fractures have associated septal fractures) 7
- Mucosal tearing (statistically significant predictor of septal fracture requiring septoplasty) 7
- Nasal obstruction 3
Common pitfall: Patients without clinical features at initial presentation rarely require surgical intervention and should not be routinely referred 6. Instead, provide a telephone number for rapid ENT access if clinical features develop within 3 weeks 6.
Imaging Before Referral
- Order CT maxillofacial imaging to characterize fracture pattern and identify extension to adjacent structures 2
- Do NOT order plain nasal radiographs (only 53-82% accuracy, does not alter management) 5, 3
- Screen for intracranial injury as 68% of maxillofacial trauma patients have associated head injury 2
- Assess for other facial fractures (zygomatic, maxillary, frontal) using CT 3
Timing of Referral
- Within 3-5 days for non-urgent cases requiring closed reduction 4
- Within 2 weeks for optimal fracture reduction outcomes 2
- Immediate for septal hematoma, CSF leak, open fractures, or complex midface injuries 3, 2, 4
Initial Management Before Referral
For Epistaxis:
- Instruct patient to lean forward and pinch soft part of nose for 15 minutes 3
- If bleeding persists, spray 2 sprays of oxymetazoline (65-75% resolution rate) 3
For Pain:
- Prescribe regular paracetamol unless contraindicated 3
- Use opioids cautiously in elderly patients with renal dysfunction 3
- Avoid NSAIDs in patients with renal dysfunction 3