When should a patient with a suspected broken nose and possible history of bleeding disorders or previous nasal injuries see an Ear, Nose, and Throat (ENT) specialist?

When to See an ENT Specialist for a Broken Nose

A patient with a suspected nasal fracture should see an ENT specialist if there are clinical features present (visible deformity, functional obstruction, or persistent symptoms), if there is concern for septal hematoma, or if bleeding is difficult to control—but emergent hospital evaluation takes priority over outpatient ENT referral when there is active bleeding with hemodynamic instability, airway compromise, or signs of significant blood loss. 1, 2, 3, 4

Immediate Triage: Hospital vs. ENT Clinic

The first critical decision is whether the patient needs emergent hospital evaluation or can be directed to an ENT clinic:

Send to Emergency Department/Hospital Immediately if:

• Active bleeding with airway compromise or hemodynamic instability 1, 2
• Bleeding duration >30 minutes over 24 hours 1, 2
• Bilateral bleeding or bleeding from the mouth (suggests posterior source) 2
• Signs of acute hypovolemia (tachycardia, syncope, orthostatic hypotension) 5
• History of hospitalization or prior blood transfusion for nosebleeds 1, 2
• Suspected septal hematoma requiring urgent drainage 4

Can Be Assessed in ENT Clinic if:

• Minor active bleeding without airway or hemodynamic concerns 2
• No active bleeding with history of only minor prior bleeding 2
• Stable patient with nasal deformity or functional concerns 3, 4

Specific Indications for ENT Referral After Nasal Fracture

Refer to ENT if Clinical Features Are Present:

The most important evidence comes from a 2004 study showing that patients with nasal fractures should only be referred to ENT if they demonstrate clinical features on initial presentation—those without clinical features rarely require intervention. 3 This study found that patients showing clinical features in the emergency department were significantly more likely to attend their appointment (P < 0.005) and undergo surgical correction (P < 0.001). 3

Clinical features warranting ENT referral include:

• Visible nasal deformity or displacement 3, 4
• Functional nasal obstruction or difficulty breathing 3, 4
• Persistent symptoms after initial management 3
• Suspected septal hematoma (requires urgent drainage within hours) 4

Timing of ENT Referral:

• Displaced nasal fractures should be referred for reduction within a 2-week window before the bones start uniting 4
• However, a 2015 prospective study of 400 patients showed patient satisfaction with manipulation performed up to 5 weeks post-injury 6
• For patients who develop clinical features over the first 3 weeks after injury, provide a telephone number for rapid access to ENT clinic 3

Special Considerations for Bleeding Disorders and Anticoagulation

Patients with Bleeding Disorders or on Anticoagulation:

These patients require modified management but not necessarily immediate ENT referral unless bleeding is difficult to control:

• Use resorbable packing materials only (Nasopore, Surgicel, Floseal) to reduce trauma during removal 5, 1
• Document all anticoagulants and antiplatelet agents 1
• In the absence of life-threatening bleeding, initiate first-line treatments (compression, cautery, packing) before reversing anticoagulation 5, 2
• Obtain PT/INR and aPTT if there is clinically relevant bleeding 1

When Bleeding Is Difficult to Control:

Refer to ENT (or perform if trained) for nasal endoscopy when:

• Anterior rhinoscopy fails to identify the bleeding source 5, 2
• Bleeding is difficult to control despite compression and packing 5
• There is concern for unrecognized pathology 5
• Nasal endoscopy localizes the bleeding site in 87-93% of cases 5, 7

Patients with Previous Nasal Injuries

Previous nasal injuries or surgeries increase the complexity of management and lower the threshold for ENT referral:

• Document prior nasal/sinus surgery or nasal trauma as risk factors 2
• These patients may have altered anatomy making self-limited bleeding less likely 2
• Consider earlier ENT consultation for patients with recurrent nasal trauma 6

Common Pitfalls to Avoid

• Do not refer all suspected nasal fractures to ENT—only those with clinical features present on initial examination 3
• Do not delay local control measures (firm compression for 5-10 minutes) while arranging specialty consultation 1, 2
• Do not order routine X-rays—they are not helpful for assessing traumatic nasal injuries 4
• Do not miss a septal hematoma—this requires urgent drainage and cannot wait for outpatient ENT follow-up 4
• Do not automatically reverse anticoagulation—use resorbable packing and local measures first unless there is life-threatening bleeding 5, 2

Algorithm for Decision-Making

1. First: Control active bleeding with firm sustained compression for 5-10 minutes 1, 2
2. Second: Assess for emergent features requiring hospital evaluation (see list above) 1, 2
3. Third: If stable, examine for clinical features (deformity, obstruction, septal hematoma) 3, 4
4. Fourth: If clinical features present, refer to ENT within 2 weeks 3, 4
5. Fifth: If no clinical features, provide telephone number for rapid access if symptoms develop over next 3 weeks 3