Do All Nasal Trauma Patients Need CT?
No, not all nasal trauma requires CT imaging—only those with suspected complex injuries, associated facial fractures, or specific clinical findings warrant CT maxillofacial imaging. 1
Clinical Indications for CT Imaging
CT maxillofacial without IV contrast is indicated when any of the following are present: 1
- Visible or palpable nasal deformity
- Suspected complex injuries or associated facial fractures (naso-orbital-ethmoid, Le Fort, zygomaticomaxillary complex) 2, 1
- Deep lacerations with exposed cartilage 1
- Persistent epistaxis despite conservative measures 1
- Signs suggesting extension beyond isolated nasal injury (orbital, maxillary, frontal, or zygomatic involvement) 3
When CT is NOT Needed
Isolated, non-displaced nasal fractures without clinical deformity do not require any imaging. 4 Clinical examination by an experienced provider remains the gold standard for determining management in simple nasal trauma. 5
Key Evidence Against Routine Imaging:
- Plain radiographs have poor diagnostic accuracy (only 53-82%) and do not alter clinical management 2, 4, 6
- CT findings do not predict need for surgery better than clinical examination—surgery rates are similar whether diagnosed by CT (41%) or clinical exam alone (37%) 5
- Overdiagnosis is far more common than missed fractures (24.5% overdiagnosis rate vs 1.9% missed diagnoses), particularly when imaging is used without specialist consultation 7
Why CT When Indicated
When complex injury is suspected, CT maxillofacial provides: 2
- High-resolution detection of subtle non-displaced fractures with thin-section acquisitions
- Multiplanar and 3D reconstructions critical for surgical planning in complex fractures
- Full characterization of injury extent and detection of additional facial fractures 2
- Superior sensitivity compared to radiographs for confirming nasal bone fractures 2
Critical Clinical Pitfall
Always exclude septal hematoma on physical examination—this requires urgent ENT referral for drainage regardless of imaging findings, as it can lead to septal necrosis. 4, 6 This is a clinical diagnosis that does not require imaging.
Alternative Imaging Consideration
Ultrasound may be considered for isolated nasal bone fractures, showing 90-100% sensitivity and 98-100% specificity, though it is not typically first-line. 2, 1 Ultrasound can even detect non-displaced fractures and anterior septal cartilage deviation better than CT in some cases. 2
Associated Injuries Requiring Broader Imaging
Remember that 68% of patients with maxillofacial trauma have associated head injuries. 2, 6 If there are signs of intracranial injury or other facial fractures beyond isolated nasal trauma, head CT should be obtained. 2 However, CT head is not indicated for isolated nasal bone injury alone. 2, 1