How should an acute nasal fracture be assessed and treated, including indications for reduction, anesthesia type, splinting, pain control, septal hematoma drainage, antibiotic prophylaxis, imaging, activity restrictions, and follow‑up?

Management of Acute Nasal Fractures

For isolated nasal bone fractures, perform closed reduction under local anesthesia within 5-14 days, but immediately refer to maxillofacial surgery if CT reveals complex midface fractures (naso-orbital-ethmoid, Le Fort, or zygomaticomaxillary complex injuries). 1, 2

Initial Assessment and Imaging

Clinical Evaluation

• Check for septal hematoma immediately by examining the nasal septum for bluish, fluctuant swelling—this requires urgent drainage to prevent septal necrosis and saddle nose deformity 2, 3
• Look for CSF rhinorrhea (clear watery drainage), which indicates cribriform plate injury requiring neurosurgical consultation 2
• Document visible nasal deformity, epistaxis severity, mucosal tearing (highly predictive of septal fracture), and any exposed cartilage 4, 5
• Record mechanism of injury, previous nasal trauma, and pre-existing deformity 3

Imaging Strategy

• Order CT maxillofacial without IV contrast for suspected complex injuries, associated facial fractures, or when surgical planning is needed 1, 4
• Do not order plain nasal radiographs—they have only 53-82% accuracy and do not change management 1, 4
• Consider point-of-care ultrasound for isolated nasal bone fractures (90-100% sensitivity, 98-100% specificity), particularly useful for detecting non-displaced fractures 1, 4
• Order head CT only if signs of intracranial injury or other facial fractures are present—not needed for isolated nasal injury 4
• Screen for cervical spine injury in high-velocity trauma, as 7-11% of maxillofacial trauma patients have concomitant cervical spine fractures 6

Immediate Management

Epistaxis Control

• Instruct patient to lean forward and apply firm sustained compression to the soft part of nose for 15 minutes 2
• If bleeding persists, spray oxymetazoline 2 sprays per nostril (65-75% resolution rate) 2
• Use resorbable packing for patients on anticoagulants or with bleeding disorders 6

Pain Management and Supportive Care

• Prescribe regular acetaminophen (paracetamol) as first-line analgesia 2
• Apply ice for first 48-72 hours to reduce swelling 2
• Use humidification and saline nasal spray for symptomatic relief 2
• Instruct patients to avoid nose-blowing, contact sports, and nasal manipulation 2

Indications for Reduction

Timing

• Perform reduction within 5-14 days of injury before significant healing occurs 3, 7
• Earlier reduction (within 3-5 days) may be preferable if swelling permits adequate assessment 3

Criteria for Reduction

• Visible or palpable nasal deformity with functional or cosmetic concerns 4
• Nasal obstruction from displaced fracture fragments 3
• Patient dissatisfaction with appearance after swelling resolves 8

Anesthesia Type

Use local anesthesia for simple nasal bone fractures requiring closed reduction—this is effective first-line treatment and should be standard practice 3, 7

• Consider outpatient general anesthesia for severe septal fracture-dislocation requiring primary septal reconstruction 7
• Local anesthesia involves topical application and infiltration to anesthetize the fracture site 6

Treatment Algorithm by Fracture Complexity

Simple Isolated Nasal Bone Fractures

• Perform closed reduction under local anesthesia 3, 7
• Recognize that 96% of simple nasal fractures have associated septal injury—examine septum carefully via anterior rhinoscopy or endoscopy 5
• If mucosal tearing is present, septal fracture is highly likely and may require septoplasty 5

Fractures with Significant Septal Deviation

• Septal correction must precede nasal bone realignment 1, 2
• Perform septoplasty or submucosal resection for severe septal fractures (78.8% of cases require this) 5
• Position septum into midline using transverse root osteotomy if needed 1
• Place strut between medial crura for support and realignment 1

Complex Midface Fractures

• Immediately refer to maxillofacial surgery for naso-orbital-ethmoid, Le Fort, or zygomaticomaxillary complex injuries 2
• These require subspecialist management to prevent telecanthus, enophthalmos, lacrimal obstruction, and eyelid ptosis 2

Comminuted Fractures

• Consider camouflaging techniques using dorsal onlay grafts with septal cartilage to hide residual deviations when complete correction is impossible 1

Surgical Technique Principles

• Preserve periosteal and mucosal attachments of nasal bone to minimize destabilization 1
• Use smallest manipulative force necessary to achieve reduction 1
• Avoid creating periosteal tunnels, which are detrimental to support 1
• Perform smallest possible osteotomies for mobilization 1
• Avoid intermediate osteotomies—they risk visible irregularities in areas with thin overlying skin 1

Splinting

• Apply external nasal splint after reduction to maintain alignment 3
• Duration typically 5-7 days, though specific guidelines vary by surgeon preference 3
• Internal splints may be used if septoplasty performed 5

Antibiotic Prophylaxis

The provided guidelines do not specifically address antibiotic prophylaxis for nasal fractures. In clinical practice, antibiotics are generally reserved for open fractures with exposed cartilage or when nasal packing is placed, though this should be individualized based on contamination risk.

Activity Restrictions

• Avoid contact sports and activities risking re-injury during healing period 2
• No nose-blowing to prevent disruption of reduction 2
• Avoid nasal manipulation 2

Follow-Up

• Assess outcome within 30 days or document transition of care 6
• Long-term follow-up at 3 months and 3 years shows 90% patient satisfaction and 84% normal nasal airflow with closed reduction 8
• Revision rate should be approximately 9% with proper technique including complete nasal assessment and primary septal reconstruction when needed 7
• Secondary deformities (saddling or hump) may develop during follow-up period in some cases 8

Critical Pitfalls to Avoid

• Missing septal hematoma—examine every nasal fracture patient for this complication requiring urgent drainage 2, 3
• Failing to identify septal fractures—96% of simple nasal fractures have septal involvement that may require correction 5
• Relying on CT alone to determine need for septoplasty—CT cannot accurately predict septal fracture severity (only 33.5% correlation with operative findings) 5
• Attempting osteotomies on short nasal bones—this is a relative contraindication due to risk of bony communication with limited benefit 1
• Missing complex midface fractures—always obtain CT to rule out naso-orbital-ethmoid, Le Fort, or zygomaticomaxillary injuries requiring subspecialist care 2, 4
• Performing closed reduction alone when significant septal injury present—this leads to high rates of posttraumatic deformity (14-50%) 7