Management of Acute Nasal Fractures CORRY J. KUCIK, LT, MC, USN, TIMOTHY CLENNEY, CDR, MC, USN, and JAMES PHELAN, CDR, MC, USN Naval Hospital Jacksonville, Jacksonville, Florida In cases of facial trauma, nasal fractures account for approximately 40 percent of bone injuries. Treatment in the primary care setting begins with evaluating the injury, taking an accurate history of the situation in which the injury occurred, and ascertaining how the face and nose appeared and functioned before the injury occurred. Serious injuries should be treated, then nasal inspection and palpation may be performed to assess for airway patency, mucosal laceration, and sep- tal deformity. A thorough examination of the nose and surrounding structures, including the orbits, mandible, and cervical spine, should be completed. Imaging studies are necessary for facial or mandibular fractures. Patients with septal hematomas, cerebrospinal fluid rhi- norrhea, malocclusion, or extraocular movement defects should be referred to a subspecialist. Treatment in the primary care setting con- sists of evaluation, pain and infection management, minimal debride- ment and, when the physician is appropriately trained, closed reduc- tion. If an immediate referral is not indicated, close follow-up, possibly with a subspecialist, should be arranged within three to five days after the injury. (Am Fam Physician 2004;70:1315-20. Copyright© 2004 American Academy of Family Physicians.) njuries to the nose are relatively com- of the face. The nose is supported by cartilage mon; in cases of facial trauma, nasal anteriorly and inferiorly, and by bone poste- fractures account for approximately 40 riorly and superiorly (Figure 1). The paired percent of bone injuries.1 Fights and nasal bones, the nasal process of the frontal I sports injuries account for most nasal frac- bone, and the maxilla form a framework to tures in adults, followed by falls and vehicle support the cartilaginous skeleton. Although crashes. Play and sports account for most most of the nasal structures are cartilaginous, nasal fractures in children. Physical abuse the nasal bones usually are fractured in an should be considered in children and women, injury. and should be appropriately ruled out.2 Overlying this framework are soft tissues, Nasal fractures may occur in isolation or mucous glands, muscles, and nerves respon- in association with other facial injuries. Fur- sible for sensation and function of the nose. thermore, many nasal fractures go undiag- By virtue of its natural taper, the supporting nosed and untreated because some patients nasal septum becomes increasingly thin and do not seek medical care.3 Though seen occa- is therefore subject to fracture toward the tip sionally in family practice, patients with nasal of the nose. fractures are more likely to present to emer- The relative ease by which epistaxis can gency departments or urgent care settings. occur with minor trauma is explained by Fractures that are more than two days old the dense and redundant vascular network will have substantial edema and should be that supplies the nose. This plexus, known referred urgently for subspecialty evaluation. as Kiesselbach’s area, is responsible for the vast majority of normal epistaxis.4 However, Anatomy bleeding as a result of nasal fracture usually The nose is easily exposed to trauma because originates from other locations within the it is the most prominent and anterior feature nose. For example, profuse anterior bleeding October 1, 2004 ◆ Volume 70, Number 7 www.aafp.org/afp American Family Physician 1315 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2004 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Understanding the mecha- may originate from the anterior wish to determine whether the patient had nism of trauma is helpful to ethmoid artery (a branch of the been drinking before the injury. This point ophthalmic artery), while pos- may have implications for selection of pain the physician in determin- terior bleeding is more likely medications, potential for repeat injury, and ing the extent of the injury. to arise from a branch of the the ability to assess for mental status changes sphenopalatine artery. Arterial associated with head injury. ligation may be necessary if packing fails to control bleeding. In such cases, early consulta- PHYSICAL EXAMINATION tion with an otolaryngologist is indicated.5,6 Most nasal fractures are the result of minor trauma such as being punched or elbowed. Assessment However, when assessing a patient with an HISTORY acute nasal injury, the physician should avoid Understanding the mechanism of trauma is focusing solely on the obviously traumatized helpful to the physician in determining the nose. This is particularly important if the extent of the injury. It is useful to know the patient has experienced a violent traumatic responsible object, the direction from which event such as a motor vehicle crash or an it came, and the strength of force sustained by assault. A substantial direct blow to the the nose. For example, a direct frontal blow mid-face area can result in cervical spine can depress the dorsum of the nose, causing injury, and the physician must therefore the fractured bones to telescope posteriorly. exercise clinical judgment in using appropri- Likewise, a laterally directed injury can cause ate precautions until a cervical spine injury is a depression on the side of the impact, often ruled out. During the initial assessment, the with a corresponding outward displacement physician should be certain that the patient on the opposite side of the nose. Traction has an adequate airway and is ventilating and torsion injuries, though rare, also can appropriately. cause cartilaginous disruption.7 A nasal injury may be associated with other The patient should be asked about the head and neck trauma that could compromise timing and extent of any bleeding associ- the patency of the trachea. Furthermore, given ated with the injury. The history also should the close proximity of the nose to other facial include information regarding previous sur- structures, the physician must consider the geries, injuries, and a subjective assessment possibility of an associated facial or mandib- of baseline nasal function and appearance. ular fracture.3 Therefore, all bony structures Finally, because alcohol use frequently is of the face, including the malar eminences, associated with such trauma, physicians may orbital rims, zygomatic arches, mandible, and teeth, should be carefully inspected and pal- pated for irregularity or tenderness. All facial lacerations, swellings, and deformities should Nasal bone Frontal process be noted, and the eyes should be examined of maxilla for symmetry and mobility of gaze.8 If a facial Medial crus or mandibular fracture is suspected, radio- Upper lateral cartilage logic assessment with computed tomography Fibroareolar (CT) is indicated.9 tissue Lateral A deformity of the nose usually will be crus evident when a nasal fracture has occurred. However, epistaxis without obvious nasal deformity may be the only clinical finding Medial and lateral Septal cartilage in some nasal fractures. Edema and ecchy- crura of lower lateral cartilage mosis of the nose and periorbital structures ILLUSTRATIONS BY CHRISTY KRAMES ordinarily will be present, particularly if Figure 1. Anatomic relationship between the nasal bones, cartilage, examination is performed more than sev- and septum. eral hours after the injury. Palpation of the 1316 American Family Physician www.aafp.org/afp Volume 70, Number 7 ◆ October 1, 2004 Nasal Fractures Failure to identify and treat a septal hema- toma can result in a saddle deformity of the septum, which will require surgical repair. A thorough internal examination is facili- tated with good lighting, suction, anesthesia, and vasoconstrictive nasal sprays. A nasal speculum and a headlamp will improve Figure 2. Bilateral septal hematomas associ- visualization, as will a fiberoptic endoscope, ated with a nasal fracture. if available. The initial internal inspection usually will reveal the presence of large nasal structures should be done to elicit any blood clots, which should be removed with crepitus, indentation, or irregularity of the warm saline irrigation, suction, and cotton- nasal bone. Uncommon findings such as tipped applicators. a cerebrospinal fluid (CSF) leak posing as Adequate anesthesia and vasoconstric- clear rhinorrhea, subcutaneous emphysema, tion should be obtained before the complete mental status changes, new malocclusion, internal examination. This is best achieved or limited extraocular movement should with topical agents administered as sprays, prompt immediate subspecialty referral.3,10 impregnated cotton-tipped applicators, or Knowledge of the shape and appearance of local injections. Cocaine in a 5 or 10 percent the patient’s nose before the injury will aid solution, though often difficult to obtain, in comprehending the severity of the nasal is a highly effective single therapy appro- injury. This is best accomplished by view- priate for both vasoconstriction and anal- ing a good quality photograph of the patient gesia. Alternatives for anesthesia include taken before the injury. If a photograph is intranasal topical lidocaine (Xylocaine), not available, the photo on a driver’s license bupivacaine