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Emergency and Acute Medicine – Nasal Fractures
Nasal fractures are the most common fractures of the facial skeleton and of the body overall. They usually result from blunt trauma, most commonly due to motor vehicle crashes, sports injuries, and interpersonal altercations. Lateral forces are more likely to cause displacement than direct frontal blows. Although many nasal fractures are isolated and uncomplicated, certain historical and physical features suggest more serious associated injuries, including high-force trauma, loss of consciousness, obvious facial bone injury, frontal bone crepitus, or cerebrospinal fluid (CSF) leakage.
The etiology of nasal fractures is overwhelmingly direct trauma. In adults, altercations are the most frequent cause, whereas in children, sports-related direct blows predominate. Because the pediatric nasal skeleton is more cartilaginous and flexible, significant injury may be present even when deformity appears minimal.
Patients typically present with nasal pain, swelling, deformity, asymmetry, ecchymosis, and epistaxis. Periorbital ecchymosis (“raccoon eyes”) may indicate injury to branches of the ethmoidal artery and raises concern for nasofrontoethmoid complex fractures. Palpable irregularities, sharp edges, crepitus, or abnormal mobility of nasal bones strongly suggest fracture. A critical associated finding is a septal hematoma, which appears as a bluish, fluctuant swelling of the nasal septum; failure to promptly identify and drain it can lead to septal necrosis and permanent deformity. Flattening of the nasal bridge with widening of the intercanthal distance (telecanthus) suggests a serious nasofrontoethmoid injury. Clear rhinorrhea raises concern for a CSF leak, which may be delayed, and anosmia suggests more significant trauma.
History should focus on the mechanism of injury, presence of epistaxis, visual or olfactory changes, and other associated injuries. Physical examination must include careful inspection and palpation of the nose and midface, with particular attention to identifying a septal hematoma and signs of telecanthus. Examination for CSF rhinorrhea is essential; blood-tinged CSF may produce a “double-ring” sign on filter paper, though this finding is not fully reliable.
Routine imaging is rarely required for simple nasal fractures, as radiographs seldom change management. Gross deformities warrant specialist referral regardless of imaging findings, and nondisplaced fractures are treated conservatively even if radiographically evident. Computed tomography is the imaging modality of choice when facial bone fractures, nasofrontoethmoid injuries, or skull base fractures are suspected, and clinicians should have a low threshold for ordering CT when associated injuries are possible.
Initial management prioritizes airway and cervical spine protection, especially in patients with multisystem trauma. Nasotracheal intubation is contraindicated; if airway control is required, orotracheal intubation or cricothyroidotomy should be performed. Epistaxis is often controlled with direct pressure but may require topical anesthetics and vasoconstrictors, cauterization, or nasal packing. Patients with nasal packing should receive prophylactic antibiotics to reduce the risk of sinus and staphylococcal infections.
Definitive reduction of displaced nasal fractures is usually deferred until swelling subsides, typically within 3–5 days, and is performed by an ENT, plastic surgeon, or oral and maxillofacial surgeon. Immediate reduction in the emergency department is generally unnecessary unless airway compromise exists. In contrast, septal hematomas require urgent drainage in the ED, followed by bilateral nasal packing and antibiotic therapy to prevent reaccumulation and infection.
Most patients with isolated nasal fractures can be discharged once epistaxis is controlled and no associated injuries are identified, provided they have reliable follow-up. Admission is reserved for patients with nasoethmoid fractures, CSF leaks, or significant craniofacial injuries. All patients should receive clear instructions to follow up with a specialist within 3–5 days, or sooner (within 24 hours) if a septal hematoma was drained. Careful documentation of the absence or presence of a septal hematoma is essential in every case, as missed hematomas are a common and preventable cause of long-term complications.
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