After a direct blow to the nose the patient usually arives at the
emergency department with minimal continued hemorrhage. There is
usually tender ecchymotic swelling over the nasal bones or the anterior
maxillary spine; inspection and palpation may (or may not) disclose a
What to do:
Examine for any associated injuries (i.e., blowout fractures, zygoma
With minor injuries, explain that x rays are not routinely used or
useful, because all therapeutic decisions are made on the basis of the
physical examination. If there is a fracture, but it is stable and in good
position clinically, it need not be reset. Conversely, a broken and
displaced cartilage may obstruct breathing and require operation, but
never show up on the film. Send the patient for x rays of the nasal
bones only if there is a good reason.
If bleeding continues, instill cotton pledgets soaked in 4% cocaine or
2% tetracaine (Pontocaine) mixed 1:1 with 1% Neo-Synephrine or
epinephrine 1:1000 into both nasal cavities.
After removing the.cotton pledgets, inspect the nasal mucosa for large
lacerations or a septal hematoma.
Patients with nondisplaced fractures without deformity should be sent
home with analgesics, cold packs, and instructions to avoid contact
sports and related activities for six weeks.
Patients with displaced fractures and/or nasal deformity should have
otolaryngologic or plastic surgery consultation for immediate or delayed
reduction. Patients can be instructed that reduction is more accurate
after the swelling subsides and there is no greater difficulty if it is done
within six days of the injury.
Septal hematomas should be drained to prevent septal necrosis and the
development of a saddle nose deformity. Otolaryngologic consultation is
An isolated fracture of the anterior nasal spine (in the columella of
the nose), does not necessitate restricting activities. It only hurts when
What not to do:
Do not automatically x ray every injured nose. Patients may expect
this, because it is the old practice, but routine films have turned out not
Do not assume a negative x ray means no fracture when a deformity
is apparent. X rays can often be inaccurate in determining the presence
and nature of a nasal fracture. Rely on your clinical assessment. When
there is swelling, arrange for re-examination in 3-4 days when the
swelling subsides, to look for subtle deformities.
Do not pack an injured nose that does not continue to bleed. Packing
is generally unnecessary and will only add to the patient's discomfort.
The two most common indications for reducing a nasal fracture
are an unacceptable appearance and inability of the patient to breathe
through the nose. Regardless of x-ray findings, if neither breathing nor
cosmesis is a concern, it is not necessary to reduce the fracture. Nasal
fractures are uncommon in young children, because their noses are
mostly pliable cartilage. Suspect septal hematoma when a patient's
nasal airway is completely occluded. Within 48 to 72 hours a
hematoma can compromise the blood supply to the cartilage and cause