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Nasal Fractures, Emergency Medicine

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Nasal Fractures, Emergency Medicine

Basics

Description

If concern for anything other than a simple nasal fracture: ‚

Coagulation studies if on anticoagulants with uncontrolled epistaxis ‚

  • Fractures of nasal skeleton are the most common body fractures.
  • Most nasal fractures are result of blunt trauma, frequently from motor vehicle crashes, sports injuries, and altercations.
  • Lateral forces are more likely to cause displacement than straight-on blows.
  • Characteristics that suggest associated injuries:History of trauma with significant forceLoss of consciousnessFindings of facial bone injuryFrontal bone crepitusCSF leak
  • History of trauma with significant force
  • Loss of consciousness
  • Findings of facial bone injury
  • Frontal bone crepitus
  • CSF leak

Etiology

  • The vast majority of nasal fractures are from direct trauma
  • Altercations account for most nasal fractures in adults
  • Direct blows, especially sports, account for most nasal fractures in children

Diagnosis

Signs and Symptoms

  • Nasal deformity, asymmetry, swelling, or ecchymosis
  • Epistaxis
  • Periorbital ecchymosis ( "raccoon eyes " ť) from damage to branches of ethmoidal artery:May indicate nasofrontoethmoid complex injury
  • Palpable sharp edges, depressions, or other irregularities suggest nasal fracture.
  • Crepitus or mobility of skeletal parts on palpation
  • Septal hematoma:Bluish fluid-filled sac overlying nasal septumCritical to detect because it must be drainedFailure to drain can result in necrosis of the septum
  • Flattening of nasal root and widening of intercanthal distance (telecanthus):Indicative of serious nasofrontoethmoid complex injury
  • Clear rhinorrhea indicates possible CSF leak:Rhinorrhea may be delayed.
  • Loss of sense of smell suggests significant injury.
  • Tear duct injuries may be present with abnormal tearing.
  • Associated eye injuries:Subconjunctival hemorrhageHyphemaRetinal detachments
  • May indicate nasofrontoethmoid complex injury
  • Bluish fluid-filled sac overlying nasal septum
  • Critical to detect because it must be drained
  • Failure to drain can result in necrosis of the septum
  • Indicative of serious nasofrontoethmoid complex injury
  • Rhinorrhea may be delayed.
  • Subconjunctival hemorrhage
  • Hyphema
  • Retinal detachments
  • Direct blow
  • Associated injuries or symptoms
  • Presence of epistaxis
  • Changes in vision or smell
  • Thorough physical exam with visual inspection and palpation is vital.
  • It is critical to identify a septal hematoma:Bluish bulging mass on nasal septum
  • Septal deviation
  • Epistaxis or intranasal laceration
  • Examine closely for telecanthus:Intercanthal width >30 " “35 mmWider than width of 1 eyeMay indicate nasofrontoethmoid fractureUsually associated with depressed nasal bridge
  • CSF rhinorrhea:Indicates more serious underlying facial bone or skull fractureCSF mixed with blood will often cause double ring sign when placed on filter paper, although this sign is not 100% reliable.
  • Bluish bulging mass on nasal septum
  • Intercanthal width >30 " “35 mm
  • Wider than width of 1 eye
  • May indicate nasofrontoethmoid fracture
  • Usually associated with depressed nasal bridge
  • Indicates more serious underlying facial bone or skull fracture
  • CSF mixed with blood will often cause double ring sign when placed on filter paper, although this sign is not 100% reliable.

Essential Workup

  • Evaluate nasolacrimal duct for patency:Instill fluorescein into eye and look for it in nasopharynx under inferior turbinate.Absence implies duct injury.
  • Eyelash traction test:Grasp eyelashes on eyelid and pull laterally:If eyelid margin does not become taut or "bow string, " ť then medial portion of tendon has been disrupted.This test is performed on both upper and lower eyelids.Possible for only 1 portion of tendon to be selectively injured
  • Instill fluorescein into eye and look for it in nasopharynx under inferior turbinate.
  • Absence implies duct injury.
  • Grasp eyelashes on eyelid and pull laterally:
  • If eyelid margin does not become taut or "bow string, " ť then medial portion of tendon has been disrupted.
  • This test is performed on both upper and lower eyelids.Possible for only 1 portion of tendon to be selectively injured
  • Possible for only 1 portion of tendon to be selectively injured

Diagnosis Tests & Interpretation

  • Nasal radiographs are rarely indicated:Normally do not alter initial or subsequent managementGross deformities will need referral.Fractures without deformity will be treated conservatively regardless of radiographic findings.Patients with associated facial bone deformity, crepitus, or tenderness may require radiographs.
  • CT is test of choice if facial bone, nasofrontoethmoid, or depressed skull fractures are suspected; have low threshold for ordering CT if other injuries are suspected.
  • Normally do not alter initial or subsequent management
  • Gross deformities will need referral.
  • Fractures without deformity will be treated conservatively regardless of radiographic findings.
  • Patients with associated facial bone deformity, crepitus, or tenderness may require radiographs.

Differential Diagnosis

  • Other facial injuries such as orbital, frontal sinus, maxillary sinus, or cribriform plate fractures
  • Nasofrontoethmoid fracture

Treatment

Pre-Hospital

  • Management of airway takes precedence.
  • Nasotracheal intubation is contraindicated.
  • Consider orotracheal intubation or cricothyroidotomy if definitive airway control is needed.
  • Cervical spine precautions are indicated if there is associated trauma.
  • Epistaxis can normally be controlled with direct pressure; pinch nares together.

Initial Stabilization/Therapy

  • Airway management with orotracheal intubation or cricothyroidotomy:Nasotracheal intubation is contraindicated.
  • Cervical spine precautions
  • Other injuries take precedence.
  • Nasotracheal intubation is contraindicated.

Ed Treatment/Procedures

  • Abrasions and lacerations:Proper cleansing of facial wounds is essential.Lacerations may be sutured.
  • Epistaxis must be controlled if it does not stop spontaneously:Anesthetize/vasoconstrict with topical cocaine, lidocaine, or neosynephrine spray.Identify bleeding source; cauterize anterior source if necessary.Pack nares with petroleum jelly, impregnated gauze, or any number of commercial packs.Posterior packs are rarely needed.Prophylactic antibiotics to prevent sinus infection are indicated if packed: Amoxicillin, amoxicillin/clavulanate, or trimethoprim " “sulfamethoxazole or azithromycin in penicillin allergic patients.Displaced fractures do not need reduction in ED unless airway is compromised.Generally recommended to allow swelling to abate and reduce fracture in 3 " “5 days, although there are many specialists who recommend local anesthesia and immediate reduction.
  • Septal hematoma must be drained immediately in ED:Anesthetize with topical cocaine or lidocaine and vascular constriction with neosynephrine.Attempt to aspirate with 18G to 20G needle on 3-mL syringe.Rolling cotton swab down septum may facilitate drainage.Holding mucosa down against cartilage must be done to prevent reaccumulation.This can be done with petroleum jelly gauze packing.Both nares should be packed to ensure adequate pressure:Packing is left in place for 3 " “5 days or until follow-up with ear, nose, and throat (ENT).Prophylactic antibiotics are prescribed.
  • Proper cleansing of facial wounds is essential.
  • Lacerations may be sutured.
  • Anesthetize/vasoconstrict with topical cocaine, lidocaine, or neosynephrine spray.
  • Identify bleeding source; cauterize anterior source if necessary.
  • Pack nares with petroleum jelly, impregnated gauze, or any number of commercial packs.
  • Posterior packs are rarely needed.
  • Prophylactic antibiotics to prevent sinus infection are indicated if packed: Amoxicillin, amoxicillin/clavulanate, or trimethoprim " “sulfamethoxazole or azithromycin in penicillin allergic patients.
  • Displaced fractures do not need reduction in ED unless airway is compromised.
  • Generally recommended to allow swelling to abate and reduce fracture in 3 " “5 days, although there are many specialists who recommend local anesthesia and immediate reduction.
  • Anesthetize with topical cocaine or lidocaine and vascular constriction with neosynephrine.
  • Attempt to aspirate with 18G to 20G needle on 3-mL syringe.
  • Rolling cotton swab down septum may facilitate drainage.
  • Holding mucosa down against cartilage must be done to prevent reaccumulation.
  • This can be done with petroleum jelly gauze packing.
  • Both nares should be packed to ensure adequate pressure:Packing is left in place for 3 " “5 days or until follow-up with ear, nose, and throat (ENT).
  • Prophylactic antibiotics are prescribed.
  • Packing is left in place for 3 " “5 days or until follow-up with ear, nose, and throat (ENT).

Medication

  • Amoxicillin: 500 mg PO TID (peds: 40 mg/kg PO div. TID)
  • Amoxicillin/clavulanate: 500/125 " “875/125 mg PO BID (peds: 40 mg/kg/d of amoxicillin PO BID)
  • Azithromycin: 500 mg PO day 1 followed by 250 mg PO daily for 4 additional days (peds: 10 mg/kg PO day 1, followed by 5 mg/kg PO days 2 " “4)
  • Cocaine: Topical 4%
  • Lidocaine: 1 " “2% without epinephrine
  • Neosynephrine nasal spray
  • Trimethoprim " “sulfamethoxazole: Double strength (DS) PO BID (peds: 40 mg/kg/d sulfamethoxazole PO BID)

In-Patient Considerations

  • Most nasal fractures do not require admission.
  • Admit patients with nasoethmoid fractures or more significant craniofacial injuries.
  • No evidence of significant head, neck, or other injuries.
  • Epistaxis controlled
  • Reliable companion or caregiver
  • Follow up with specialist sooner because fibrous union begins in only 3 " “4 days
  • Consider contacting child protective services if any suspicion of nonaccidental trauma:History does not fit injury.Always consider nonaccidental trauma as potential mechanism of injury.
  • Fractures are rare in children; nasal injuries in children are more likely to be cartilaginous.
  • Significant injuries in children are not always fully appreciated.
  • History does not fit injury.
  • Always consider nonaccidental trauma as potential mechanism of injury.

Follow-Up

Follow-Up Recommendations

  • Follow up with ENT, plastic surgery, or oral maxillofacial (OMF) surgeon in 3 " “5 days for management:Patients with septal hematoma should follow up in 24 hr for re-evaluation after drainage.
  • Return for signs of clear rhinorrhea, difficulty breathing, fever, or signs associated with head injury.
  • Patients with septal hematoma should follow up in 24 hr for re-evaluation after drainage.

Pearls and Pitfalls

  • The absence of a septal hematoma must be documented in every case.
  • Every patient discharged with nasal packing should be placed on antistaphylococcal antibiotics.
  • Consider cribriform plate fractures in patients with clear rhinorrhea after nasal injury.
  • Have a low threshold for ordering facial bone CT if there is suspicion for associated injuries or fractures.

Additional Reading

  • Atighechi ‚ S, Baradaranfar ‚ MH, Akbari ‚ SA. Reduction of nasal bone fractures: A comparative study of general, local, and topical anesthesia techniques. J Craniofac Surg. 2009;20(2):382 " “384.
  • Ondik ‚ MP, Lipinski ‚ L, Dezfoli ‚ S, et al. The treatment of nasal fractures: A changing paradigm. Arch Facial Plast Surg. 2009;11(5):296 " “302.
  • Repanos ‚ C, Carswell ‚ AJ, Chadha ‚ NK. Manipulation of nasal fractures under local anaesthetic: A convenient method for the Emergency Department and ENT clinic. Emerg Med J. 2010;27(6):473 " “474.
  • Wright ‚ RJ, Murakami ‚ CS, Ambro ‚ BT. Pediatric nasal injuries and management. Facial Plast Surg. 2011;27(5):483 " “490.
  • Ziccardi ‚ VB, Braidy ‚ H. Management of nasal fractures. Oral Maxillofac Surg Clin North Am. 2009;21(2):203 " “208.

See Also (Topic, Algorithm, Electronic Media Element)

  • Epistaxis
  • Facial Fractures

Codes

ICD9

  • 801.00 Closed fracture of base of skull without mention of intra cranial injury, unspecified state of consciousness
  • 802.0 Closed fracture of nasal bones
  • 920 Contusion of face, scalp, and neck except eye(s)

ICD10

  • J34.89 Other specified disorders of nose and nasal sinuses
  • S02.2XXA Fracture of nasal bones, init encntr for closed fracture
  • S02.19XA Oth fracture of base of skull, init for clos fx

SNOMED

  • 263171005 fractured nasal bones (disorder)
  • 282450009 Contusion of nasal septum (disorder)
  • 81639003 closed fracture of nasal bones (disorder)
  • 76542006 Fracture of frontal sinus (disorder)
  • 10859002 Fracture of ethmoid sinus (disorder)
  • 413878002 Closed, displaced fracture of nasal bone (disorder)