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Nasal Trauma
Diagnosis/Definition
- Nasal trauma is most commonly due to a blunt impact, but can be generally defined as any injury to the nose. The severity of the trauma and need for subsequent management can vary greatly.
Initial Diagnosis and Management - History: The diagnosis of nasal trauma is made by the history and in all cases requires an evaluation to determine the severity of the injury and the presence of associated injuries.
- Specific historical points should include the mechanism of injury, loss of consciousness, degree of epistaxis, presence of rhinorrhea, and visual symptoms, all of which can help diagnose other injuries.
- Complaints of nasal obstruction in the acute setting may indicate a collapsed airway from a bony fracture, a septal deviation, or a septal hematoma.
- In trauma that is greater than 1 week old, the major complaints dictating management are severe cosmetic deformity and nasal obstructive symptoms.
- Physical: After a complete head and neck examination to rule out associated injuries, the nasal exam focuses on ruling out pathology requiring immediate intervention (i.e. a septal hematoma, significant lacerations, or persistent epistaxis). The intranasal cavity needs to be visualized with a good light source, a nasal speculum, and suction. A septal hematoma appears as a very edematous, erythematous, and boggy mass within the septum, often filling the majority of the nasal cavity. The nasal examination should also document the displacement of the nasal bones and apparent external deviation of the nose despite initial edema, including a comparison from old photos if possible. Any visible airway obstruction should be noted.
- Ancillary Tests: Plain films are rarely indicated as they seldom aid in the diagnosis. CT scans may be indicated for diagnostic confirmation of associated injuries.
Initial Management
The goal of initial management of nasal trauma (assuming no need for immediate intervention) is to control any bleeding, reduce swelling, and maintain a patent airway. This is typically accomplished with elevation, ice packs, and nasal decongestants.
Ongoing Management and Objectives
Observation for resolution of edema, bleeding, and nasal obstruction.
Indications for Specialty Care Referral
Any nasal trauma with evidence of a septal hematoma, complex laceration, or uncontrolled epistaxis should be referred to Otolaryngology for evaluation immediately.
Patients that complain of significant nasal obstruction after conservative management that are less than 10 days out from the trauma should be referred to Otolaryngology by contacting the resident on call.
Patients that have significant cosmetic deformity and are less than 10 days out from the trauma should be referred to Otolaryngology by contacting the resident on call. It is important to refer nasal fractures to ENT before 10 days for immediate repair to be effective.
Patients who have a significant nasal deformity or nasal obstruction that are more than 10 days out from the trauma, and who desire surgical evaluation, should be referred on a routine basis.
Criteria for Return to Primary Care
Resolution or control of the problem by appropriate medical or surgical therapy.
