UH Clinical Update - April 2017

By Fadi Abbass, MD, FACS, and Hassan Abbass, MD, FACS, Otolaryngology

As we approach the warmer weather, we typically see an increase in the number of injuries associated with outdoor/sports activities. Being the most prominent facial feature, the nose is the most frequently injured/fractured facial structure. Delayed or inadequate treatment frequently leads to long-term issues related to both function and appearance.

In most cases, the diagnosis of nasal fracture can be made clinically without the need for imaging. The history of substantial trauma to the nose requires a thorough evaluation, including careful external and internal inspection and palpation. Specific findings that should be noted include presence/absence of bruising/ecchymosis of the nasal and periorbital area, nasal dorsal deviation, tenderness, palpable bony irregularity, septal hematoma or dislocation, and blood clots in the nasal cavity.

Imaging for suspected nasal fracture is controversial, and routine imaging is generally discouraged. In fact, many experts believe that the time and expense involved cannot be justified, as imaging rarely changes the management plan. However, in some cases imaging can be helpful. Examples include cases when severe edema or pain precludes an adequate exam or when the severity of the nasal injury raises the possibility of other injuries, such as an orbital or nasoethmoid fracture. Simple radiographs are rarely helpful. In fact, studies have shown that simple radiographs are normal in 47 percent of patients with a nasal bone fracture. If imaging has the potential to change the treatment plan, and that’s generally rare, then CT scan is the study of choice.

There is also some controversy about the treatment of nasal fractures. Fractures with minimal displacement can be observed and rarely require intervention. In cases where surgical intervention is warranted, timely treatment is crucial, especially in younger patients. In these patients, delayed treatment makes it more difficult to obtain an ideal outcome due to decreased mobility of the nasal bones.

Ideally, treatment should be done within three hours of the injury, before the onset of edema, as the presence of edema adds some difficulty to the repair. In most cases, it’s not feasible and repair is usually delayed until the edema has mostly subsided – usually within three to seven days. This delay does not seem to negatively impact the final outcome.

Treatment of nasal fractures should also include counseling. A history of prior nasal fracture frequently precludes an ideal result. Therefore, the patient should be counseled regarding the need to minimize the chance of a repeat fracture. This is especially important in cases involving children. The importance of using proper protective gear during sport activities should be emphasized to the patient/parents. And contact sports should be avoided for at least four weeks.