A nasal fracture occurs when there is a direct blow to the nose. Common signs are swelling, tenderness, and possible deformity over the nasal bones. Minor injuries may not require x-rays, as treatment decisions are based on physical exam. Displaced or deformed fractures may require realignment, while stable fractures can heal without intervention. Bleeding can be stopped with topical anesthetic, and lacerations or septal hematomas should be inspected for. Instructions depend on severity, from avoiding contact sports to surgical consultation for realignment.

1. Nasal Fracture
Presentation
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 nasal deformity.
What to do:
• Examine for any associated injuries (i.e., blowout fractures, zygoma fractures).
• 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
advisable.
• An isolated fracture of the anterior nasal spine (in the columella of the nose),
does not necessitate restricting activities. It only hurts when you smile.
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 to help.
• 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.

2. • 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.
Discussion
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 irreversable damage.