Nasal Trauma


Flowchart

Nasal Trauma.png

Red Flags requiring urgent secondary care review:

  • Septal haematoma (refer to ENT)

  • Epistaxis not resolving with appropriate nasal pressure (refer to ENT)

  • Signs or concerns about a skull base or facial fracture (A&E review)

  • Large wound (A&E, ENT, plastic surgery review)

Assessment

History

  • Date of injury

  • Mechanism (?collapse, high or low velocity, safeguarding)

  • Epistaxis

  • Clear rhinorrhoea (concerning for CSF)

  • Head injury history (vomiting, reduced GCS etc)

  • Vision 

  • Patient’s perception of nasal deformity (“has your nose changed shape since the injury?”).

Examination

  • Face: lacerations, bruising, periorbital ecchymosis (base of skull fracture), nasal symmetry (look at the line of light reflecting off the nose. Previous photos of the patient can be used to compare)

  • Ear: post-auricular bruising (base of skull fracture), haemotympanum (blood behind the ear drum (base of skull fracture)

  • Nose: septal haematoma (if unsure if it’s a haematoma or septal deviation use a skin swab to press to identify if it’s fluctuant), septal deviation

Investigations

  • None required for non-complicated nasal trauma. X-rays are not required.

  

Nasal Trauma

Localised swelling soon after nasal injury makes accurate assessment of deformity difficult. There is only a small window for managing patients due to the onset of healing.

It is important to rule out red flags (septal haematoma, severe epistaxis, skull base or facial fracture or a large wound). Traumatic epistaxis generally self-terminates.

Septal haematoma

Septal haematoma occurs between the cartilage of the septum and the perichondrium. It forms a fluctuant pink lump which can be seen on anterior rhinoscopy, usually blocking the airway on both sides. If not managed appropriately it can form an abscess and/or cause nasal collapse. Patients with a septal haematoma should be referred immediately to ENT for drainage.

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Epistaxis

Epistaxis not improving with adequate nasal pressure on the wide cartilaginous part of the nose should be referred immediately to ENT.

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Skull base or facial fractures

These may present after high impact trauma. Bruising patterns which suggest a base of skull fracture are peri-orbital and post-auricular bruising. Clear nasal discharge could be a sign of a CSF leak. A palpable step deformity, cheek paraesthesia, reduced eye movements or jaw movements may indicate a facial fracture.

Nasal deformity

Patients with a suspected new, lateral, bony nasal deviation should be referred to ENT as soon as possible. Specialist review should ideally take place 5-10 days after injury, and always within 3 weeks. Manipulation can be offered under LA or GA to improve nasal symmetry. Please note that nasal humps or septal deviations do not respond to manipulation.

No nasal deformity

Those patients with no new nasal deformity should be told to avoid nasal trauma for 6-8 weeks and discharged with safety netting advice. Radiologically diagnosed fractures without subjective deformity do not need treatment.

Nasal trauma >3 weeks previous

Patients with a post-traumatic nasal deformity older than 3 weeks can be referred routinely for consideration for reconstructive surgery. However, funding is variable depending on whether there is a functional element.

Referral pathways 

Same-day referral:

  • Septal haematoma

  • Severe epistaxis

  • Skull base or facial fracture

  • Wound which requires closure

Referral to ENT emergency clinic (< 1 week)

  • Patients with suspected new nasal deformity without red flags

Routine referral to ENT/rhinology

  • Patients with nasal deformity >3 weeks following injury

 

More information

https://www.nhs.uk/conditions/broken-nose/

https://www.entuk.org/nasal-injuries

Authors:

Mr Elliot Heward, ENT Registrar, North West Deanery

Mr Thomas Jacques, Consultant Rhinologist/ENT Surgeon, St. George’s Hospital, London