Nasal fractures
===============

* Jess Rhee
* Sheena Belisle
* Julie Strychowsky

## Nasal bone radiographs should not be ordered in the evaluation of nasal bone fractures

Radiography has low sensitivity (64.9% [standard deviation 4.8%]) and specificity (67.8% [standard deviation 4.7%]) in identifying nasal fractures in both adult and pediatric populations and does not change clinical management.1 Physical examination is the gold standard for the diagnosis of nasal fractures.2

## Computed tomography (CT) should not be used in the workup of isolated nasal trauma

If multiple facial bone fractures are suspected, or there is a high velocity mechanism of trauma, CT should be considered to guide management.3 There is no role for CT in isolated nasal trauma.4

## The decision to perform reduction of a nasal fracture is based on clinical assessment

Physical examination should include evaluation for nasal deformity or malposition, with palpation for local nasal tenderness with step-off deformity or crepitus.4 Periorbital swelling or ecchymoses, epistaxis or local nasal tenderness may be seen. The decision to perform nasal reduction depends on degree of external deformity, breathing difficulty and patient preference, none of which are assessed by radiography.4

## Assessment for associated septal hematoma is essential

The reported rate of septal hematomas after nasal injury is 1% and may be higher in children.5 If identified, they should be incised and drained immediately. Without treatment, hematomas can lead to necrosis of the underlying cartilage, causing saddle nose deformity.4 Untreated septal hematomas can become infected and spread to the sinuses or intracranially.4

## Nasal fracture reduction should ideally occur within 2 weeks of injury

Timely referral for consideration of nasal fracture reduction is paramount. If swelling and edema of the nose make examination difficult, patients should be reassessed within 5–10 days.4 Reduction should ideally occur within 2 weeks before nasal bones fixate. Untreated nasal fractures can lead to nasal obstruction and chronic rhinosinusitis.3

## Footnotes

*   **Competing interests:** Julie Strychowsky reports grants outside the submitted work: Department of Otolaryngology–Head and Neck Surgery Catalyst Grant at Western University, Academic Medical Organization of Southwestern Ontario Opportunities Fund Grant, Academic Medical Organization of Southwestern Ontario Innovation Fund Grant, Children’s Health Foundation Grant, and Department of Surgery Internal Research Funding. No other competing interests were declared.

*   This article has been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

## References

1.  Hwang K, Jung JS, Kim H. Diagnostic performance of plain film, ultrasonography, and computed tomography in nasal bone fractures: a systematic review. Plast Surg (Oakv) 2018; 26: 286–92.
    
    

2.  Rebours C, Glatre R, Plaisance P, et al. Diagnostic errors of nasal fractures in the emergency department: a monocentric retrospective study. World J Emerg Med 2022;13:120–3.
    
    

3.  Westfall E, Nelson B, Vernon D, et al. Nasal bone fractures and the use of radiographic imaging: an otolaryngologist perspective. Am J Otolaryngol 2019;40:102295 doi:10.1016/j.amjoto.2019.102295.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/j.amjoto.2019.102295&link_type=DOI) 

4.  Wang W, Lee T, Kohlert S, et al. Nasal fractures: the role of primary reduction and secondary revision. Facial Plast Surg 2019; 35: 590–601.
    
    

5.  Ioannidis CA. Soft tissue injuries of the head and neck. Switzerland: Springer Nature Switzerland AG; 2023. doi: 10.1007/978-3-031-14915-3.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1007/978-3-031-14915-3&link_type=DOI)