Rosen & Barkin's 5-Minute Emergency Medicine Consult (470 page)

• Nasal deformity, asymmetry, swelling, or ecchymosis
  
• Epistaxis
  
• Periorbital ecchymosis (“raccoon eyes”) from damage to branches of ethmoidal artery:
  
  • May indicate nasofrontoethmoid complex injury
    
• Palpable sharp edges, depressions, or other irregularities suggest nasal fracture.
  
• Crepitus or mobility of skeletal parts on palpation
  
• Septal hematoma:
  
  • Bluish fluid-filled sac overlying nasal septum
    
  • Critical to detect because it must be drained
    
  • Failure to drain can result in necrosis of the septum
    
• Flattening of nasal root and widening of intercanthal distance (telecanthus):
  
  • Indicative of serious nasofrontoethmoid complex injury
    
• Clear rhinorrhea indicates possible CSF leak:
  
  • Rhinorrhea may be delayed.
    
• Loss of sense of smell suggests significant injury.
  
• Tear duct injuries may be present with abnormal tearing.
  
• Associated eye injuries:
  
  • Subconjunctival hemorrhage
    
  • Hyphema
    
  • Retinal detachments
    

• Direct blow
  
• Associated injuries or symptoms
  
• Presence of epistaxis
  
• Changes in vision or smell
  

• Thorough physical exam with visual inspection and palpation is vital.
  
• It is critical to identify a septal hematoma:
  
  • Bluish bulging mass on nasal septum
    
• Septal deviation
  
• Epistaxis or intranasal laceration
  
• Examine closely for telecanthus:
  
  • Intercanthal width >30–35 mm
    
  • Wider than width of 1 eye
    
  • May indicate nasofrontoethmoid fracture
    
  • Usually associated with depressed nasal bridge
    
• CSF rhinorrhea:
  
  • Indicates more serious underlying facial bone or skull fracture
    
  • CSF mixed with blood will often cause double ring sign when placed on filter paper, although this sign is not 100% reliable.
    

If concern for anything other than a simple nasal fracture:

• Evaluate nasolacrimal duct for patency:
  
  • Instill fluorescein into eye and look for it in nasopharynx under inferior turbinate.
    
  • Absence implies duct injury.
    
• Eyelash traction test:
  
  • Grasp eyelashes on eyelid and pull laterally:
    
  • If eyelid margin does not become taut or “bow string,” then medial portion of tendon has been disrupted.
    
  • This test is performed on both upper and lower eyelids.
    
    • Possible for only 1 portion of tendon to be selectively injured
      

Coagulation studies if on anticoagulants with uncontrolled epistaxis

• Nasal radiographs are rarely indicated:
  
  • Normally do not alter initial or subsequent management
    
  • Gross deformities will need referral.
    
  • Fractures without deformity will be treated conservatively regardless of radiographic findings.
    
  • Patients with associated facial bone deformity, crepitus, or tenderness may require radiographs.
    
• CT is test of choice if facial bone, nasofrontoethmoid, or depressed skull fractures are suspected; have low threshold for ordering CT if other injuries are suspected.
  

• Other facial injuries such as orbital, frontal sinus, maxillary sinus, or cribriform plate fractures
  
• Nasofrontoethmoid fracture
  

TREATMENT

• Management of airway takes precedence.
  
• Nasotracheal intubation is contraindicated.
  
• Consider orotracheal intubation or cricothyroidotomy if definitive airway control is needed.
  
• Cervical spine precautions are indicated if there is associated trauma.
  
• Epistaxis can normally be controlled with direct pressure; pinch nares together.
  

• Airway management with orotracheal intubation or cricothyroidotomy:
  
  • Nasotracheal intubation is contraindicated.
    
• Cervical spine precautions
  
• Other injuries take precedence.
  

• Abrasions and lacerations:
  
  • Proper cleansing of facial wounds is essential.
    
  • Lacerations may be sutured.
    
• Epistaxis must be controlled if it does not stop spontaneously:
  
  • Anesthetize/vasoconstrict with topical cocaine, lidocaine, or neosynephrine spray.
    
  • Identify bleeding source; cauterize anterior source if necessary.
    
  • Pack nares with petroleum jelly, impregnated gauze, or any number of commercial packs.
    
  • Posterior packs are rarely needed.
    
  • Prophylactic antibiotics to prevent sinus infection are indicated if packed: Amoxicillin, amoxicillin/clavulanate, or trimethoprim–sulfamethoxazole or azithromycin in penicillin allergic patients.
    
  • Displaced fractures do not need reduction in ED unless airway is compromised.
    
  • Generally recommended to allow swelling to abate and reduce fracture in 3–5 days, although there are many specialists who recommend local anesthesia and immediate reduction.
    
• Septal hematoma must be drained immediately in ED:
  
  • Anesthetize with topical cocaine or lidocaine and vascular constriction with neosynephrine.
    
  • Attempt to aspirate with 18G to 20G needle on 3-mL syringe.
    
  • Rolling cotton swab down septum may facilitate drainage.
    
  • Holding mucosa down against cartilage must be done to prevent reaccumulation.
    
  • This can be done with petroleum jelly gauze packing.
    
  • Both nares should be packed to ensure adequate pressure:
    
    • Packing is left in place for 3–5 days or until follow-up with ear, nose, and throat (ENT).
      
  • Prophylactic antibiotics are prescribed.
    

• Amoxicillin: 500 mg PO TID (peds: 40 mg/kg PO div. TID)
  
• Amoxicillin/clavulanate: 500/125–875/125 mg PO BID (peds: 40 mg/kg/d of amoxicillin PO BID)
  
• Azithromycin: 500 mg PO day 1 followed by 250 mg PO daily for 4 additional days (peds: 10 mg/kg PO day 1, followed by 5 mg/kg PO days 2–4)
  
• Cocaine: Topical 4%
  
• Lidocaine: 1–2% without epinephrine
  
• Neosynephrine nasal spray
  
• Trimethoprim–sulfamethoxazole: Double strength (DS) PO BID (peds: 40 mg/kg/d sulfamethoxazole PO BID)
  

• Most nasal fractures do not require admission.
  
• Admit patients with nasoethmoid fractures or more significant craniofacial injuries.
  

• No evidence of significant head, neck, or other injuries.
  
• Epistaxis controlled
  
• Reliable companion or caregiver
  

• Follow up with specialist sooner because fibrous union begins in only 3–4 days
  
• Consider contacting child protective services if any suspicion of nonaccidental trauma:
  
  • History does not fit injury.
    
  • Always consider nonaccidental trauma as potential mechanism of injury.
    
• Fractures are rare in children; nasal injuries in children are more likely to be cartilaginous.
  
• Significant injuries in children are not always fully appreciated.
  

FOLLOW-UP

• Follow up with ENT, plastic surgery, or oral maxillofacial (OMF) surgeon in 3–5 days for management:
  
  • Patients with septal hematoma should follow up in 24 hr for re-evaluation after drainage.
    
• Return for signs of clear rhinorrhea, difficulty breathing, fever, or signs associated with head injury.
  

• The absence of a septal hematoma must be documented in every case.
  
• Every patient discharged with nasal packing should be placed on antistaphylococcal antibiotics.
  
• Consider cribriform plate fractures in patients with clear rhinorrhea after nasal injury.
  
• Have a low threshold for ordering facial bone CT if there is suspicion for associated injuries or fractures.
  

• Atighechi S, Baradaranfar MH, Akbari SA. Reduction of nasal bone fractures: A comparative study of general, local, and topical anesthesia techniques.
  J Craniofac Surg.
  2009;20(2):382–384.
  
• Ondik MP, Lipinski L, Dezfoli S, et al. The treatment of nasal fractures: A changing paradigm.
  Arch Facial Plast Surg.
  2009;11(5):296–302.
  
• Repanos C, Carswell AJ, Chadha NK. Manipulation of nasal fractures under local anaesthetic: A convenient method for the Emergency Department and ENT clinic.
  Emerg Med J.
  2010;27(6):473–474.
  
• Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries and management.
  Facial Plast Surg
  . 2011;27(5):483–490.
  
• Ziccardi VB, Braidy H. Management of nasal fractures.
  Oral Maxillofac Surg Clin North Am.
  2009;21(2):203–208.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Epistaxis
  
• Facial Fractures
  

CODES