- Patients with associated base of skull fracture / other facial injuries
- Septal haematoma
- Severe traumatic epistaxis requiring nasal packing (about 90% of traumatic epistaxis stops with conservative methods)
Why is this important?
Nasal bone fractures are common (40% of all facial injuries) especially on weekend nights! Nasal trauma can result in damage to skin, bone and cartilage. Complications of such fractures include:
- Septal haematoma
- CSF leak
- Septal deviation leading to nasal obstruction
Do not miss septal haematomas - if left untreated, they can lead to abscesses and/or necrosis of the septal cartilage and resultant saddle deformity and/or septal perforation.
Some of these patients may have other associated injuries ie base of skull fractures, which should be investigated by A&E and referred to the neurosurgical/trauma/maxillofacial teams before involving ENT.
When to involve the ENT registrar
When there is a septal haematoma as this usually requires relatively prompt incision and drainage under general anaesthesia.
When there is heavy traumatic epistaxis.
Who to admit
Under ENT: Patients who have a septal haematoma or traumatic severe epistaxis, with no other major injury.
Joint care with neurosurgeons/maxillofacial surgeons etc.: Patients who have other major injuries but who may also have a septal haematoma or severe traumatic epistaxis.
Patients with an isolated nasal fracture and no septal haematoma or epistaxis do not normally require admission under ENT.
Assessment and recognition
Out-of-hours, these patients are generally seen by A&E etc. staff. However, if you are called, you could ask the following questions:
- Is there a serious head injury, other facial fractures or need for a CT head?
- Have you cleaned and closed any wounds?
- Have you investigated causes of trauma eg "collapse ?cause", possible stroke, non-accidental injuries
- Is there a septal haematoma?
- Has epistaxis stopped?
- After epistaxis has subsided, is there continuous clear and watery (rather than mucus) rhinorrhoea?
Patients with isolated nasal injuries can be managed as outpatients as the nose is too swollen immediately after trauma. It can only be effectively assessed five to seven days later, once the swelling has subsided. Patients discharged from A&E with nasal trauma should be booked into the ENT emergency clinic seven to ten days afterwards for manipulation and further treatment.
NB - Plain radiographs of the nose are not useful in the assessment of isolated nasal bone fractures and should not be done. This is not the case for mid-face fractures.
You may be asked to rule out a septal haematoma, which is blood collecting under the lining of the septal cartilage causing a purple, boggy/fluctuant swelling inside the nose on both sides. This is sometimes mistaken for a deviated nasal septum but if you look in the other nostril, the septum will appear deviated to that side as well. Presence of a haematoma can be confirmed by aspirating blood and clot with a green needle.
Note that, if you can see blood or haematoma inside the nose, this is not a septal haematoma. To reiterate, a septal haematoma collects beneath the mucosa and perichondrium of the septum and presents as a fluctuant mucosal swelling rather than frank clot.
Patients sometimes attend a few days after the event complaining of continuous clear and watery nasal discharge. If you can see evidence of this, send a sample (a few millilitres) to the lab for beta-2 transferrin to determine whether it is CSF or not. If there is no immediate evidence, you can give a small plastic tub to the patient to catch the discharge, should it recur.
Immediate and overnight management
As outlined above.
Ensure patients have analgesia (NSAIDs are good for reducing nasal swelling).
Patients who need to be packed should be observed for at least 24 hours before removing packs (see epistaxis).
A septal haematoma will have to be drained as soon as practical, which will require senior input.
A possible CSF leak can be managed conservatively if there are no symptoms of meningism and no neurological signs. Standard neurosurgical practice is not to give antibiotic prophylaxis. CSF leaks are unlikely in isolated nasal injuries with no loss of consciousness. Most will heal spontaneously and only a few require a specialist rhinological/skull base opinion.
Patients can be assessed in ENT emergency clinic five to seven days after injury to determine if they are suitable for a manipulation under anaesthesia.
This can be local or general anaesthesia based on patient’s preference - and local policy.
Manipulation should take place within 14 days after the injury otherwise the bones will heal in the deformed position. The patient should be informed that the deformity may not be corrected completely. Any residual deformity even after manipulation may require more surgery 12 months or more after the injury (eg septorhinoplasty; only funded by the NHS in certain cases).
ENT UK - Nasal injuries
Page last reviewed: 3 March 2017