Nasal bone fractures are the most common facial fracture, accounting for approximately 50–59% of all facial skeletal injuries. [1] They are predominantly a clinical diagnosis managed in the outpatient setting, with the critical ED task being to identify complications requiring urgent intervention — particularly septal hematoma and associated midface fractures.
1. History
- Mechanism of injury: Direct blow to the nose — falls (42%), violence/assault (24%), sports (19%), motor vehicle collisions (9%), work-related (5%) [2]
- Pre-injury appearance and function: Baseline nasal deviation, prior rhinoplasty, or previous nasal fracture — essential for determining whether deformity is new [3-4]
- Symptom characterization: Pain, swelling, epistaxis, nasal obstruction, cosmetic deformity
- Timing: When did the injury occur? (Determines reduction window)
- Associated symptoms: Facial numbness, visual changes, diplopia, malocclusion, clear rhinorrhea (CSF leak), loss of consciousness
- Important negatives: No LOC, no neck pain, no visual changes, no clear nasal drainage
2. Alarm Features
- Septal hematoma — bilateral boggy, bluish-purple septal swelling causing nasal obstruction; if missed, leads to abscess, cartilage necrosis, and saddle nose deformity (23% of missed cases in pediatric series) [5-6]
- CSF rhinorrhea — clear, watery unilateral drainage suggesting cribriform plate fracture
- Airway compromise — significant bilateral nasal obstruction or posterior hemorrhage
- Periorbital ecchymosis / raccoon eyes — suggests naso-orbital-ethmoid (NOE) fracture or basilar skull fracture
- Telecanthus — widened intercanthal distance suggesting NOE fracture
- Diplopia, restricted extraocular movements, infraorbital hypoesthesia — orbital floor fracture [7]
- Malocclusion — Le Fort or mandibular fracture [7]
- Uncontrolled epistaxis requiring posterior packing
3. Medications
- First-line analgesia: NSAIDs (ibuprofen 400–600 mg q6–8h or naproxen 500 mg q12h) are preferred for their anti-inflammatory and analgesic properties. Acetaminophen 1,000 mg q6h may be used alone or in combination. [8-9]
- Topical NSAIDs are recommended by ACP/AAFP guidelines as primary treatment for acute musculoskeletal injuries [9]
- Opioids: Generally unnecessary; reserve for severe pain refractory to NSAIDs/acetaminophen. If prescribed, limit to ≤3-day course [10]
- Topical decongestant: Oxymetazoline spray for epistaxis and nasal congestion (limit to 3 days to avoid rebound)
- Antibiotics: Not routinely indicated for closed fractures; consider if open fracture with mucosal laceration or nasal packing is placed
- Caution: Avoid aspirin and anticoagulants acutely due to bleeding risk
4. Diet
- No specific dietary restrictions
- Soft diet may be more comfortable if concurrent jaw pain or facial swelling
- Adequate hydration; avoid alcohol (increases bleeding risk and swelling)
- Ice application to nasal bridge for 15–20 minutes every 1–2 hours in the first 48 hours to reduce swelling
5. Review of Systems
- HEENT: Visual changes, diplopia, facial numbness, hearing changes, dental pain, malocclusion, clear nasal drainage
- Neurologic: Headache, LOC, confusion, amnesia (concurrent head injury)
- Respiratory: Nasal obstruction, mouth breathing, snoring
- Hematologic: Bleeding history, anticoagulant use, easy bruising
6. Collateral History and Family History
- Pre-injury photos — invaluable for comparison; ask patient or family to provide [11]
- Witnesses to mechanism — especially in assault, sports, or pediatric cases (consider non-accidental trauma in children)
- Coagulopathies — personal or family history of bleeding disorders
- Social context: Domestic violence screening if mechanism inconsistent with injury; alcohol/substance use at time of injury
7. Risk Factors
- Contact sports participation (boxing, MMA, football, basketball, soccer) [7]
- Assault/interpersonal violence — second most common cause [2]
- Falls — most common overall etiology, especially in elderly and young children [2]
- Motor vehicle collisions
- Anticoagulant/antiplatelet therapy — increases hemorrhagic complications
- Prior nasal fracture or rhinoplasty — weakened nasal framework, complicates diagnosis [4]
- Peak age groups: 10–19 years (23%) and 20–29 years (21%) [2]
- Male predominance (~70%) [2]
8. Differential Diagnosis
- Nasal soft tissue contusion without fracture — swelling and tenderness without bony disruption; most common diagnosis in pediatric nasal trauma (82.5%) [12]
- Naso-orbital-ethmoid (NOE) fracture — telecanthus, epiphora, CSF leak; requires CT and surgical consultation
- Le Fort fractures (I, II, III) — midface mobility, malocclusion, facial elongation
- Orbital floor (blowout) fracture — diplopia, enophthalmos, infraorbital hypoesthesia [7]
- Zygomatic arch/zygomaticomaxillary complex fracture — flattened cheek, trismus, step-off at infraorbital rim
- Septal fracture without nasal bone fracture — nasal obstruction, septal deviation
- Nasal cartilage injury — deformity without bony fracture on imaging
- Basilar skull fracture — raccoon eyes, Battle sign, CSF rhinorrhea
9. Past Medical History
- Prior nasal fractures or nasal surgery (rhinoplasty/septoplasty) — affects baseline anatomy and complicates radiographic interpretation [4]
- Bleeding disorders or anticoagulant use
- Obstructive sleep apnea (nasal obstruction may worsen)
- History of facial trauma or midface surgery
10. Physical Exam
- Inspection: Swelling, ecchymosis (periorbital and nasal), visible deformity, deviation, lacerations, epistaxis
- Palpation: Tenderness (96%), bony crepitus (rare, 0.4%), step-off deformity, depression (27%), nasal deviation (25.8%) [2]
- Systematic facial palpation: Supraorbital rims → infraorbital rims → zygoma → zygomatic arches → nasal bones → maxilla → mandible [7]
- Anterior rhinoscopy (critical): Assess for septal hematoma (bilateral boggy, fluctuant, cherry-red or bluish swelling of the septum), mucosal lacerations, active bleeding source, septal deviation [5][13]
- Extraocular movements and pupillary exam: Rule out orbital fracture
- Dental occlusion check: Rule out mandibular/maxillary fracture
- Cranial nerve exam: Especially V2 (infraorbital sensation)
- Otoscopy: Hemotympanum (basilar skull fracture)
11. Lab Studies
- Routine labs are not indicated for isolated nasal fractures
- CBC, coagulation studies (PT/INR, PTT): If significant epistaxis, anticoagulant use, or suspected coagulopathy
- Type and screen: Only if severe hemorrhage or surgical intervention anticipated
- Beta-hCG: In women of childbearing age if imaging planned
12. Imaging
- Isolated nasal fractures are primarily a clinical diagnosis; imaging is often unnecessary and does not change management [14]
- Plain radiographs: Limited diagnostic accuracy (53–82%); 70% of experienced otolaryngologists report imaging is "rarely" or "never" helpful for isolated nasal fractures [1][14]
- CT maxillofacial (without contrast): Gold standard when imaging is needed; indicated when suspecting associated midface fractures, NOE fractures, orbital involvement, or when clinical exam is limited by swelling [1]
- Bedside ultrasound: Emerging modality with sensitivity 85–100% and specificity 89–100%; radiation-free, useful in pediatrics and for POCUS-trained providers [1][15-16]
- Imaging is unnecessary for straightforward isolated nasal fractures with no red flags — physical exam is sufficient [14]
13. Special Tests
- Anterior rhinoscopy with headlamp/nasal speculum: Essential to rule out septal hematoma — the single most important bedside assessment
- Halo test / beta-2 transferrin: If clear rhinorrhea is present, to evaluate for CSF leak
- Point-of-care ultrasound: High sensitivity/specificity for nasal fracture detection at bedside [1][15]
- Pre-injury photographs: Comparison photos are the most practical tool for assessing cosmetic deformity and guiding reduction decisions [11]
14. ECG
- Not routinely indicated for isolated nasal fractures
- Consider ECG if syncope preceded the fall/injury, or in elderly patients with unexplained mechanism
15. Assessment
Nasal bone fractures are classified by CT into types based on displacement and septal involvement: [2]
- Type I: Simple fracture without displacement (13.8%) — typically conservative management
- Type II: Fracture with displacement (unilateral IIA 33.9%, bilateral IIB 20.8%) — closed reduction indicated
- Type IIs: Displaced fracture with septal fracture (IIAs 14.9%, IIBs 14.0%) — higher revision rate
- Type III: Comminuted with telescoping/depression (2.6%) — may require open reduction
Key clinical considerations:
- Most are simple, displaced fractures amenable to closed reduction (96.9% of cases) [2]
- Significant septal involvement predicts higher rates of subsequent open revision [17]
- Swelling may obscure the true extent of deformity; reassessment at 5–7 days after edema resolves is standard practice [3][18]
16. Treatment Plan
Acute ED management
- Control epistaxis: Direct pressure, oxymetazoline spray, anterior nasal packing if needed [7]
- Drain septal hematoma immediately if identified — incision and drainage with quilting sutures or packing to prevent reaccumulation [5-6]
- Ice, head elevation, analgesia (NSAIDs + acetaminophen) [8][19]
- Wound care for any lacerations
Definitive management
- Non-displaced fractures: Conservative management — ice, analgesia, nasal precautions, follow-up
- Displaced fractures: Closed reduction ideally performed at 7–10 days post-injury (after swelling resolves but before bony healing, within a 14-day window) [11][17-18]
- Reduction can be performed under local anesthesia (infraorbital and anterior ethmoidal nerve blocks) in an outpatient setting, which is cost-effective and comparable to general anesthesia in outcomes [20-21]
- Comminuted or severely displaced fractures with significant septal involvement may benefit from delayed open septorhinoplasty (>3 months) for definitive correction [17]
- Post-reduction: External nasal splint for 7–10 days; internal packing if needed (removed in 24–72 hours)
17. Disposition
- Discharge (vast majority): Isolated nasal fractures without complications are managed entirely as outpatients [3]
- Admission criteria:
- Uncontrolled epistaxis requiring posterior packing
- Concurrent significant injuries (head injury, polytrauma, other facial fractures)
- Airway compromise
- Suspected CSF leak
- Specialist consultation triggers:
- Immediate ENT/OMFS: Septal hematoma, CSF rhinorrhea, open fracture, severe comminution, airway compromise [3]
- Outpatient ENT referral: All displaced fractures for reassessment and reduction within 5–7 days [18]
- Ophthalmology: If orbital fracture suspected (diplopia, EOM restriction, enophthalmos)
18. Follow Up / Return Precautions
- Follow-up timing: ENT or primary care reassessment at 5–7 days post-injury once swelling has subsided to determine need for closed reduction [3][18]
- Return immediately for:
- Increasing nasal obstruction with painful septal swelling (septal hematoma)
- Fever, purulent nasal discharge (septal abscess)
- Clear watery nasal drainage (CSF leak)
- Worsening or new visual changes
- Uncontrolled nosebleeds
- Patient counseling:
- Sleep with head elevated for 48–72 hours
- Avoid contact sports for 6 weeks minimum
- Avoid nose blowing for 1–2 weeks
- Avoid wearing glasses resting on the nasal bridge for 4–6 weeks if displaced fracture
- Expected recovery: Swelling peaks at 48–72 hours, bruising resolves over 1–2 weeks
- Residual cosmetic deformity may be addressed with septorhinoplasty after 3 months if needed [17]
References
1. ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey. — Expert Panel on Neurological Imaging, Parsons MS, Policeni B, et al. Journal of the American College of Radiology : JACR. 2022.
2. Analysis of Nasal Bone Fractures: A 17-Year Study of 3785 Patients. — Hwang K, Yoon JM. The Journal of Craniofacial Surgery. 2022.
3. Management of Acute Nasal Fractures. — Kucik CJ, Clenney T, Phelan J. American Family Physician. 2004.
4. Facial Trauma Affects the Radiological Diagnosis of Nasal Bone Fractures. — Kim D, Oh JT, Ahn SH, Kim HJ, Bae MR. The Journal of Craniofacial Surgery. 2024.
5. Nasal Septal Hematoma in Children: Time to Diagnosis and Resulting Complications. — Ali HM, Zavala H, Chinnadurai S, Roby B. International Journal of Pediatric Otorhinolaryngology. 2021.
6. Nasal Septal Hematoma and Abscess in Children: An Uncommon Otorhinolaryngology Emergency Revisited. — Sayin I, Yazici ZM, Abakay MA, Saygan GB, Gunes S. The Journal of Craniofacial Surgery. 2021.
7. Management of Head and Neck Injuries by the Sideline Physician. — Usman S. American Family Physician. 2022.
8. Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians. — Qaseem A, McLean RM, O'Gurek D, et al. Annals of Internal Medicine. 2020.
9. Management of Acute Pain From Non-Low Back Musculoskeletal Injuries: Guidelines From AAFP and ACP. — Arnold MJ. American Family Physician. 2020.
10. Pharmacologic Therapy for Acute Pain. — Amaechi O, Huffman MM, Featherstone K. American Family Physician. 2021.
11. Comparison of the Diagnosis and Treatment of Nasal Bone Fracture by Physicians in China With Different Levels of Experience. — Jian F, Wu S. The Journal of Craniofacial Surgery. 2024.
12. Pediatric Nasal Traumas: Contribution of Epidemiological Features to Detect the Distinction Between Nasal Fractures and Nasal Soft Tissue Injuries. — Cakabay T, Ustun Bezgin S. The Journal of Craniofacial Surgery. 2018.
13. Nasal Septal Hematoma Is a Rare and Self-Recognizable Complication of Nasal Bone Fracture: A Retrospective Study. — Guchlerner L, Ernst BP, Issing C, et al. American Journal of Otolaryngology. 2025.
14. Nasal Bone Fractures and the Use of Radiographic Imaging: An Otolaryngologist Perspective. — Westfall E, Nelson B, Vernon D, et al. American Journal of Otolaryngology. 2019.
15. The Accuracy of Bedside USG in the Diagnosis of Nasal Fractures. — Caglar B, Serin S, Akay S, et al. The American Journal of Emergency Medicine. 2017.
16. Ultrasound for Management of Pediatric Nasal Fractures. — Noy R, Gvozdev N, Ilivitzki A, Nasrallah N, Gordin A. Rhinology. 2023.
17. Nasal Fractures: Acute, Subacute, and Delayed Management. — Trujillo O, Lee C. Otolaryngologic Clinics of North America. 2023.
18. Nasal Fractures: A Dedicated Clinic Providing Reduction Under Local Anaesthesia Improves Time to Manipulation. — Pinto R, Wright R, Ghosh S. Annals of the Royal College of Surgeons of England. 2020.
19. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations. — Anne S, Mims JW, Tunkel DE, et al. Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 2021.
20. Manipulation of Nasal Fractures With Local Anaesthetic: A 'How to Do It' With Online Video Tutorial. — Repanos C, Anderson D, Earnshaw J, Mitchell D, Coman W. Emergency Medicine Australasia : EMA. 2010.
21. Acute Management of Nasal Bone Fractures: A Systematic Review and Practice Management Guideline. — Paliwoda ED, Newman-Plotnick H, Buzzetta AJ, et al. The American Surgeon. 2025.