Nasal Bone FractureMANAGEMENT

ENT AND MAXILLOFACIAL PRESENTATIONS · 12 SECTIONS

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684 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Acute laryngitis Acute pharyngitis Auricular hematoma Bezold's Abscess Cerumen impaction Dry socket Ear foreign body Epistaxis (anterior)Epistaxis (Posterior)Labyrinthitis Ludwig's Angina Malignant Otitis Externa Marcus Gunn Pupil Mastoiditis Meniere's Disease Nasal Bone Fracture Nasal foreign body Nasal Septal Hematoma Otitis externa Otitis Media Post-tonsillectomy hemorrhage Sialolithiasis and sialadenitis Sinusitis Sudden Sensorineural Hearing Loss TMJ dislocation Tympanic membrane perforation Vestibular Neuronitis

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp55

Immediate priorities

›Airway and hemorrhage threats

›Posterior epistaxis causing airway compromise

›Bilateral nasal obstruction with active bleeding

›Oropharyngeal blood pooling

›Severe midface instability

›Le Fort II or III pattern with palatal mobility

›NOE fracture with impending airway loss

›If airway compromised, early intubation prior to swelling progression

›Video laryngoscopy preferred with facial trauma

›Surgical airway available at bedside

›Septal hematoma — the critical do-not-miss

›Immediate anterior rhinoscopy on all nasal trauma patients

›Boggy, fluctuant, cherry-red or bluish-purple septal swelling

›Bilateral obstruction suggesting hematoma not deviation

›Unrecognized septal hematoma leads to abscess and saddle nose deformity

›23% complication rate in missed pediatric cases

›Cartilage avascular necrosis within 3–4 days

›Immediate incision and drainage if septal hematoma confirmed

›Through-and-through quilting sutures or anterior nasal packing

›ENT consultation for operative drainage if bilateral or recurrent

Red flag recognition

›Critical alarm features requiring urgent action

›CSF rhinorrhea

›Clear, watery unilateral nasal drainage

›Suggests cribriform plate fracture

›Raccoon eyes or Battle sign

›Basilar skull fracture pattern

02History/hx52

Mechanism and injury context

›Mechanism of injury

›Falls — most common overall etiology (42%)

›Especially elderly and young children

›Interpersonal violence or assault (24%)

›Screening for domestic violence if inconsistent mechanism

›Sports (19%)

›Contact sports: boxing, MMA, football, basketball, soccer

›Motor vehicle collision (9%)

›Higher energy — greater midface fracture risk

›Work-related (5%)

›Injury timing

›Time elapsed since injury

›Determines reduction window (ideally 5–14 days)

›Swelling peaks at 48–72 hours — may need delayed reassessment

›Pre-injury nasal appearance

›Baseline nasal deviation or prior rhinoplasty

›Previous nasal fracture — weakened framework

Symptom characterization

›Primary complaints

›Nasal pain and tenderness

›Epistaxis

›Duration and severity

›Anterior vs posterior source

›Nasal obstruction

›Unilateral vs bilateral

›Progressive worsening after injury (septal hematoma concern)

›Cosmetic deformity or deviation

03Physical Exam/exam58

Facial and nasal inspection

›Facial inspection

›Periorbital ecchymosis

›Raccoon eyes pattern — basilar skull fracture

›Facial swelling distribution

›Nasal bridge, medial canthi, periorbital

›Visible nasal deviation

›New vs baseline — compare to pre-injury photos

›Lacerations

›Open fracture risk if overlying nasal skin

›Telecanthus

›Widened intercanthal distance — NOE fracture

›Nasal palpation

›Nasal bone tenderness (sensitivity 96%)

›Step-off or depression deformity (27% of cases)

›Bony crepitus (rare, 0.4%)

›Systematic facial palpation sequence

›Supraorbital rims, infraorbital rims, zygoma, zygomatic arches, nasal bones, maxilla, mandible

Anterior rhinoscopy — mandatory

›Rhinoscopy with headlamp and nasal speculum

›Septal hematoma

›Bilateral boggy, fluctuant swelling of the septum

›Cherry-red or bluish-purple discoloration

›Does not blanch with decongestant — distinguishes from edema

›Septal deviation

›Unilateral obstruction consistent with fracture

›Active bleeding source

›Kiesselbach plexus — anterior epistaxis

04Differential Diagnosis/ddx35

Life-threatening and urgent diagnoses

›Basilar skull fracture

›ICD-10 S02.19

›Raccoon eyes, Battle sign, hemotympanum, CSF rhinorrhea

›Naso-orbital-ethmoid (NOE) fracture

›ICD-10 S02.8

›Telecanthus, epiphora, CSF leak, periorbital ecchymosis

›Le Fort fracture

›ICD-10 S02.4 (Le Fort I), S02.3 (Le Fort II), S02.8 (Le Fort III)

›Midface mobility, malocclusion, facial elongation

›Orbital floor blowout fracture

›ICD-10 S02.3

›Diplopia, enophthalmos, infraorbital hypoesthesia

›Zygomatic complex fracture

›ICD-10 S02.40

›Flattened cheek, trismus, infraorbital rim step-off

Common mimics

›Nasal soft tissue contusion without fracture

›Most common diagnosis in pediatric nasal trauma (82.5%)

›Swelling and tenderness, no bony disruption on CT or US

›Septal fracture without nasal bone fracture

›Nasal obstruction, septal deviation, C-shaped or S-shaped deformity

›Nasal cartilage injury

›Deformity without bony fracture on imaging

›Most common in younger patients with more cartilaginous skeletons

›Septal hematoma

›ICD-10 S09.90

›Distinct entity requiring immediate drainage

05Laboratory Tests/lt30

Routine workup

›Isolated nasal fracture without complications

›Routine labs not indicated

›Clinical diagnosis sufficient for uncomplicated cases

›ACR Appropriateness Criteria support imaging over lab-based workup

›No role for routine CBC or coagulation studies in uncomplicated cases

Targeted lab testing

›Bleeding and coagulation assessment

›Complete blood count

›If significant epistaxis or suspected coagulopathy

›Hemoglobin/hematocrit baseline if posterior packing needed

›Coagulation studies — PT/INR and aPTT

›Anticoagulant use

›Bleeding disorder history

›Pre-operative requirement if surgical drainage anticipated

›Type and screen

›Severe hemorrhage only

›Surgical intervention anticipated

›Pregnancy testing

›Beta-hCG in women of childbearing age if imaging (CT) planned

›Informs radiation exposure decision

›Ultrasound preferred if positive

›Point-of-care glucose

›Head injury co-presentation

›Elderly patients with unexplained mechanism

CSF rhinorrhea workup

›Beta-2 transferrin assay

›Gold standard for CSF identification

06Diagnostic Tests/dt60

Scoring Systems

›Nasal fracture classification (CT-based)

›Type I — simple non-displaced (13.8%)

›Conservative management

›Type IIA — unilateral displaced (33.9%)

›Closed reduction

›Type IIB — bilateral displaced (20.8%)

›Closed reduction

›Type IIAs — unilateral displaced with septal fracture (14.9%)

›Higher post-reduction revision rate

›Type IIBs — bilateral displaced with septal fracture (14.0%)

›Highest revision rate; consider delayed septorhinoplasty

›Type III — comminuted with telescoping or depression (2.6%)

›May require open reduction internal fixation

MRI

›MRI for nasal bone fracture

›Not indicated for acute nasal bone fracture evaluation

›CT and POCUS are the primary modalities

›MRI reserved for specific complications

›MRI brain/skull base

›If CSF rhinorrhea confirmed and CT inconclusive for cribriform plate defect

›MRI cisternography or intrathecal gadolinium for leak localization

›MRI orbit

›Orbital floor entrapment with equivocal CT findings

›Muscle herniation assessment

›CT maxillofacial without contrast

›Gold standard when imaging indicated

07Disposition/dispo44

Discharge criteria

›Safe for ED discharge

›Isolated nasal fracture — vast majority discharged

›No septal hematoma

›No CSF rhinorrhea

›No concurrent significant head injury

›Epistaxis controlled

›Outpatient ENT referral arranged

›Displaced fractures: ENT reassessment at 5–7 days post-injury

›After swelling resolves to assess true deformity and reduction need

›Discharge instructions provided

›Return precautions clearly communicated

Admission criteria

›Indications for hospital admission

›Uncontrolled posterior epistaxis requiring posterior packing

›Posterior packing admission for airway monitoring

›ENT consult prior to admission

›Concurrent significant injuries

›Head injury with GCS change

›Polytrauma

›Other facial fractures requiring operative planning

›Airway compromise

›Bilateral nasal obstruction with respiratory distress

›Suspected CSF rhinorrhea

›Neurosurgery consultation

›Bed rest and head of bed elevation

›Septal hematoma in resource-limited or unreliable follow-up setting

›Drainage in ED; consider admission if bilateral or at risk for reaccumulation

08Treatment/t99

Epistaxis control

›Acute hemorrhage management

›Direct pressure

›Continuous digital pressure for 10–15 minutes

›Pinching soft nasal tip, not bony bridge

›Topical vasoconstrictor

›Oxymetazoline 0.05% nasal spray

›2–3 sprays per nostril

›Limit to 3 days to avoid rebound congestion

›Anterior nasal packing

›Anterior source refractory to pressure and oxymetazoline

›Vaseline gauze or commercial nasal tampon

›Left in place 24–48 hours

›Posterior nasal packing or balloon tamponade

›Posterior source or anterior packing failure

›Foley catheter or commercial double-balloon

›Admission required for airway monitoring

›ENT consultation

Septal hematoma drainage

›Incision and drainage procedure

›Local anesthetic

›Topical lidocaine/oxymetazoline spray followed by injection

›1% lidocaine with epinephrine — submucosal

›Incision placement

›Horizontal or curved incision at inferior aspect of hematoma

›Through mucoperichondrium on one side

›Drainage and irrigation

›Evacuate clot completely

›Irrigate with normal saline

›Prevention of reaccumulation

›Through-and-through quilting sutures (4-0 chromic)

›Bilateral anterior nasal packing as alternative

›Packing removed at 24–72 hours

›Antibiotics post-drainage

›Amoxicillin-clavulanate 875/125 mg PO BID for 5–7 days

›Covers Staphylococcus aureus and anaerobes

›Penicillin allergy: clindamycin 300 mg PO TID

›MRSA risk: trimethoprim-sulfamethoxazole DS PO BID

›ENT follow-up within 24–48 hours

›Recheck for reaccumulation

Analgesia

›First-line analgesia — multimodal approach

›NSAIDs

›Ibuprofen 400–600 mg PO q6–8h with food

›ACP/AAFP guideline: primary treatment for acute musculoskeletal injuries

›Anti-inflammatory and analgesic properties

›Naproxen 500 mg PO q12h alternative

›Acetaminophen

›1000 mg PO q6h (maximum 4 g/day)

›Combinable with NSAIDs for additive effect

›Topical NSAIDs

›Diclofenac gel as adjunct for localized pain

›ACP/AAFP recommendation for musculoskeletal injuries

›Opioid analgesia

›Reserved for severe pain refractory to NSAIDs and acetaminophen

›Maximum 3-day course — AAO-HNS opioid prescribing guideline

›Lowest effective dose

›Avoid aspirin and anticoagulants acutely

›Increased epistaxis risk

›Local and regional anesthesia for reduction

›Infraorbital nerve block

›1% lidocaine with epinephrine 1:100,000

›Infraorbital foramen approach

›Anterior ethmoidal nerve block

›Topical cocaine 4% or lidocaine-epinephrine pledgets

›Intranasal topical anesthesia

›Lidocaine 4% with oxymetazoline pledgets for 10 minutes

Closed reduction

›Timing of closed reduction

›Optimal window: 5–14 days post-injury

›After swelling resolves, before bony consolidation

›Most authors recommend reassessment at 5–7 days

›Earlier reduction (2–3 days) may be considered if deformity clear and patient returns promptly

›Closed reduction technique

›Instruments

›Walsham forceps — bilateral nasal bone manipulation

›Asche forceps — septum

›Boies elevator — intranasal elevation

›Setting

›Outpatient ENT clinic under local anesthesia — cost-effective, comparable outcomes to GA

›Emergency department if trained provider

›Operating room for complex fractures or children requiring GA

›Post-reduction support

›External nasal splint or thermoplastic cast for 7–10 days

›Internal nasal packing if needed (removed 24–72 hours)

›96.9% of nasal fractures amenable to closed reduction

Conservative management (non-displaced fractures)

›Non-displaced fracture care

›Ice application

›15–20 minutes every 1–2 hours for first 48 hours

›Reduce swelling and pain

›Head elevation

›30–45 degrees for 48–72 hours

›Reduces dependent edema

›Nasal saline irrigation

›Maintains mucosal moisture and clot clearance

›Activity restriction

›Contact sports avoidance for 6 weeks minimum

Delayed surgical options

›Open septorhinoplasty

›Indicated for comminuted fractures or failed closed reduction

›Deferred at least 3 months post-injury

›Allows bony consolidation and swelling resolution

›Significant septal involvement predicts higher revision rates

›IIAs and IIBs fracture types — counsel patient

09Special Populations/sp88

Pregnancy

›Imaging considerations in pregnancy

›Ultrasound preferred first-line imaging

›No ionizing radiation risk to fetus

›POCUS sensitivity 85–100% for nasal fracture

›CT maxillofacial if red flags present

›Fetal radiation dose from head/face CT approximately 0.001–0.01 mGy

›Threshold for teratogenicity 50 mGy — CT face poses negligible fetal risk

›However ultrasound should be used first when adequate

›Avoid plain radiographs

›Low diagnostic yield and still involves radiation

›Analgesia in pregnancy

›Acetaminophen 1000 mg PO q6h — safe in all trimesters

›First-line for nasal fracture pain in pregnancy

›NSAIDs — caution

›First and second trimester: use with caution

›Third trimester: contraindicated (premature ductus arteriosus closure)

›Opioids: avoid unless severe refractory pain

›Neonatal abstinence syndrome risk with prolonged use

›Oxymetazoline topical

›Limited systemic absorption; short-term use considered acceptable

›Restrict to 3 days maximum

›Septal hematoma drainage in pregnancy

›Lidocaine local anesthesia safe

›Epinephrine in small doses for hemostasis — acceptable

›ENT consultation for drainage — same urgency as non-pregnant

Geriatric

›Fall epidemiology

›Falls most common mechanism in elderly patients

›Ground-level falls with significant facial impact

›Syncope or cardiac event may have preceded fall — evaluate

›ECG if unexplained fall mechanism

›Arrhythmia or ACS preceding fall

›Anticoagulation considerations

›High prevalence of anticoagulant and antiplatelet use

›Warfarin, DOAC, aspirin, clopidogrel

›Check INR for warfarin users with significant epistaxis

›Reversal if INR supratherapeutic with uncontrolled bleeding

›Epistaxis more severe and prolonged

›Lower threshold for anterior nasal packing

›Lower threshold for admission if posterior source

›Fracture healing and reduction

›Bone quality reduced — osteoporosis

›Higher rate of comminuted fractures

›Lower threshold for CT to characterize extent

›Skin fragility — external splint pressure necrosis risk

›Padding under splint edges

›Cognitive impairment affects consent and follow-up

›Family involvement for discharge instructions

›Analgesia in elderly

›NSAIDs with caution

›Renal function impairment risk

›GI bleeding risk — add PPI if prescribed

›Cardiovascular risk — limit duration

›Acetaminophen 1000 mg q6h — preferred agent

›Hepatic impairment: reduce to 500 mg q6h

Pediatrics

›Epidemiology and anatomy

›Nasal soft tissue contusion without fracture most common in children (82.5%)

›Cartilaginous skeleton absorbs impact better than adult bone

›True nasal fracture less common in young children

›Peak pediatric incidence age 10–19 years

›Non-accidental trauma

›Inconsistent mechanism with injury pattern — mandatory reporting

›Patterned injury, multiple injuries at different healing stages

›Septal hematoma in children

›Particularly high-risk in children

›23% complication rate when missed — cartilage necrosis and saddle nose deformity

›Thinner perichondrium with less blood supply

›Abscess develops rapidly — within days

›Urgent ENT consultation for drainage in children

›Imaging in children

›POCUS preferred — radiation-free

›Pediatric nasal fracture POCUS sensitivity and specificity comparable to adults

›Rhinology 2023 study validates POCUS for pediatric nasal fracture management

›CT reserved for suspected associated fractures — NOE, orbital, Le Fort

›Use low-dose pediatric protocols

›Plain radiographs not recommended

›Poor sensitivity and specificity, radiation exposure without benefit

›Reduction in children

›General anesthesia often required

›Uncooperative with local anesthesia

›Allows complete exam under anesthesia

›Reduction window may be shorter — faster bone consolidation

›Closed reduction ideally within 7–10 days

›ENT consultation for all displaced pediatric nasal fractures

›Analgesia in children

›Ibuprofen 10 mg/kg PO q6–8h (maximum 600 mg per dose)

›Acetaminophen 15 mg/kg PO q4–6h (maximum 1000 mg per dose)

›Intranasal dexmedetomidine or midazolam for procedural anxiolysis

›Opioids avoided if possible; if needed: morphine 0.1 mg/kg IV

10Background/b73

Epidemiology

›Incidence and prevalence

›Most common facial fracture

›50–59% of all facial skeletal injuries

›Estimated 3.6–4 million nasal fractures annually in the United States

›Age distribution

›Peak: 10–19 years (23%) and 20–29 years (21%)

›Second peak in elderly due to falls

›Sex distribution

›Male predominance approximately 70%

›Male-to-female ratio approximately 2:1 to 3:1

›Etiology distribution

›Falls 42%

›Violence and assault 24%

›Sports 19%

›Motor vehicle collisions 9%

›Work-related 5%

›Fracture type distribution (CT-based series)

›Type IIA — most common (33.9%)

›Approximately 96.9% amenable to closed reduction

›Type III comminuted — 2.6%

Pathophysiology

›Anatomic vulnerability

›Nasal bones project prominently and are the thinnest facial bones

›Most vulnerable to direct force

›Nasal tip cartilaginous — protects tip but transfers force to bones

›Nasal bones fuse at midline suture

›Lateral displacement from off-axis blow

›Frontal blow produces depression and comminution

›Cartilaginous septum injury

›Septal cartilage fracture occurs in ~30% of nasal fractures

›Septal deviation and obstruction

›Hematoma forms between mucoperichondrium and cartilage

›Septal hematoma pathophysiology

›Vessel rupture in subperichondrial space

›Bilateral if blood tracks across midline

›Cartilage avascular — depends on perichondrium

›Untreated: suppurative chondritis → saddle nose deformity

›Swelling dynamics

›Edema peaks at 48–72 hours post-injury

›Masks true deformity extent

›Reason for delayed reassessment at 5–7 days

›Bony consolidation begins at 2–3 weeks

›Reduction after 14 days increasingly difficult — open revision required

›Associated injury mechanism

›NOE fracture — central midface impact transmitting force to ethmoids

›Orbital blowout — hydraulic transmission of force from globe to orbital floor

›Le Fort — high-energy vector engaging pterygoid plates

Therapeutic Considerations

›Clinical vs radiographic diagnosis

›Nasal bone fracture is primarily a clinical diagnosis

›Imaging does not change management in isolated uncomplicated fractures

›70% of experienced otolaryngologists report imaging rarely or never helpful for isolated cases

›ACR Appropriateness Criteria: imaging usually appropriate only when associated fractures suspected

›Decision to image should be guided by red flags and clinical exam findings

›Reduction timing evidence

›Optimal window 5–14 days

›Too early: edema masks deformity, unstable fragments

›Too late: bony union prevents reduction

›Closed reduction under local anesthesia

›Comparable outcomes to general anesthesia

›More cost-effective and avoids anesthetic risk

›Failed closed reduction — open septorhinoplasty

›Deferred minimum 3 months — allows complete tissue healing

›Antibiotic use evidence

›Closed fractures — antibiotics not routinely indicated

›Open fractures with mucosal laceration — short course prophylaxis

›Nasal packing in situ — prophylaxis considered

›No strong evidence for routine prophylaxis with anterior packing

›Posterior packing — more commonly prescribed

›Post septal hematoma drainage — antibiotics recommended

›Covers S. aureus and anaerobes

›Opioid stewardship

›AAO-HNS 2021 guideline on opioid prescribing for otolaryngology

›NSAIDs and acetaminophen sufficient for most nasal fracture pain

›Opioids reserved for severe refractory pain: maximum 3-day course

11Patient Discharge Instructions/pdi44

copy discharge instructions

›Diagnosis and overview

›Nasal bone fracture diagnosis

›You have a broken nose. This is one of the most common facial injuries.

›Most broken noses are treated without surgery.

›Swelling will peak over the next 2–3 days and then gradually improve.

›Home care instructions

›Ice application

›Apply ice wrapped in a cloth to your nose for 15–20 minutes every 1–2 hours for the first 48 hours

›Do not apply ice directly to skin

›Head elevation

›Sleep with your head elevated on 2–3 pillows for the first 2–3 days

›Reduces swelling

›Pain management

›Take ibuprofen 400–600 mg every 6–8 hours with food as needed

›Acetaminophen (Tylenol) 1000 mg every 6 hours may be added or used instead

›Do not take aspirin — increases bleeding risk

›Nasal precautions

›Do not blow your nose for 1–2 weeks

›If you must sneeze, sneeze with your mouth open

›Avoid rubbing or touching the nose

›Activity restrictions

›No contact sports for 6 weeks minimum

›No heavy lifting or strenuous activity for 1–2 weeks

›Do not wear glasses resting on the nasal bridge for 4–6 weeks if fracture was displaced

›Nasal hygiene

›Saline nasal spray or rinse may be used to keep nasal passages moist

›Oxymetazoline nasal spray for congestion — do not use more than 3 days

12References/r46

Guidelines and key sources

›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. 2022

›doi: 10.1016/j.jacr.2022.02.013

›Hwang K, Yoon JM — Analysis of Nasal Bone Fractures: A 17-Year Study of 3785 Patients

›Journal of Craniofacial Surgery. 2022

›PMID: 37439559

›Kucik CJ, Clenney T, Phelan J — Management of Acute Nasal Fractures

›American Family Physician. 2004

›PMID: 15508543

›Paliwoda ED et al. — Acute Management of Nasal Bone Fractures: A Systematic Review and Practice Management Guideline

›The American Surgeon. 2025

›PMID: 40638849

›Trujillo O, Lee C — Nasal Fractures: Acute, Subacute, and Delayed Management

›Otolaryngologic Clinics of North America. 2023

›PMID: 37353368

Septal hematoma and complications

›Ali HM et al. — Nasal Septal Hematoma in Children: Time to Diagnosis and Resulting Complications

›International Journal of Pediatric Otorhinolaryngology. 2021

›PMID: 33930759

›Sayin I et al. — Nasal Septal Hematoma and Abscess in Children

›Journal of Craniofacial Surgery. 2021

›PMID: 33705048

›Guchlerner L et al. — Nasal Septal Hematoma Is a Rare and Self-Recognizable Complication of Nasal Bone Fracture

›American Journal of Otolaryngology. 2025

›PMID: 41135290

Learn More: Nasal Bone Fracture→

Comprehensive Clinical Review

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.