Clear unilateral rhinorrhea after significant trauma
Basilar skull fracture concern
Treatment
Analgesia and initial supportive care
Symptom control
Pain management
Paracetamol dosing per local protocol
Avoid duplication with combination products
Hepatic disease precautions
Ibuprofen dosing per local protocol
Avoid with significant bleeding risk
Renal disease precautions
Epistaxis control basics
Direct pressure
Continuous pressure duration guidance
Avoid repeated short attempts
Topical vasoconstrictor when appropriate
Oxymetazoline intranasal dosing per local protocol
Hypertension precautions
Septal hematoma and abscess management
Septal hematoma pathway
If septal hematoma present, urgent drainage
ENT preferred when available
Time critical to prevent cartilage necrosis
Post drainage measures
Nasal packing or splints per ENT
Close follow up within 24 to 48 hours
Antibiotics for hematoma or abscess pathway
Coverage per local antibiogram
Staphylococcus aureus consideration
Reduction and stabilization
Closed reduction planning
Reduction indications
Cosmetic deformity bothersome to patient
Nasal airway obstruction
Timing considerations
Reassessment after swelling improves
Typical reassessment within several days
Window before fracture sets
Reduction commonly within 1 to 2 weeks
Earlier if minimal edema
Avoid late reduction without specialist plan
Splinting and packing
External splint post reduction per specialist
Wear duration per local protocol
Skin care under splint
Internal packing when indicated
Septal support
Bleeding control
Antibiotics and tetanus
Antibiotic strategy
Closed uncomplicated fracture after closed reduction
Routine prophylaxis generally not beneficial
Shared decision making for special risk contexts
Antibiotics when higher infection risk
Grossly contaminated open wound
Skin laceration communicating with fracture
Soil contamination
Septal hematoma or abscess management
Post drainage coverage
Systemic infection features
Tetanus prophylaxis
Status review for any open wound
Booster timing per local guidelines
Immune globulin when indicated
Complication management
Persistent obstruction or deformity
Delayed septorhinoplasty discussion
Typically delayed until healing complete
Functional and cosmetic goals
Persistent septal deviation
Septoplasty consideration per specialist
Mucosal injury considerations
Special Populations
Pregnancy
Pregnancy considerations
Imaging prioritization
Clinical diagnosis favored when safe
CT only when associated injury suspected and benefits outweigh risks
Medication safety
Paracetamol preferred for analgesia
NSAID use considerations by trimester and local guidance
Epistaxis physiology
Increased mucosal vascularity
Lower threshold for recurrent bleeding counseling
Geriatric
Geriatric considerations
Higher risk coagulopathy
Anticoagulant prevalence
Low threshold for targeted labs
Frailty and fall mechanism
Broader injury screening
Head injury coexistence risk
Reduction goals
Airway and function emphasis
Comorbidity informed anesthesia planning
Pediatrics
Pediatric considerations
Septal hematoma vigilance
Mandatory exclusion on day of presentation
Urgent management to prevent deformity
Timing of specialist review
Early follow up after swelling reduction
Growth plate and cartilage injury consideration
Imaging minimization
Avoid routine nasal bone radiographs
CT reserved for suspected associated facial fracture
Background
Epidemiology
Frequency and patterns
Common facial fracture
Often managed without imaging
High prevalence in assault and sports
Pediatric patterns
More cartilage injury relative to bone
Deformity can be subtle early
Practice recommendations against routine X ray
Low diagnostic accuracy of plain films
Low impact on management decisions
Pathophysiology
Injury mechanics
Nasal bone displacement
Lateral impact causing deviation
Frontal impact causing depression
Septal injury
Cartilage fracture or dislocation
Subperichondrial bleeding forming septal hematoma
Complication cascade
Hematoma leading to cartilage ischemia
Necrosis leading to saddle nose deformity
Therapeutic Considerations
Treatment logic
Clinical exam driven decisions
Deformity and obstruction guide need for reduction
Septal hematoma exclusion prevents major morbidity
Reduction timing physiology
Edema obscures anatomy early
Callus formation reduces success later
Antibiotic stewardship
Low infection rates in closed reduction
Prophylaxis not routinely helpful in uncomplicated cases
Patient Discharge Instructions
copy discharge instructions
Discharge instructions
Ice packs for swelling
10 to 15 minutes at a time
Skin protection barrier
Head elevation during rest
Reduce swelling
Reduce bleeding risk
Avoid nose blowing
Prevent bleeding restart
Reduce swelling and pain
Avoid contact sports and re injury risk
Activity restriction duration per clinician plan
Protective gear discussion
Pain control plan
Paracetamol as directed
NSAID only if approved given bleeding risk
Return to emergency care now for red flags
Worsening nasal blockage on one or both sides
New or increasing deformity after swelling improves
Persistent bleeding despite pressure
Fever or worsening pain
Clear watery fluid from one nostril after injury
Vision change or double vision
Severe headache or repeated vomiting
Follow up plan
Recheck once swelling decreases
ENT or facial plastics appointment if deformity or obstruction
References
Guidelines and evidence sources
Evidence base
Choosing Wisely Canada recommendation against routine nasal bone X rays for nasal fractures
Low sensitivity and specificity for plain films
Low impact on management
CMAJ clinical update on nasal fractures
Septal hematoma exclusion is essential
Reduction timing within typical window
StatPearls nasal septal fracture review
Closed reduction timing commonly within 2 weeks
Edema delay of several days can improve precision
ENT UK nasal trauma guideline
Assessment timing and reduction timing guidance
Complications including septal hematoma
Royal Children’s Hospital clinical guideline on nasal fracture
Septal hematoma must be excluded on presentation
Pediatric follow up after swelling reduction
Evidence on antibiotics after closed nasal reduction
Studies showing no significant benefit of routine prophylaxis in uncomplicated closed reduction
Stewardship rationale for selective use
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