Nasal trauma
Disclaimer
These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.
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Aim
To guide PCH Emergency Department (ED) staff with the assessment and management of nasal trauma.
Background
- Nasal fracture may not be an isolated injury: exclusion of other injuries is vital
- Acute complication such as septal haematoma and cerebrospinal fluid (CSF) rhinorrhoea requires early detection and management to prevent complications
- Proper assessment of a nasal fracture with surgical corrective intent is best made in the Ear, Nose and Throat (ENT) Clinic after the soft tissue swelling has settled 7-10 day post injury1.
Key points2
- Nasal fracture results from either lateral or frontal forces to the nose
- Common causes of nasal fractures in the paediatric population are contact games and sports followed by falls
- Nasal fractures are often associated with other facial injuries, hence a search for significant other injuries is important as part of the initial assessment
- Proper history taking from patient, witnesses and parents / carers is vital to estimate severity and extent of injury
- A period of loss of consciousness is an indication of closed head injury.
Assessment– Common Presenting Signs and Symptoms3,4,5
- Swollen nose
- Periorbital ecchymosis
- Epistaxis
- Blocked nose
- Pain
History6
- Mechanism of injury.
- Midline injuries and high-energy mechanisms confer risk of instability and of complex fracture patterns.
- High-energy central facial trauma may cause posterior telescoping of the nasal root, resulting in a naso-orbito-ethmoid (NOE) fracture.
- Significant force is transmitted through the nasal bridge to disrupt the ethmoid bone, frontal sinus, anterior cranial fossa and/or orbits.
- May be associated with lacrimal duct injury, dural tears and traumatic brain injury.
- A lateral blow to the nose (often in the context of assault) is more likely to result in septal injury.
- Ensure the reported mechanism of injury matches the injury pattern.
- Consider inflicted injury, especially in the non-mobile child.
- Timing of injury and timing of presentation in relation to injury.
- Presence of epistaxis.
- Clear nasal discharge (may suggest CSF rhinorrhoea).
- Symptoms of nasal obstruction.
- Facial paraesthesia, vision changes, altered bite/malocclusion (suggesting additional regional injury).
- Prior nasal surgery or injury.
- History of breathing difficulty, nasal congestion, snoring, sleep apnoea, nasal drainage and use of inhalers or allergy medications.
- Review recent (pre-injury) photographs of the child’s face in profile and frontal views if available.
Examination
- Features suggesting nasal fracture:
- gross deformity of nasal bones or septum
- local oedema
- tenderness, step-off deformity or bony crepitus
- nasal bone mobility
- ecchymosis
- epistaxis
- Additional features suggesting “open” fracture:
- laceration to the overlying skin or (on bedside rhinoscopy) the nasal mucosa
- nasal septum haematoma
- suggested by deviation/asymmetry, swelling or discolouration of the septum
- assess via direct visualisation of septum by anterior rhinoscopy with otoscope/headlamp/loupes and nasal speculum
- suction away clots
- consider use of Co-Phenylcaine spray (vasoconstriction)
- assess by gentle palpation of nasal septum between two fingers or with a cotton applicator, feeling for fluctuance/bogginess
- must be screened for on initial assessment, delays to diagnosis can lead to erosion/necrosis of cartilage and significant deformity
- identification of septal haematoma mandates emergent ENT referral
Septal Haematoma
- Naso-orbito-ethmoid fractures.
- Suggested by increased inner canthal distance (telecanthus) and flattening of the nasal dorsum.
- In young children, these findings can represent “open book” nasal fracture.
- Where NOE complex injuries are suspected, consult a senior clinician or ENT.
Management
- All patients with a nasal fracture are assumed to have other head / facial injuries until proven otherwise. Hence, all of these patients require complete neurological examination, including cranial nerve examination and palpation of the facial bones for other facial fractures.
- Management of intracranial or orbital injuries takes precedence over nasal fractures.
- If a nasal fracture is an isolated injury, acute complications need to be excluded:
- Septal haematoma
- CSF rhinorrhoea
- Investigations:
- Isolated nasal fractures are usually diagnosed clinically. X-rays are not required. CT may be needed for suspected associated fractures or intracranial injury.
Septal haematoma
- Presents as a unilateral or bilateral fluctuant septal swelling resulting in occlusion of the nasal passage
- Septal deviation (bent cartilage septum) may present with similar appearance except that it is solid rather than fluctuant on palpation
- Septal haematoma should be treated as a surgical emergency requiring incision and drainage within 24 hours
- Patients need referral to paediatric ENT team urgently
- Untreated septal haematoma may lead to septal abscess resulting in cavernous sinus thrombosis and meningitis, or cartilage destruction with a “saddle nose” deformity.
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CSF Rhinorrhoea
- Presentation of traumatic CSF leaks can be subtle and diligence is required when one is suspected
- May presents with unilateral continuous nasal drip of clear water consistency
- May be positional in nature, most commonly associated with standing or leaning forward
- Consider need for head computerised tomography (CT) and referral to paediatric Neurosurgical team, +/- ENT team.
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Discharge criteria
- After proper examination and exclusion of the acute emergencies, the patient with a nasal fracture is advised to rest at home with the following instructions:
- Avoid contact sports and pressure on the nose
- Avoid aggressive blowing of the nose
- Analgesia
- Give parent or carer the Head Injury fact sheet – Refer to Useful Resources for the relevant sheet (on the right).
- Seek medical review if worsening pain, headache and fever (septal abscess).
Referrals and follow-up
- Patients with suspected nasal fracture require review in ENT Outpatient Clinic in 7-10 days
- Explain to the patient that this duration will allow time for swelling to settle, enabling the Paediatric ENT Team to properly assess the nose for deformity and nasal obstruction
- Any necessity of intervention will be discussed at the clinic review.
References
- Roby, B, Bohm, L. Cummings Pediatric Otolaryngology 2nd Ed. [Internet]. Michigan. Pg 105-117. Elselvier. 2021. [Cited 10 Jun 2026]. Available from: Clinical Key.
- Reyes Mendez D, Lapointe A, Nasal trauma and fractures in children and adolescents. UpToDate 2023 [Last updated; 15 February 2022, Cited; 11 July 2023] Available from: Nasal trauma and fractures in children and adolescents - UpToDate (health.wa.gov.au)
- Pediatric Otolaryngology Practical Clinical Management By: Raymond Clarke Hardcover Published: 13th July 2017
- Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine Eighth Edition. Journal of Pediatric Critical Care 8.2 (2021): 116. Web. Kundan Mittal.
- Pediatric Otolaryngology for the Clinician By: Ron B. Mitchell (Editor), Kevin D. Pereira (Editor) 2010
- Royal Children’s Hospital. Nasal Fracture. [Internet]. Royal Children’s Hospital. Clinical Practice Guidelines. [Cited 10 Jun 2026]. Available from: Clinical Practice Guidelines : Nasal fracture
| Endorsed by: |
Co-director, Surgical Services, (Nursing) |
Date: |
Jun 2026 |
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