Nasal fracture

If there is evidence of septal haematoma or abscess or a high-force midline nasal trauma with concern of orbital or frontal sinus fracture, send to nearest Emergency Department immediately.

Young children (especially <2 years of age) presenting with injuries suspicious for inflicted injury or with a history of possible inflicted injury should be discussed with the Child Protection Unit or Emergency Department for possible medical assessment.

Introduction

Nasal fractures may involve the nasal bones, septum, or both. Specific fracture patterns depend upon whether the injury force is lateral or midline. Post injury oedema may mask underlying nasal bone deformity, and delayed assessment is important¹.

In toddlers, due to the anatomy of the developing nasal bones, more energy is generally required to fracture the nose of a toddler than an older child. If you are seeing a toddler with fractured nasal bones, this should prime you to look for other head injuries, as well as to ensure that the reported mechanism of injury fits the injuries seen.

Patients who have an obvious nasal bone fracture with deviation or where swelling has developed require delayed evaluation by an Ear, Nose & Throat (ENT) surgeon 7 - 10 days later to permit swelling to recede prior to reduction. Successful fracture reduction is very difficult if more than 14 days elapse between injury and reduction, as bone healing has commenced

Septal hematomas are uncommon but important injuries to identify, especially in young children³. Trauma to the nasal septum can tear the blood vessels that are adjacent to the septal cartilage. When a septal haematoma is suspected the patient should be seen in the Emergency Department that day for review and urgent drainage.

Apparent septal deviation may be explained by a previous septal deviation or may be caused by a hematoma or abscess. Thus, the area of the septum that appears to be deviated should be palpated with a cotton-tipped applicator to determine whether it is compressible. Immediate consultation with an ENT Surgeon is warranted for patients who have compressible lesions.

Pre-referral investigations 

• Imaging is not necessary for most patients with isolated nasal trauma unless suspicion of other injuries exist.

Pre-referral management

• Physical examination to assess degree of bony deformity.
  • Nondisplaced fractures do not require surgical reduction; radiographs are only needed for medico-legal documentation or when the diagnosis of a displaced fracture is in doubt.
• Please refer to the PCH Emergency Department guidelines for more information on nasal trauma.

When to refer

• If patient has a suspected nasal fracture, refer to PCH ENT within 7-10 days of injury.
  • If any child with a suspected non accidental injury, please discuss with Child Protection Unit first via PCH Switchboard.

How to refer

• Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals are made via the PCH Referral Office.
• Urgent referrals that require review within 7-14 days, please call Perth Children's Hospital Switch on 6456 2222 to discuss referral with the on-call ENT specialist. 

Referrals should not be sent through the Central Referral Service as this may delay processing the referral and may prevent the patient from being seen within 14 days.

Essential information to include in your referral

• State the exact date of injury to ensure timely follow up
  • Ideally 7-10 days post injury, and no longer than 14 days post injury
• Any related imaging. 

Useful resources

• Perth Children’s Hospital Emergency Department Guideline - Head Injury
• Perth Children’s Hospital patient Health Facts sheet - Head Injury
• Perth Children’s Hospital Child Protection Unit (health.wa.gov.au)
• The Royal Children’s Hospital Melbourne - Maxillofacial injury
• RACGP - Traumatic nasal injuries in general practice

References

1. Borner U, Anschuetz L, Kaiser N, et al. Blunt nasal trauma in children: a frequent diagnostic challenge. Eur Arch Otorhinolaryngol 2019; 276:85.
2. Nigam A, Goni A, Benjamin A, Dasgupta AR. The value of radiographs in the management of the fractured nose. Arch Emerg Med 1993; 10:293.
3. Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries and management. Facial Plast Surg 2011; 27:483.

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