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nose, supplied by branches of both the internal (anterior ethmoidal) and external (superior labial, palatine) carotid arteries, nasal hemorrhage can be difficult to stop despite usual conservative measures (e.g., anterior compression) Treatment of persistent epistaxis may require anterior and/or posterior nasal packing with gauze or tampon, or the placement of an epistaxis balloon catheter If a bleeding vessel can be identified, silver nitrate cauterization can be performed Septal hematomas arise because of hemorrhage from an artery beneath the mucoperichondrium, separating it from the septal cartilage Because the septal cartilage is avascular and relies on the overlying mucoperichondrium for its blood supply, a hematoma may result in cartilage necrosis and eventual septal perforation Septal hematomas require urgent incision and drainage (see Chapter 106 ENT Trauma ) Nasoorbital ethmoid fractures involve complete separation of the nasal bones and medial walls of the orbits from the stable frontal bone superiorly and infraorbital rim laterally These injuries are usually the result of high-velocity trauma to the central midface The bones are often fragmented and telescoped posteriorly into the ethmoid region These patients display a characteristic flattened nose, with the loss of anterior projection on the lateral view of the face Because the medial canthal tendons attach firmly to the medial walls of the orbits, lateral drift of the fracture segments results in traumatic telecanthus Normal mean intercanthal distance is 16 mm at birth, which increases to 25 mm in a female and 27 mm in a male at full facial growth A significant increase in intercanthal distance or gross asymmetry in the medial canthal to facial midline distance should raise suspicion of this fracture Traumatic telecanthus suggests the diagnosis of a nasoorbital ethmoid fracture, which unlike a nondisplaced nasal fracture, requires urgent subspecialist input Current Evidence Nasal fractures are largely a clinical diagnosis Though rarely required for diagnosis, CT is the optimal modality for complex fractures More recent studies suggest that high-resolution ultrasonography may be more sensitive than CT or plain radiography for the detection of simple nasal fractures While repair of nasal fractures can be successfully performed within a few hours after the injury, immediate repair is usually not possible because of the significant swelling that often develops rapidly with such injuries The optimal timing after the immediate injury period is controversial Some reports have demonstrated improved cosmetic outcome when repair is performed within days of injury, while other studies have not demonstrated a difference in cosmesis