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Initial Assessment The mechanism of injury should be solicited to assess for risk of other associated concerns (e.g., closed head injury) Physical examination should focus on a careful assessment for nasal septal hematoma, obvious fracture or nasal deviation, and signs of associated ophthalmologic or severe head injury CSF leak should be considered with any clear fluid drainage from the nose Associated sinus fractures may be identified by crepitus or tenderness over the sinus Management When the history and/or examination are concerning for a simple nasal fracture, no diagnostic imaging is indicated If there is concern for CSF leak, fluid can be tested using the halo test (see above), or by assessing glucose concentration Beta2-transferrin testing is the most accurate, though results are often not available in a timeframe to be useful during acute evaluation and management Maxillofacial CT imaging may be performed if there is concern for associated bony injuries (see Chapters 107 Facial Trauma and 114 Ocular Trauma ) but is not indicated for isolated nasal fractures If persistent nasal bleeding occurs in the setting of nasal trauma, apply direct pressure, topical vasoconstrictors, and ice Routine packing and/or splinting is not indicated Once the bleeding has stopped, treatment for simple nasal fractures is supportive care with pain management and follow-up with otolaryngology or plastic surgery to assess for deformity in to days (see Fig 106.1 ) It is important that patients are followed up by an otolaryngologist to manage deformities which can occur in up 10% of injuries There is no significant difference in deformity rate for closed versus open reduction, local versus general anesthesia, and acute versus delayed repair Deformities that are not corrected lead to more functional (e.g., nasal obstruction) and cosmetic problems Compound nasal fractures or those with associated midface fractures should be treated with antibiotics for week Isolated sinus fractures should be treated with antibiotics for week and the patient should maintain “sinus precautions” which include avoidance of nose blowing, straining, swimming, and use of a straw Follow-up for sinus fractures should also occur at week, although they rarely require subsequent intervention Nasal septal hematomas should be incised and drained, and nasal packing or a pressure dressing should be left in place to avoid reaccumulation Follow-up is critical to assess for reaccumulation Admission and elevation of head of the bed is indicated for children with suspected CSF leak
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