Please note that the following is a general guideline only.
Pathophysiology
The resultant effect of nasal injury depends on
1 patients age (young more elastic)
2 Direction of injury
3 Force
Younger patients have more cartilage, hence less likely to sustain a fracture. If there is a fracture, it tends to be cartilaginous making it difficult to manipulate into a better position
Frontal injury tends to give a depressed fracture. May also give a septal fracture/ haematoma.
Lateral (side) injury may give unilateral bone depression, contralateral bone deviation, septal fracture
Important Hx
Timing of injury- must be seen by an ENT surgeon within 1 week
Associated injury- CSF leak, Epistaxis, Facial fracture- diplopia,
Past Hx- was there old nasal fracture, does the nose look different now (ensure the deviation is not an old injury)
Important aspects of the examination
Examine the external appearance, note if it is a new deviation.
Palpate the fracture line is it tender- new injury
Examine intranasally after decongestion (use Co phenyl or Otrivin spray)
If the septum appears swollen check if it is a boggy swelling- i.e. palpate with a firm probe. If boggy, this could be a haematoma.
Look for other injuries
facial fractures, check vision, check diplopia due to ocular muscle entrapment, Dental, Lefort Fractures
Swollen, L depressed, R deviated. Hence MUA needs elevation of the L side and push in of the R side. This would be done under GA by most. Splint is applied for some protection
This is a large septal haematoma which had become infected. One must palpate the septum with an instrument and if boggy could be a haematoma.
Investigations
No need for XR for nasal fracture alone. If the nose has changed shape, it is likely to be a fracture that needs MUA
if a facial fracture is suspected need CT and Maxillofacial review
Treatment
if septal haematoma needs drainage (by an ENT surgeon) followed by either suturing of the septum or packing to prevent recollection.
If Abscess- also need URGENT drainage, Drain placement and packing to prevent recollection and antibiotic cover
Drain as well as splints in place to prevent recollection