Complications

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The complications of a nasal fracture include nasal deformity, deviated nasal septum, septal hematoma, cribiform plate fracture, and associated facial, head, or spinal injuries.

A septal hematoma is a rare complication. It is a collection of blood beneath the septal perichondrium. Easily visualized using an otoscope, it appears as a bluish, fluid-filled sac overlying the septum. Such a hematoma is easily managed by making an incision for drainage, followed by packing the nasal cavity to prevent reaccumulation. If undiagnosed or left untreated, it may progress to an abscess or result in avascular necrosis (AVN) of the cartilaginous septum within three to four days. Septal AVN is associated with the cosmetic complications of saddle nose deformity, retraction, and changes in phonation.

Fracture through the cribiform plate of the ethmoid bone is associated with a cerebrospinal fluid (CSF) leak through torn meninges. It represents a violation in the integrity of the subarachnoid space. Cerebrospinal fluid rhinorrhea is suspected in any patient presenting with a clear nasal discharge following facial injury. CSF rhinorrhea is usually seen within the first week as cerebral edema resolves, but it may be delayed days to weeks following a traumatic event. If untreated, possible sequelae include meningoencephalitis or brain abscess. Fortunately, this is rare.

The identification of CSF rhinorrhea can be difficult in nasal injuries because it is not unusual for there to be a clear transudate from the traumatized nasal mucosa. One method of detecting CSF is to put a drop of the suspected liquid on a piece of filter paper and see if a clear area surrounds a central blood stain. An alternative is that CSF can be detected by using a glucose reagent strip. If the glucose content of suspected fluid is greater than 30 mg/dL, then the presence of CSF is suggested. These tests should not be used to definitively exclude the diagnosis. All patients with suspected CSF rhinorrhea should undergo a head CT and urgent neurosurgical consultation. If a fracture of the cribiform plate is clinically suspected, the patient should be placed in an upright position, intranasal packing avoided, and immediate neurosurgical consultation obtained. Coughing, sneezing, nose blowing, and straining by the patient should be avoided.

Other injuries often seen with nasal trauma are fractures of the orbital wall, sinuses, and zygoma. The emergency physician should also be suspicious of cervical spine damage or closed-head injury in any patient with significant facial trauma.

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