Cosmesis and the ability to breathe through the nose are key issues in nasal fractures. Apart from management of a septal hematoma, a fractured nose is of little medical concern, unless deformity or airway obstruction is present. Ask the patient several key questions to evaluate nasal fractures: (1) "Have you ever broken your nose before?" (2) "How does your nose look to you?" (3) "Are you having trouble breathing through your nose?" Because nasal deformity may be due to either new or old trauma, solicit the patient's opinion. On physical examination, observe for deformity and palpate for crepitus. The intranasal exam is key to detect septal hematoma, as described earlier. Drain any septal hematomas in the ED after anesthetizing with a topical anesthetic such as cocaine or benzocaine. Use a no. 11 blade to incise the inferior portion of the hematoma and allow it to drain. Packing the nose with Vaseline (petroleum jelly) gauze will prevent reaccumulation of blood.
After drainage, reevaluate the patient in 2 to 3 days or arrange for ear-nose-throat follow-up.
The need for nasal films remains controversial. Nasal films do not determine the need for intervention and do not affect surgical planning. Despite the presence of a fracture on x-ray, there is no need for intervention if there is no cosmetic deformity and no obstruction to airflow. Obvious nasal deformity (new or old) in the absence of radiographic findings may prompt rhinoplasty.
For these reasons, many physicians never, or only rarely, order nasal x-rays. Some might obtain nasal films because of patient insistence. Patients with obvious deformity or difficulty breathing through the nose should be referred to a consultant on an outpatient basis. Those with significant swelling or questionable deformity need reevaluation in 5 to 7 days, when edema has resolved. This follow-up is more valuable than radiographic imaging.
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