Inspect the nose from various angles to detect any deformity. Posttraumatic edema often obscures nasal deviation. The patient can assist in the exam by identifying preexisting nasal deformity. Palpation will detect crepitus, subtle deformity, and subcutaneous air. The two most important potential findings are septal hematoma and cerebrospinal fluid (CSF) rhinorrhea. Septal hematoma appears as a bluish, bulging mass on a widened septum. If in doubt, palpate the septum with a cotton swab to appreciate the doughy swelling.
CSF mixed with blood forms a double ring or halo sign when dropped on a paper towel or a bed sheet. This occurs because blood and CSF have different diffusion properties. This finding is not specific for CSF and will occur with traumatized rhinorrhea. Unlike CSF, simple rhinorrhea (absent blood) does not contain glucose. Unfortunately, the bedside glucose tests cannot distinguish between spinal fluid and rhinorrhea. However, a standard laboratory glucose test can make the distinction.
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