Nasal Injuries

Objectives

To guide the assessment and management of patients presenting to medical facilities following acute nasal trauma.

Scope

This guideline describes the assessment and management of isolated nasal injuries. This term includes fractures of the nasal bone, trauma to the nasal septum and surrounding cartilage. Management of traumatic epistaxis is covered in a separate guideline. Treating clinicians must consider the possibility of concomitant facial fractures, the management of which is covered in the maxillofacial injuries guideline.

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in a forward medical location or in an Emergency Department on deployed operations.

Initial Assessment & Management

Exclude associated injuries

When making a diagnosis of isolated nasal injury, clinicians must exclude significant injuries that are commonly associated with nasal trauma:

  • Cervical spine injury (High risk if multiple facial fractures present).
  • Clinically significant head injury.
  • Associated facial fractures – Refer to Maxillofacial trauma guideline [LINK PENDING].

 

Identify time-critical complications

Nasal trauma may lead to complications requiring urgent management and evacuation:

Septal haematoma +/- abscess will require evacuation to hospital care for advanced management to prevent septal necrosis. If access to advanced management is not possible within 24 hours, manage as per prolonged casualty care guidance (below).

Be aware that septal haematoma may develop up to 72 hours after initial injury.

Persistent or recurrent traumatic epistaxis – Manage as per epistaxis guideline.

 

Isolated nasal injury is a clinical diagnosis.  If clinical suspicion for associated injuries is low, there is no requirement to evacuate a casualty only for imaging.

 

Consider other complications

Nasal deformity does not require immediate reduction of fracture/dislocation of the nasal bone is no longer recommended. Evacuation should be planned to facilitate reduction at 7-10 days as per advanced management (below).

Once swelling has developed, typically within a few hours of injury, it often becomes impossible to determine whether significant underlying deformity is truly present. Consider serial re-assessment as swelling improves.
Immediate reduction of fracture/dislocation of the nasal bone is no longer a recommended approach.

Septal injuries are present in around half of nasal fractures. They pose an increased risk for septal haematoma and complicate fracture reduction. They often require ENT specialist input. This should be taken into account when planning evacuation.

 

 

 

Advanced Assessment & Management

Management of septal haematoma

Septal haematoma should be drained as soon as possible. If untreated, this can result in necrosis, abscess formation and CNS infection.

Bilateral septal haematomas pose an extremely high risk for septal ischaemia and necrosis. 

  1. Incision and drainage is preferred to needle aspiration, especially for a large haematoma or delayed presentations. This can be performed using methoxyflurane (Penthrox) or ketamine for procedural sedation.
  2. Once the haematoma is evacuated, use through and through septal quilting sutures to close the potential space.
  3. Gentle nasal packing may also prevent haematoma re-formation.
  4. If abscess is suspected, give antibiotics as per deployed healthcare antimicrobial guidelines.

 

Imaging

  • X-rays are not routinely indicated in isolated nasal injures.

 

Reduction of displaced fractures

  1. Closed reduction of simple nasal pyramid fracture-dislocations may be achieved using methoxyflurane (Penthrox) or under procedural sedation using ketamine.
  2. Reduction should be delayed until 7-10 days when swelling has settled and the extent of deformity can be adequately visualised. If patients present beyond 14 days, closed reduction is unlikely to be successful so expert ENT review will be required.
  3. Consider availability of onward evacuation before attempting closed reduction, noting that complications of attempted reduction include septal haematoma and epistaxis.
  4. Extensive fracture-dislocation of nasal bones and septum or open fractures may not be suitable for awake manipulation and may require general anaesthesia.
For experts trained in facial nerve blocks, local anaesthesia can be achieved through external infiltration along the nasomaxillary groove, the infraorbital nerve in its foramen and around the infratrochlear nerve. Without this expertise, methoxyflurane (Penthrox) or under procedural sedation using ketamine are good options. Intranasal topic anaesthesia (in combination with phenylephrine) delivered by atomiser is also acceptable.

Prolonged Casualty Care

Evacuation of septal haematomas must be performed as soon as possible to prevent necrosis and infection:

  1. If evacuation to advanced care is not possible within 24 hours, needle aspiration (18-20 gauge) should be attempted in the forward setting.
  2. If the haematoma is organised (particularly in large haematomas or delayed presentations), needle aspiration may fail. In which case application of topical anaesthesia and attempted incision and drainage with a scalpel should be considered. If bilateral haematomas present, attempt to stagger incisions to prevent septal perforation.
  3. Once aspiration/drainage is complete, gently pack to reduce bleeding/haematoma re-formation
  4. In a forward location, give prophylactic antibiotics as per deployed healthcare antimicrobial guidelines.

Paediatric Considerations

Be aware that fracture healing may take place sooner in children. Reduction is therefore recommended at 3-7 days. 

Assessment Guidance

The following list is not exhaustive, but should assist clinicians when considering possible associated injuries vs a diagnosis of isolated nasal injury:

History:

  1. Mechanism of injury: penetrating injury or a high energy mechanism should give a high index of suspicion for associated injuries; clinical exclusion may not be appropriate.
  2. Loss of consciousness, amnesia or vomiting may indicate clinically significant head injury.
  3. Visual disturbance, diplopia, ecchymosis, epiphora may indicate orbital and/or globe injury.
  4. New sensory/motor deficit may indicate nerve injury and/or facial fractures.
  5. Painful nasal obstruction may be due to septal haematoma.
  6. Watery rhinorrhoea or hyposmia may be linked to nasoethmoid injury with CSF leak.
  7. Altered bite or trismus may indicate temporomandibular joint injury.
  8. Loose teeth indicates possible mandibular as well as dental injury.
Remember to explicitly ask the patient (or parent) about change in appearance, noting that an apparent nasal deformity may be pre-existing, typically related to historic nasal injury.

Examination:

  1. Inspect external nose for swelling, deviation, bruising or lacerations.
  2. Palpate external nose for bone mobility, depression or step deformity.
  3. Inspect nasal septum using a Thudicum and headlight or pen torch for:
    1. Septal haematoma or septal abscess.
    2. Significant deviation may indicate a septal fracture.
  4. Inspect the face including the orbit and jaw for obvious deformity. Nasal injuries may co-present with the following facial injuries:
    1. Ethymoid bone (CSF rhinorrhoea or Periorbital emphysema)
    2. Zygomaticomaxillary complex.
    3. Zygmatic arch.
    4. Orbital floor.
    5. Le Fort type midface.
Septal haematoma typically presents as a red or purple swelling to the nasal septum, and may be unilateral or bilateral. It can be difficult to differentiate haematoma from septal deviation, but if gently palpated the swelling of a haematoma should feel soft and fluctuant.

Investigations

  1. Radiographic
    1. Facial X-rays do not aid in the diagnosis of isolated nasal bone fractures. This diagnosis can be made based on clinical assessment alone.
    2. XR/CT may aid diagnosis if associated facial/head/neck injuries are suspected. Refer to the relevant guidelines for further information.
  2. Biochemical
    1. Samples of watery rhinorrhoea may be tested for beta-2 transferrin if available to aid in diagnosis of CSF rhinorrhoea.

Last reviewed: 01/04/2026

Next review date: 01/04/2027