Nasal Injury

The nose is a combination of small thin bones which create the rigid upper part of the nasal ridge and more flexible cartilages which make up the lower more flexible part of the ridge and nasal tip and the skin that covers these structures. Inside the nose is a wall of bone and cartilage, named the septum, that divides the two chambers and covered with moist mucosa. Any nasal injury can damage one or more of these structures. A nasal bone fracture is a break in the bones of the nasal ridge. It usually results from a blunt injury and is one of the most common facial fractures.

Most nasal trauma is associated with a lot of bleeding. The bleeding can be from lacerations (cuts) or abrasions (scraps) of the skin or the mucosa inside the nose.

Fractures of the nasal cartilage (usually a nasal septal fracture) are less frequent, but require a more complicated repair. Nasal septal fractures often cause bleeding under the nasal mucosa and this blood collects inside the nose as a septal hematoma. This blood clot can cause trouble by injuring or thickening the septal cartilage. Injured septal structures may result in the loss of structural support (shape) of the nose and obstruct the nose.

Symptoms of a broken nose include pain, blood coming from the nose, bruising around the eyes, misshapen appearance, swelling, and difficulty breathing through the nose.

Bruising results from blood spreading into the skin and the underlying tissues. The bruises often migrate around the eyes and eventually down the cheeks. The body slowly absorbs this pigmentation. Difficulty breathing through the nose may be due to swelling and blood clots or to displaced nasal bones or cartilage.

However, it may be hard to tell if your nose is broken. Swelling can make your nose look crooked even if it is not broken.

What do I need to do?

Go to an emergency room or clinic within hours of the nasal injury.  Delays in treatment can cause problems. The most important step is to have a medical professional examine your nose.  Someone needs to determine whether or not there is a septal hematoma.  Visible skin cuts may need to be repaired or internal nasal mucosal bleeding needs to be packed. 
 

Sometimes an x-ray is needed. With minor injuries, plain x-rays are not always necessary because the decision about what to do will be made on the basis of the physical examination. Sometimes the added detail of a CT scan can give valuable details about the injury.

The emergency room doctor will be able to evaluate and stabilize the initial injury, including nasal packing and laceration repair. Antibiotics may be needed. Ice in a plastic bag over a wash cloth applied intermittently over the nasal bridge and elevation of the head will minimize nasal swelling and bruising. You may need pain medicine, such as acetaminophen (Tylenol). Do not take nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Aleve or Motrin) or aspirin, for 48 hours after a nose injury. They will prolong bleeding and worsen bruising. A follow-up appointment with an ENT doctor is usually arranged.

When to see an ENT doctor:

Serious nose injuries, such as a septal hematoma, require immediate attention by an otolaryngologist, often within 24 hours. However, for most nose injuries, it is best for the ENT doctor to evaluate the nasal injury 3-10 days after the injury, after the swelling subsides, to evaluate the nature of the damage and to remove nasal packing, if necessary.

If nasal packings were placed, they need to be taken out of the nose in 2-5 days. Any laceration sutures needs to be removed in 5 days. Remember to bring any nasal x-ray films for review. The management of nasal fractures is based primarily on how the nose looks and works. On the one hand, it may take a week for enough swelling to resolve for anyone to determine if there is a lasting change in the shape or function of the nose. On the other hand, patients should not wait too long or the bones will begin to heal and no longer be easily moved.

Not all nasal bone fractures need to be reduced. Fractures that are not displaced or are only mildly displaced and are not affecting the appearance or function of the nose do not need repositioning (reduction) of the nasal bones. But, if the bones are too far out of place, a person can be left with both an unfavorable appearance and function.

Many individuals have pre-existing nasal injuries or asymmetries. We ask that you bring a pre-injury photograph to help see what your nose was like before the trauma. A fracture reduction will not improve old deformities. One other factor in nasal bone fractures is the effect that an injury will have on the positioning of a pair of glasses. The alternative to being seen for evaluation is to let the nose heal as it is. This choice does run the risk of a misshapen or blocked nose. It may be a more involved procedure to fix these problems later.

•An x-ray of a displaced (depressed) nasal bone fracture

Fracture reduction can be a very quick and simple procedure. But it is usually performed under general anesthesia to avoid possibly unpleasant pain, noise, bleeding and packing.

Under certain circumstances, with local anesthesia, nasal bones can be reduced in the office. A combination of numbing medicines, sprayed and injected around the nose, lessens the discomfort.

Usually a thin metallic or plastic splint is molded over the ridge of the nose to protect the bones from moving again while healing. This “cast” is usually removed within 5-7 days. If you wear glasses, discuss this issue with your doctor. After nasal reduction, there is usually minimal new pain, swelling or bleeding. You will not be restricted to a bed, but keeping one’s head elevated reduces the feeling of pressure and bleeding.

Bending and vigorous activities should be avoided for about a week. Returning to work depends on what you do and the degree of your injuries.

There are rarely significant risks. But with the initial nasal trauma there is almost always some bleeding into the soft tissues of the nasal ridge and this blood will form some scar tissue. Depending on the location and amount of scar tissue, even an effective nasal bone reduction may result in some bumps and asymmetries along its surface. If you had a laceration, there will be a resulting scar. Sometimes this needs a delayed treatment. Also, on rare occasion, the blood and swelling of the injury, and sometimes a packing, will lead to a secondary sinus or nasal infection.

Only the more complex or delayed nasal fractures require a septoplasty (repair of the internal nasal wall) or rhinoplasty (repair of the bones and cartilages that provide the shape of the nose). About 6 week after treatment of a nasal bone fracture, the nose has stablized enough to allow return to contact sports.

Nonetheless, the nose is not at full strength for months and might be tender if hit. Moreover, competitive athletes might want to protect their nose from further injury. Consider a sports protective mask. (Link to Mueller nasal guard)

“ I had my deviated septum and broken nose fixed. I was very uncomfortable the first few days. Then the pain went away and I was just uncomfortable. I was back to work three days after surgery. This was the first time for me with an ENT.” - Tony Durante