See also

Maxillofacial injury 

Epistaxis 

Trauma: inter-hospital transfer

Key points

1. Septal haematoma must be excluded on the day of presentation. Delayed management is associated with significant complication
2. Children with any suspected nasal deformity should be reviewed by ENT once the swelling has reduced, usually 3-7 days post injury
3. Suspected nasal fractures without deformity can be reviewed 3-5 days post injury by a GP. If any deformity is suspected on GP review, urgent referral to ENT is required
4. Fractures with nasal deformity should be reduced within 14 days of injury

Background

• Nasal fractures may involve the nasal bones, nasal septum, or both
• Nasal fractures may be complicated by:
  • nasal obstruction
  • epistaxis
  • headache
  • septal haematoma and abscess
  • structural or cosmetic deformity
  • lacrimal duct obstruction
  • maxillary hypoplasia and atrophic rhinosinusitis
  • toxic shock syndrome
  • naso-oral fistula
• Untreated septal haematoma can result in septal necrosis or growth-centre disruption
  • This can in turn cause deformity (classically "saddle nose" deformity)
  • This may also lead to septal abscess formation, which may be further complicated by central nervous system infection or cavernous sinus thrombosis

Assessment

History

• Mechanism of injury
• Midline injuries and high-energy mechanisms confer risk of instability and of complex fracture patterns
• High-energy central facial trauma may cause posterior telescoping of the nasal root, resulting in a naso-orbito-ethmoid (NOE) fracture 
  • significant force is transmitted through the nasal bridge to disrupt the ethmoid bone, frontal sinus, anterior cranial fossa, and/or orbits
  • may be associated with lacrimal duct injury, dural tears, and traumatic brain injury
• A lateral blow to the nose (often in the context of assault) is more likely to result in septal injury
• Ensure the reported mechanism of injury matches the injury pattern
• Consider inflicted injury, especially in the non-mobile child
• Timing of injury and timing of presentation in relation to injury
• Presence of epistaxis
• Clear nasal discharge (may suggest CSF rhinorrhoea)
• Symptoms of nasal obstruction
• Facial paraesthesia, vision changes, altered bite/malocclusion (suggesting additional regional injury)
• Prior nasal surgery or injury
• History of breathing difficulty, nasal congestion, snoring, sleep apnoea, nasal drainage, and use of inhalers or allergy medications
• Review recent (pre-injury) photographs of the child's face in profile and frontal views if available

Examination

Features suggesting nasal fracture:  

• gross deformity of nasal bones or septum
• local oedema
• tenderness, step-off deformity, or bony crepitus
• nasal bone mobility
• ecchymosis
• epistaxis 

Nasal bridge swelling and subtle malalignment

Palpable lump on right side of nasal bridge	Depressed nasal bone fracture

Additional features suggesting "open" fracture 

• Laceration to the overlying skin or (on bedside rhinoscopy) the nasal mucosa
• Nasal septal haematoma  
• Suggested by deviation/asymmetry, swelling, or discolouration of the septum
• Assess via direct visualisation of septum by anterior rhinoscopy with otoscope/headlamp/loupes and nasal speculum
  • Suction away clots
  • Consider use of Co-Phenylcaine spray (vasoconstriction)
• Assess by gentle palpation of nasal septum between two fingers or with a cotton applicator, feeling for fluctuance/bogginess
• Must be screened for on initial assessment, delays to diagnosis can lead to erosion/necrosis of cartilage and significant deformity
• Identification of septal haematoma mandates emergent ENT referral

Septal haematoma

• Naso-orbito-ethmoid fractures
• Suggested by increased inner canthal distance (telecanthus) and flattening of the nasal dorsum
  • In young children, these findings can represent "open book" nasal fracture
• Where NOE complex injuries are suspected, consult a senior clinician or ENT

Associated facial fractures

Management

Investigations

Isolated nasal fractures are usually diagnosed clinically. X-rays are not required. CT may be needed for suspected associated fractures or intracranial injury

Treatment

Consider consultation with ENT when

• NOE fracture
• Clinical evidence of septal haematoma or abscess
• At time of referral if required by local practices

Consider consultation with maxillofacial surgery/plastics team when

• Non-nasal maxillofacial fracture
• Concern for "open" nasal fracture

Consider transfer when

• Septal haematoma (if no ENT surgeon onsite)
• Children requiring care beyond the level of comfort of the local healthcare facility

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval services

Consider discharge when

• Nasal septal haematoma, open fracture, and other significant injury warranting admission have been excluded
• The child has appropriate follow-up organised

Parent information

• Children discharged with nasal fractures should avoid all sporting activities until seen by their GP or an ENT team who can then advise on ongoing restrictions
• Children should receive cold therapy - a cold compress applied to nasal bridge for 10-15 minutes several times a day - for the first 24 hours
• Parents should seek medical attention if their child develops progressive nasal obstruction, persistent or worsening pain, rhinorrhoea, or fever
  • These features can suggest evolving nasal septal haematoma or abscess and require urgent review and possible discussion with an ENT team

Last updated October 2025

Reference List

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