Broken Nose

 

broken nose can be defined as structural and possible functional damage to a nose due to acute trauma. Typical initial symptoms are swelling, tenderness, bleeding, uni-lateral or bilateral obstruction, visible deformity, and a crunching or crackling sound when the nose is touched.  Nasal injuries are the most common facial traumas and are more commonly seen in young men aged 15-30 years

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Exclude Red Flag Symptoms

Exclude the following red flag symptoms:

  • History suggestive of or any clinical evidence of potential significant head or facial injury
  • Palpable step in either orbital rim +/- suspicious facial haematoma
  • Surgical emphysema in facial soft tissue
  • Clear watery fluid leak from nose (?csf)
  • Potential for penetrating injuries with or without foreign bodies
  • Septal haematoma (untreated, this can lead to necrosis of the cartilage and collapse of the nasal bridge)
  • Broken nose in a young child – the nose is still mostly cartilage and would require considerable force to break, consider possible inflicted injury

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Management

NOTE Presentation with acute severe or complex trauma would be unusual in a General Practice setting. The patient may have been to Accident and Emergency immediately after the trauma and now presents, after an interval of recovery, with continuing and unresolved or perceived new problems. Also there could have possibly been another (minor) trauma shortly after the first, whilst the nose was still vulnerable

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  1. Double check the history of the mechanism and the precise timeline of the event or events. When was the last time the nose looked or felt “normal” and worked normally?
  2. Double check any sign for potential complex or extensive facial or head injury
  3. Ask about nasal obstruction, sense of smell and taste, patient’s perception of abnormal appearance
  4. Examine function of nose (air flow), tenderness and nasal septum
  5. Check shape of nose by frontal inspection and by looking over the patient’s head whilst standing behind them
  6. Elicit ideas, concerns and expectations of the patient
  7. The outcomes of simple fractures are usually good in the long term. Explain that usually no investigations (such as X-rays) are needed if this appears to be a simple fracture and that full healing and stabilisation can take up to eight weeks (like in all broken bones). However, mention that setting of the bones happens to a degree in first 10 days that manual re-positioning with local anaesthetic can be difficult or unreliable thereafter, so, would probably then need a general anaesthetic with all the associated implications. Also, the outcomes (appearance and function) can potentially worsen with surgery. A functionally impairing nasal septum deviation can be surgically corrected
  8. If the patient requires review for possible manipulation of a nasal deformity under local anaesthetic and is still within 10 days of the injury, speak to the on-call SHO directly

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When to refer

Immediate referral is required if there is:

  • Marked deviation
  • Epistaxis that is failing to settle
  • Septal haematoma; this requires incision and drainage to prevent abscess and/or necrosis
  • CSF rhinorrhoea; this implies breach of the cribriform plate. CT and referral to neurosurgery are required
  • Widening of intercanthal distance suggests nasoethmoidal fracture which requires surgical repair
  • Facial anaesthesia, facial or mandibular fracture and ophthalmoplegia require immediate referral to the maxillofacial surgeons

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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