Overview
A fractured nose is normally obvious immediately after the injury occurs. However, if a patient is seen two or more hours after the injury, there is often so much oedema (swelling) that it is difficult to be certain whether the nasal bones are fractured or not. This swelling generally subsides by days 5 to 7. Within 14 to 18 days, however, the nasal bones will have set in their displaced position — making the window for manipulation time-critical.
In an uncomplicated patient, the management pathway is straightforward: book the patient into the ENT emergency clinic (or your local equivalent) approximately 5 to 7 days after the injury. This timing achieves two goals — the oedema has sufficiently resolved to allow accurate assessment of nasal deformity, and there remains adequate time before the two-week deadline to arrange a manipulation of nasal bones (MUA — manipulation under anaesthesia) if required.
Manipulation under anaesthesia (MUA) is a brief procedure performed under general anaesthesia in which the displaced nasal bones are pushed back into a more anatomically correct position so that they can heal in proper alignment. It is not indicated if the nose is cosmetically acceptable to the patient, or if the patient declines.
Immediate Management at Presentation
Before discharging any patient with a nasal injury, ensure you have covered the following:
General Safety Checks
- Mechanism of injury: Was this a mechanical impact, or did the patient faint or collapse first? A syncopal episode may require its own investigation.
- Loss of consciousness: The patient has clearly sustained a head injury — did they lose consciousness? Follow your department's protocol for the management of head injuries, including observation criteria and imaging thresholds.
- Analgesia: Prescribe appropriate analgesia (paracetamol and ibuprofen are usually sufficient). Advise the patient to apply ice wrapped in a cloth to the nose for 10 minutes at a time to reduce swelling — do not apply ice directly to skin.
ENT-Specific Assessment
Move on to the ENT-focused components of the assessment. Check carefully for each of the following:
- Ongoing epistaxis (nosebleed): Deal with this accordingly — refer to the Epistaxis guide for full details on management.
- CSF rhinorrhoea (cerebrospinal fluid leaking from the nose): This is likely due to a cribriform plate fracture at the base of the skull. The cribriform plate is a thin sieve-like bone that separates the nasal cavity from the anterior cranial fossa. Fractures here allow CSF to drain into the nose — the fluid has a characteristic clear, watery appearance and may form a halo on tissue. These are usually managed conservatively with prophylactic antibiotics (to prevent meningitis) and bed rest. If suspected, test the fluid for beta-2-transferrin (the gold standard test) and arrange a high-resolution CT scan of the skull base.
- Diplopia (double vision): This may indicate facial fractures or a blow-out fracture of the orbital floor, in which inferior rectus muscle or orbital fat becomes trapped in the fracture. A CT scan of the orbits will be required.
- Infraorbital sensation: Test sensation in the distribution of the infraorbital nerve (cheek, upper lip, upper teeth). Reduced sensation in this area suggests a fracture of the orbital floor or maxilla and will require CT assessment.
- Facial bony step deformities: Palpate along the zygomatic arches and orbital rims carefully for step deformities, which suggest associated facial fractures beyond a simple nasal fracture.
- Septal haematoma (EMERGENCY): This is the most important thing you must not miss. A septal haematoma appears as a bright red or bluish-red cherry-like swelling on one or both sides of the nasal septum — they are almost always bilateral. Do not be fooled by a grossly deviated septum into missing one. The septal cartilage has no direct blood supply and relies entirely on its overlying perichondrium (the thin membrane covering cartilage). A haematoma strips the perichondrium from the cartilage, cutting off its nutrition. If left untreated, the cartilage will undergo avascular necrosis within days, resulting in a characteristic saddle nose deformity — a permanent cosmetic and functional problem. A septal haematoma must be incised and drained as an emergency procedure. Contact your ENT registrar immediately.
Referral and Timing Summary
For uncomplicated nasal fractures with no associated complications:
- Book into ENT emergency clinic at 5 to 7 days post-injury (after swelling has resolved but within the two-week manipulation window)
- Prescribe regular analgesia and advise ice application
- Advise the patient to return immediately if they develop worsening pain, increasing swelling of the nasal septum, or visual changes
- Give written discharge advice if available
For complicated nasal fractures with septal haematoma, CSF leak, diplopia, infraorbital numbness, or suspected orbital involvement — escalate to ENT registrar immediately and arrange appropriate imaging.
Frequently Asked Questions
Do I need to X-ray every patient with a nasal injury?
No. Nasal fracture is a clinical diagnosis and plain radiographs of the nasal bones are not routinely indicated — they do not change acute management and have poor diagnostic accuracy. CT imaging is reserved for patients with suspected orbital, frontal sinus, or skull base involvement (e.g. diplopia, infraorbital numbness, CSF rhinorrhoea).
Why is the timing of ENT follow-up so important in nasal fractures?
There is a narrow window for manipulation. The acute oedema takes approximately 5 to 7 days to resolve, allowing accurate assessment of deformity. However, nasal bones begin to unite and set in position after approximately 14 days. The ENT follow-up appointment must therefore fall between day 5 and day 14. If the patient is seen too early the assessment will be inaccurate; too late and surgical manipulation will be impossible without a formal rhinoplasty.
What is a septal haematoma and why is it a surgical emergency?
A septal haematoma is a collection of blood in the potential space between the septal cartilage and its overlying perichondrium (the vascular membrane that supplies nutrients to the avascular cartilage). Because the cartilage depends entirely on the perichondrium for its blood supply, stripping it away causes ischaemia. Within 3 to 4 days, the cartilage undergoes avascular necrosis, causing the nasal dorsum to collapse — the classic saddle nose deformity. There is also a high risk of superinfection and abscess formation (septal abscess). Incision and drainage must be performed urgently, usually under local anaesthesia, followed by nasal packing and antibiotics.
What does CSF rhinorrhoea look like and how do I test for it?
CSF rhinorrhoea appears as a clear, watery, non-viscous fluid draining from one or both nostrils. Classically it worsens when the patient leans forward and may stop and restart. The halo sign (a ring of clear fluid surrounding a central blood stain on absorbent material) is a traditional bedside test but is not reliable. The gold-standard test is beta-2-transferrin, a protein found only in CSF, perilymph, and vitreous humour — a positive result confirms CSF. Additionally, arrange a high-resolution CT scan of the skull base to define the anatomy of the leak.
What is manipulation under anaesthesia (MUA) and who needs it?
MUA (manipulation under anaesthesia) is a brief procedure performed under general or local anaesthesia in which the surgeon uses an instrument (such as a Walsham's or Asch's forceps) to reposition displaced nasal bones into better alignment. It is offered to patients who have a visible or palpable nasal deformity that was not present before the injury and that is cosmetically unacceptable to them. It is not indicated for an undisplaced fracture, a fracture that has not caused deformity, or in a patient who declines. The procedure is performed through 5 to 14 days after injury.
A patient attends 10 days after a nasal injury. Is it too late for MUA?
Potentially. The accepted window for MUA is generally within 14 days of injury, ideally performed at 5 to 10 days once the acute swelling has resolved. At 10 days, there may still be sufficient mobility, but this depends on individual healing. The patient should be seen urgently by the ENT team for assessment — do not simply discharge them. If the bones have already united (a bridge of fibrous callus begins forming from around day 10 to 14), the patient may require a formal rhinoplasty at a later date.
How would you differentiate a simple nasal fracture from a more complex mid-facial fracture on assessment?
This is a common ST3 viva question. Simple nasal fractures are limited to the nasal bones and possibly the septum. Red flags for complex mid-facial fractures include: diplopia or restricted eye movements (orbital blow-out or ZMC fracture), enophthalmos (sunken globe), infraorbital nerve numbness, flattening of the malar eminence, a palpable step deformity along the orbital rim or zygomatic arch, CSF rhinorrhoea, and a mobile maxilla (Le Fort fractures). Any of these findings warrant CT imaging and multidisciplinary input from OMFS or plastics.
How would you manage a confirmed septal haematoma at 2 am when no ENT senior is immediately available?
A septal haematoma is a surgical emergency. Contact the ENT registrar on-call immediately — they should attend. While awaiting assistance, ensure appropriate analgesia is prescribed. The procedure involves making a small incision through the mucoperichondrium over the most dependent part of the haematoma (usually under local anaesthesia with a fine blade), evacuating the blood, then packing the nose bilaterally or placing a through-and-through quilting suture to prevent re-accumulation. A broad-spectrum antibiotic (e.g. co-amoxiclav) should be prescribed to prevent secondary infection. Do not attempt the procedure alone without ENT supervision if you have not been trained in it.
What advice do you give a patient at discharge after a nasal fracture?
Discharge advice should include: apply ice (wrapped in a cloth, not directly on skin) for 10 minutes at a time to reduce swelling; take regular analgesia as prescribed; do not blow the nose — this can force air into the periorbital tissues causing surgical emphysema, particularly if there is a skull base fracture; avoid contact sports for at least six weeks; return immediately if they develop increasing nasal swelling, particularly on the septum (possible haematoma), visual changes, or clear fluid from the nose; and attend their ENT follow-up appointment in 5 to 7 days.
References
- ENT UK. Epistaxis and Nasal Trauma Guidelines. ENT UK Clinical Standards Committee; 2021.
- Rajapaksa SP, Murrant N. Nasal fractures: a guide to management. Trends in Urology & Men's Health. 2012;3(2):26–29.
- Mondin V, Rinaldo A, Ferlito A. Management of nasal bone fractures. Am J Otolaryngol. 2005;26(3):181–185.
- Fattahi T, Steinberg B, Fernandes R, et al. Repair of nasal complex fractures and the need for secondary septo-rhinoplasty. J Oral Maxillofac Surg. 2006;64(12):1785–1789.
- Burm JS, Oh SJ. Septal hematoma and abscess after nasal trauma. Clin Plast Surg. 1992;19(1):97–102.
- Murray JA, Maran AG. The treatment of nasal injuries by manipulation. J Laryngol Otol. 1980;94(12):1405–1410.