ENT (Otorhinolaryngology) · MU Sofia

27. Fracture of the nasal bones. Hematoma of the nasal septum.

Covers fractures of the nasal bones and haematoma of the nasal septum, starting with the causes and mechanisms of injury behind each fracture pattern. It then lists three fracture classes, the clinical signs and when imaging is or is not useful, and treatment timing from conservative care to closed and open reduction. The septal haematoma section gives its pathogenesis, which leads to cartilage necrosis, the clinical findings, and urgent drainage with packing or quilting sutures. A differential diagnosis table closes the note, comparing septal haematoma with other conditions.

Inside: 3 sections · 5 labelled pictures · 1 table · 15 flashcards · 7 min

Topic 27 of 52 in the MU Sofia syllabus for ENT (Otorhinolaryngology) (Medicine, Year 4). The free AceMed note covers it in 3 sections, about 926 words (7 min of reading), with 15 flashcards.

In this note

  1. Fracture of the nasal bones. Hematoma of the nasal septum.
  2. Nasal Bone Fracture
  3. Hematoma of the Nasal Septum

Nasal Bone Fracture

1. Definition: A nasal bone fracture is a break in one or both nasal bones and/or the nasal cartilage framework, usually resulting from external trauma; it is the most common facial fracture.

2. Etiopathogenesis

  • Etiology: The vast majority of cases result from blunt trauma to the nose due to its prominent position.
  • Pathogenesis: The mechanism of injury determines the fracture pattern:
  • Lateral Blow: Causes the nasal bones to be pushed inward on the side of impact and outward on the opposite side, often involving a fracture and displacement of the nasal septum.
  • Direct Frontal Blow: Tends to depress or telescope the nasal bones posteriorly, often resulting in a comminuted fracture and septal fracture/dislocation.
  • Sports injuries
  • Road traffic accidents
  • Falls

3. Classification

  1. 1. Laterally Displaced Fractures: Most common. Result from a lateral blow.
  2. 2. Posteriorly Depressed Fractures: Result from a direct frontal blow, pushing the nasal bones inward. Always involves the nasal septum and may be associated with more extensive facial fractures (eg, Naso-Orbito-Ethmoid, Le Fort).
  3. 3. Disarticulation of Upper Lateral Cartilage: Severe, localized strong blow to the central third of the nose.

4. Clinical Picture

  • Pain
  • Nasal obstruction
  • Epistaxis (very common)
  • Swelling
  • Difficulty breathing through the nose
  • Inspection:
  • External Deformity: Deviation of the nasal pyramid, dorsal hump, flattening/broadening of the nasal dorsum. This may be masked by swelling initially.
  • Soft Tissue: Periorbital/nasal ecchymosis ("racoon eyes”—> skull base fracture), significant edema (swelling).
  • Palpation:
  • Bony Crepitus: A grating sound/sensation upon gentle palpation.
  • Mobility: Abnormal movement of the nasal bones.
  • "Step-off" Deformity: Discontinuity or irregularity along the nasal bone contour.
  • Anterior Rhinoscopy: Essential to rule out a septal hematoma, check for mucosal tears, and assess septal deviation.

5. Paraclinical and Radiological Examinations

  • Paraclinical (Diagnostic Gold Standard): Physical examination is the mainstay of diagnosis.
  • Radiological:
  • X-rays: Generally not recommended for isolated, uncomplicated nasal fractures. They have low sensitivity/specificity, cannot visualize cartilage, and rarely change management.
  • CT scan: Reserved for extensive facial trauma, suspected associated fractures, or a CSF leak is suspected.

6. Treatment Options

  • Conservative: Ice packs, analgesics, decongestants, head elevation. Indicated for non-displaced fractures.
  • Closed Reduction: Manipulating the bones back into position using specialized instruments (eg, Walsham's or Boies elevators) under local or general anesthesia, best performed 3-10 days post-injury
  • Ideal timing: Wait 3–5 days for swelling to subside, then perform within 7–14 days (adults) or 5–7 days (children) before fracture consolidation.

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