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nose, supplied by branches of both the internal (anterior ethmoidal) and external
(superior labial, palatine) carotid arteries, nasal hemorrhage can be difficult to
stop despite usual conservative measures (e.g., anterior compression). Treatment
of persistent epistaxis may require anterior and/or posterior nasal packing with
gauze or tampon, or the placement of an epistaxis balloon catheter. If a bleeding
vessel can be identified, silver nitrate cauterization can be performed.
Septal hematomas arise because of hemorrhage from an artery beneath the
mucoperichondrium, separating it from the septal cartilage. Because the septal
cartilage is avascular and relies on the overlying mucoperichondrium for its blood
supply, a hematoma may result in cartilage necrosis and eventual septal
perforation. Septal hematomas require urgent incision and drainage (see Chapter
106 ENT Trauma ).
Nasoorbital ethmoid fractures involve complete separation of the nasal bones
and medial walls of the orbits from the stable frontal bone superiorly and
infraorbital rim laterally. These injuries are usually the result of high-velocity
trauma to the central midface. The bones are often fragmented and telescoped
posteriorly into the ethmoid region. These patients display a characteristic
flattened nose, with the loss of anterior projection on the lateral view of the face.
Because the medial canthal tendons attach firmly to the medial walls of the orbits,
lateral drift of the fracture segments results in traumatic telecanthus. Normal
mean intercanthal distance is 16 mm at birth, which increases to 25 mm in a
female and 27 mm in a male at full facial growth. A significant increase in
intercanthal distance or gross asymmetry in the medial canthal to facial midline
distance should raise suspicion of this fracture. Traumatic telecanthus suggests
the diagnosis of a nasoorbital ethmoid fracture, which unlike a nondisplaced nasal
fracture, requires urgent subspecialist input.
Current Evidence
Nasal fractures are largely a clinical diagnosis. Though rarely required for
diagnosis, CT is the optimal modality for complex fractures. More recent studies
suggest that high-resolution ultrasonography may be more sensitive than CT or
plain radiography for the detection of simple nasal fractures.

While repair of nasal fractures can be successfully performed within a few
hours after the injury, immediate repair is usually not possible because of the
significant swelling that often develops rapidly with such injuries. The optimal
timing after the immediate injury period is controversial. Some reports have
demonstrated improved cosmetic outcome when repair is performed within 5
days of injury, while other studies have not demonstrated a difference in cosmesis