Pediatric emergency medicine trisk 3271 3271

Initial Assessment
The mechanism of injury should be solicited to assess for risk of other associated
concerns (e.g., closed head injury). Physical examination should focus on a
careful assessment for nasal septal hematoma, obvious fracture or nasal deviation,
and signs of associated ophthalmologic or severe head injury. CSF leak should be
considered with any clear fluid drainage from the nose. Associated sinus fractures
may be identified by crepitus or tenderness over the sinus.
Management
When the history and/or examination are concerning for a simple nasal fracture,
no diagnostic imaging is indicated. If there is concern for CSF leak, fluid can be
tested using the halo test (see above), or by assessing glucose concentration. Beta2-transferrin testing is the most accurate, though results are often not available in
a timeframe to be useful during acute evaluation and management. Maxillofacial
CT imaging may be performed if there is concern for associated bony injuries
(see Chapters 107 Facial Trauma and 114 Ocular Trauma ) but is not indicated for
isolated nasal fractures. If persistent nasal bleeding occurs in the setting of nasal
trauma, apply direct pressure, topical vasoconstrictors, and ice. Routine packing
and/or splinting is not indicated. Once the bleeding has stopped, treatment for
simple nasal fractures is supportive care with pain management and follow-up
with otolaryngology or plastic surgery to assess for deformity in 4 to 7 days (see
Fig. 106.1 ). It is important that patients are followed up by an otolaryngologist to
manage deformities which can occur in up 10% of injuries. There is no significant
difference in deformity rate for closed versus open reduction, local versus general
anesthesia, and acute versus delayed repair. Deformities that are not corrected
lead to more functional (e.g., nasal obstruction) and cosmetic problems.
Compound nasal fractures or those with associated midface fractures should be
treated with antibiotics for 1 week. Isolated sinus fractures should be treated with
antibiotics for 1 week and the patient should maintain “sinus precautions” which
include avoidance of nose blowing, straining, swimming, and use of a straw.
Follow-up for sinus fractures should also occur at 1 week, although they rarely
require subsequent intervention. Nasal septal hematomas should be incised and
drained, and nasal packing or a pressure dressing should be left in place to avoid

reaccumulation. Follow-up is critical to assess for reaccumulation. Admission and
elevation of head of the bed is indicated for children with suspected CSF leak.