AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 8  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Intervention
• Multimedia
• References

Background

"If thou examinest a man having a break in the column of his nose, his nose being disfigured, and a depression being in it, while the swelling that is on it protrudes, he has discharged blood from both his nostrils. Thou shouldst say concerning him: 'One having a break in the column of his nose. An ailment which I will treat.'"

—Ancient Egypt, Edwin Smith Surgical Papyrus, 3000 BC

Although nasal fractures are the most common facial fracture, they often go unnoticed by both physicians and patients. Patients with nasal fractures usually present with some combination of deformity, tenderness, hemorrhage, edema, ecchymosis, instability, and crepitation; however, these features may not be present or may be transient.¹ To further complicate the matter, edema can mask underlying nasal deformity, crepitation, and instability; thus, many physicians and patients fail to pursue further diagnosis and appropriate treatment. If untreated, nasal fractures can result both in unfavorable appearance and in unfavorable function, especially when the underlying structural integrity of bone and cartilage is lost.

Untreated nasal fractures account for the high percentage of rhinoplasty and septoplasty procedures performed months to years after the initial trauma occurs. Thus, appropriate treatment is best rendered in a timely manner, before scarring and soft tissue changes occur. As always, thorough history taking and physical examination should precede radiographic evaluation. If radiographic evaluation is warranted, it is best used when other facial fractures are suspected in combination with a nasal fracture, because isolated nasal fractures are treated on the basis of the physical examination alone. The fact that patients may have displaced nasal fractures and normal-appearing plain radiographic findings should be emphasized.^{1, 2, 3, 4, 5, 6, 7, 8, 9, 10}

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles, Broken Nose and Facial Fracture.

Related Medscape topics:
Specialty Site Radiology
Specialty Site General Surgery
Resource Center Trauma Resource Center
Resource Center Patient Safety Resource Center
CME/CE Examining the Ears, Nose, and Oral Cavity in the Older Patient
CME The Unrestrained Driver

Pathophysiology

The nasal bones and underlying cartilage are susceptible to fractures because the nose maintains a prominent position and central location on the face and because it has a low breaking strength. Patterns of fracture are known to vary with the momentum of the striking object and the density of the underlying bone.³ As with other facial bones, younger patients tend to have larger nasoseptal fracture segments, whereas older patients are more likely to present with more comminuted fracture patterns.^{2, 4, 6, 7, 10, 11}

Weak areas are noted in the cartilage framework and the junctions of the upper lateral cartilages with the nasal bones and the septal cartilage at the maxillary crest. The weak areas account for an increase in the rate of fracture/dislocation after nasal trauma. A lateral force of only 16-66 kPa and a greater frontal force of 114-312 kPa can displace the bony dorsum.³ A large force in any direction can cause comminution of the nasal bones with an associated C-shaped deformity of the nasal septum. The C-shaped deformity usually begins under the dorsum of the nose, extends posteriorly and inferiorly through the perpendicular plate of the ethmoid, and ends with an anterior curve in the cartilaginous septum approximately 1 cm above the maxillary crest.³

Murray et al reported that almost any deviation of the fractured nasal bones involves a concomitant fracture of the septal cartilage.³ Cartilage fracture lines are often oriented vertically in the caudal septum and horizontally in the posterior portions.

Lateral impact injuries are the most common type of nasal injury leading to fracture.⁵ Lateral injury produces a depression of the ipsilateral nasal bone that usually involves the lower one half of the bone, the nasal process of the maxilla, and a variable portion of the pyriform margin. Nasal fracture and displacement without septal fracture usually occur with weaker applied forces; however, with increased force, displacement of the bilateral nasal bones may be noted, and the septum is usually dislocated and fractured as well.⁴

Other injuries that are commonly associated with nasal fractures include midface injuries involving the frontal, ethmoid, and lacrimal bones; nasoorbital ethmoid fractures; orbital wall fractures; cribriform plate fractures; frontal sinus fractures; and maxillary Le Fort I, II, and III fractures (see Images 1-6, 16-22).^{1, 2, 6, 7, 10, 11}

Frequency

United States

Fracture of nasal bones is the most common site-specific bone injury of the facial skeleton. Nasal fractures account for 39-45% of all facial fractures.⁶

Mortality/Morbidity

• The morbidity of nasal fractures includes nasal airway obstruction resulting from dorsal nasal collapse; septal deviation; valvular collapse; epistaxis; or a poor cosmetic outcome.
• Perhaps the worst morbidity results from septal hematoma, leading to septal perforation and necrosis, which causes severe nasal collapse and deformation.

Sex

The male-to-female ratio in nasal fractures is greater than 2:1.

Age

• The incidence is increased in patients aged 15-30 years.⁷
• A small but significant increase in the number of nasal fractures is noted in the elderly population because of a higher rate of falls.
• Most nasal bone fractures in young adults are related more to altercations and sporting injuries and less to motor vehicle accidents; these rates vary according to the location of the conducted study and the association with alcohol.^{6, 7, 10, 12}

Anatomy

The nasal skin is thin and loosely adherent over the superior two thirds of the nose. The skin thickens and adheres more tightly over the caudal one third of the nose. Sensory innervation of the nose is supplied by the supratrochlear, infratrochlear, anterior ethmoid, and infraorbital nerves. Blood is supplied to the external nose by the dorsal nasal, external nasal, lateral nasal, and septal arteries.

The paired, rectangular, flat nasal bones project from the frontal processes of the maxilla, joining in the midline and articulating with the nasal process of the frontal bone at the nasion. The thinner caudal portion of the nasal bones articulate with the upper lateral cartilages; this area is vulnerable to dislocation as a result of trauma. The nasion is more stable than the midline scaffolding provided by the cartilaginous septum. The ethmoid air cells are situated posterior to the nasal bones. Approximately 80% of fractures occur at the lower one third to one half of the nasal bones.³ This area represents a transition zone between the thicker proximal and thinner distal segments.

The cartilaginous septum is a quadrangle-shaped cartilage set between 2 bony structures: the vomer and the perpendicular plate of the ethmoid. The septovomerine angle is the center of growth for the cartilaginous septum. The hard palate represents the floor of the nasal cavity, and the cribriform plate constitutes the roof.

Clinical Details

Patients with nasal fractures usually present with some combination of dorsal or septal deformity, tenderness, hemorrhage,¹³ hematoma, edema, ecchymosis, instability, and crepitation. However, these features may not be present, or they may be transient.

Preferred Examination

Although the use of plain images is not suggested (see Limitations of Techniques, below), the preferred examination includes the acquisition of Waters and lateral nasal views.

Limitations of Techniques

Controversy regarding radiologic techniques

The use of plain images and computed tomography (CT) scans for the diagnosis and management of nasal fractures has been controversial. Several small studies have shown that use of these modalities is neither cost-effective nor beneficial to the patient or physician. Nasal fractures are usually evident and can be elicited by means of careful history taking and physical examination. Rarely is the radiologic confirmation of these injuries needed.¹⁴ However, some clinicians still use plain images and CT scans, and the radiologist must understand some of the diagnostic pitfalls to reduce the rate of erroneous readings.

De Lacey et al evaluated 100 consecutive patients presenting to the emergency department with a history of trauma to the nose.¹⁵ Nasal radiographs were obtained in each patient, including both the Waters and lateral views. There were no radiographic findings of fracture in 65 of the 100 patients. Nasal fractures were depicted in 45 patients, yet only 3 patients required reduction, and 31 of 45 patients were discharged without treatment. The authors then compared the lateral radiographs in 50 control subjects and 50 persons with dry skulls.

When images from control subjects were compared with images of persons with dry skulls, misreads were identified and classified as midline defects, high lateral-wall defects, and low lateral-wall defects. In 50 control subjects, 33 cortical defects were observed. After close inspection, the misreads were found to be the result of the midline nasal suture, the nasomaxillary suture (low defect), and thinning of the nasal wall (high defect). De Lacey et al concluded that the lateral view was unreliable for the evaluation of nasal fractures because of the high incidence of similar defects found in noses from control subjects and in patients with dry skulls when evaluated using plain radiography.¹⁵

Clayton and Lesser prospectively evaluated 54 patients clinically, radiologically, and under anesthesia within 19 days after nasal injury.¹⁶ At each stage, these examinations were evaluated to assess the contribution of each study to the care of the patient. Occipitomental (Waters) views and lateral views were obtained in all patients. External examination and nasal rhinoscopy were performed to evaluate the patients clinically. The patients were grouped into 3 categories: patients not needing manipulation, patients requiring manipulation, and patients requiring later review because of edema. Manipulation was required in 24 patients, and 19 patients underwent further examination with anesthesia at the time of repair.

Six patients had no clinical evidence of a fracture despite radiographic evidence of a fracture. None of these 6 patients required manipulation. Examination under anesthesia changed the type of repair necessary in 5 patients: 1 patient was found not to have a septal fracture, and 4 were found to have bilateral fractures. The authors concluded that examination under anesthesia provided more accurate information than radiography or clinical examination alone or together. The authors also found that the Waters view, the lateral view, or the 2 views in combination did not provide useful information, as compared with physical examination alone. Standard radiographs were not helpful in deciding whether to perform manipulation or when and how to perform manipulation for repair.¹⁶

Logan et al prospectively examined 100 consecutive patients seeking treatment in an emergency department for nasal trauma.¹² Both Waters and lateral views were obtained in all patients. Of the 100 patients, 19 were discharged home from the emergency department with radiographic evidence of a fracture, and 35 were referred to an ear, nose, and throat surgeon for treatment (31 of these were believed to have fracture on the basis of the radiographic findings). Only 24 of the 35 referred patients kept their appointments; of these, 8 required manipulation. The authors clearly state that the radiographs and the radiologist's report failed to influence the final management of even a single patient in this study.¹²

In 2006, Hwang et al compared 503 nasal bone fractures.¹⁷ The fractures were analyzed with plain-film radiographs in both lateral and Waters views, as well as with CT. Only 82% of nasal fractures were identified with plain films, as compared with CT scans. These authors felt that plain films were unreliable in the diagnosis of nasal bone fractures.

When evaluation of children is necessary and one wishes to limit exposure to radiation, sonography has been helpful to some in evaluating nasal fractures, septal deviation, and level of comminution. This can be accomplished with a 7-15 MHz linear array transducer.¹⁸

In the utilization of 3-dimensional (3D) CT for facial and nasal fractures, better evaluation scores were achieved with surface rendering protocols than with volume rendering protocols. Surface rendering offered better overall image quality than volume rendering.¹⁹

DIFFERENTIALS

Section 3 of 8  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Intervention
• Multimedia
• References

Other Problems to Be Considered

Previous nasal fractures
Associated facial fractures

RADIOGRAPH

Section 4 of 8  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Intervention
• Multimedia
• References

Findings

Waters view

The Waters (occipitomental) view is perhaps the best overall view for observing facial fractures in general. The radiograph is obtained in the posteroanterior position with the canthomeatal line at an angle of approximately 37° relative to the surface of the film (see Image 7). The patient's dentures and oral prosthetic devices, if any, should be removed because these structures may cause interference.

The Waters view demonstrates the orbits, maxillae, zygomatic arches, dorsal pyramid, lateral nasal walls, and septum (see Images 8-9). The radiologist should look for abnormalities of the nasal septum and arch, keeping in mind the areas of relative weakness (see Pathophysiology). Marked deviation, displacement with sharp angulation, and soft tissue swelling are all signs of possible fracture. Soft tissue edema can be sufficient to obscure the extent of a fracture. Other structures, such as the frontal, maxillary, and ethmoid sinuses, may also be involved. Any such involvement should alert the physician to the possibility of concomitant fractures. Some have found that coronal sutures can mimic nasal fractures because the sutures can become superimposed over the nasal bones.²⁰

Lateral view

The lateral view (profilogram) is obtained with the infraorbitomeatal line parallel to the transverse axis of the film and the intrapupillary line perpendicular to the plate. This orientation provides a true lateral projection that is neither tilted nor rotated; therefore, paired structures are superimposed. Many prefer to include the full profile from the forehead to the chin with a technique that uses a Bucky grid (see Image 10).²¹

Fractures of the nasal bones are frequently transverse. The lateral view obtained by using a soft tissue technique is probably best for depicting both old and new fractures of the nasal bones. The profilogram provides no information regarding a possible laterally displaced nasal bone.^{4, 21} Short lucent lines that reach the anterior cortex of the nasal bone, with or without displacement, should be regarded as a fracture.¹⁵ Evaluation of air zones by profilogram can provide important information, because the air zones commonly are lost after trauma. Alterations of air-zone shapes may indicate cartilage volume increases or septal hematoma.²¹

Other lines, such as normal sutures or longitudinally oriented nasociliary grooves, can be mistaken for longitudinal fractures. However, a nasociliary groove should never cross the plane of the nasal bridge; if this is demonstrated, the line is a fracture. Fortunately, fractures usually demonstrate a sharpened delineation, with greater lucency than normal sutures and grooves.¹¹ The radiologist must look closely for marked deviation, displacement with sharp angulation, and soft tissue swelling. It is important to remember that only approximately 15% of old fractures heal by ossification; as a result, old fractures are easily mistaken for new fractures, and this increases the rate of false-positive readings.¹²

Degree of Confidence

Radiographic findings consistent with nasal fracture may be identified in 53-90% of patients with isolated nasal fractures.²² Because of this and other concerns, Logan et al questioned the reliability of nasal bone radiographs.¹²

False Positives/Negatives

Logan et al believed that the high percentage of false-negative and false-positive results with nasal bone radiographs had a number of causes. Old fractures, vascular markings, cartilage fractures, midline nasal sutures, nasomaxillary sutures, and thinning of the nasal wall represent a few of the many features that may mislead even an experienced radiologist. Logan et al reported a true-positive rate of 86% and a false-positive rate of 8%.¹² De Lacey et al conducted a similar study that showed that 66% of control subjects had a false-positive reading using Waters view radiographs.¹⁵ Unfortunately, an accurate depiction of the rate of false-positive and false-negative results from injured patients cannot be obtained by using their data.

CT SCAN

Section 5 of 8  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Intervention
• Multimedia
• References

Findings

CT scans are usually obtained when another traumatic facial or skull fracture is suspected. Many fractures are also demonstrated on routine head CT scans in patients with trauma. Although CT scans can be used to demonstrate the extent of nasal injury, they are rarely required. Contiguous, thin (2-3 mm), axial and coronal sections with bone windows must be obtained; however, axial images can be used to reconstruct coronal planes. These scans are helpful when associated injuries are suspected in combination with nasal fractures (see Images 11-15, 23-29).

CT scans depict important structures, such as the orbital walls, zygomatic arches, frontozygomatic sutures, maxillary buttresses, ethmoid air cells, nasal bones, dorsal pyramid, and floor of the frontal sinuses with the associated nasofrontal ducts. Recent nasal fractures usually are easily recognized on CT scans; however, as with plain radiographs, old fractures and normal sutures may be mistaken for new fractures.

INTERVENTION

Section 6 of 8  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Intervention
• Multimedia
• References

Fractures of the nasal bones are the most site-specific bone injury of the facial skeleton. If left uncorrected, the loss of structural integrity and the soft tissue changes that follow may lead to both unfavorable appearance and function. Thus, appropriate and timely treatment is warranted to decrease morbidity in patients with these fractures. The management of nasal fractures is based solely on the clinical assessment of function and appearance; therefore, a thorough physical examination of a decongested nose is paramount.

Many patients who sustain nasal trauma present with profuse bleeding, which can usually be controlled with clot removal and the application of a topical vasoconstrictor. If this approach is unsuccessful, gauze packing, balloon catheterization, or other procedures may be required; the ligation of vessels is rarely necessary. Nasal packing is the most common procedure performed to control bleeding after topical vasoconstrictors fail. Packing material is placed directly at the area of hemorrhage to supply pressure; however, bilateral packing is occasionally necessary to control bleeding from several areas. The packing is commonly removed in 2-5 days; nasal reduction can be performed at the time of removal.

Profuse edema of the soft tissues surrounding the nose is a common phenomenon, one that may cause delay of treatment. The fixation of the fractured nasal bones is usually observed after 2-3 weeks, but adherence to surrounding soft tissues can occur in as few as 5-10 days. Elevation of the head and locally applied ice packs can quickly decrease the edema and pain associated with many nasal fractures, allowing more timely and proper reduction.

Fracture reduction should be accomplished when accurate evaluation and manipulation of the mobile nasal bones can be performed; this is usually within 5-10 days in adults and 3-7 days in children.⁴ In patients with minimal swelling, immediate reduction can be performed, especially if the patient is scheduled for other operative procedures; however, nasal fracture reduction is a lower priority compared with most other emergency surgical interventions.

Closed reduction is the initial plan of treatment preferred by most facial plastic surgeons. If the reduction is not maintained or if poor cosmesis occurs, open septorhinoplasty can be accomplished in a controlled fashion months later.^{3, 23}

Medical/Legal Pitfalls

• Wexler opined that nasal radiographs were a medicolegal necessity and considered them an important adjunct in acute injuries to the nasal bones.²³ Unfortunately, this opinion was not founded on solid experimental data. The practice of ordering unnecessary radiographs encourages poor patient care and devalues the importance of thorough history taking and physical examination. This practice also leads to needless irradiation, expense, and wasted time.²⁴ Several other authors neither share Wexler's opinion nor present data to support such a belief.^{12, 15, 16, 22}
• Clayton and Lesser published information from one of the leading medical defense organizations in Britain.¹⁶ The organization stated that radiography of the nasal bones is indicated only if it is in the best interests of the individual patient and will help in surgical management. The same organization stated that radiographs are not a medicolegal requirement. Logan et al supported this dictum by demonstrating that nasal radiography has a high incidence of false-positive and false-negative results; thus, the degree of accuracy is low.¹² This low degree of accuracy greatly reduces the medicolegal value of radiographs.¹⁶ It should be noted that these results are observer dependent, and some radiologists have a greater knowledge and aptitude for reading such images.
• De Lacey et al found that occipitomental views are of no help in the diagnosis of nasal fractures.¹⁵ They found that lateral views were helpful for diagnosing nasal fractures in only some patients. Lateral radiographs offer no information regarding lateral nasal displacement. De Lacey et al believed that in patients in whom isolated nasal bone fractures are suspected, radiographs are unnecessary. They stated, "[I]t requires stating emphatically that there is no medico-legal reason for taking x-rays of the nasal bone, as treatment of a fracture will depend solely on the function or cosmetic effect and this depends only on the clinical findings."¹⁵
• History taking and physical examination are the best tools for diagnosing nasal fractures and for determining which nasal fractures require treatment by a specialist. Unfortunately, despite a large body of evidence against the use of radiographs for isolated nasal trauma, practitioners continue to routinely request nasal radiographs. The legal value of an examination depends on the degree of medical findings supported by the examination results.²² In isolated cases of nasal trauma, radiographs have a high number of false-negative results and a large but unknown number of false-positive results. Thus, the legal value is low because of the uncertain degree of confidence in the findings. Radiographic examinations of the nose have been known to fail in the assessment of nasal fractures.²²

See also the Medscape topic Medical Malpractice and Legal Issues.

MULTIMEDIA

Section 7 of 8  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Intervention
• Multimedia
• References

Media file 1:  Nasal fractures. Patient presenting 48 hours after an assault, with complaints of right eye pain, nasal airway obstruction, and deformity. Note the asymmetry of the nasal bones and dorsal nasal column (same patient in Images 1-6).
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Media file 2:  Nasal fractures. Patient presenting 48 hours after an assault, with complaints of right eye pain, nasal airway obstruction, and deformity (same patient as in Images 1-6).
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Media file 3:  Nasal fractures. Patient presenting 48 hours after an assault, with complaints of right eye pain, nasal airway obstruction, and deformity (same patient as in Images 1-6).
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Media file 4:  Nasal fractures. Patient presenting 2 weeks after nasal osteotomies and closed nasal reduction, which were performed after an assault (same patient as in Images 1-6). The patient had multiple previous nasal fractures and refused open septorhinoplasty. Note the broad nasal dorsum.
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Media file 5:  Nasal fractures. Patient presenting 2 weeks after nasal osteotomies and closed nasal reduction, which were performed after an assault (same patient as in Images 1-6). The patient had multiple previous nasal fractures and refused open septorhinoplasty.
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Media file 6:  Nasal fractures. Patient presenting 2 weeks after nasal osteotomies and closed nasal reduction, which were performed after an assault (same patient in Images 1-6). The patient had multiple previous nasal fractures and refused open septorhinoplasty. Note the broad nasal dorsum.
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Media file 7:  Nasal fractures. Posteroanterior view shows displaced septum from the maxillary crest and a deviated nasal root to the patient's right.
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Media file 8:  Nasal fractures. Waters view shows a deviated nasal septum, quadrangular cartilage displaced from the maxillary crest, and a nasal root deviated to the right.
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Media file 9:  Nasal fractures. Waters view (close-up view of Image 8) shows a deviated nasal septum, quadrangular cartilage displaced from the maxillary crest, and a nasal root deviated to the right.
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Media file 10:  Nasal fractures. Lateral nasal images placed back to back. Notice the dorsal deformity of the nasal bones and the small lucent lines that pass all the way through the nasal bones. Short lucent lines that reach the anterior cortex of the nasal bone, with or without displacement, should be regarded as nasal fractures.
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Media file 11:  Nasal fractures. Coronal CT scan demonstrates a nasal fracture with root deviation to the right. Note that the fracture has occurred in the weaker lower portion of the nasal bones.
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Media file 12:  Nasal fractures. Coronal CT scan demonstrates a nasal fracture with root deviation to the right. Note that the fracture has occurred in the weaker lower portion of the nasal bones.
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Media file 13:  Nasal fractures. Coronal CT scan demonstrates a nasal fracture with root deviation to the right. Note that the fracture has occurred in the weaker lower portion of the nasal bones. Note the septal involvement.
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Media file 14:  Nasal fractures. Axial CT scan demonstrates a nasal fracture with root deviation to the right. Note that the fracture involves the septum as well and that the septum is severely deviated.
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Media file 15:  Nasal fractures. Axial CT scan demonstrates a nasal fracture with root deviation to the right. Note that the fracture involves the septum as well and that the septum is severely deviated.
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Media file 16:  Nasal fractures. This patient presented to the emergency department 6 hours after an aggravated assault (same patient in Images 16-22). Note the obvious dorsal column flattening and deviation. The patient had no associated facial fractures, but because of a high suspicion for other fractures, a CT scan was obtained.
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Media file 17:  Nasal fractures. This patient presented to the emergency department 6 hours after an aggravated assault (same patient as in Images 16-22). Note the obvious nasal deviation and flattened nasal dorsum.
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Media file 18:  Nasal fractures. This patient presented to the emergency department 6 hours following an aggravated assault (same patient as Images 16-22). Note the obvious nasal deformity.
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Media file 19:  Nasal fractures. This patient presented to the emergency department 6 hours after an aggravated assault (same patient as Images 16-22). Note the obvious nasal deformity.
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Media file 20:  Nasal fractures. Image was obtained 7 days after septoplasty and nasal osteotomies (same patient as in Images 16-22).
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Media file 21:  Nasal fractures. Image was obtained 7 days after septoplasty and nasal osteotomies (same patient as in Images 16-22).
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Media file 22:  Nasal fractures. Image was obtained 7 days after septoplasty and nasal osteotomies (same patient in Images 16-22).
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Media file 23:  Nasal fractures. Coronal CT scan demonstrates a nasal fracture with root deviation to the left. Note that a portion of the nasal bones is involved.
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Media file 24:  Nasal fractures. Coronal CT scan demonstrates a nasal fracture with root deviation to the left. Note that a portion of the nasal bones is involved.
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Media file 25:  Nasal fractures. Coronal CT scan demonstrates a nasal fracture with root deviation to the left. Note that a portion of the nasal bones is involved.
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Media file 26:  Nasal fractures. Axial CT scan demonstrates a nasal fracture with root deviation to the left. Note that the fracture involves the septum as well and that the septum is deviated.
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Media file 27:  Nasal fractures. Axial CT scan demonstrates a nasal fracture with root deviation to the left. Note that the fracture involves the septum as well and that the septum is deviated.
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Media file 28:  Nasal fractures. Axial CT scan demonstrates a nasal fracture with root deviation to the left. Note that the fracture involves the septum as well and that the septum is deviated.
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Media file 29:  Nasal fractures. Axial CT scan demonstrates a nasal fracture with root deviation to the left. Note that the fracture involves the septum as well and that the septum is deviated.
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REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Intervention
• Multimedia
• References

1. Tremolet de Villers Y, Schultz RC. Nasal fractures. J Trauma. Apr 1975;15(4):319-27. [Medline].
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3. Murray JA, Maran AG, Mackenzie IJ, Raab G. Open v closed reduction of the fractured nose. Arch Otolaryngol. Dec 1984;110(12):797-802. [Medline].
4. Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology Head and Neck Surgery. Vol II. 3rd ed. St Louis: Mosby-Year Book;1998.
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9. Doerr TD, Arden RL, Mathog RH. Otolaryngology-head & neck surgery. In: Cummings CW, Fredrickson JM, Krause CJ, Harker LA, eds. Nasal Fractures. 3rd ed. Mosby-Year Book;1998: 866-82.
10. Scherer M, Sullivan WG, Smith DJ Jr, et al. An analysis of 1,423 facial fractures in 788 patients at an urban trauma center. J Trauma. Mar 1989;29(3):388-90. [Medline].
11. Redman HC, Purdy PD, Miller GL. Facial trauma. In: Redman HC, Miller GL, Purdy PD, eds. Emergency Radiology. Philadelphia:. WB Saunders Co;1993: 96-105.
12. Logan M, O''Driscoll K, Masterson J. The utility of nasal bone radiographs in nasal trauma. Clin Radiol. Mar 1994;49(3):192-4. [Medline].
13. Liu WH, Chen YH, Hsieh CT, Lin EY, Chung TT, Ju DT. Transarterial embolization in the management of life-threatening hemorrhage after maxillofacial trauma: a case report and review of literature. Am J Emerg Med. May 2008;26(4):516.e3-5. [Medline].
14. Jones TR. The nose. In: Greco RJ, ed. Emergency Plastic Surgery. Boston:. Little, Brown & Co;1991: 365-72.
15. de Lacey GJ, Wignall BK, Hussain S, Reidy JR. The radiology of nasal injuries: problems of interpretation and clinical relevance. Br J Radiol. Jun 1977;50(594):412-4. [Medline].
16. Clayton MI, Lesser TH. The role of radiography in the management of nasal fractures. J Laryngol Otol. Jul 1986;100(7):797-801. [Medline].
17. Hwang K, You SH, Kim SG, Lee SI. Analysis of nasal bone fractures; a six-year study of 503 patients. J Craniofac Surg. Mar 2006;17(2):261-4. [Medline].
18. Hong HS, Cha JG, Paik SH, Park SJ, Park JS, Kim DH, et al. High-resolution sonography for nasal fracture in children. AJR Am J Roentgenol. Jan 2007;188(1):W86-92. [Medline].
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Article Last Updated: Jun 4, 2008