A 24-year-old man arrives after colliding face-first with another player during a basketball game. Blood darkens the gauze beneath his nose, and the bridge looks newly crooked; each breath produces a faint whistle through the left nostril. He insists he can breathe “well enough” and denies losing consciousness, but his friend says the nose looked different immediately after impact. You lift the tip of the nose to inspect the septum, and the next decision is still pending.

— What’s your move? Read on.

Before you read
  • Which nasal injury requires urgent drainage?
  • When is imaging unnecessary, and when does the patient need specialty follow-up?

When to Think of It

Nasal deformity, tenderness, epistaxis, swelling, crepitus, obstruction, or periorbital ecchymosis after blunt facial trauma. Always consider associated orbital, naso-orbito-ethmoid, maxillary, skull-base, and cervical injuries.

Sick or Not Sick

Sick vs. not sick: Is there an airway-threatening or time-sensitive associated injury? Look specifically for septal hematoma, uncontrolled hemorrhage, CSF rhinorrhea, open fracture, severe deformity, malocclusion, ocular injury, facial instability, or altered mental status.

The First Fifteen Minutes

  • Sit the patient forward and apply firm, continuous pressure to the soft nasal alae for 10–15 minutes; this is the fastest mechanical control of anterior epistaxis.
  • Ongoing anterior bleeding → oxymetazoline 0.05% nasal spray, 2 sprays per nostril, then repeat pressure; vasoconstriction shrinks mucosal vessels. Avoid or use cautiously in severe uncontrolled hypertension or significant ischemic disease.
  • Pain without major bleeding → acetaminophen 1,000 mg PO; it provides analgesia without impairing platelet function. If pain is severe and bleeding is controlled → fentanyl 25–50 mcg IV, titrated every 5 minutes, because rapid opioid analgesia facilitates examination; monitor ventilation.
  • Visible septal hematoma → urgent ENT consultation for incision and drainage; do not merely prescribe medication, because trapped blood threatens septal cartilage.
  • Suspected open or grossly contaminated fracture → cefazolin 2 g IV once, because it provides early skin-flora coverage while definitive evaluation occurs; antibiotic choice and duration should follow local facial-trauma protocol.
  • Tetanus status incomplete or unknown with a contaminated/open wound → tetanus toxoid-containing vaccine 0.5 mL IM; add tetanus immune globulin 250 IU IM when the wound is dirty and the patient has an incomplete/unknown primary series, because passive antitoxin is needed before active immunity develops.

Definitive Care & Disposition

No routine imaging is needed for an uncomplicated isolated nasal fracture; plain films rarely change care. CT maxillofacial imaging is appropriate for suspected complex facial fracture, significant mechanism, ocular findings, malocclusion, facial instability, or concerning neurologic findings. Reassess after swelling improves; displaced deformity or persistent obstruction generally needs closed reduction by ENT/plastics, often within 7–14 days in adults. Septal hematoma, CSF leak, open/complex fracture, uncontrolled epistaxis, or associated injuries warrant urgent specialty evaluation or admission. Discharge uncomplicated injuries with elevation, cold packs, analgesia, sinus precautions when indicated, and follow-up.

How This One Kills

The lethal-to-function failure is missing a septal hematoma: the patient may have little external deformity, but bilateral or unilateral boggy septal swelling progressively devascularizes cartilage and later produces saddle-nose deformity or abscess.
The Differential — What Else Looks Like This
  • Septal hematoma — fluctuant, boggy swelling of the septum that does not shrink with topical vasoconstrictor; confusing it with congestion causes cartilage loss.
  • Naso-orbito-ethmoid fracture — telecanthus, medial canthal tendon laxity, or CSF rhinorrhea; treating it as an isolated nasal fracture misses major midface injury.
  • Le Fort fracture — mobile maxilla or malocclusion; missed instability can compromise airway and require operative fixation.
  • Simple epistaxis without fracture — bleeding but no new deformity, tenderness, or instability; unnecessary imaging and reduction add harm without benefit.

The Second-Day Story

In older adults, anticoagulated patients, and patients presenting hours after injury, swelling and bruising may obscure the deformity while pain is muted. In children, the cartilage injury may be more important than radiographically visible bone injury. A careful intranasal examination—looking for septal asymmetry, fluctuation, obstruction, and clear drainage—plus assessment of occlusion and ocular findings catches the clinically important injury even when the nose looks only mildly swollen.
Back to Our Patient
Back to the 24-year-old basketball player: he has a new mild dorsal deformity and tenderness but no malocclusion, ocular abnormality, CSF-like drainage, facial instability, or septal swelling; bleeding stops with pressure and oxymetazoline. He is therefore not sick from an airway-threatening associated injury, and the likely problem is an isolated displaced nasal fracture. After analgesia and a complete intranasal examination, he is discharged without routine imaging, with cold packs, return precautions for obstruction or recurrent bleeding, and ENT/plastics follow-up for reassessment and possible reduction after swelling decreases.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“This is a 24-year-old man with blunt nasal trauma during basketball, presenting with epistaxis, pain, left-sided obstruction, and a new dorsal deviation. He has no loss of consciousness, vomiting, malocclusion, diplopia, vision loss, facial instability, or clear rhinorrhea. His bleeding stopped with pressure and topical vasoconstrictor; exam shows localized nasal tenderness and deformity but no septal hematoma, ocular injury, or other midface instability. He is hemodynamically stable and neurologically intact. My assessment is an isolated displaced nasal fracture without an emergent complication, so I plan analgesia, no routine imaging, discharge precautions, and ENT follow-up for reassessment and possible reduction.”

Study Directive

  • Practice a trauma nose examination: external deformity, septum, occlusion, ocular motility, visual acuity, and CSF-leak screen.
  • Review photographs or diagrams of septal hematoma, NOE fracture, and Le Fort fractures; identify the discriminating finding for each.
  • Write a discharge plan for isolated nasal fracture and a separate escalation plan for septal hematoma.
  • Complete 10 facial-trauma questions and explain why CT is or is not indicated in each.

Recent Literature