Nasal Trauma Referral Guidelines

Nasal Trauma/Nasal Dyspnea/Deviated Nasal Septum Diagnosis/Definition

• Nasal trauma is most commonly due to a blunt impact, but can be generally defined as any injury to the nose. The severity of the trauma and need for subsequent management can vary greatly.
• Nasal dyspnea is defined as difficulty breathing through the nose. This can be related to anatomic findings to include enlarged turbinates, deviated nasal septum, or nasal valve narrowing.

Initial Diagnosis and Management

• History: The diagnosis of nasal trauma is made by the history and in all cases requires an evaluation to determine the severity of the injury and the presence of associated injuries.
• Specific historical points should include the mechanism of injury, loss of consciousness, degree of epistaxis, presence of rhinorrhea, and visual symptoms, all of which can help diagnose other injuries.
• Complaints of nasal obstruction in the acute setting may indicate a collapsed airway from a bony fracture, a septal deviation, or a septal hematoma.
• In trauma that is greater than 1 week old, the major complaints dictating management are severe cosmetic deformity and nasal obstructive symptoms. 
• Complaints of nasal dyspnea unrelated to trauma may indicate a deviated nasal septum or nasal valve narrowing.
• Physical: After a complete head and neck examination to rule out associated injuries, the nasal exam focuses on ruling out pathology requiring immediate intervention (i.e. a septal hematoma, significant lacerations, or persistent epistaxis). The intranasal cavity needs to be visualized with a good light source, a nasal speculum, and suction. A septal hematoma appears as a very edematous, erythematous, and boggy mass within the septum, often filling the majority of the nasal cavity. The nasal examination should also document the displacement of the nasal bones and apparent external deviation of the nose despite initial edema, including a comparison from old photos if possible. Any visible septal deviation or airway obstruction should be noted.
• Ancillary Tests: Plain films are rarely indicated as they seldom aid in the diagnosis. CT scans may be indicated for diagnostic confirmation of associated injuries. 

Initial Management

• The goal of initial management of nasal trauma (assuming no need for immediate intervention) is to control any bleeding, reduce swelling, and maintain a patent airway. This is typically accomplished with elevation, ice packs, and nasal decongestants.
• Nasal septal deviation or nasal dyspnea unrelated to recent nasal trauma can be treated initially with a trial of medical management: antihistamine, nasal steroid and nasal saline. Often there is an allergic rhinitis component that may contribute to the nasal dyspnea and should be medically managed prior to surgical consideration.

Indications for Specialty Care Referral

• Any nasal trauma with evidence of a septal hematoma, complex laceration, or uncontrolled epistaxis should be referred to Otolaryngology for evaluation immediately.
• Patients that complain of significant nasal obstruction after conservative management that are less than 10 days out from the trauma should be referred to Otolaryngology by contacting the resident on call.
• Patients that have significant cosmetic deformity and are less than 10 days out from the trauma should be referred to Otolaryngology by contacting the resident on call. It is important to refer nasal fractures to ENT before 10 days for immediate repair to be effective.
• Patients who have a significant nasal deformity or nasal obstruction that are more than 10 days out from the trauma, and who desire surgical evaluation, should be referred on a routine basis.
• Patients with nasal septal deviation or nasal dyspnea unresponsive to medical management should be referred routinely for surgical consultation.

Indications for Specialty Care Referral

• All cases of hoarseness that persist for greater than two weeks despite medical therapy should be referred to Otolaryngology for routine evaluation.
• All cases with a suspected neoplastic or traumatic etiology should be discussed with an ENT provider and referred within 72 hours to Otolaryngology for evaluation.