eMedicine Specialties > Sports Medicine > Face and Head
Nasal Fracture: Treatment & Medication
Updated: Jun 17, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Medical Issues/Complications
High-force midfacial injuries may involve structures other than the nose itself.- Septal hematoma
- This is a common and serious complication of nasal trauma. Septal hematomas are collections of blood in the subperichondrial space. This places pressure on the underlying cartilage, resulting in irreversible necrosis of the septum. The patient also becomes predisposed to infection. A saddle deformity may develop from loss of tissue.
- Drainage procedure: Septal hematomas must be drained immediately upon their being found. Cotton pledgets soaked in 4% cocaine are used for topical anesthesia. A scalpel incision must be made to allow drainage. A small Penrose-type drain is placed to prevent reaccumulation. Finally, nasal packing is placed. The patient should be started on oral antibiotics with antistaphylococcal coverage.
- Blowout fractures
- Orbital wall and orbital floor blowout fractures may occur.
- Any abnormality of ocular anatomy or function should alert the clinician of the possibility of these injuries.
- A common finding is extraocular muscle dysfunction, commonly characterized by the inability to look up on the affected side, suggesting entrapment of a nerve or muscle.
- The presenting complaint may be diplopia.
- Nasolacrimal duct injury
- The nasolacrimal complex lies in close proximity to the nasal bones.
- High-force midfacial injuries or those resulting in comminuted fractures require a consultation with an ophthalmologist.
- Infection: Although rare, infections resulting from nasal fractures can cause serious complications. For this reason, patients should be placed on antibiotics with coverage for staphylococcal pathogens.
- Fracture of the cribriform plate
- This type of injury may predispose to leakage of CSF, allowing rare but extremely serious complications such as meningitis, encephalitis, or brain abscess to follow.
- Drainage of clear rhinorrhea immediately after trauma to the mid face and up to several days later should alert the clinician to the possibility of this associated fracture of the cribriform plate.
Related eMedicine topic:
Resource Center Wound Management
Surgical Intervention
High-force nasal trauma resulting in deformity from displaced fractures or dislocations or from comminuted fractures may require open reduction and/or fixation by a surgeon.
Related Medscape topics:
Resource Center Fracture
Resource Center Trauma
Specialty Site Surgery
Consultations
If specialists were not consulted for the initial patient visit, appropriate referral to an otolaryngologist, maxillofacial surgeon, or plastic surgeon for outpatient management is warranted.
Other Treatment
In the acute phase, the patient should apply ice to the nose and elevate the head to aid in reduction of any swelling present. Nasal decongestants are prescribed to help reduce swelling and mucosal congestion.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications and infections.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Amoxicillin and clavulanate (Augmentin)
Drug combination that treats bacteria resistant to beta-lactam antibiotics.
Adult
875 mg PO bid for 5-7 d
Pediatric
25 mg/kg/d PO divided bid
>3 months: Base dosing protocol on amoxicillin content; due to different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use the 250-mg tab until child weighs >40 kg.
Coadministration with warfarin or heparin increases the risk of bleeding.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust the dose in renal impairment.
Penicillin VK (Pfizerpen)
Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.
Adult
250-500 mg PO qid
Pediatric
25-50 mg/kg/d PO divided bid
Probenecid may increase the effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in the presence of renal impairment.
Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft-tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking the dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. DOC in penicillin-allergic patients.
Adult
150-300 mg PO qid
Pediatric
8-20 mg/kg/d PO divided tid/qid
Increases the duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption.
Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust the dose in the presence of severe hepatic dysfunction; no adjustment is necessary in the presence of renal insufficiency; associated with severe, and possibly, fatal colitis
Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Adult
160 mg TMP/800 mg SMZ PO bid
Pediatric
<2 mo: Do not administer
>2 mo: 1 tsp/10 kg/dose PO bid
May increase PT duration when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase the blood levels of both drugs; coadministration of diuretics increases the incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate the effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase the levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of a skin rash or sign of an adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in the presence of folate deficiency (eg, chronic alcoholics, elderly persons, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in G6PD deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in the presence of renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Decongestants
Decongestants reduce mucosal edema.
Phenylephrine (Neo-Synephrine)
Applied directly to nasal mucous membranes where it stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.
Adult
2 sprays each nostril bid/qid
Pediatric
1 spray each nostril qid (parent may need to administer)
Bretylium may potentiate the action of vasopressors on adrenergic receptors, possibly resulting in arrhythmias.
MAOIs may significantly enhance the adrenergic effects of phenylephrine, and pressor response may be increased 2- to 3-fold.
Guanethidine may increase pressor response of direct-acting vasopressors, possibly resulting in severe hypertension.
Documented hypersensitivity; severe hypertension or ventricular tachycardia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use topical decongestants for more than 3-5 d; caution in the presence of hyperthyroidism, coronary artery and ischemic heart disease, diabetes mellitus, increased intraocular pressure, or prostatic hypertrophy; because of the increase in vasoconstriction, hypertensive patients may experience change in blood pressure
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and promote pulmonary toilet.
Acetaminophen (Tylenol, Feverall, aspirin-free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants. Effective in relieving mild to moderate acute pain; however, it has no peripheral anti-inflammatory effects. May be preferred in elderly patients because of fewer GI and renal side effects.
Adult
325-650 mg PO/PR q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 4 g/d
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity; known G6PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible in those with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in toxicity due to cumulative doses exceeding the recommended maximum dose
Hydrocodone and acetaminophen
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 y: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 y: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazine may decrease the analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants.
Documented hypersensitivity; high-altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The tablets contain metabisulfite that may cause hypersensitivity; caution in patients who are dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction; caution if taking in conjunction with acetaminophen as hepatotoxicity may result
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs have analgesic and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Treatment of pain tends to be patient specific.
Ibuprofen (Advil, Excedrin IB, Ibuprin, Motrin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Do not recommend in the acute phase of an injury due to a theoretic increase in bleeding; caution in the presence of congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
Anesthetics
Anesthetic agents are used to produce local anesthesia.
Cocaine 4%
Decreases membrane permeability to sodium ions, which, in turn, inhibits depolarization and blocks conduction of nerve impulses.
Use the lowest dose necessary to produce anesthesia. The 4% solution is available as a 4-mL unit-dose vial (total of 16 mg of cocaine) or 10-mL multidose vial (total of 40 mg cocaine).
Adult
One 4 mL unit-dose vial, titrate to desired effect; not to exceed 0.5 mg/kg, (two 4-mL unit-dose vials or approximately 32 mg in a 70-kg adult)
Pediatric
Not established
Increases toxicity of MAOIs
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in the presence of hypertension, cardiovascular disease, thyrotoxicosis; avoid use in traumatized mucosa and sepsis at the region of the intended application; do not inject; not recommended for use in pediatric patients on mucous membranes
More on Nasal Fracture |
| Overview: Nasal Fracture |
| Differential Diagnoses & Workup: Nasal Fracture |
 Treatment & Medication: Nasal Fracture |
| Follow-up: Nasal Fracture |
| Multimedia: Nasal Fracture |
| References |
| « Previous Page | Next Page » |
References
Cavalcanti AL, Melo TR. Facial and oral injuries in Brazilian children aged 5-17 years: 5-year review. Eur Arch Paediatr Dent. Jun 2008;9(2):102-4. [Medline].
Kim MG, Kim BK, Park JL, et al. The use of bioabsorbable plate fixation for nasal fractures under local anaesthesia through open lacerations. J Plast Reconstr Aesthet Surg. Jun 2008;61(6):696-9. [Medline].
Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. Apr 2008;60(4):398-403. [Medline].
Cantrill SV. Facial trauma. In: Rosen P, ed. Emergency Medicine: Concepts in Clinical Practice. Vol 1. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998:459.
Smith JA. Nasal emergencies and sinusitis. In: Tintinalli JE, Ruiz E, Krome RL, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York, NY: McGraw-Hill Publishing; 1996:1087-91.
Colton JJ, Beekhuis GJ. Management of nasal fractures. Otolaryngol Clin North Am. Feb 1986;19(1):73-85. [Medline].
Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. Aug 2000;106(2):266-73. [Medline].
Losken HW, van Aalst JA, Mooney MP, et al. Biodegradation of Inion fast-absorbing biodegradable plates and screws. J Craniofac Surg. May 2008;19(3):748-56. [Medline].
Further Reading
Keywords
nasal fracture, nose fracture, maxillofacial injury, facial trauma, facial fractures, septal hematoma, nerve entrapment, muscle entrapment, diplopia, blowout fracture, nasolacrimal duct injury, cribriform plate fracture, epistaxis, CSF rhinorrhea
