HNY Policy and Pathway Repository - York

Structural and possible functional damage to nose due to acute trauma. Typical initial symptoms can include swelling, tenderness, bleeding, uni-lateral or bilateral obstruction, visible deformity.

• History suggestive of or any clinical evidence of potential significant head or facial injury
• Palpable step in either orbital rim +/- suspicious facial haematoma
• Surgical emphysema in facial soft tissue
• Clear watery fluid leak from nose (csf)
• Potential for penetrating injuries with or without foreign bodies
• Septal haematoma (fluctuant swelling, often bilateral, not uncommon in children. Untreated, this can lead to necrosis of the cartilage and collapse of the nasal bridge or potentially serious life threatening infective complications)
• Broken nose in a young child: the nose is still mostly cartilage and would require considerable force to break, consider possible inflicted injury or deliberate playing down of the situation and impact

Presentation with acute severe or complex trauma would be unusual in a General Practice setting. The patient may have been to Accident and Emergency immediately after the trauma and now presents, after an interval of recovery, with continuing and unresolved or perceived new problems. Also beware of another (minor) trauma shortly after the first, whilst the nose was still vulnerable.

• Double check the history of the mechanism and the precise timeline of the event or events. When was the last time the nose looked or felt “normal” and worked normally?
• Double check any sign for potential complex or extensive facial or head injury
• Ask about nasal obstruction, sense of smell and taste, patient‟s perception of abnormal appearance
• A reduced or vanished sense of smell (and taste) after a head injury can take months, sometimes one or two years, for a potential spontaneous (partial) recovery. There is little medical or surgical intervention available to speed this up or to improve possible outcomes overall. A referral in this context would only be required if there are concerns about a possible more severe head injury
• Examine function of nose (air flow), tenderness and nasal septum
• Check shape of nose by frontal inspection and by looking over the patient‟s head whilst standing behind them
• Elicit ideas, concerns and expectations of the patient (including their perception of risks / problems versus possible benefits of hospital management for their problem)
• The outcomes of simple fractures are usually good in the long term. Explain that usually no investigations (such as X-rays) are needed and that full healing and stabilisation can take up to eight weeks (like in all broken bones). However, mention that setting of the bones happens to a large degree in first 10 days, so that manual re-positioning under local anesthetic can be difficult or unreliable thereafter. Surgery is more risk and may lead to unsatisfactory outcomes in terms of appearance and function.
• If the patient requires or wishes a review for possible manipulation of a nasal deformity under local anesthetic and is still within 10 days of the injury, speak to the on-call SHO directly.

Information to include in referral letter

• Mechanism of trauma(s), timeline, previous injuries or operations.
• Possible details or reasons for presentation in General Practice rather than elsewhere.
• Relevant current medications or allergies.
• Expectation and understanding of the patient what a specialist may or may not be able to offer.
• Details of a physical examination, which confirms, that you have excluded possible acute red flag conditions or complications
   

Investigations prior to referral

• none needed (no X-ray for apparently simple broken noses)
   

Referral Criteria

• Refer to on-call SHO by telephone within less than 10 days of the trauma, if corrective manipulation under local anaesthesia is to be considered
• Long standing external nasal deformities should not be referred on the NHS, as they are regarded as a cosmetic problem, unless there is a significant and objective / visible internal deformity of the nasal septum with a functional impact.
• Reduced sense of smell after a nasal / head injury can take up to two years to spontaneously (partially) recover, and there are limited medical or surgical options to facilitate this. Therefore a referral is unlikely to be of benefit.

Patient information leaflets/ PDAs

http://www.nhs.uk/conditions/broken-nose/Pages/Introduction.aspx 
 

References

Corry J. Kucik. Management of acute nasal fractures.Am Fam Physician 2004;70:1315-20