The comment about getting a CT if you can't get close follow-up did not make sense to me. Lack of follow-up for cosmetic nasal fractures is a societal decision. We should only get facial ct if it will change our therapy in the ED.
Thanks for your comment. I think you’re right in that many of our decisions are based on culture and resources, and there is plenty of practice variation.
When I first started, I would not get any imaging and refer to outpatient ENT. Of course some of these patients have a head injury and a typical CT brain will capture a nasal fracture. I still don't order imaging in the ED for a nasal fracture. The real issue is not imaging, it's management. I was cautious initially, listening to voices that said these needed to fixed in the OR; and that they can bleed a lot. Then I got working in the community, where ENT follow-up is not as quick and honestly, you feel pretty useless patting the patient on the back, telling them to "let the swelling come down" and have them seen an ENT in 2-4 weeks. So, I asked around and started reducing these myself. Some patients need no analgesia, but usually I have a colleague give some ketofol, or propofol, and just straighten their nose myself in the ED. It's not hard. I use two blunt instruments in the nostrils to give me a bit more leverage. It works fine, the patient is happier, and sure, they still get ENT follow-up - but they look better, and I think they feel better and breathe better likely too.
Thanks for sharing this. I have not reduced these myself but I do not work in the type of environment you described. As with the above comment, I think there’s a lot of practice variation here.
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Byron F. - May 24, 2022 7:02 AM
The comment about getting a CT if you can't get close follow-up did not make sense to me. Lack of follow-up for cosmetic nasal fractures is a societal decision. We should only get facial ct if it will change our therapy in the ED.
Jess Mason - June 7, 2022 5:01 AM
Thanks for your comment. I think you’re right in that many of our decisions are based on culture and resources, and there is plenty of practice variation.
Raghu V. - June 6, 2022 9:44 PM
When I first started, I would not get any imaging and refer to outpatient ENT. Of course some of these patients have a head injury and a typical CT brain will capture a nasal fracture. I still don't order imaging in the ED for a nasal fracture. The real issue is not imaging, it's management. I was cautious initially, listening to voices that said these needed to fixed in the OR; and that they can bleed a lot. Then I got working in the community, where ENT follow-up is not as quick and honestly, you feel pretty useless patting the patient on the back, telling them to "let the swelling come down" and have them seen an ENT in 2-4 weeks. So, I asked around and started reducing these myself. Some patients need no analgesia, but usually I have a colleague give some ketofol, or propofol, and just straighten their nose myself in the ED. It's not hard. I use two blunt instruments in the nostrils to give me a bit more leverage. It works fine, the patient is happier, and sure, they still get ENT follow-up - but they look better, and I think they feel better and breathe better likely too.
Jess Mason - June 7, 2022 5:02 AM
Thanks for sharing this. I have not reduced these myself but I do not work in the type of environment you described. As with the above comment, I think there’s a lot of practice variation here.