Nasal trauma

Nasal deviation as a result previous trauma is common referral in our population. In primary care patients will present either acutely or following a period of healing.  

In the acute setting patients should be assessed as per any facial injury with an ATLS approach as there are often other associated injuries. The majority of acute cases will present to A+E but if seen in primary care, it is important to rule out;

• Evidence of concussion or more significant head injury
• Associated injuries (mandible or orbital fracture)
• Septal haematoma
• Clear unilateral rhinorrhoea

In the absence of the above issues, an isolated nasal fracture has a window of 2-3 weeks before the bones will reset, therefore if the patient wants to be considered for a nasal manipulation we need to see them ideally 1-2 weeks after the traumatic event. (Follow referral guidance below). If seen by the GP after 3 weeks, document the injury, and advise the patient they need to wait 6 months and if still symptomatic represent to the GP who can then refer as described below.

When considering routine referrals, there are two occasions when we will consider a rhinoplasty as an isolated or part of a combined surgical procedure. These are if there is a functional impairment and a rhinoplasty will help improve the function of the nose, or if there has been NHS documentation of trauma within a year of the injury. We don’t accept purely cosmetic referrals with no history of trauma within a year. Even with document trauma and/or a functional issue we don’t offer septoplasty or septorhinoplasty until at least the age of 18. This is to allow the mid face to grow unimpeded.

In Scotland we are governed by the adult exceptional referral protocol (AERP) please see the document below in other evidence. One of the most important aspects to consider prior to referral is the psychological state of the patient.

Referral contraindicated;

• Significant life event in the last 12 months (birth, relationship breakdown, bereavement)
• Episode of self harm within the last 2 years

Emergency

• A+E – If concern regarding head injury or other facial injuries
• ENT (bleep 4496) – If evidence of a septal haematoma or nasal deviation where patient would like to consider a nasal manipulation (ideally within 2 weeks of an injury and no later than 3 weeks).

Routine

• ENT
  • If the structural concern is related to a functional problem
  • Following nasal trauma if the patient has sought initial medical attention within a year of the injury.

Nasal manipulation patient information leaflet

Scottish Aesthetic referral protocol

The Exceptional Referral Protocol (ERP)

Rhinoplasty

Procedures not usually provided by NHSScotland

All procedures where the primary aim is to alter the appearance of the nose.
Congenital anomalies (e.g. nasal deformity associated with cleft lip) will usually be in a continuing programme of treatment and are not subject to the protocol.

Clinical Psychology

Referrals only for nasal obstruction do not require specialist Clinical Psychology.
Where surgery will cause a change in appearance as a secondary outcome clinical psychology input should be considered prior to the procedure.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for this type of surgery.

Considerations for treatment

Indications for referral

A deviated nose and functional problem of the nasal airway.
Procedures to alter the appearance of the nose after trauma will usually be supported if the patient has sought initial medical attention within one year of injury.

Contraindications for referral

Simple cosmetic rhinoplasty will not be supported.

Waiting Times

Procedures for nasal obstruction are subject to the 18 Weeks Referral to Treatment Standard.
All other indications for rhinoplasty are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Referrer must first assess the following before taking the decision to make a referral under the protocol. All criteria must be met prior to referral.

Physical criteria: all must be met.

Psychological distress: must be met.

Contraindications