My son fell on his face last night in basketball practice and hurt his nose. There was some edema, and he complained that it hurt. How do we know if it's broken without an X-ray? Should we just go and have it checked out immediately, or wait until after the swelling goes down?

W.S.

When I used to teach medical students, I'd have them look at a clock with a second hand and tell them, "I am going to teach you everything you need to know about broken noses in 60 seconds." Then I would take a deep breath and begin...

Assuming the injury is LIMITED TO THE NOSE, there is only one reason to see a doctor immediately. Prompt diagnosis and treatment of septal hematoma is essential to prevent an eventual cosmetic deformity of the nose. (The septum is the bony and cartilaginous "divider" between the two nasal cavities. A hematoma is a collection of blood.) Septal hematoma is not a subtle diagnosis: A physician will see a large, bluish bulge in one or both nasal cavities. The hematoma separates the tissues lining the septum from the underlying cartilage, depriving the cartilage of its blood supply. If untreated, the cartilage will die, and the nose will collapse over the next several months. This is a BAD deformity. Thus, it is useful to have an immediate examination (by an emergency-room doc or family doc) to rule out septal hematoma.

The only reason to obtain an X-ray is "medico-legal" necessity. That is, do you need to document a nasal fracture for insurance purposes? For purely medical purposes, I really don't care whether the X-ray shows a fracture or not. The X-ray will only show a deformity if it is in the bony part of the nose, but the patient may have an isolated injury to the cartilage.

However, I do need answers to the following two questions after much of the swelling has resolved -- ideally, about five to seven days after the injury:

1. Does your nose look different now? If so, do you find the cosmetic change to be unacceptable? (It is often helpful if the patient can bring a pre-injury photo to the doctor -- a large, frontal view of the face is ideal.)
   
2. Can you breathe through your nose?
   

If the nose looks much the same as it did pre-injury (or if the patient is not terribly bothered by the change in appearance), and if he or she can breathe through the nose, then no further treatment is necessary. On the other hand, if there is a cosmetic deformity and/or nasal-airway obstruction, then intervention is recommended. The medical term for this procedure is "closed (or open) reduction of a nasal fracture." ("Open reduction" indicates that incisions were necessary to fix the fractures. A closed reduction does not require incisions.) Some ENTs do closed reductions in their offices, while others prefer their patients to be in the operating room, under general anesthesia. This is a painful procedure, and some patients would not tolerate closed reduction in the office.

Another option is to wait several months for the nose to heal, and then have the deformity corrected via a formal septorhinoplasty (commonly called a "nose job"). Many ENTs believe this provides superior results. One can certainly opt for an immediate treatment of the nasal fracture, followed months later by a septorhinoplasty if needed.

There IS a time limit for the immediate treatment of a nasal fracture. I prefer to do this procedure within 10 days of the injury and would be very reluctant to attempt treatment if the fracture were more than two weeks old. Healing is rapid, especially in young people, and it is very hard to budge a healed fracture.