Nasal septal hematoma

Background

• Submucosal vessels disrupted
• Blood accumulates between perichondrium and cartilaginous septum
• Requires immediate incision and drainage to prevent nasal septum necrosis
  • Can lead to saddle nose deformity, nasal septum abscess
  • May be complicated by necrosis and perforation
• Suspect septum abscess in patient who presents late after facial trauma with systemic symptoms
• Ensure thorough examination of both nares - Nasal septum cartilage easily fractures (form bilateral hematomas)

Clinical Features

• Adults present with significant facial trauma and nasal fracture
• Dark purple hematoma against septum
• Common symptoms in peds, usually within first 24-72 hrs with even minor nasal trauma, include:
  • Nasal obstruction (95%)
  • Pain (50%)
  • Rhinorrhea (25%)
  • Fever (25%)

Differential Diagnosis

Maxillofacial Trauma

• Le Fort fractures
• Skull fracture (peds)
• Auricular hematoma
• Nasal fracture
  • Nasal septal hematoma
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Dental trauma
• Mandible fracture

Orbital trauma

Acute

• Ruptured Globe^
• Corneal Abrasion
• Ocular foreign body
• Conjunctival laceration
• Caustic Keratoconjunctivitis^^
• Subconjunctival hemorrhage
• Traumatic iritis
• Traumatic hyphema
• Retinal detachment
• Retrobulbar hemorrhage/hematoma
• Traumatic mydriasis
• Orbital fracture
  • Frontal sinus fracture
  • Naso-ethmoid fracture
  • Inferior orbial wall fracture
  • Medial orbital wall fracture

Subacute/Delayed

• Endophthalmitis^
• Corneal Ulcer^

Evaluation

• Usually clinical
• Oxymetazoline will not change size of hematoma, as opposed to typical soft tissue edema from trauma

Management

1. Place lidocaine-soaked cotton pledgets in nose for 5min
2. Achieve visualization with nasal speculum
3. Make horizontal incision superficially through the mucosa and the perichondrium
   • Ensure that you do not incise the cartilagenous septum
4. Evacuate clot with Frazier suction or forceps
5. Insert single 1/8in iodoform gauze wick into the incision to avoid premature closure
6. Perform bilateral anterior nasal packing with nasal tampons coated with topical antibiotics
   • Prevents reaccumulation of clot and keeps septum midline
7. Give oral antibiotics (cover S. aureus, H. flu, S. pneumo)
   • Amoxicillin-clavulanate for uncomplicated
     • Clindamycin if abscess suspected

Disposition

• Discharge with 24hr ENT or ED follow-up

See Also

• Nasal fracture
• Maxillofacial trauma

References

Authors

Kevin Lu, Jordan Swartz, Neil Young, Ross Donaldson, Daniel Ostermayer