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)

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%)

Acute

Subacute/Delayed

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

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