Nasal septal hematoma

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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

Bilateral nasal septal hematoma
  • 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

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)

Disposition

  • Discharge with 24hr ENT or ED follow-up

See Also

References