High Yield Topics

Nasal Septal Hematomas

By admin



Ovid: 5-Minute Sports Medicine Consult, The


Nasal Septal Hematomas
Brandon Bockewitz
Daryl A. Rosenbaum
Basics
  • Hematoma contained in the tight submucosal space can lead to pressure necrosis or abscess. This results in cartilage destruction and collapse of the nasal dorsum, or a saddle nose deformity.
  • Dorsal nose deformity causes significant cosmetic and functional morbidity that usually is permanent. Although rare, monitor for the presence of septal hematoma in every case of nasal trauma, and treat promptly when it is diagnosed.
Description
  • Bleeding between cartilaginous and mucosal layers of the nasal septum resulting from trauma to the nose that collects to form a hematoma
  • Septal hematomas can occur bilaterally or unilaterally.
Diagnosis
History
Trauma to the nose, most often an inferior blow, because the supportive structure of the lower 2/3 of the nose is composed entirely of cartilage
Physical Exam
  • Signs and symptoms:
    • Epistaxis, nasal deformity and swelling, ecchymosis, pain, and crepitant to palpation, usually from associated nasal fracture
    • Difficulty breathing through one or both sides of the nose
  • Physical examination:
    • Septal hematoma will appear as a bluish red bulge from the septum into the nasal vestibule or as an asymmetric mucosal fold. Newly formed hematomas may lack the classic bluish red discoloration, making direct palpation a more reliable exam finding.
    • Control bleeding with direct pressure, topical decongestants, or cautery, as indicated for optimal visualization.
    • Patient positioning: Drainage of blood from the nose is best achieved with the patient in a supine position with the head elevated.
    • Visualize the anterior septum, preferably using a nasal speculum or otoscope with the tip inserted past the nasal vestibule. If necessary, a rigid nasal endoscope may be needed. Sufficient lighting and suction are helpful.
    • Direct palpation: Using a gloved finger, gently palpate along the entire nasal septum, feeling for swelling, fluctuance, widening of the septum, or any other abnormalities.
      • Blood clots adjacent to the nasal septum can falsely represent a septal hematoma and should be evacuated before examining the nasal septum.
      • Masses located deep within the nasal cavity, out of the reach of a gloved finger, may require palpation by a cotton swab, again, feeling for a soft mass as opposed to the firm cartilaginous septum.
Diagnostic Tests & Interpretation
Lab
  • Rarely necessary for routine cases
  • Delayed presentation to health care providers or failed drainage can lead to nasal septal abscess.
  • Purulent specimens should be sent for Gram stain and culture, both aerobic and anaerobic.
Treatment
  • Acute treatment
  • Prompt intervention:
    • Needle aspiration or sharp incision and drainage under local or general anesthesia followed by suction of the clot, if needed, and irrigation (1,2,3):
      • Mucosal incision should be made over the area of greatest fluctuance, with care taken not to damage the underlying cartilage.
      • Bilateral hematomas should be treated with staggered incisions to decrease risk of possible through-and-through perforation.
    • Wick or drain placement is unnecessary unless suspicious for septal abscess (4)[C].
    • If a drain was placed, it can be removed when drainage has stopped for 24 hr.

      • P.399


    • Bilateral anterior nasal packing to approximate the perichondrium and prevent recurrence of the hematoma (3)[C]
    • Usually 2–4 days
    • Systemic antibiotic coverage with clindamycin or amoxicillin–clavulanic acid provides appropriate coverage against the most common abscess pathogens (1,2,3)[C], including:
      • Staphylococcus aureus
      • Streptococcus pneumoniae
      • Group A β-hemolytic Streptococcus
      • Haemophilus influenzae
Ongoing Care
Follow-Up Recommendations
  • Patients and parents should be instructed on signs and symptoms of nasal septal hematoma because formation may be delayed up to 14 days after the initial trauma (3).
  • Close follow-up after diagnosis and drainage for evaluation of possible failed drainage or reaccumulation of blood after successful drainage
  • Children should be followed for 12–18 mos for cartilaginous changes and cosmetic defects (3).
Complications
  • Reaccumulation of hematoma
  • Nasal septal abscess
  • Saddle nose deformity
References
1. Menger DJ, Tabink I, Nolst Trenité GJ. Treatment of septal hematomas and abscesses in children. Facial Plast Surg. 2007;23:239–243.
2. Lopez MA, Liu JH, Hartley BE, et al. Septal hematoma and abscess after nasal trauma. Clin Pediatr (Phila). 2000;39:609–610.
3. Savage RR, Valvich C. Hematoma of the nasal septum. Pediatr Rev. 2006;27:478–479.
4. Perkins SW, Dayan SH. Management of nasal trauma. Aesthetic Plast Surg. 2002;26 (Suppl 1):3
Additional Reading
Kaufman BR, Heckler FR. Sports-related facial injuries. Clin Sports Med. 1997;16:543–562.
See Also
Incision and drainage of a septal hematoma or abscess
Codes
ICD9
920 Contusion of face, scalp, and neck except eye(s)
Clinical Pearls
  • Special populations: Children (4)[C]:
    • Increased incidence of septal hematoma secondary to highly cartilaginous nasal skeleton
    • Minor trauma can lead to hematoma formation, even without signs of external injury.
    • Any history of nasal trauma warrants intranasal examination.
  • The nasal packing usually is left in for about 2–4 days so that the mucosa can heal and fill in the space where the hematoma formed.
  • Return to play is not advised until the packing is removed owing to impaired breathing and the need to protect the septal mucosa while it heals.
  • After removal of packing, return to play is based on consideration of the associated nasal fracture and whether or not an infection is present.


Continue Reading
You might also like More from author

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More