Nasal Septal Hematoma Drainage

The nose is the most frequently injured facial structure. In the setting of trauma to the anterior nasal septum, hematoma formation may occur. ^[1] Although septal hematomas are rare, early diagnosis and treatment is important to prevent abscess formation, septal perforation, saddle-nose deformity, and potentially permanent complications. ^{[2, 3]}

The anterior portion of the nasal septum is composed of a thin cartilaginous plate with a closely adherent perichondrium and mucosa. Submucosal blood vessels are torn as buckling forces pull the perichondrium from the cartilage. Subsequently, blood may collect between the perichondrium and the septal cartilage. Bacterial proliferation and abscess formation may then result from the presence of stagnant blood. A hematoma may become infected within 3 days of the trauma. See images below.

The nasal septum derives its blood supply from the sphenopalatine and the anterior and posterior ethmoid arteries with the added contribution of the superior labial artery (anteriorly) and the greater palatine artery (posteriorly). The Kiesselbach plexus, or the Little area, represents a region in the anteroinferior third of the nasal septum, where all 3 of the chief blood supplies to the internal nose converge. For more information about the relevant anatomy, see Nasal Anatomy.

The nasal septum is normally 2-4 mm thick. If the cartilage is fractured, blood can dissect through the fracture line and form bilateral hematomas; therefore, both sides should be examined. According to a study by Canty et al, the most common symptoms noted in children were nasal obstruction (95%), pain (50%), rhinorrhea (25%), and fever (25%). ^[4] Symptoms usually appear within the first 24-72 hours.

Nasal septal hematoma in adults typically occurs with significant facial trauma and nasal fracture. However, in children, nasal septal hematoma may be found with minor nasal trauma such as simple falls, collisions with stationary objects, or minor altercations with siblings. ^{[5, 6, 7]} Additionally, the presence of nasal septal hematoma with or without concomitant injuries should raise suspicion for child abuse, especially in infants and toddlers.

A careful examination is important for anyone who sustains nasal trauma. Signs of external trauma, such as nasal deformity, epistaxis, or significant pain, are associated with a septal hematoma. However, a septal hematoma may be present without any signs of external trauma. ^[1]

A septal hematoma can usually be diagnosed by inspecting the septum with a nasal speculum or an otoscope. Asymmetry of the septum with a bluish or reddish fluctuance may suggest a hematoma. Direct palpation may also be necessary, as newly formed hematomas may not be ecchymotic. The best way to palpate is to insert a gloved small finger into the patient’s nose and palpate along the entire septum, feeling for swelling, fluctuance, or widening of the septum. Blood clots should be suctioned to allow better visualization.

Urgent hematoma drainage is indicated for all nasal septal hematomas. ^[8]

No absolute contraindications exist to nasal septal hematoma drainage.

Topical or injectable lidocaine without epinephrine is recommended.

For more information, see the Clinical Procedures topic Topical Anesthesia.

See the list below:

• Topical or injectable anesthesia

• Light source (head lamp or otoscope)

• Nasal speculum

• Suction apparatus (Frazier suction tip)

• Gloves

• Needle, 18-20 gauge (ga)

• Syringe, 5 mL

• Scalpel, No. 11 blade

• Commercially produced nasal tampon

  • Gelfoam (absorbable gelatin)

  • Surgicel (oxidized cellulose)

• Small Penrose drain

The patient is best positioned supine with some elevation of the head of the bed to allow drainage of blood out of the nose.

See the list below:

• If a septal abscess is suspected, needle aspiration under topical anesthesia can be performed using an 18- to 20-ga needle.

• Except in patients who present immediately after hematoma formation, specimens should be sent for gram stain and aerobic and anaerobic cultures. Systemic antibiotics should then be administered.

• To drain the hematoma, incise the mucosa over the area of greatest fluctuance without incising cartilage. Bilateral staggered incisions should be made for bilateral hematomas to avoid a through-and-through perforation. See image below.

  Incision of nasal septal hematoma.

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• Suction out the clot; then irrigate with sterile normal saline.

• A small section of the mucoperichondrium should be excised to prevent premature closure of the incision. See image below.

  Excision of mucoperichondrium with ring forceps.

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• Place a small Penrose drain and suture it in place. See image below.

  Placement of Penrose drain.

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• Finally, pack both nostrils, as in anterior epistaxis, to reapproximate the perichondrium to the cartilage. The drain and packing remain in place until the drainage stops for 24 hours; this usually takes 2-3 days. ^{[9, 10, 11]}

• Broad spectrum antibiotics should be administered. If infection is suspected, the patient should be admitted for parenteral antibiotics.

• The patient should follow up with an otolaryngologist without delay. Children should also be evaluated periodically for 12-18 months to avoid cosmetic deformities.

• Prophylactic treatment with an antibiotic is recommended to cover Streptococcus pneumoniae and beta-lactamase–producing organisms. Although no clear consensus exists on the choice of antibiotic or duration of treatment, most case reports have used amoxicillin/clavulanate (Augmentin). If an abscess is suspected, coverage for MRSA is recommended as initial therapy until culture results are available.

See the list below:

• Clinicians should have a high clinical suspicion for nasal septal hematoma in patients who have sustained nasal trauma. ^[12]

• Septal hematomas should be drained as soon as possible to prevent long-term complications.

• Prophylactic broad-spectrum antibiotics should be administered to cover Staphylococcus aureus, Haemophilus influenzae, and S pneumoniae.

• Close follow-up with an otolaryngologist must be arranged to avoid potentially delayed complications. ^[13] Children should follow-up periodically for 12-18 months after initial treatment.

Though nasal septal abscesses are rare, they are the most common acute complications of septal hematomas. ^[14] Abscesses can result in the spread of bacteria into the paranasal and intracranial structures. ^[2] Further complications, including meningitis, intracranial abscesses, orbital cellulitis, and cavernous sinus thrombosis, may ensue. ^[15]

An expanding hematoma can cause pressure-induced avascular necrosis of the cartilage. Collapse of the nasal septum and loss of dorsal support can lead to depression of the nasal bridge and a subsequent saddle-nose deformity. ^[16] Early drainage of the hematoma improves blood flow to the septal cartilage but may not reverse antecedent cartilage destruction. Therefore, the clinician must have a high index of suspicion of a nasal septal hematoma after any nasal trauma in order to initiate proper early surgical treatment.