The nose is important. Certainly our appreciation of the nasal cavity has increased during the current COVID-19 pandemic as we now ask everyone about their sense of smell, but let us not forget some other important nostril considerations. We know that the nose has a large blood supply that we can use to our advantage (ex, Intranasal Medications). Of course, this also leads to lots of epistaxis that we must deal with. That bleeding may be due to bleeding disorders (ex, Von Willebrand’s, Hemophilia Disease), foreign bodies (ex, Nasal Foreign Bodies, Button Battery), or trauma (ex, Facial Fractures, Nasal Fractures). Even minor nasal trauma does bring to mind another specific condition we need to be vigilant for – Nasal Septal Hematoma:

Nasal Septal Hematoma: Basics

Nasal septal hematoma is rare. [32890169: Sayin, 2020]

• May be more common in children than adults.
• ~15% of patients with nasal fractures will have septal hematoma.
• Nasal fractures do not need to be present for septal hematoma to occur though! [21492944: Alshaikh, 2011]

Nasal septal anatomy matters. [29019747: Rodriguez, 2017; 21492944: Alshaikh, 2011]

• Nasal septum is derived from 5 bones and the cartilaginous quadrangular cartilage.

• The nasal septum is surrounded by a rich network of blood vessels.
  • Branches from both the internal and external carotid arteries supply blood flow.
  • The cartilage receives nutrients via diffusion, as the vascular network does not directly supply it.

• Separation of the cartilage from its overlaying mucoperichonrium will lead to impairment of the blood supply.
  • This will lead to ischemia of the cartilage as well as eventual necrosis.
  • Hematoma formation or abscess formation can both impair blood supply to the cartilage.

Nasal septal hematoma is a collection of blood between the septum and the mucoperichonrium. [29019747: Rodriguez, 2017; 32890169: Sayin, 2020]

• This can lead to short-term and long-term consequences.
• The hematoma may become infected and lead to Nasal Septal Abscess.
• Long-term morbidity may occur with significant cosmetic deformities.
  • Septal necrosis, perforation, and saddle nose deformity can occur.
  • Early detection and treatment is critical to avoid deformity.
  • Also important to have children with nasal fractures follow-up within 7-10 days as outpatients (in case hematoma develops after initial evaluation).

Nasal septal hematoma can lead to nasal septal abscess. [21492944: Alshaikh, 2011]

• Nasal septal abscess is very uncommon, but also has significant consequences.
• Abscess formation most often occurs due to nasal trauma.
• Other causes include:
  • Local dental or sinonasal infection
  • Iatrogenic from local procedures
  • Spontaneously (ie, no clear etiology)
• Typically noticed within 3 days after initial trauma.
  • May present with nasal obstruction, pain, fever, and/or headache. [8956753: Canty, 1996]
  • S. Aureus is the most common pathogen.
• Complications include:
  • Orbital cellulitis
  • Intracranial abscess
  • Meningitis
  • Cavernous Sinus Thrombosis

Nasal Septal Hematoma: Management

Early recognition in children is imperative. [21492944: Alshaikh, 2011]

• Early drainage will help prevent destruction and loss of cartilage.
• Early reconstruction of the damaged / lost cartilage helps to prevent the long term effect on growth of the facial skeleton.

Distinguishing septal hematoma and/or septal abscess on exam can be difficult. [32890169: Sayin, 2020]

• Visualization is difficult in small children.
  • Make them comfortable.
  • Consider vasoconstriction to aid in visualization.
  • Ensure you have adequate light and use a nasal speculum.
  • See the entire septum is at risk – don’t be happy with assessing the distal aspect only.
    
• Septal hematoma often appear Bluish.

• Palpation (by fingertip or cotton-tipped applicator) can help too, although both abscess and hematoma may be fluctuant or firm.

• CT scan may be obtained to evaluate for other injuries.
  • Septal hematoma will appear as an iso/hypoattenuated fluid collection in the septum. [29019747: Rodriguez, 2017]
  • Septal abscess will appear as a fluid collection with peripheral enhancement. [29019747: Rodriguez, 2017]

• ENT surgeons often recommend Fine-Needle Aspiration to help distinguish hematoma vs abscess.
  • Also helps with decompression of region.
  • Specimen should be sent for culture.
  • Any concern or evidence for infection / abscess requires IV antibiotics. [21492944: Alshaikh, 2011]

• While much is spoken about draining septal hematoma once it is noticed in the ED, ENT literature supports incision and drainage in the OR under general anesthesia. [32890169: Sayin, 2020]
  • The drainage of the hematoma or abscess is only part of the management.
  • Assessment of the cartilage and debridement is important.
  • Reconstruction of septal structure can also occur during this surgery.
  • Placement of drain and packing can be done in more precise manner.

Moral of the Morsel

• Think of the worse even when it was minor. Even minor trauma to the nose can lead to septal hematoma.
• Optimize your view! Don’t be content with wrestling the child and using the otoscope haphazardly.
• Abscess may follow Hematoma. Minor trauma occurring a few days prior to presentation of fever and pain? Think of nasal septal abscess.
• Don’t be cavalier! Sure the hematoma and/or abscess needs to be drained, but discuss with the ENT team as it may be more prudent to have the child go to the OR.

References