Nasal Septal Hematoma

Etiology

A septal hematoma usually occurs secondary to nasal trauma. The latter can be in the form of sports injuries, road-side accidents, falls, assault or occupational injuries. Even a minor injury can lead to nasal septal hematoma, especially in children. In-fact a nasal septal hematoma without injury should raise the suspicion of child abuse, especially in infants and toddlers. Iatrogenic septal hematoma may arise as a complication of nasal surgeries like septal correction, endoscopic sinus surgery or turbinate surgery. Atraumatic septal hematoma is rarely seen in patients with bleeding diathesis or as an adverse effect of antiplatelet/anticoagulant drugs.[5][6][7]

Epidemiology

A septal hematoma is a rare entity and can occur in any age group. The exact incidence of septal hematoma remains unknown. However, it has been reported to occur in 0.8% to 1.6% of patients with nasal injury attending ear, nose, and throat clinic. Unfortunately, a large number of cases often remain undiagnosed, especially in children, until complications occur.

Pathophysiology

The anterior part of the nasal septum consists of a thin cartilaginous layer with closely adherent mucosa and perichondrium. The nasal septum is about 3-4 mm thick and derives its blood supply from the anterior and posterior ethmoid arteries and the sphenopalatine artery. The area known as Kiesselbach plexus (little area) is found in the anterior inferior third of the nasal septum, where all the key blood vessels anastomose. When the nasal cartilage is fractured, blood can dissect and form hematoma, which may be bilateral.

The exact mechanism underlying the formation of nasal septal hematoma remains controversial.  Septal cartilage is an avascular structure, 2 mm to 4 mm thick, which receives its nutrients supply from the overlying perichondrium. Physicians hypothesize that trauma results in sharp buckling forces that pull the closely adherent mucoperichondrium from the underlying cartilage. This causes the rupture of submucosal vessels which ultimately causes a collection of blood between the cartilage and the perichondrium. Hematoma thus formed, results in pressure-related ischaemic changes and the subsequent necrosis of the septal cartilage.

If the trauma is severe enough, the septal cartilage gets fractured, and blood sweeps to the opposite side resulting in a bilateral septal hematoma. This situation is more hazardous as it doubles the compromise on the nutrient supply of septal cartilage and hastens the process of cartilage necrosis.

Hematoma acts as an ideal medium for bacterial proliferation and colonization. If left untreated, it gets infected within 72 hours leading to the formation of a septal abscess.

History and Physical

A nasal hematoma usually presents within the first 24 to 72 hours after trauma. However delayed presentation has also been reported. The most common symptom is the nasal obstruction (95%) which can be either unilateral or bilateral depending on the type of hematoma. Other symptoms include pain (50%), rhinorrhea (25%), and fever (25%). In many cases, symptoms are non-specific. Therefore, a high index of suspicion should be kept especially if a patient presents with nasal deformity and/or nasal pain following trauma. Also if a post-traumatic nasal obstruction does not resolve with a local vasoconstrictive agent or blood clot removal, the possibility of a nasal hematoma should be strongly considered.

Clinical examination is usually confirmatory. It can either be accomplished with a nasal speculum or otoscope.  Blood clots, if any should be suctioned. Asymmetry of the septum with bluish or reddish mucosal swelling suggests a hematoma. A newly formed hematoma is not always ecchymotic and can only be picked up by palpation. Direct palpation is carried out by gently inserting the little finger into the patient's nose. A hematoma feels soft and fluctuant in contrast to deviated nasal septum which will be firm and concave on the opposite side. Another important feature of septal hematoma is the lack of reduction in size on the application of decongestant sprays like oxymetazoline 0.05%.

Evaluation

Usually clinical diagnosis. Rarely CT or MRI might be considered if the diagnosis is equivocal on physical exam.

Treatment / Management

A nasal septal hematoma should be drained urgently to avoid undue complications. The procedure is done under local anesthesia. However general anesthesia might be required in apprehensive adults and children.[8][9][10](A1)

Following equipment/instruments should be available before draining a septal hematoma:

1. Topical anesthesia
2. Light source (head-lamp or otoscope)
3. Nasal speculum
4. Suction apparatus (Frazier suction tip)
5. Gloves
6. Needle, 18-20 gauge (Ga)
7. Syringe, five mL
8. Scalpel, No. 11 blade or 15 blade
9. Commercially produced nasal tampon
10. Gelfoam (absorbable gelatin)
11. Surgicel (oxidized cellulose)
12. Small Penrose drain

The patient should lie in the reclining position with the head end of the table slightly raised. Small hematomas can be aspirated with an 18-Ga to 20 -Ga needle. Larger hematomas are drained by incising the mucosa over the most fluctuant area. The incision is given in the anteroposterior direction parallel to the nasal floor. In the case of a bilateral hematoma, a staggered incision is made to avoid through and through the septal perforation. The clot is suctioned, and saline irrigation is carried out on an 18-Ga to 20-Ga catheter. A small piece of the mucosa is excised from the incision edge for better drainage and the prevention of premature closure. A small Penrose drain is placed into the opened hematoma cavity and secured with a suture. The nose is packed on both sides to prevent the re-accumulation of blood. Systemic antibiotics are prescribed to prevent serious, infective complications. Pack and drain are usually kept in situ for 2 to 3 days and is removed only when there is no further drainage for at least 24 hours. Patients should be kept on regular follow up to prevent delayed complications.

Differential Diagnosis

• Angiofibroma

• Adenoid hypertrophy

• Chronic sinusitis

• Chondromas

• Hemangioma

• Malignancies

• Nasal polyps

• Papillomas

• Pyogenic granulomas

• Rhinitis

• Septal abscess

• Septal deformities

Complications

A nasal septal abscess is a major complication of a septal hematoma. The abscess can easily spread to adjacent structures including the sinuses and the brain.

The expanding hematoma can cause avascular necrosis of the cartilage and collapse, leading to a saddle nose deformity.