Nasal Septal Hematoma

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

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Overview

Historical Perspective

Classification

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 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.

Causes

  • The most common cause of nasal septal hematoma is nasal trauma.
    • Nasal trauma can be secondary to sports injuries, road-side accidents, falls, assault or occupational injuries.
    • Even a minor injury can lead to nasal septal hematoma, especially in children.
  • Nasal septal hematoma without history of injury must look into the suspicion of child abuse.
  • Iatrogenic septal hematoma may arise as a complication of nasal surgeries.
  • Atraumatic septal hematoma is rarely seen in patients with bleeding diathesis or as an adverse effect of antiplatelet/anticoagulant drugs.

Differentiating Nasal Septal Hematoma from other Diseases

Nasal septal hematoma must be differentiated from other diseases with similar presentation


Epidemiology and Demographics

  • The exact incidence of nasal septal hematoma is unknown as majority of the cases are undiagnosed.
  • However, from the reported cases of nasal injuries incidence of septal hematoma was 0.8% to 1.6%.

Risk Factors

  • The most potent risk factor in the development of nasal septal hematoma is injury to the nose.
  • Risk factors for nose injury include:
    • Contact sports
    • Motor vehicle accident (MVA)
    • Recental nasal surgery
    • Nasal fracture

Screening

Natural History, Complications, and Prognosis

Natural History

If left untreated, the infection can spread to the nearby anatomical structures like paranasal sinuses, orbit or intracranial structures, through the venous draining the mid-face. Avascular necrosis and secondary infection can lead to the collapse of septal cartilage causing various types of nasal deformities.  In children, destruction can cause an altered growth of mid-face and permanent facial deformity.

Complications

Common complications associated with untreated septal hematoma include:

Local
  • Septal abscess
  • Saddle nose
  • Deviated nasal septum
  • Nasal valve collapse
  • Sinusitis
  • Facial cellulitis
  • Nasal vestibulitis
Systemic
  • Sepsis
  • Bacteremia
Orbital
  • Orbital cellulitis
  • Sub-periosteal abscess
  • Orbital abscess
Intracranial Complications
  • Cavernous sinus thrombosis
  • Epidural abscess
  • Meningitis


Diagnosis

Diagnostic Study of Choice

Nasal septal hematoma is a clinical diagnosis. The diagnosis of septal hematoma can be established by taking a careful history and performing complete physical examination.

History and Symptoms

The majority of patients with nasal septal hematoma presents within within the first 24 to 72 hours after trauma. The most common symptom are

  • Nasal obstruction ( unilateral or bilateral)
  • Pain
  • Rhinorrhea
  • Fever
  • Nasal deformity /Nasal pain

Physical Examination

Clinical examination of nasal septal hematoma is usually confirmatory. Findings on nasal speculum or otoscope include

  • Blood clots
  • Asymmetry of the septum with bluish or reddish mucosal swelling suggests a hematoma.
  • On direct palpation by inserting the little finger feels soft and fluctuant in contrast to deviated nasal septum which will be firm and concave on the opposite side.
  • Lack of reduction in size on the application of vasoconstrictive agents.
Examination Physical Findings
Inspection Identifies location and extent of nasal injury
  • Epistaxis, edema, and ecchymosis suggest septal injury
Palpation Tenderness over the tip of nose is specific for septal hematoma
Examination of the nasal cavity Findings suggestive of septal hematoma include:
  • Asymmetry of the septum
  • Blue or red discoloration of the nasal septum
  • Nasal mucosal swelling obstructing the nasal passage
  • Lack of reduction in size on the application of vasoconstrictive agents.

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

References


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