Anatomy:
· The vascular supply to the septal cartilage is provided through the perichondrium.
· A hematoma lifts the perichondrium, disrupting blood supply to the cartilage.
Signs and Symptoms:
· Discolored lateral bulging discolored.
· Nasal septal hematoma appears as blue, boggy swelling.
· Pediatrics can present with nasal obstruction, pain, rhinorrhea, and fever.
Procedure:
· If hematoma is small, can use a needle to attempt to aspirate clot. If failing or larger hematoma then place patient in “sniffing position,” and do rhinoscopy with a nasal speculum, light source, suction, irrigation, and packing materials.
· Anesthetize the nasal mucosa by placing three cotton pledgets soaked in a 1:1 mixture of 4% lidocaine solution for 5 minutes, followed by infiltrative anesthesia if required.
· Make a small horizontal incision superficially through the mucosa. Do not incise the cartilaginous septum.
· Evacuate the clot with suction or with forceps.
· Place bilateral anterior nasal packing coated in topical antibiotic ointment to prevent reaccumulating of the clot and keep the septum midline.
· Discharge with 24-hour ENT of ED follow-up.
· Consider prophylactic antibiotics (cover for staph aureus, H. flu, strep pneumo (Amoxicillin-clavulanate)) for patients with packing in place, but not completely necessary if the packing will be removed in 24 to 36 hours.
· Bilateral hematomas can be drained in the OR
Complications:
· Permanent thickening of the septum
· Partial airway obstruction of the nasal passage
· Necrosis and subsequent erosion of the septum, resulting in communication between the nasal passageways
· Secondary infection
· Seroma or Abscess
· Septal erosion leading to a saddle-nose deformity
Procedure Video:
https://www.youtube.com/watch?v=J5xzYyxgQ0g
TLDR:
· Examine the nasal septum in your trauma patients
· Anesthetize, incise, evacuate clot
· Prevent reformation with nasal tampon or packing
· Consider antibiotics
· Follow up ENT
· Serious complications if missed
References:
https://www.aafp.org/afp/2004/1001/p1315.html
https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683§ionid=45343819#57718045
Tintinalli’s Emergency Medicine a Comprehensive Study Guide 8th Edition
https://wikem.org/wiki/Nasal_septal_hematoma