Nasal septal hematoma

Background

Submucosal vessels disrupted
Blood accumulates between perichondrium and cartilaginous septum
Requires immediate incision and drainage to prevent nasal septum necrosis
- Can lead to saddle nose deformity, nasal septum abscess
- May be complicated by necrosis and perforation
Suspect septum abscess in patient who presents late after facial trauma with systemic symptoms
Ensure thorough examination of both nares - Nasal septum cartilage easily fractures (form bilateral hematomas)

Bilateral nasal septal hematoma

Adults present with significant facial trauma and nasal fracture
Dark purple hematoma against septum
Common symptoms in peds, usually within first 24-72 hrs with even minor nasal trauma, include:
- Nasal obstruction (95%)
- Pain (50%)
- Rhinorrhea (25%)
- Fever (25%)

Usually clinical
Oxymetazoline will not change size of hematoma, as opposed to typical soft tissue edema from trauma

Place lidocaine-soaked cotton pledgets in nose for 5min
Achieve visualization with nasal speculum
Make horizontal incision superficially through the mucosa and the perichondrium
- Ensure that you do not incise the cartilagenous septum
Evacuate clot with Frazier suction or forceps
Insert single 1/8in iodoform gauze wick into the incision to avoid premature closure
Perform bilateral anterior nasal packing with nasal tampons coated with topical antibiotics
- Prevents reaccumulation of clot and keeps septum midline
Give oral antibiotics (cover S. aureus, H. flu, S. pneumo)
- Amoxicillin-clavulanate for uncomplicated
  - Clindamycin if abscess suspected

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