Nasal Septal Haematoma

A collection of blood between the septal cartilage and its overlying mucoperichondrium. It is an emergency because the cartilage depends entirely on the perichondrium for its blood supply, and separation causes avascular necrosis within days.

Why it destroys the septum

Septal cartilage is avascular and receives nutrients by diffusion from the perichondrium on both sides. A haematoma lifts the perichondrium away, interrupting this supply. Cartilage necrosis begins within 3 days and is established by 7 to 10 days. The collection is also an ideal culture medium, and superadded infection with Staphylococcus aureus produces a septal abscess that liquefies cartilage far faster, within 24 to 48 hours.

The consequences of missed diagnosis are:

• Septal perforation.
• Saddle nose deformity from loss of dorsal support, with columellar retraction and tip ptosis.
• In children, disruption of the septal growth centres with midface hypoplasia and progressive deformity through adolescence, which is far more difficult to correct than an adult deformity.
• Intracranial spread through the valveless veins of the face to the cavernous sinus, producing cavernous sinus thrombosis, meningitis and brain abscess.

Mechanism

Blunt nasal trauma with shearing of the mucoperichondrium over the cartilage, often with a septal fracture. It occurs after apparently trivial trauma, particularly in children whose flexible cartilage allows deformation without fracture. It also occurs after septoplasty and nasal surgery, and spontaneously in patients on anticoagulants or with bleeding disorders.

The clinical rule: every patient with nasal trauma must have the septum inspected. This is the single most important reason for examining inside the nose after a nasal injury, and it is the step most commonly omitted in emergency departments.

• Progressive bilateral nasal obstruction developing over hours to days after nasal trauma, which is the cardinal symptom. Obstruction that worsens after nasal injury rather than improving is a haematoma until proven otherwise.
• Nasal pain and a sensation of pressure or fullness.
• Rhinorrhoea.
• Headache and general malaise.
• In children, irritability, feeding difficulty in infants who are obligate nasal breathers, and mouth breathing.

Signs of septal abscess, which indicate a more urgent situation

• Fever, systemic upset.
• Severe pain and tenderness.
• Erythema and swelling of the nasal dorsum and tip.
• Cellulitis of the external nose and face.
• Signs of cavernous sinus thrombosis: periorbital oedema, proptosis, ophthalmoplegia, reduced consciousness and meningism.

Examination

• Bilateral, smooth, cherry red or bluish fluctuant swelling of the septum, obstructing both nasal cavities. Bilaterality is characteristic, since blood tracks around the cartilage or the cartilage is fractured.
• Loss of the normal narrow septal profile, with a broad soft mass.
• Fluctuance on gentle palpation with a cotton tipped applicator, which distinguishes it from a simple deviation. This palpation step is essential, since a deviated septum can look similar and a haematoma is soft and compressible.
• Use adequate lighting, a nasal speculum and suction. Blood clot in the nasal cavity must be cleared before the septum can be assessed.
• Examine the external nose for fracture and deformity, assess for cerebrospinal fluid rhinorrhoea, and perform a full trauma assessment including cervical spine and head injury where indicated.

Clinical, made by direct inspection and palpation. No imaging is needed for the haematoma itself and imaging must not delay drainage.

• Distinguish from a simple septal deviation, which is firm and not compressible.
• Full blood count and coagulation studies where the haematoma follows minimal trauma, where the patient is anticoagulated, or where a bleeding disorder is suspected.
• Culture of pus at drainage, with specific attention to Staphylococcus aureus including methicillin resistant strains.
• Computed tomography only where there is suspected intracranial extension, cavernous sinus thrombosis, orbital involvement or complex facial fracture. Contrast enhanced imaging with venography where cavernous sinus thrombosis is a concern.
• In children with nasal trauma and any suspicion of non accidental injury, follow safeguarding procedures.

Immediate drainage. There is no role for observation, aspiration alone with the expectation of resolution, or waiting for a list the following week.

Drainage technique

• Local anaesthesia with topical cocaine or lidocaine with adrenaline on pledgets, followed by infiltration, is adequate in cooperative adults. General anaesthesia is required in children and in uncooperative patients.
• Make a horizontal or L shaped incision over the most dependent part of the collection, ideally on one side only to reduce the risk of creating opposing mucosal defects and a perforation. Where bilateral incisions are necessary, offset them so they are not opposite each other.
• Evacuate the clot completely with suction and a small curette. Irrigate with saline.
• Inspect the cartilage for necrosis and fracture. Send any material for culture.
• Where cartilage is fragmented, reposition and, where necessary, reconstruct.

Preventing reaccumulation, which is the part most often done inadequately

• Quilting sutures with 4-0 absorbable material passed through both mucoperichondrial flaps and the cartilage, obliterating the dead space. This is the most effective method and is preferable to packing.
• Alternatively, silastic septal splints sutured in place for 5 to 7 days, or a small drain such as a corrugated or vessel loop drain for 24 to 48 hours.
• Bilateral anterior nasal packing where suturing is not feasible, removed at 48 to 72 hours, with antibiotic cover to reduce the risk of toxic shock syndrome.
• Simple needle aspiration without a means of preventing reaccumulation fails and should not be used as definitive treatment.

Antibiotics

• Cover Staphylococcus aureus in every case.
• Co amoxiclav 625 mg orally three times daily for 7 days in adults; 45 mg/kg per day of the amoxicillin component divided twice daily in children.
• Flucloxacillin 500 mg orally four times daily as an alternative.
• Clindamycin 300 to 450 mg orally four times daily in penicillin allergy.
• Established septal abscess or systemic illness requires admission and intravenous therapy: co amoxiclav 1.2 g every 8 hours, or ceftriaxone 2 g daily plus flucloxacillin, with vancomycin where methicillin resistant Staphylococcus aureus is suspected, converting to oral therapy once improving to complete 10 to 14 days.
• Suspected intracranial extension requires high dose intravenous therapy with central nervous system penetration, urgent imaging and neurosurgical involvement.

Additional care

• Analgesia with paracetamol and a nonsteroidal anti inflammatory drug, avoiding the latter if there is ongoing bleeding risk.
• Nasal saline and gentle irrigation once healing has begun.
• Advise against nose blowing and strenuous activity for 2 weeks.
• Review anticoagulation and correct any coagulopathy.

Follow up

• Review at 48 to 72 hours to confirm no reaccumulation, which is the key early check.
• Review at 1 week and again at 4 to 6 weeks with endoscopy to assess the septum for perforation and cartilage loss.
• In children, arrange long term follow up through the growth period, since deformity from growth centre disruption may not become apparent until adolescence. Explain this to the family at the outset.

Late reconstruction

• Septal perforation is managed conservatively with saline gels and emollients where asymptomatic, or with surgical repair using local mucosal advancement flaps with an interposition graft of temporalis fascia, cartilage or acellular dermis, or with a silastic septal button for patients unfit for or unwilling to undergo repair.
• Saddle nose deformity requires dorsal augmentation with autologous costal cartilage, calvarial bone or septal cartilage where available, with caudal septal reconstruction to restore tip support. This is major reconstructive surgery, and prevention through prompt drainage is vastly preferable.
• Delay definitive reconstruction until growth is complete in children, and until at least 6 to 12 months after infection has fully resolved in adults.

Prevention and education

• Teach emergency and primary care clinicians to examine the septum in every nasal injury, and to give clear safety netting advice to any patient discharged after nasal trauma: return immediately if the nose becomes progressively blocked, painful or swollen over the following days.
• The great majority of destroyed septa result not from the injury but from a haematoma that was not looked for.