Nasal Septal Hematoma

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

Synonyms and keywords:

Classification

There is no established system for the classification of nasal septal hematoma.

	Classification of heamatoma
	Type 1
	Type 2
Type C	Type Ca
	Type Cb

Pathophysiology

Anatomy

• The nasal septum is made up of a cartilage along with thin layer of mucosa and perichondrium.
• The nasal septum derives its blood supply from the anterior and posterior ethmoid arteries and the sphenopalatine artery.

• All these blood vessels form an anastomosis known as Kiesselbach plexus which is found in the anterior inferior third of the nasal septum.

Pathogenesis

• When the nasal cartilage is fractured, blood can dissect and form hematoma, which may be bilateral.
• The exact pathogenesis of development of hematoma is not fully understood.
• Though septal cartilage is an avascular structure, it gets nourished from the overlying perichondrium.
• Any trauma to nasal septum disrupts the blood supply to the perichondrium due to external force that pull the closely adherent mucoperichondrium from the underlying cartilage.
• Hematoma sets in the vacant space due to the rupture of submucosal vessels.
• Further expansion of the hematoma exerts pressure induced ischemic changes on the cartilage.
• If not rapidly evacuated, pressure-induced ischemic changes leads to avascular necrosis of the nasal cartilage ultimately into perforation
• The accumulated blood and necrotic tissue also form a nidus for infection with bacteria that colonize the nasal mucosa.
• Once necrosis and/or septal abscess occur, the replacement of necrotic tissue by fibrous tissue, retraction of scar tissue, and loss of support to the lower nose may lead to facial deformity, including saddle nose, displacement of the maxilla, retraction of the anterior nasal septum (columella), widening of the nasal base, and diminished size of the nasal cavity
• 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.

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

• Angiofibroma

• Adenoid hypertrophy

• Chronic sinusitis

• Chondromas

• Hemangioma

• Malignancies

• Nasal polyps

• Papillomas

• Pyogenic granulomas

• Rhinitis

• Septal abscess

• Septal deformities

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

The [a'dajfa'g

When to screen

• WHen the patoient comes with bleeding
• WHen they invokve in fight

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

Prognosis

If hematoma is not evacuated early, it may lead to irreversible damage as soon as 24 hours after injury.

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.

References

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