Nasal Septal Hematoma
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Synonyms and keywords:
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
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 |
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| Systemic |
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| Orbital |
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| Intracranial Complications |
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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 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, (should be suctioned)
- Asymmetry of the septum with bluish or reddish mucosal swelling suggests a hematoma.
- A newly formed hematoma is not always ecchymotic and can only be picked up by palpation.
- 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.
- Another important feature of septal hematoma is the lack of reduction in size on the application of decongestant sprays like oxymetazoline 0.05%.