Case
A 10-year-old child presented with his mother as an emergency appointment with nasal and maxillary oedema and fever. Four days previously he had hit the kerb while riding his bike and fallen onto his face.
Although his nose had bled and was slightly swollen, the pain had subsided after a few hours and his mother was confident it wasn't broken.
On examination, the GP found oedema of both nasal fossae with the left nostril completely blocked, fluctuation and a grossly enlarged nasal septum with purulent discharge.
The child was sent immediately to A&E where he was admitted for emergency surgical drainage under general anaesthesia.
A vertical hemitransfixation incision was made and 2.5ml of purulent material drained. He was prescribed ceftriaxone for seven days.
There were no post-operative complications and two months after surgery the cosmetic and functional outcomes were good.
The problem
- A nasal septal haematoma is a collection
- of blood between the nasal septal cartilage and the overlying perichondrium and mucosa.
- The nose is the most frequently injured facial structure, and in around 1% of cases
- shearing forces pull the perichondrium from the cartilage – causing the submucosal blood vessels to tear and a haematoma to form.
- Bacterial infection may then develop within a few days of the trauma.1
- Although rare in adults, it is much more common in children and one study suggested as many as 15% of children who facture their nose will develop a septal haematoma.2
- Early diagnosis and treatment is important to prevent abscess formation, septal perforation, saddle-nose deformity and potentially permanent complications.2
Features
- Symptoms usually appear within the first 24 to 72 hours after trauma.
- Nasal septal haematoma in adults typically occurs with significant facial trauma and nasal fracture.
- In children, it can develop after relatively minor nasal trauma such as simple falls, collisions with stationary objects, or fights or rough play with other children. But keep aware of its potential as a sign of abuse.
- The most common symptoms in children are nasal obstruction (95%), pain (50%), rhinorrhoea (25%) and fever (25%).2
Diagnosis
- It is important to carefully examine anyone who sustains nasal trauma.
- The nasal septum is normally 2-4mm thick, but if the cartilage is fractured blood can diffuse through the fracture line and form bilateral haematomas – so both sides should be examined.
- Signs of external trauma – such as nasal deformity, epistaxis or significant pain – are associated with a septal haematoma, but it can present without any signs of external trauma.
- A septal haematoma can usually be diagnosed by inspecting the septum with a nasal speculum or an otoscope.
- Asymmetry of the septum with a bluish or reddish fluctuance can suggest a haematoma, but direct palpation may also be necessary because newly formed haematomas may not be the characteristic colour.
- Palpate by inserting a gloved small finger into the nose and palpate along the entire septum, feeling for swelling, fluctuance or widening of the septum.
- A suspected septal haematoma requires urgent referral to otolaryngology for drainage.
Management
- Early surgical drainage of the haematoma reduces the risk of cartilage necrosis and is always indicated.
- An incision is made at the lower border of the nasal septal cartilage (as the perichondrium is already separated from the cartilage) and blood and pus are aspirated.
- The nose is firmly packed on both sides to ensure adherence of the perichondrium to the cartilage.
- Antibiotics are usually given to prevent septal abscess.
Dr Raj Singh is an ENT GPSI in Manchester
References
1 Alshaikh N and Lo S. Nasal septal abscess in children: from diagnosis to management and prevention. Int J Pediatr Otorhinolaryngol 2011;75:737-44
2 Canty P and Berkowitz R. Haematoma and abscess of the nasal septum in children. Arch Otolaryngol Head Neck Surg 1996;122:1373-6
3 Junnila J. Swollen masses in the nose. Am Fam Physician 2006;73:1617-8
