Difference between revisions of "Nasal septal hematoma"

(Management)
 
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==Background==
 
==Background==
 +
*Submucosal vessels disrupted
 +
*Blood accumulates between perichondrium and cartilaginous septum
 
*Requires immediate incision and drainage to prevent nasal septum necrosis
 
*Requires immediate incision and drainage to prevent nasal septum necrosis
 
**Can lead to saddle nose deformity, nasal septum abscess
 
**Can lead to saddle nose deformity, nasal septum abscess
*Suspect septum abscess in pt who presents late after facial trauma with systemic symptoms
+
**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)
 
*Ensure thorough examination of both nares - Nasal septum cartilage easily fractures (form bilateral hematomas)
  
*Adults present with significant facial trauma and nasal fracture
+
==Clinical Features==
 
+
[[File:PMC5042625 OAMJMS-4-413-g001.png|thumb|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:
 
*Common symptoms in peds, usually within first 24-72 hrs with even minor nasal trauma, include:
 
**Nasal obstruction (95%)
 
**Nasal obstruction (95%)
 
**Pain (50%)
 
**Pain (50%)
 
**Rhinorrhea (25%)
 
**Rhinorrhea (25%)
**Fever (25%)
+
**[[Fever]] (25%)
 +
 
 +
==Differential Diagnosis==
 +
{{Maxillofacial trauma DDX}}
 +
 
 +
==Evaluation==
 +
*Usually clinical
 +
*[[Oxymetazoline]] will not change size of hematoma, as opposed to typical soft tissue edema from trauma
  
==Treatment==
+
==Management==
#Place lidocaine-soaked cotton pledgets in nose for 5min
+
NEJM procedure video: https://www.youtube.com/watch?v=wPB5XXfhyP8
 +
#Place [[lidocaine]]-soaked cotton pledgets in nose for 5min
 
#Achieve visualization with nasal speculum
 
#Achieve visualization with nasal speculum
 
#Make horizontal incision superficially through the mucosa and the perichondrium
 
#Make horizontal incision superficially through the mucosa and the perichondrium
##Ensure that you do not incise the cartilagenous septum
+
#*Ensure that you do not incise the cartilagenous septum
 
#Evacuate clot with Frazier suction or forceps
 
#Evacuate clot with Frazier suction or forceps
 
#Insert single 1/8in iodoform gauze wick into the incision to avoid premature closure
 
#Insert single 1/8in iodoform gauze wick into the incision to avoid premature closure
#Perform b/l anterior nasal packing w/ nasal tampons coated w/ topical abx
+
#Perform bilateral anterior nasal packing with nasal tampons coated with topical antibiotics
##Prevents reaccumulation of clot and keeps septum midline
+
#*Prevents reaccumulation of clot and keeps septum midline
#Give oral abx (cover S. aureus, H. flu, S. pneumo)
+
#Give oral [[antibiotics]] (cover [[S. aureus]], [[H. flu]], [[S. pneumo]])
##Amoxicillin/clavulanate for uncomplicated
+
#*[[Amoxicillin-clavulanate]] for uncomplicated
##Clindamycin if abscess suspected
+
#**[[Clindamycin]] if [[abscess]] suspected
  
 
==Disposition==
 
==Disposition==
*Discharge w/ 24hr ENT or ED follow-up
+
*Discharge with 24hr ENT or ED follow-up
  
 
==See Also==
 
==See Also==
 
*[[Nasal fracture]]
 
*[[Nasal fracture]]
 +
*[[Maxillofacial trauma]]
  
==Source==
+
==References==
*Tintinalli
+
<references/>
*eMedicine
 
  
 
[[Category:Trauma]]
 
[[Category:Trauma]]
 
[[Category:ENT]]
 
[[Category:ENT]]

Latest revision as of 02:26, 15 June 2019

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)

Clinical Features

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%)

Differential Diagnosis

Maxillofacial Trauma

Evaluation

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

Management

NEJM procedure video: https://www.youtube.com/watch?v=wPB5XXfhyP8

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

Disposition

  • Discharge with 24hr ENT or ED follow-up

See Also

References