Difference between revisions of "Nasal septal hematoma"

(Management)
 
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**Can lead to saddle nose deformity, nasal septum abscess
 
**Can lead to saddle nose deformity, nasal septum abscess
 
**May be complicated by necrosis and perforation
 
**May be complicated by necrosis and perforation
*Suspect septum abscess in patient who presents late after facial trauma with systemic symptoms
+
*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)
  
 
==Clinical Features==
 
==Clinical Features==
*Adults present with significant facial trauma and nasal fracture
+
[[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
 
*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:
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**Pain (50%)
 
**Pain (50%)
 
**Rhinorrhea (25%)
 
**Rhinorrhea (25%)
**Fever (25%)
+
**[[Fever]] (25%)
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 
{{Maxillofacial trauma DDX}}
 
{{Maxillofacial trauma DDX}}
  
==Diagnosis==
+
==Evaluation==
 
*Usually clinical
 
*Usually clinical
*Oxymetazoline will not change size of hematoma, as opposed to typical soft tissue edema from trauma
+
*[[Oxymetazoline]] will not change size of hematoma, as opposed to typical soft tissue edema from trauma
  
 
==Management==
 
==Management==
 +
NEJM procedure video: https://www.youtube.com/watch?v=wPB5XXfhyP8
 
#Place [[lidocaine]]-soaked cotton pledgets in nose for 5min
 
#Place [[lidocaine]]-soaked cotton pledgets in nose for 5min
 
#Achieve visualization with nasal speculum
 
#Achieve visualization with nasal speculum
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#Give oral [[antibiotics]] (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==

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