Nasal septal hematoma: Difference between revisions
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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 patient 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) | ||
==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: | ||
**Nasal obstruction (95%) | **Nasal obstruction (95%) | ||
**Pain (50%) | **Pain (50%) | ||
**Rhinorrhea (25%) | **[[Rhinorrhea]] (25%) | ||
**Fever (25%) | **[[Fever]] (25%) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Maxillofacial trauma DDX}} | {{Maxillofacial trauma DDX}} | ||
== | ==Evaluation== | ||
*Usually clinical | *Usually clinical | ||
*[[Oxymetazoline]] will not change size of hematoma, as opposed to typical soft tissue edema from trauma | |||
==Management== | ==Management== | ||
| Line 31: | Line 36: | ||
#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== | ||
| Line 39: | Line 44: | ||
*[[Nasal fracture]] | *[[Nasal fracture]] | ||
*[[Maxillofacial trauma]] | *[[Maxillofacial trauma]] | ||
==External Links== | |||
*NEJM procedure video: https://www.youtube.com/watch?v=J5xzYyxgQ0g | |||
==References== | ==References== | ||
Revision as of 21:27, 13 December 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
- 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
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Evaluation
- Usually clinical
- Oxymetazoline will not change size of hematoma, as opposed to typical soft tissue edema from trauma
Management
- Place lidocaine-soaked cotton pledgets in nose for 5min
- Achieve visualization with nasal speculum
- Make horizontal incision superficially through the mucosa and the perichondrium
- Ensure that you do not incise the cartilagenous septum
- Evacuate clot with Frazier suction or forceps
- Insert single 1/8in iodoform gauze wick into the incision to avoid premature closure
- Perform bilateral anterior nasal packing with nasal tampons coated with topical antibiotics
- Prevents reaccumulation of clot and keeps septum midline
- Give oral antibiotics (cover S. aureus, H. flu, S. pneumo)
- Amoxicillin-clavulanate for uncomplicated
- Clindamycin if abscess suspected
- Amoxicillin-clavulanate for uncomplicated
Disposition
- Discharge with 24hr ENT or ED follow-up
See Also
External Links
- NEJM procedure video: https://www.youtube.com/watch?v=J5xzYyxgQ0g