Soft tissue and bony injuries of the nose are common because the nose is centrally located and the most anteriorly protruding structure of the face.1,2 Suspect a nasal septal hematoma, although an uncommon complication of nasal trauma, in any individual who has sustained a nasal injury.3,4 All individuals who have sustained nasal trauma must undergo a careful examination of the septum and nasal passages regardless of the mechanism of injury or the findings on external examination.3,5,6 A nasal septal hematoma is blood or a clot accumulated between the cartilaginous nasal septum and the overlying nasal mucosa.7
Blunt trauma, either intentional or unintentional, is the most common cause of a nasal septal hematoma. Consider a bleeding diathesis if the hematoma develops after a seemingly trivial injury.3,8-10 Other etiologies include sports injuries and child abuse.8,9 Iatrogenic nasal septal hematomas following nasal septal surgery are probably more common than reported in the literature. Evaluate patients who have had recent nasal surgery and present with complaints of pain and nasal obstruction for a possible nasal septal hematoma.
Nasal septal hematomas are characterized by severe localized nasal pain, tenderness, instability on palpation of the nasal tip, and a cherry-like swelling or bluish discoloration of the nasal mucosa emanating from the septum that obstructs all or a portion of the nasal passage (Figure 204-1).1,3,4,11-13 Septal hematomas can also present bilaterally if a fracture of the nasal cartilage is involved and allows blood to dissect through the fracture. Thus, it is critical that both nares be examined scrupulously. Evacuation must be performed to prevent complications.1,3,8,10,14,15 Infections can develop as soon as 3 days after injury. A simple incision to allow the clot to drain followed by anterior packing is usually adequate as an initial management.
The nasal septal hematoma. A. Bilateral nasal septal hematomas creating a partial obstruction. B. Anatomy of a nasal septal hematoma. C. Bilateral nasal septal hematomas (arrows). (Used with permission from reference 14.)
The most common complication of a nasal septal hematoma or an abscess is cartilage necrosis that results in nasal structural collapse and a saddle nose deformity (Figure 204-2).2
Artist illustration of the saddle nose deformity.
ANATOMY AND PATHOPHYSIOLOGY
The nose is a sensory organ and a respiratory organ. It performs an important ...