Septal hematoma, with or without abscess formation, is an uncommon complication of septal surgery or direct nasal trauma. Bleeding from submucosal blood vessels leads to an accumulation of blood between the mucoperichondrium and the septal cartilage, which may lead to ischemic avascular necrosis of the underlying cartilage, destruction of the cartilage, and saddle nose deformity (see Fig. 1.30). The hematoma and any necrotic cartilage may then serve as a nidus for infection, resulting in a septal abscess. Chronic cocaine use results in vasoconstriction and eventual necrosis of the septal cartilage, leading to perforation.
Septal injuries may lead to cosmetic nasal deformity, chronic sinus infections, recurrent epistaxis, and sleep disturbances. Rarely, it can result in more serious complications such as cavernous sinus thrombosis and meningitis. Since the original trauma is often minor, patients may present days to weeks after the injury. Young children and infants may present with poor feeding, fever, and rhinorrhea. Older children and adults may note bleeding, headache, and more focal pain.
Nasal examination reveals a large, red, round swelling originating off the septum and occluding most of the nasal cavity. The mass is tender to palpation and may cause the outer aspects of the nose to be tender as well. Septal abscesses tend to be more painful and larger than uncomplicated hematomas. Fever is frequently present. S aureus, GABHS, H influenzae, and S pneumoniae are the organisms most commonly isolated in septal abscesses. A septal perforation is easily seen with penlight examination.
Management and Disposition
Suspicion and recognition are essential in diagnosing septal injuries. Prompt referral to an otolaryngologist is mandatory for incision and drainage of the hematoma or abscess.
Septal Hematoma. Fluctuant grapelike structure in the right naris after blunt facial trauma consistent with a septal hematoma. (Photo contributor: Lawrence B. Stack, MD.)
Septal Abscess. A septal abscess is seen in both nares 1 week after blunt nasal trauma. (Photo contributor: Lawrence B. Stack, MD.)
Intranasal examination for septal hematoma in all patients with a history of nasal trauma regardless of severity is crucial.
Antibiotics are required in septal hematomas with a clinical suspicion for a secondary infection or abscess.
The physician must explore the possibility of child abuse in young children and infants with a septal hematoma or abscess.
Septal Abscess. A postoperative septal abscess is seen in both nares. (Photo contributor: Naval Medical Center Portsmouth).