Chapter 171. Nasal Septal Hematoma Evacuation

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 Suspect a nasal septal hematoma, although an uncommon complication of nasal trauma, in any individual who has sustained a nasal injury.2,3 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.2

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.2,4,5 Other etiologies include sports injuries and child abuse.5,6 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 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 passage1–3,7 (Figures 171-1 & 2). Evacuation must be performed to prevent complications.1,2,4,5 Patients require bilateral nasal packing, oral antibiotics, and close follow-up with an Otolaryngologist to prevent complications following the evacuation of the hematoma.2,4,8

Distinguishing an uncomplicated nasal septal hematoma from one that has become infected is difficult, particularly if there has been a delay of several days in seeking medical attention following the injury.2 Nasal septal abscesses are a rare complication of nasal septal hematomas that occur following nasal trauma. Nasal septal abscesses generally are larger and more painful than uncomplicated nasal septal hematomas. The overlying nasal mucosa is inflamed and occasionally has an inflammatory exudate.2 Local extension of the infection, if left untreated, into the cavernous sinus with subsequent intracranial infection is the most important potential complication.5,8 The most common complication of a nasal septal abscess is cartilage necrosis that results in nasal structural collapse and a saddle nose deformity (Figure 171-3).

The nose is both a sensory organ and a respiratory organ. It performs an important function for the entire body by providing both physical and immunologic protection from the environment.9 The nose aids in the formation of basic speech sounds.9 The supporting structure of the nose consists of bone, cartilage, and connective tissue. The nose, on frontal view, is in the shape of a pyramid of which approximately the upper two-fifths comprise the bony vault and the lower three-fifths comprise the cartilaginous vault. The upper narrow end joins the forehead at the glabella and is referred to as the root of the nose. The two nares are separated from each other by a skin-cartilage septum known as the columella.9,10 The cartilaginous framework of the nose provides both its structure and function. The septal cartilage is avascular and receives its blood supply from the adherent mucoperichondrium.

The skin covering the external nose is thin and contains an areolar type of subcutaneous tissue. The skin is loosely attached over the upper half. The skin over the lower half of the nose is intimately bound to the lower lateral cartilage and may sometimes be thick, fatty, and contain sebaceous glands.9,10

The precise mechanism for a nasal septal hematoma formation following nasal trauma is not known. Nasal septal hematomas are thought to occur when a mechanical force to the nasal cartilage results in rupture or leakage from the perichondrial blood vessels of the nasal septum. In instances where the nasal cartilage is fractured, blood may dissect through the fracture line and form bilateral septal hematomas. Most nasal septal hematomas are secondary to a fracture or surgery. Thus, they almost always distend the mucoperichondrium on both sides of the nose. Accumulation of the extravasated blood strips the perichondrium from the cartilage, forming a closed space in which the blood accumulates (Figure 171-2). The nasal septal hematoma, when not recognized initially and evacuated promptly, can expand and mechanically obstruct the blood vessels that supply the nasal cartilage. Pressure-induced avascular necrosis of the nasal septal cartilage can develop rapidly because there is no alternative blood supply to the cartilage.1–3,7 The accumulated blood and necrotic tissue can form a nidus for infection from bacteria that colonize the nasal mucosa.1–3,7

Cartilage necrosis subsequently leads to the saddle nose deformity. The term “saddle nose deformity” is a nonspecific description of a nose with a depression over its dorsal surface9 (Figure 171-3). The saddle nose deformity is a result of the nasal septal cartilage becoming ischemic from loss of its blood supply, subsequent nasal septal cartilage resorption and collapse, and the lack of support for the nasal bridge. The deformity is the ultimate result of a nasal septal hematoma or abscess not being evacuated. Necrosis with subsequent fibrosis may develop causing a permanent thickening or absorption of the nasal septum with partial obstruction of the nasal airway.7–9

The sphenopalatine branches of the internal maxillary artery and the ethmoidal arteries from the ophthalmic artery supply the internal nose. The veins terminate in the anterior facial and ophthalmic veins.10 Venous drainage is clinically important in understanding the complications of a septal abscess. Branches of the trigeminal nerve provide sensory innervation to the nose.9,10

Any significant nasal septal hematoma requires evacuation. A nasal septal hematoma may progress to form an abscess with associated complications of avascular necrosis of the nasal septum, meningitis, or cavernous sinus thrombosis in as little as 3 to 4 days.7,8 It is not urgent to evacuate a simple nasal septal hematoma in the Emergency Department as complications occur over a period of days. It is essential, however, to identify a nasal septal hematoma so that a treatment plan is initiated and to rule out a septal abscess that does require immediate evacuation.5

There are no absolute contraindications to the evacuation of a nasal septal hematoma. Address any life-threatening or serious injuries or conditions prior to drainage of the nasal septal hematoma. This procedure requires a cooperative patient to prevent secondary iatrogenic injury. Any patient that is uncooperative, unable to follow instructions, very young, or that has an altered mental status may require evacuation under procedural sedation or general anesthesia.

• Headlight
• Nasal speculum
• Nasal vasoconstrictor (e.g., 2% ephedrine. 0.25% oxymetazoline or phenylephrine)
• Nasal anesthetic (e.g., 4% cocaine, 2% pontocaine, and 4% lidocaine)
• Nasal atomizer device, optional
• Alcohol swabs
• Povidone iodine or chlorhexidine solution
• Cotton-tipped applicators
• 1 mL and 10 mL syringes
• 25 or 27 gauge needle, 1½ inches long
• Local anesthetic solution containing epinephrine, lidocaine, or bupivacaine
• #15 surgical blade on a handle
• Frazier suction catheter
• Suction source and tubing
• Nasal speculum
• Bayonet forceps
• Nasal tampon or sponge
• Iodoform gauze

Explain the risks, benefits, complications, and aftercare of the procedure to the patient and/or their representative. Obtain a signed consent for the procedure. Aseptic technique should be followed and maintained throughout the procedure. The procedure is considered clean, but not sterile, as the nasal mucosa can never be sterilized. It is crucial, however, that the instruments are sterile.

Administer anesthesia for the evacuation of a nasal septal hematoma by one of two routes: topical application with supplemental infiltration or a regional block. Some authors recommend using both techniques. However, most nasal septal hematomas can be adequately evacuated with topical anesthesia supplemented by local infiltration.7 Dampen the swabs of four cotton-tipped applicators with either a solution of 2% pontocaine with ephedrine or cocaine. Insert a nasal speculum to expose one nostril. Gently insert the applicator beneath the roof of the nose so that it reaches the branches of the anterior ethmoidal nerve. Pause until some vasoconstriction and anesthesia takes place, if it meets resistance on insertion, and advance the applicator further (Figure 171-4). Pass an applicator into the nasal fossa and move it from the floor of the nasal vestibule, across the midportion of the inferior turbinate, and reaching the posterior aspect of the middle turbinate in the region of the sphenopalatine foramen.11 Infiltrate a maximum of 0.5 mL of local anesthetic solution containing epinephrine, if additional anesthesia is desired, through the mucoperichondrium and circumferentially around the hematoma.

An atomizer or nasal spray bottle can provide an alternative and commonly used method for nasal septal anesthesia. While an actual atomizer is not often available in the Emergency Department, its use is less painful to the patient than the application of cotton-tipped applicators into the nasal cavity. Alternatives to an atomizer are devices to attach to a syringe to atomize the contents or using a commercially available nasal spray container after emptying its contents. Mix equal amounts of 2% pontocaine or 4% lidocaine with ephedrine and place this in the atomizer or nasal spray bottle. Insert the nasal speculum to gain access to the entire nasal cavity. Open the nasal speculum vertically to expose as much of the nasal septum as possible. Insert the atomizer or nasal spray bottle into the nostril. Instill two puffs of solution into the nostril. Allow 5 to 10 minutes for the anesthetic to take effect. Infiltrate a maximum of 0.5 mL of local anesthetic solution containing epinephrine, if additional anesthesia is desired, through the mucoperichondrium and circumferentially around the hematoma.

Confirm the presence of a septal hematoma. Compress the area with a cotton-tipped applicator. The bulge from the hematoma is compressible with the applicator. It should not shrink with the application of a topical vasoconstrictor.2,6

Aspiration

Some authors feel that simple aspiration with an 18 gauge needle may be adequate for a small, early hematoma. Most patients require a more extensive evacuation as clotted blood cannot be removed with aspiration. Since blood clots form within minutes and remain in clotted form for days, needle aspiration is generally not effective. Simple aspiration may, however, be used to diagnosis a septal hematoma.6–8 Insert the nasal speculum. Open the nasal speculum vertically so that the nasal septum is maximally visible. Instruct an assistant to hold the nasal speculum in position and open, allowing the Emergency Physician to have both hands free to perform the procedure. Insert an 18 gauge needle, attached to a 10 mL syringe, into the nasal septal hematoma. Aspirate the contents of the hematoma. No additional procedure is necessary if the hematoma can be completely evacuated by aspiration. Simple clinical assessment of the septum is the guide to determine if the hematoma has been evacuated. Apply a nasal pack as described below.

Incision and Drainage

The incision and drainage technique is the primary procedure to drain a nasal septal hematoma. Cleanse the skin surrounding the nares of any dirt and debris. Apply an alcohol swab, povidone iodine, or chlorhexidine to the area and allow it to dry. Insert the nasal speculum. Open the nasal speculum vertically so that the nasal septum is maximally visible. Instruct an assistant to hold the nasal speculum in position and open, allowing the Emergency Physician to have both hands free to perform the procedure. Make a 1.0 to 2.0 cm long vertical incision, with a #15 scalpel blade, in the septal mucoperichondrium overlying the hematoma (Figure 171-5). Be cautious to not cut into the cartilaginous septum. The length of the incision depends upon the size of the nasal septal hematoma. Some authors prefer to use an L-shaped incision in the mucoperichondrium.12–16 These authors feel that this incision allows the mucoperichondrium to reposition flat against the cartilaginous septum. The choice of incision type is left to the preference of the Emergency Physician.

Use the Frazier suction catheter to gently evacuate any clot or necrotic debris from the hematoma cavity. Clots are difficult to evacuate by suction and may require mechanical removal. Always send a sample of the fluid or hematoma to the laboratory for Gram's stain, anaerobic cultures, and aerobic cultures.2,7,8 Apply topical antibiotic ointment over the incision, a wick, and nasal packing as described below.

A bilateral septal hematoma can, almost always, be evacuated from one side. Apply gentle pressure to the contralateral hematoma to express it out the incision. Make a second vertical incision contralaterally, either anterior or posterior to the first incision to prevent septal perforation, if complete evacuation is not achieved unilaterally.

Wick Insertion

Insert a wick of 1/8 inch iodoform gauze through the incision (Figure 171-6). Allow 1 inch of the wick to extend into the nasal cavity for easy removal. Be careful to ensure that the wick is flat between the mucoperichondrium and the cartilaginous septum. Do not pack the cavity with the wick. Some authors recommend inserting a Penrose drain, or a piece of one, instead of the iodoform gauze.6 This has not been found to be beneficial when compared to iodoform gauze.6 The Penrose drain can be a substitute if iodoform gauze is not available or the patient is allergic to iodine.

Nasal Packing

Apply bilateral nasal packs following the successful drainage of a septal hematoma. Packing inhibits the reaccumulation of the hematoma, or serous fluid, thereby preventing the severe complications associated with a septal hematoma. The use of commercially available nasal packing devices, such as nasal tampons or sponges, provides adequate protection against reaccumulation. Patients report such devices to be significantly more comfortable than traditional gauze packing. This, coupled with the ease of insertion when compared to gauze packing, has made such devices very popular.

Place the patient's head in the sniffing position. Coat a nasal tampon with a water-soluble antibiotic ointment. Insert the nasal speculum to obtain adequate visualization of the nasal septum. Grasp the nasal tampon with a bayonet forceps. Introduce the forceps with the nasal tampon in a horizontal position through the speculum. Be careful to not tear the incision in the mucoperichondrium open or to dislodge the wick. Place the nasal tampon on the floor of the nasal cavity and against the nasal septum.8 Withdraw the bayonet forceps and the nasal speculum. Repeat the nasal packing procedure on the contralateral side. Both nasal cavities must be packed to maintain the septum in the midline, prevent bowing of the septum into the contralateral nasal cavity, and the reaccumulation of the hematoma. Refer to Chapter 172 regarding the complete details of nasal packing.

Nasal septal hematomas can occur at any age. The diagnosis and treatment are the same for adult and pediatric patients. Generally, however, any treatment for children would be done under procedural sedation in the Emergency Department or general anesthesia in the operating room.

Proper follow-up is vital to prevent any infectious process or cosmetic deformity. All patients must be reevaluated within 24 hours and again in 48 hours for removal of the nasal packs. Prescribe acetaminophen and narcotic analgesics for pain control. Prescribe broad-spectrum antibiotics, specifically those with staphylococcal coverage, as prophylaxis against infection and the development of a septal abscess.6 Instruct the patient to avoid nonsteroidal anti-inflammatory drugs as they increase the risk of bleeding. Provide all patients with proper discharge instructions. They should return to the Emergency Department immediately if they experience increased pain, bleeding, or a fever. Refer all patients to an Otolaryngologist within 24 hours.

The most common acute complication of a nasal septal hematoma is an abscess or cosmetic deformity. Complications are primarily related to incomplete evacuation or reaccumulation of the hematoma. This may be avoided by adequate removal of the hematoma with suction, placement of an iodoform gauze wick, and bilateral nasal packing. An abscess may result in ascending infections including meningitis and cavernous sinus thrombosis. Staphylococcus aureus is the primary pathogen isolated from the majority of reported cases, regardless of patient age. Prescribe appropriate prophylactic antibiotics.2,5,6 Many patients cannot tolerate complete hematoma evacuation under local anesthesia. When complete evacuation is not performed, consult an Otolaryngologist and schedule the patient for evacuation under anesthesia within 24 hours. Early and/or appropriate treatment may not prevent complications if the nasal septal cartilage is already ischemic at the time of the procedure.

Other complications of nasal septal hematoma drainage are rare and include nasal bleeding, inadequate evacuation, and septal perforation. Nasal bleeding can usually be controlled with the prescribed packing. Incomplete removal of the hematoma is not a serious problem if identified. A nasal septal hematoma may reoccur if the incision is made on opposite sides of the septum. Limit the incision to one side if possible. The second incision, if required, on the contralateral side must not oppose the first incision.

A nasal septal hematoma is a rare but potentially serious complication of nasal trauma. Proper management consists primarily of early recognition, prompt evacuation, wick insertion, and bilateral nasal cavity packing. Administration of antimicrobial therapy is necessary to prevent or treat a secondary nasal abscess. Follow-up with an Otolaryngologist is required within 24 hours of the procedure to evaluate for the reaccumulation of the hematoma and/or an abscess. These patients require continual follow-up until the nasal septum is healed.