Abstract
Septal hematoma is accumulation of blood in the subperichondrial compartment of nasal septum. It is commonly caused by injuries involving the nose and face. Unilateral septal hematoma commonly heals causing fibrosis to occur between the septal cartilage and the perichondrium. Bilateral septal hematoma compromises blood supply to nasal septum causing liquefaction necrosis of septal cartilage. This ultimately leads to depressed dorsum of nose.
Septal Hematoma
Introduction:
Septal hematoma is a collection of blood under the nasal septal cartilage 1. Since nose is the most prominent portion of face it is prone for injuries leading on to septal hematoma formation. Even though incidence of septal hematoma is rather rare early diagnosis and management of this condition will go a long way in preventing attendant complications like septal abscess, septal perforation and saddle nose deformity 2. Injuries involving the anterior portion of nasal septum commonly causes septal hematoma 3.
Pathophysiology:
When the nasal septum is subjected to sharp buckling stress, the submucosal blood vessels are frequently damaged, and if the mucosa remain intact, will result in the formation of hematoma. If the trauma is severe enough to fracture the septal cartilage, the blood will seep to the opposite side causing bilateral septal hematoma. The nasal septum is usually 2-4 mm thick, hence it is common to see fractures involving nasal septum. This bilateral septal hematoma is dangerous because it compromises the nutrition of the septal cartilage the most and cause dissolution of the whole cartilagenous septum itself. Since the nutrition of the cartilage is dependent on the intact perichondrium, elevation of the perichondrium away from the cartilage causes necrosis of the cartilage. Avascular cartilage can remain viable only for 3 days after compromise of the perichondrium. Cartilage absorption can occur with alarming rapidity.
If the hematoma is small and unilateral it may not cause necrosis of the cartilage, but may be absorbed causing permanent thickening of the nasal septum and gross fibrosis. In adults septal hematoma occurs following facial trauma / nasal bone fracture. In children even trivial fall / injury can cause septal hematoma 5.
Signs & Symptoms: usually occur within the first 24-72 hours 4.
1. Nasal obstruction: This is the dominant symptom. In unilateral septal hematoma nasal obstruction is unilateral, and in bilateral septal hematoma nasal obstruction is bilateral.
2. Pain
3. Rhinorrhoea
4. Fever
On examination:
Presence of smooth swelling in the nasal septal area. Either on one side or on both sides. In unilateral septal hematoma, there is asymmetry of nasal septum. Direct palpation of nasal septum also will help in confirming the diagnosis of septal hematoma.
Fig. 1: Figure showing unilateral septal hematoma
Treatment:
Emergency drainage of septal hematoma is a must in these patients 6. It has been shown that early surgical drainage of the hematoma reduces the risk of cartilage necrosis, and hence is always indicated. A hemitransfixation incision (incision made at the lower border of the nasal septal cartilage) is used, since the perichodrium is already lifted off the cartilage the acumulated blood and infected material is aspirated. The state of the cartilage is assesed and if there is any defect it is advisible to support the defect with homograft cartilage. These cartilage grafts can be used even if abscess formation has occured thus effectively preventing saddle nose deformities. The homograft cartilage can be harvested from patients who have under gone submucosal resection of the nasal septum. These harvested cartilages can be stored in 0.1% sodium mecurothiosalicylate.
Fig. 2: Figure showing formation of septal hematoma
Complications of septal hematoma:
External deformity of the nose: The cartilagenous dorsum of the nose is supported by the septal cartilage and if this is lost then dorsal saddling can occur causing pig snout deformity (Pig nose like). If this injury occur during childhood, it may also affect the development of the whole of the middle third of the face causing resultant maxillary hypoplasia.
Septal abscess: Hematoma is a good culture medium and hence may become infected causing abscess formation. This complication is always associated with severe pain, together with manifestations of toxemia, such as increased pulse rate.
Septal deviation:
Minor hematomas especially the unialteral ones may get absorbed and appear as thickened areas in the nasal septum with extensive fibrosis leading on to deviation of nasal septum to that side due to contracture caused by fibrosis.
References
- http://www.drtbalu.co.in/sep_haem.html
- Matsuba HM, Thawley SE. Nasal septal abscess: unusual causes, complications, treatment, and sequelae. Ann Plast Surg. Feb 1986;16(2):161-6
- Ambrus PS, Eavey RD, Baker AS, et al. Management of nasal septal abscess. Laryngoscope. Apr 1981;91(4):575-82
- Canty PA, Berkowitz RG. Hematoma and abscess of the nasal septum in children. Arch Otolaryngol Head Neck Surg. Dec 1996;122(12):1373-6
- Toback S. Nasal septal hematoma in an 11-month-old infant: a case report and review of the literature. Pediatr Emerg Care. Aug 2003;19(4):265-7
- Chukuezi AB. Nasal septal haematoma in Nigeria. J Laryngol Otol. May 1992;106(5):396-8
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