*Disclaimer: This POTD contains multiple images of the inner nares. Proceed at your own risk.*
The nasal septum is a combination of bony and cartilaginous structures that forms the midline of the nasal cavity. When the nose sustains trauma, blood can accumulate in the space between the septal cartilage and the perichondrium, a surrounding connective tissue layer. This collection of blood is known as a nasal septal hematoma.
Nasal septal hematomas are relatively rare, occurring in only about 1% of patients with nasal trauma. However, they are often overlooked. One study estimated that approximately 50% of nasal septal hematomas have a delayed diagnoses.
Prompt diagnosis is important because untreated nasal septal hematomas can cause irreversible nasal deformities. The perichondrium, the only blood supply for the nasal cartilage, becomes separated from the underlying cartilage when a hematoma forms. This condition makes the cartilage susceptible to avascular necrosis. Necrotic nasal cartilage can collapse and create a “saddle nose deformity.”
To avoid delayed diagnosis, providers should evaluate all trauma patients for the presence of a nasal septal hematoma. These patients typically complain of nasal obstruction (95%), pain (50%), and rhinorrhea (25%).
The best way to look for nasal septal hematomas is to examine the inner nares using an otoscope. If a hematoma is present, it will appear as a red, blue, or purple bulge extending from the septal mucosa. The hematoma will feel boggy (soft and watery) when palpated and will not shrink in size when vasoconstrictive agents like Afrin are administered. Since we are not ENTs, I have included some images below of normal nares, nares with nasal septal hematomas, and nares with other conditions that can mimic the appearance of a hematoma.
Normal Nares
Nasal Septal Hematoma
Nasal Spur (cartilaginous outgrowth, will be more firm than a hematoma)
Nasal Septal Deviation (septum is off center so looks like a protrusion)
Nasal Polyp (soft grape like growth from the nasal mucosa, usually clear/white/yellow)
Once a nasal septal hematoma is diagnosed, urgent drainage is necessary to prevent complications. To perform this procedure, you’ll need the following equipment: a light source (such as an otoscope or Schiller’s headlamp), lidocaine with epinephrine, pledgets (which can be found in the trauma bay), an empty 5 mL syringe attached to an 18G needle, a 11-blade scalpel, forceps, a 10 mL saline-filled syringe attached to an 18G angiocatheter, and two rhino rockets. Ideally, a nasal speculum would be used for better visualization, but I’ve never personally seen one at Maimo.
Here is a step-by-step guide:
Position the patient supine with their neck slightly extended.
Soak two pledgets (or rolled-up sterile gauze) in lidocaine with epinephrine. Insert one into each nostril and ensure they touch both sides of the nasal septum. Leave these in place for 5-10 minutes before removing them. Afterwards you may inject a small amount of local lidocaine at the anticipated incision site.
Insert the 18G needle into the hematoma and aspirate the blood using the 5ml syringe.
Use the scalpel to make a horizontal incision along the inferior border of the hematoma. Be careful not to cut the cartilaginous septum.
Evacuate the hematoma by using forceps to extract any clotted blood.
Irrigate the hematoma by inserting the 18G angiocatheter into the incision and flushing it with sterile saline.
Pack the nose with bilateral rhino rockets. You must pack both nares to keep the septum midline.
Once the hematoma has been evacuated, the patient can be discharged. They should be prescribed prophylactic antibiotics, typically Augmentin 875 mg PO BID for 7 days. They must follow up with an ENT specialist or return to the ED within 24-48 hours for nasal packing removal.
Sources:
https://www.ncbi.nlm.nih.gov/books/NBK470247/
https://www.tamingthesru.com/blog/masteringminorcare/nasalseptalhematoma?rq=minor%20care
https://wikem.org/wiki/Nasal_septal_hematoma
https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683§ionid=45343819