Nasal Septal Hematoma

Aka: Nasal Septal Hematoma, Septal Hematoma, Nasal Septal Hematoma Drainage, Septal Hematoma Evacuation

1. Definitions
   1. Septal Hematoma
      1. Blood between septal cartilage and mucoperichondrium
2. Causes
   1. Nasal Trauma including Nasal Fracture
      1. Septal Hematoma may result from even mild Trauma in Children (consider Nonaccidental Trauma)
3. Signs
   1. Soft, fluctuant swelling of septum
   2. Bilateral is most common
4. Management: General
   1. Urgent referral to otolaryngology
   2. Drainage should be done as soon as possible
      1. Within hours of onset is preferred
5. Management: Incision and Drainage
   1. Informed Consent
      1. Risk of Hematoma reaccumulation
      2. Risk of ongoing bleeding
         1. Caution in Anticoagulant use or Coagulopathy
   2. Topical and local Anesthetic
      1. Lidocaine 2-4% via MADD Atomizer
      2. Consider Lidocaine 1% injected into mucosal wall of Septal Hematoma
   3. Incision and Drainage
      1. Using a number 11 blade, make a small, 5-10 mm longitudinal incision into Hematoma
      2. Apply pressure or suction to evacuate the Hematoma of clots (some experts irrigate cavity)
      3. Needle Aspiration may be performed as an alternative but risk of reaccumulation
   4. Bilateral Nasal Packing for no more than 48 to 72 hours
      1. Some recommend that packing should contain anti-staphylococcal antibiotic (controversial)
   5. Consider prophylactic antibiotics
   6. Follow-up for recheck with ENT within 72 hours
6. Complications
   1. Infected Septal Hematoma
   2. Nasal septal perforation
   3. Nasal obstruction
   4. Saddle nose deformity
      1. Results from infection and septal cartilage necrosis
7. References
   1. Warrington (2021) Crit Dec Emerg Med 35(2): 11
   2. Wu in Herbert (2012) EM:Rap 12(11): 10
   3. Kucik (2004) Am Fam Physician 70(7):1315-20 [PubMed]