Septal hematoma

By

Dr. T. Balasubramanian M.S. D.L.O.

Definition: Septal hematoma is collection of blood between the perichondrium of nasal septum and the septal cartilage. 

Nose is the most prominent part of the face and hence is more prone for injuries resulting in a hematoma formation in the nasal septum.

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.  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.

Signs & symptoms:
The dominant symptom is nasal obstruction.  If hematoma is unilateral then obstruction is also unilateral, if hematoma is bilateral then obstruction is also bilateral.  Examination must be carried out without a nasal speculum.  It will reveal a smooth rounded unilateral / bilateral swelling often extending up to the lateral nasal wall causing severe obstruction.

Treatment:

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.

Diagramatic representation of septal hematoma

Figure showing the site of incision to drain septal hematoma

Figure showing hematoma being extruded

Complications:

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.

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