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Septal Hematoma Following Nasal Trauma
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.07.016
Visual Diagnosis in Emergency Medicine
SEPTAL HEMATOMA FOLLOWING NASAL TRAUMA Michael D. Puricelli, MD and Robert P. Zitsch III, MD Department of Otolaryngology – Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri Reprint Address: Robert P. Zitsch III, MD; Department of Otolaryngology – Head and Neck Surgery, University of Missouri School of Medicine, One Hospital Dr., MA314, Columbia, MO 65212
INTRODUCTION
DISCUSSION
The nasal bones are the third most frequently fractured bone in the human skeleton, with coexistent septal injury in about 90% of cases (1). There are few issues with nasal injuries that require urgent intervention, however, awareness of such conditions is critical to avoid complications.
All patients with nasal trauma should be assessed for septal hematoma, epistaxis, open fractures, and
CASE REPORT A 56-year-old man presented to the Emergency Department after falling from a standing position. His face struck the side of a brick building. He sustained facial lacerations and experienced obstructed nasal breathing as well as generalized midfacial pain. There was no evidence of cerebrospinal fluid leak. On examination, lacerations were present on the forehead and through the right nasal ala. Computed tomography of the facial bones demonstrated bilateral nasal bone fractures. Endonasal examination (Figure 1) demonstrated right nasal obstruction with bluish swelling along the septum, which was fluctuant on palpation. Aspiration confirmed blood. The septum was incised to the subperichondrial plane and the hematoma evacuated (Figure 2). The nasal cavity was packed to reduce the risk of recurrence, and antibiotics to prevent toxic shock syndrome were prescribed. Packing was removed in 2 days, with no evidence of hematoma recurrence. At follow-up 4 months after drainage, there was no saddle deformity.
Figure 1. Nasal septal hematoma prior to drainage. Black arrow indicates the nasal septal hematoma.
RECEIVED: 20 July 2015; ACCEPTED: 25 July 2015 1
2
M. D. Puricelli and R. P. Zitsch
as 24 h and necrosis within 72 h (1). If not promptly treated, patients may develop future cosmetic distortion, including saddle nose deformity or secondary infection, resulting in septal abscess (1,4). The nasal septum may be evaluated with an otoscope or nasal speculum using an adjunct light source (3). A septal hematoma is identifiable by bulging and fluctuance, particularly if it persists after administration of a vasoconstrictive agent (3). In some cases, it may be difficult to differentiate a septal hematoma from a caudal septal deviation. The texture of the septum to palpation with a cotton tip applicator can differentiate these conditions, or the region of concern may be aspirated (1). If a septal hematoma is present, the area is anesthetized, and fluid collection opened over a distance of 5–10 mm (3). Suction is applied to ensure complete evacuation, and the nasal cavity should be packed for 2–3 days to avoid recurrence (1,3). Antistaphylococcal antibiotics are recommended while the packing is in place (3). REFERENCES Figure 2. Nasal septal hematoma after drainage. Black arrow indicates the drainage incision.
cerebrospinal fluid leak (2). A nasal septal hematoma arises from the collection of blood in the potential subperichondrial space (3). The hematoma inhibits adequate perfusion and can lead to cartilage damage in as little
1. Sanyaolu LN, Farmer SE, Cuddihy PJ. Nasal septal haematoma. BMJ 2014;349:g6075. 2. Boswell KA. Management of facial fractures. Emerg Med Clin North Am 2013;31:539–51. 3. Kass JI, Ferguson BJ. Videos in clinical medicine. Treatment of hematoma of the nasal septum. N Engl J Med 2015;372:e28. 4. Wexner S, Armstrong L, French A, Buchanan JA. Images in emergency medicine. Male with facial trauma. Septal hematoma. Ann Emerg Med 2011;57:541, 549.
http://dx.doi.org/10.1016/j.jemermed.2015.07.016
Visual Diagnosis in Emergency Medicine
SEPTAL HEMATOMA FOLLOWING NASAL TRAUMA Michael D. Puricelli, MD and Robert P. Zitsch III, MD Department of Otolaryngology – Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri Reprint Address: Robert P. Zitsch III, MD; Department of Otolaryngology – Head and Neck Surgery, University of Missouri School of Medicine, One Hospital Dr., MA314, Columbia, MO 65212
INTRODUCTION
DISCUSSION
The nasal bones are the third most frequently fractured bone in the human skeleton, with coexistent septal injury in about 90% of cases (1). There are few issues with nasal injuries that require urgent intervention, however, awareness of such conditions is critical to avoid complications.
All patients with nasal trauma should be assessed for septal hematoma, epistaxis, open fractures, and
CASE REPORT A 56-year-old man presented to the Emergency Department after falling from a standing position. His face struck the side of a brick building. He sustained facial lacerations and experienced obstructed nasal breathing as well as generalized midfacial pain. There was no evidence of cerebrospinal fluid leak. On examination, lacerations were present on the forehead and through the right nasal ala. Computed tomography of the facial bones demonstrated bilateral nasal bone fractures. Endonasal examination (Figure 1) demonstrated right nasal obstruction with bluish swelling along the septum, which was fluctuant on palpation. Aspiration confirmed blood. The septum was incised to the subperichondrial plane and the hematoma evacuated (Figure 2). The nasal cavity was packed to reduce the risk of recurrence, and antibiotics to prevent toxic shock syndrome were prescribed. Packing was removed in 2 days, with no evidence of hematoma recurrence. At follow-up 4 months after drainage, there was no saddle deformity.
Figure 1. Nasal septal hematoma prior to drainage. Black arrow indicates the nasal septal hematoma.
RECEIVED: 20 July 2015; ACCEPTED: 25 July 2015 1
2
M. D. Puricelli and R. P. Zitsch
as 24 h and necrosis within 72 h (1). If not promptly treated, patients may develop future cosmetic distortion, including saddle nose deformity or secondary infection, resulting in septal abscess (1,4). The nasal septum may be evaluated with an otoscope or nasal speculum using an adjunct light source (3). A septal hematoma is identifiable by bulging and fluctuance, particularly if it persists after administration of a vasoconstrictive agent (3). In some cases, it may be difficult to differentiate a septal hematoma from a caudal septal deviation. The texture of the septum to palpation with a cotton tip applicator can differentiate these conditions, or the region of concern may be aspirated (1). If a septal hematoma is present, the area is anesthetized, and fluid collection opened over a distance of 5–10 mm (3). Suction is applied to ensure complete evacuation, and the nasal cavity should be packed for 2–3 days to avoid recurrence (1,3). Antistaphylococcal antibiotics are recommended while the packing is in place (3). REFERENCES Figure 2. Nasal septal hematoma after drainage. Black arrow indicates the drainage incision.
cerebrospinal fluid leak (2). A nasal septal hematoma arises from the collection of blood in the potential subperichondrial space (3). The hematoma inhibits adequate perfusion and can lead to cartilage damage in as little
1. Sanyaolu LN, Farmer SE, Cuddihy PJ. Nasal septal haematoma. BMJ 2014;349:g6075. 2. Boswell KA. Management of facial fractures. Emerg Med Clin North Am 2013;31:539–51. 3. Kass JI, Ferguson BJ. Videos in clinical medicine. Treatment of hematoma of the nasal septum. N Engl J Med 2015;372:e28. 4. Wexner S, Armstrong L, French A, Buchanan JA. Images in emergency medicine. Male with facial trauma. Septal hematoma. Ann Emerg Med 2011;57:541, 549.