Dr. T. Balasubramanian M.S. D.L.O.
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.
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.
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
Diagramatic representation of septal hematoma
Figure showing the site of incision to drain
Figure showing hematoma being extruded
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
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.
Copyright drtbalu 2007