Septal Hematoma

What happens in a septal hematoma

The nasal septum is made of cartilage at the front and bone further back. The cartilage has no blood vessels of its own; it gets oxygen and nutrients from the lining (perichondrium) on each side. Trauma can tear small blood vessels and let blood collect between the cartilage and lining, lifting the lining away. Within about 3 days, the cartilage can begin to die. Trapped blood also easily becomes infected.

Children are at particular risk because their septum is more flexible and they often cannot explain their symptoms. A septal hematoma in a young child without a clear injury history should raise concern about non-accidental injury.

Symptoms

• a nasal blockage on one or both sides that develops after injury
• pain and tenderness of the nose
• a soft, rounded, purple, bluish or red swelling seen inside the nostril, often on both sides of the septum
• swelling that feels "boggy" when gently pressed
• nosebleed
• headache or facial pressure
• if infected: fever, worsening pain, redness over the nose

Diagnosis

A clinician looks inside the nose with a light and speculum after shrinking the lining with a decongestant spray. A septal hematoma does not shrink with decongestant, unlike normal swollen lining. Gently pressing with a cotton swab shows a soft, fluctuant swelling. CT may be done if a nasal fracture or other facial fractures are suspected, but a hematoma is usually diagnosed by examination.

Every nose injury, and any facial trauma, should include a check inside the nose for a septal hematoma.

Treatment

1. Drainage: under local anesthetic (or general anesthetic in children), the clinician makes a small cut in the lining and drains the blood or pus. Sometimes a needle aspiration is used for small hematomas.
2. Prevent reaccumulation: nasal packing, silicone splints or stitches through the septum keep the lining against the cartilage.
3. Antibiotics: often given to prevent or treat infection.
4. Follow-up: within 24 to 48 hours to check for reaccumulation and remove packing.
5. Pain relief: acetaminophen (paracetamol). Avoid aspirin and, unless advised, NSAIDs immediately after injury because of bleeding risk.

Any associated nasal fracture may be reset at the same time or a few days later when swelling settles.

Complications if untreated

• septal abscess (abscess of the nose) with fever and severe pain
• septal perforation (a hole in the septum, see septal rupture), causing crusting, whistling and nosebleeds
• saddle nose deformity: collapse of the bridge of the nose from cartilage loss
• spread of infection to the face, eye socket, brain (meningitis, abscess) or veins (cavernous sinus thrombosis)
• in children, disturbed nose and mid-face growth

Outlook

When drained quickly, most septal hematomas heal without lasting problems. Delayed treatment increases the risk of deformity and the need for reconstructive surgery.

Frequently asked questions

What does a septal hematoma look like?

It looks like a soft, smooth, purple, red or bluish swelling on the wall between the nostrils, often on both sides, that blocks the nose after an injury. It feels spongy when pressed and does not shrink with decongestant spray.

Is a septal hematoma an emergency?

Yes, it needs urgent treatment within hours to a day. Without drainage, the cartilage can die or become infected within a few days, leading to an abscess, a hole in the septum, or a collapsed nose bridge.

Can a septal hematoma heal on its own?

It should not be left to heal on its own. Even small ones need drainage, because trapped blood cuts off the cartilage's blood supply and can become infected.

How long does it take to recover from a septal hematoma?

After drainage, most people recover in 1 to 2 weeks. Packing or splints are usually removed within a few days, and follow-up checks that the blood has not returned.