Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes

Haematoma and Abscess of Nasal Septum, Clinical Features and

Surgical Treatment Outcomes
Salim hussain Ibrahim
Department of surgrry

Abstract
Objective: To evaluate the clinical features, and surgical treatment of haematoma and abscess of the
nasal septum (HANS).
Patients& methods: Retrospective study. In the Ear nose and throat department at Tikrit Teaching
Hospital.Iraq.Thirty-eight patients with HAND were admitted during eight years, 22 patients(57.8%)
with septal abscess and 16 patients(42.2%) with septal haematoma.All treated by urgent drainage
under GA,and to prevent recollection, a corrugated drain and packing were used in 17
patients(44.7%)(Group A), and a unilateral incision along septal floor, with septal splint and packing
in 21 patients (55.3%)(Group B). Four patients from this group with septal abscess dorsal and
columellar strut were done using available septal cartilage and bones(Group C).All receive
antibiotics. Follow up of the patients for functional and cosmetic results for minimum six months.
Results: The HANS were common in children 27 patients (71.1%) were in age between (3mon.-10
year). History of trauma was in (92.1%). The mean time of diagnosis following trauma in septal
haematoma was(1.9day) ,and for septal abscess was(5.7days).Bilateral nasal obstruction was the
commonest symptoms in(94.7%),then rhinorrhea (57.267%) , pain and tenderness (55.26%).Toxemia
(pyrexia and rapid pulse) found only in patients with septal abscess in (86.4%). The complications
were more in septal abscess, especially external nasal deformities was (86.4%) in septal abscess, and
(6.25%) in septal haematoma. The use of unilateral septal incision and splint found effective in
reducing recollection of blood or pus, thick septum, nasal obstruction, and septal perforation. But
little significant on preventing external nasal deformities. Three patients(75%) with immediate
septal reconstruction not have saddle nose deformity. No septic intracranial complications occurs.
Conclusion: The HAND are uncommon condition, but should be considered in any patient with
history of nasal trauma, especially in children, presented with acute nasal obstruction, The toxemia
with pain suggestive formation of septal abscess which have a dangerous complications. The
immediate septal reconstruction in septal abscess, and unilateral septal incision and septal splint are
effective to minimize the functional and cosmetic complications.
Key word: Nasal Septal Haematoma; Nasal septal Abscess; Nasal -Injuries; Saddle nose deformity;
Nasal septum-Diseases-Complications.

Introduction
Nasal septal haematoma is collection of
blood beneath mucoperichndrium or
mucoperi-osteum of the septum (1). It follows
trauma to the septum (2)(3), when sub- mucosal
blood vessels torn with intact mucosa, rare in
blood dyscresia.Thehaematoma interfere with
the vitality of the cartilage which depends on
the perichondrium for nutrition ,by diffusion
(4)
. Avascular cartilage can probably remain
for three days, then the chondrocytes die and
absorption of the cartilage follows, which
easily infected leads to septal abscess
formation(5)(6), which may follows measles,
scarlet fever ,nasal furnuclosis (1), immuno-

compromized patients, and sphenoidal

sinusitis(7). The septal abscess leading to nasal
deformities (saddle nose)and sever impairment
of nasal patency and growth(8), so late
recognition and the improper management of
septal haematoma may have a disastrous
outcome(3), like septal abscess and intracranial
complications(9)(10), even death in (6.52%) of
cases due to brain abscess(11).

Patients and Methods

This a retrospective study was carried
out on patients with haematoma or abscess of
the nasal septum, admitted in the E.N.T

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes
department at Tikrit Teaching Hospital. Iraq.
During the period from Jan.1997-Dec. 2004.
They were 38 patients,22 patients (57.8%)
with septal abscess and 16 patients (42.2%)
with septal haematoma. They were evaluated
by history taken about nasal trauma
(type&duration), recent external nasal
deformities,
nasal
obstruction,
nasal
discharge, nasal pain and headache.
General appearance of the patients, pulse rate,
temperature.
Full E.N.T examination was done stressing
mainly on the nose, inspection for swelling,
deformity, palpation for tenderness, elevation
tip of the nose by the thumb for septal
swelling mostly occlude the lumen of both
nostrils, cystic in probing and anterior
rhinoscopy for localized septal haematoma or
abscess. The diagnosis was confirmed by
needle aspiration of blood or pus. All patients
underwent general anesthesia,oro-trachial
intubation, pharyngeal pack was inserted, Via
hemitransfixation incision, subperichondrial
dissection and evacuation of the blood, pus
and all necrotic cartilage removed, the pus
send for culture and sensitivity test.
To prevent recollection before 2001 Insertion
of small corrugated drain in the floor of the
septum with anterior nasal packing for three
days (Group A). After 2001 a longitudinal
incision was made along the inferior border of
the septum on one side, septal splint and
anterior nasal pack for three days, the stent
removed after seven days (Group B).
(Group C). Includes patients with septal
abscess were immediate reconstruction of
destroyed necrotic nasal septal cartilage using
available cartilage and part of vomer bone for
dorsal and columellar strut, because there is
no cartilage bank available in our city. (The
insertion of the dorsal graft in a pocket via
unilateral intercartilagenous incision),to
prevent recollection as in (group B). Simple
close reduction was done for patients with
fracture nasal bones. All patients receive
parentral antibiotics Ampiclox or cephalothin
initially till the results of culture and
sensitivity results appears. Follow up of the
patients for functional and cosmetic outcomes
were done for at least six months.

Results
There were thirty-eight patients with
nasal septal haematoma and abscess, 21

(55.3%) were male and 17 (44.7%) were

female, underwent surgical drainage at Tikrit
Teaching Hospital during the period of eight
years by same author.22 patients (57.8%) with
septal abscess, and 16 patients (42.2%) with
septal haematoma.
Commonest age group affected was (3
months-5 years) were21 patients(55.3%),then
age Group (6-10 years) were 6 patients
(15.8%), then (11-15 year), and(>20 year)
both were4 patients (10.5%), lastly the age
group(16-20 year)was 3 patient (7.9%).The
septal abscess was common than septal
haematoma in the age groups (3 months-5
year) and (6-10 year), while septal haematoma
was common in the older age groups (Table
1). Nasal trauma was the causes for all cases
of septal haematoma, but in septal abscess 3
patients
(13.62%)
were
spontaneous
(unknown) causes. Personal accidents were the
commonest type of trauma 17 patients
(44.75%), personal assaults were 11 patients
(28.93%), animal attacks were 3 patients
(7.9%), lastly post surgical (iatrogenic)two
cases (5.26%) of septal haematoma following
septoplasty, and sporting also two patients
(5.26%) ( Table 2).
The mean time of presentation following
trauma, for septal haematoma was 1.9 day (8
hours-4 days),and for septal abscess was 5.7
days (3-14 days).
Common presentation was bilateral nasal
obstruction 36 patients (94.7%), all 22 patients
(100%) with septal abscess and 14 patients
(87.5%) with septal haematoma,two patients
with localized septal haematoma. Rhinorrhea
were 22patients (57.26%) more with septal
abscess 16 patients (72.7%),while in septal
haematoma were 6 patients (37.5%).Pain and
tenderness over nasal tip were 21 patients
(55.26%),18
patents(81.8%)with septal
abscess, and 3 patients (18.75%) with septal
haematoma due to fracture nasal bones.
Toxemia (pyrexia and rapid pulse) were found
in 19 patients (86.4%) with septal abscess
only.
External nasal swelling or deformities were 16
patients(42.1%).Five with fracture nasal
bones{three with septal haematoma,and two
with septal abscess},the others reddening of
the nasal bridge and swelling with septal
abscess (Table 3).
The 16 patients with septal haematoma, to
prevent recollection, Group(A) were(7)
patients (43.75%), and Group (B) were (9)

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes
patients (56.25%). Recollection occurs only in
Group A, were two patients (28.6%), one
patient converted to septal abscess gets
external
nasal
deformities(supra
tip
depression). Four patients (25%) gets thick
septum {3 patients Group A(42.85%) ,and one
patient (11.1%) group B}. Five patients
(31.2%) gets nasal obstruction{3 patients
(42.85%) Group A, and 2 patients (22.2%)
Group B} (Table 4).
The 22 patients with septal abscess. Group A
were 10 patients (45.45%), Group B were 8
patients (36.37%), and Group C were 4
patients (18.18%) aged 15, 17, 20, 27 year.
External nasal deformity(form simple supratip
depression to obvious saddle Nose) occurs in

18 patients (81.81%) {10 patient (100%) in

Group A, 7 patients (87.5%) in Group B, and
one patient (25%) in Group C}. Recollection
of pus occurs in 3 patients (13.6%), all patients
from Group A (30%). Thick septum occurs in
5 patients (22.7%) {4 patients (40%) were
Group A, and one patient (12.5%) Group
B}.Nasal obstruction occurs in 10 patients
45.45%){6 patients (60%) In Group A, 3
patients (37.5%) in Group B, and one patient
(25%)in Group C}. Septal perforation occurs
in one patient (4.5%) in patient with
recollection following drainage using
corrugated drain in both operations (Table 5).
No cases of intracranial septic complications
were occurred (Table 5).

Table (1):Age distribution of HANS.

Age group
(3mon-5 year )
(6-10 year)
(11-15year)
(16-20year)
( >20 year)
Total

Septal haematoma.
7 (43.75%)
2 (12.5%)
2 (12.5%)
2 (12.5%)
3 (6.25%)
16 (42.2%)

Septal abscess.
14 (63.6%)
4 (18.2%)
2 (9.1%)
1 (4.55%)
1 (4.55%)
22 (57.8%)

Total %
21 (55.3%)
6 (15.8%)
4 (10.5%)
3 (7.9%)
4 (10.5%)
38 (100%)

Table 2 : Causes of septal haematoma and abscess

Causes
Personal accidents
Personal assaults
Animal attacks
Post operative(Iatrogenic)
Sporting
Spontaneous(Unknown)
Total

Septal haematoma
NO. (%)
5 (31.25%)
6 (37.50%)
1 (6.25%)
2 (12.5%)
2 (12.5%)
o
16 (100%)

Septal Abscess No.

(%)
12 (54.54%)
5 (22.72%)
2 (9.1%)
0
0
3 (13.64%)
22 (100%)

Total
No.
(%)
17 (44.75%)
11 (28.93%)
3 (7.9%)
2 (5.26%)
2 (5.26%)
3 (7.9%)
38 (100%)

Table 3: Clinical features of nasal septal haematoma and abscess.

Mean time of presentation

Bilateral nasal obstruction
Rhinorrhea
Pain and tenderness
Toxemia(pyrexia, rapid pulse)
External deformities

Septal haematoma
1.9 day (8hr-4 days)
14 (87.5%)
6 (37 %)
3* (18.75%)
0
3 * (18.75%)

Septal abscess
5.7days(3-14 days)
22 (100%)
16 (72.7%)
18 (81.8%)
19 (86.4%)
13 **(59.1%)

Total
36 (94.7%)
22 (57.26%)
21 (55.26%)
19 (50%)
16 (42.1%)

* Three patients were having fracture nasal bones.

**Two patients were having fracture nasal bones, others due to redness and swelling.

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes
Table 4 : The results of septal haematoma.
Complications

Surgi cal

procedure

Total

Group (A)*[No.7]
Group (B)** [No.9]
Recollection
2***(28.6%)
0
2 (12.5%)
External
nasal
1**** (14.3%)
0
1 (6.25%)
deformities
Thick septum
3 (42.85%)
1 (11.1%)
4 (25%)
Nasal obstruction
3 (42.85%)
2 (22.2%)
5 (31.25%)
*Insertion of small corrugated drain in the floor of the septum with anterior nasal pack.
**A unilateral longitudinal incision was made along the inferior border of the septum with septal
splint, and anterior nasal pack.
***one case Converted to septal abscess.
****Developed supratip depression.
Table 5 : The out comes of septal abscess.
Complications

Surgical
procedure
Group (A)*
G r o u p(B)
Group(C)***
[No.10]
**[No.8]
.[No.4]
3( 30%)
0
0
10(100%)
7(87.5%)
1(25%)

Total

Recollection.
3(13.6%)
External
nasal
18(81.81%)
deformities.
Thick septum.
4 (40%)
1 (12.5%)
0
5 (22.7%)
Nasal obstruction.
5(50%)
3 (37.5%)
1(25%)
9 (40.9%)
Septal perforation.
1 (10%)
0
0
1 (4.5%)
Septic
0
0
0
0
complications.
*Insertion of small corrugated drain in the floor of the septum with anterior nasal pack.
**Aunilateral longitudinal incision was made along the inferior border of the septum with splint,
and anterior nasal pack.
*** Patients with immediate septal reconstruction, and septal incision and splint were used.
which the commonest presentation, then
rhinorrhea. The toxemia(pyrexia and rapid
Nasal septal haematoma and abscess
(13)
pulse) with pain and localized nasal
are uncommon conditions
,
were 38
tenderness suggestive septal
abscess
patients during eight years, study in Mexico
(1) (3) (5)
(12)
formation
.
The
higher
incidence
of
found 16 patients during five years , other
(14)
septal
abscess(57.8%)in
this
study,
because
found 52 patients during 10 years
, in
late presentation of the patients following
nigeria46 patients with septal haematoma
trauma, or miss diagnosed of septal
during five year represent 0.2% of total
haematoma as turbinate swelling as most cases
attendances to the ENT clinic over the period
(11)
were children examined firstly by non. Jalaludin in Singapore report 14 septal
(13)
otolaryngologist (13) [pediatricians or general
abscess during 10 years .
the mean
of presentation
Septal haematoma is common in children because the practitioner].so
muco-perichodrium
is nottime
closely
bound down to the cartilage
for
septal
abscess
were
(5.9
days)
following
nasal trauma, and the haematoma usually
trauma
due
to
delay
diagnosis
of septal
followed by septal abscess, in delay
haematoma
,
while
(1.9day)
in
haematoma.
recognition or improper management of the
Study in Nigeria was found that the majority
septal haematoma (6) (9) (12) (15). It is necessary to
of septal haematoma (65.5%) were unknown
be aware of possibility of septal haematoma
(spontaneous) causes, while ( 30.4%) were due
and abscess of the nasal septum in nasal
(6) (10) (15)
to trauma .Most studies found that nasal
trauma
, especially in children, when
trauma was the commonest causes (2) (3), Canty
presented with bilateral nasal obstruction

Discussion

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes
et al all the patients had a history of trauma (3),
Jalaludin (85.7%) of septal abscess due to
trauma(13). Alvarez H (56.2%) due to trauma
(12)
.
There is conflicting evidence regarding the
benefit of using a drain to prevent recollection
of the blood or the pus after drainage (3), author
using nasal packing for five days to allow
healing to begin adequately (16), other maintain
drainage by inserting drainage tube in the
buttom of the cavity and the mucosa replaced
and maintained in this position by nasal
packing (5), other maintain drainage by
excising
small
square
of
the
mucoperichondrium on one side with nasal
packing (1). Another treatment option is
immediate drainage and Placement of Penrose
drain (18), or using soft rubber drain with
packing (2).
In this study to prevent recollection, using
corrugated drain and anterior nasal packing for
early cases, and make a longitudinal incision
along the floor of the nose on one side and
sialastic septal stent inserted and packing in
other cases. Cosmetically both methods have
no significant effect on preventing saddle nose
in septal abscess. The use of the septal stent
found to be effective for reducing the
incidence of recollection of septal haematoma
or the abscess by preventing oozing by made
both mucoperichondrium in contact closer
than presence of the corrugated drain which
located in between, as well the longitudinal
incision along the inferior border of the
septum which made continuous drainage,
added by persistent pressure of septal stent,
while in cases using a corrugated drain
recurrence and revision surgery were indicated
in (two patients (28.6%) in septal haematoma,
and three patients (30%) in septal abscess),
and functionally septal splent gives better
results, less incidence of nasal obstruction
because of less incidence of thick nasal
septum.
Nasal obstruction due to thick(widened)
septum which reduce airway(2) due to
incomplete evacuation of blood, or continue
oozing. The blood clots will organized and
fibrosis causes thick septum. As well collapse
of the cartilaginous nasal septum in saddle
nose which commonly following septal
abscess. So the external nasal deformities, and
nasal obstruction were common in septal
abscess than septal haematoma. Saddle nose
deformity results from necrosis of septal

cartilage. The cartilage replaced with fibrous

tissue which can retract leaving the lower twothird of the nose unsupported (17).The saddle
nose
is inevitable in septal abscess,
characterized by loss of nasal dorsal height
which represent wide range of severity (10) (11),
related to the severity of cartilage necrosis
,from simple supratip depression to obvious
dorsal depression with loss of nasal tip support
and definition (10). But a study on two patients
with extensively destroyed cartilage were
examined a few months and the septal
cartilage appeared to have completely
regenerated (15), synichia which also affect
nasal patency occurs in three patients all not
use septal stent. One case of septal perforation
that usually occurs over the area of
cartilaginous necrosis. was found in one
patient with septal abscess using a drain.
The drainage and immediate reconstruction of
the destroyed nasal septum in acute phase are
the golden standard in the treatment of septum
infected haematoma in children, to prevent
short and long- term effect on nasal and mid
face growth (7)(19), Using materials taken from
the nose (20), if this material can't be obtained,
implantation of homologous bank cartilage or
mosaic plastic using small pieces of residual
septal cartilage assembled with fibrin glue(7),
or using preserved rib cartilage allo graft(21)
The homograft cartilage can be harversed from
patient who have undergone submucosal
resection and conveniently stored in 0.1%
sodium mercurothiosalicylate (5). In our study
four patients with septal abscess, dorsal and
columellar strut were done using available
healthy septal cartilage and vomer bone, with
success in three cases (75%). This may
prevent saddle nose deformity and reduce the
indication for augmentation rhinoplasty later.
Cartilage graft can be used even if the abscess
formation has occurred (22) ( 23) (24), have all
shown that these grafts takes well and
effectively in prevent the saddling deformities
which other wise inevitably occur (5).
In conclusion, the HAND
should be
considered in any patient with history of nasal
trauma, especially in childrens, presented with
acute nasal obstruction, The toxemia with pain
suggestive formation of septal abscess which
have a dangerous complications. This point l
recommended that the pediatricin and general
practitioner should aware about for early
detection
of septal haematoma
befor
converted to abscess. The immediate septal

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes
reconstruction in septal abscess, and unilateral
septal incision and septal splint are effective
to minimize the functional and cosmetic
complications.

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Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes