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 compromized patients, and sphenoidal

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-
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 Septal haematoma. Septal abscess. Total %

(3mon-5 year ) 7 (43.75%) 14 (63.6%) 21 (55.3%)
(6-10 year) 2 (12.5%) 4 (18.2%) 6 (15.8%)
(11-15year) 2 (12.5%) 2 (9.1%) 4 (10.5%)
(16-20year) 2 (12.5%) 1 (4.55%) 3 (7.9%)
( >20 year) 3 (6.25%) 1 (4.55%) 4 (10.5%)
Total 16 (42.2%) 22 (57.8%) 38 (100%)

Table 2 : Causes of septal haematoma and abscess

Causes Septal haematoma Septal Abscess No. Total No.

NO. (%) (%) (%)
Personal accidents 5 (31.25%) 12 (54.54%) 17 (44.75%)
Personal assaults 6 (37.50%) 5 (22.72%) 11 (28.93%)
Animal attacks 1 (6.25%) 2 (9.1%) 3 (7.9%)
Post operative(Iatrogenic) 2 (12.5%) 0 2 (5.26%)
Sporting 2 (12.5%) 0 2 (5.26%)
Spontaneous(Unknown) o 3 (13.64%) 3 (7.9%)
Total 16 (100%) 22 (100%) 38 (100%)

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

Septal haematoma Septal abscess Total

Mean time of presentation 1.9 day (8hr-4 days) 5.7days(3-14 days)
Bilateral nasal obstruction 14 (87.5%) 22 (100%) 36 (94.7%)
Rhinorrhea 6 (37 %) 16 (72.7%) 22 (57.26%)
Pain and tenderness 3* (18.75%) 18 (81.8%) 21 (55.26%)
Toxemia(pyrexia, rapid pulse) 0 19 (86.4%) 19 (50%)
External deformities 3 * (18.75%) 13 **(59.1%) 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 Total

Group (A)* G r o u p(B) Group(C)***
[No.10] **[No.8] .[No.4]
Recollection. 3( 30%) 0 0 3(13.6%)
External nasal 10(100%) 7(87.5%) 1(25%) 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.

Discussion which the commonest presentation, then

Nasal septal haematoma and abscess rhinorrhea. The toxemia(pyrexia and rapid
are uncommon conditions (13)
, were 38 pulse) with pain and localized nasal
patients during eight years, study in Mexico tenderness suggestive septal abscess
(1) (3) (5)
found 16 patients during five years , other (12) formation . The higher incidence of
found 52 patients during 10 years (14)
, in septal abscess(57.8%)in this study, because
nigeria46 patients with septal haematoma late presentation of the patients following
during five year represent 0.2% of total trauma, or miss diagnosed of septal
attendances to the ENT clinic over the period haematoma as turbinate swelling as most cases
(11)
. Jalaludin in Singapore report 14 septal were children examined firstly by non-
abscess during 10 years . (13) otolaryngologist (13) [pediatricians or general
Septal haematoma is common in children because the practitioner].so
muco-perichodrium the mean
is nottime of presentation
closely bound down to the cartilage
nasal trauma, and the haematoma usually for septal abscess were (5.9 days) following
followed by septal abscess, in delay trauma due to delay diagnosis of septal
recognition or improper management of the haematoma , while (1.9day) in haematoma.
septal haematoma (6) (9) (12) (15). It is necessary to Study in Nigeria was found that the majority
be aware of possibility of septal haematoma of septal haematoma (65.5%) were unknown
and abscess of the nasal septum in nasal (spontaneous) causes, while ( 30.4%) were due
trauma (6) (10) (15)
, especially in children, when to trauma .Most studies found that nasal
presented with bilateral nasal obstruction trauma was the commonest causes (2) (3), Canty
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)
. nose
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 two-
third of the nose unsupported (17).The saddle
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.
References
1. Roger F Gray;et al.Trauma to the
nose, paranasal sinuses and jaws.
synopsis of otolaryngology-Butter
worth-Heinemann Ltd.Fifth Edition
1992; 215-216.
2. Nasal and facial fracture. Logan-
Turner's, Diseases of the Nose, Throat
and ear. Edited by A.G.D maran,Tenth
edition 1988; 23-24.
3. Canty-PA; Berkowitz-RG. Hematoma
and abscess of the nasal septum in
children.Arch-Otolaryngol-Head-
Neck-Surg.1996 Dec;122(12):1373-6.
4. Dr James Mc Morron; et al.General
Practice Note book- a UK medical
encyclopedia on the world web.
5. David Brain. The nasal septum. Scott-
brown's otolaryngology. Ian S
Mackay, Rhinology. Butter worth
international Edition, 1987; 154-179.
6. Dispenza C; et al.Management of
nasal septal abscess inchildren: our
experience. Int. J Pediatr Otorhinol-
aryngol. 2004, Nov; 68(11): 1417-21.
7. Shah-SB;et al.Non traumatic nasal
septal abscess in immunocom-
promized: Am-J-Rhinol.2000 Jan-
Feb;14(1):43.
8. Cox AJ.Nasal fracture-the details.
Facial plast surgery.2000;16:87-94.
9. Matsuba-HM;Thawley-SE.Nasal
septal abscess.Ann-plast-surg. 1989:
Feb; 16(2): 161-6.
10. Thomson-CJ; Berkowitz- RG.
Extradural frontal abscess
complicating nasal septal abscess in
children. Int-J-Peddiatr-Otolaryngol.
1998 Oct 2; 45(2): 183-6.
11. Chukuez-AB.Nasal septal haematoma
in Nigeria; J-Laryngol-Otol. 1992
May; 106(5).
12. H.Alvarez.et al; Sequelae after nasal
septum injuries in children; Auris
Nasus larynx; Volum 27, Issue 4Oct.
2000; 339-342.
13. Jalaludin MA.Nasal septal abscess-
retrospective analysis:Singapore Med
J.1993 Oct; 34(5): 435-7.
14. Kryger H,Dommerby H; Haematoma
and abscess of the nasal septum;Clin-
Otolaryngol; 1987 Apr; 12(2); 125-9.
15. Close-DM; Guinness MD. Abscess of
the nasal septum after trauma.Med-J-
Aust. 1985 Apr 15; 142(8): 472-4.
16. Eugene B.Kern. Acute nasal trauma;
Rhinoplasty problems and
controversies. Thomas D. et
al;Copyright 1988 by C.V Mosby
company; P392.
17. Rafael S,MD.Nasal septal abscess;
Acase report, Clinical Article.
International pediatrics.Vol.14;No 4;
1999. P228-233.
18. Dispenza C; et al.Management of
nasal septal abscess inchildren: our
experience. Int.J Pediatr Otorhino-
laryngol. 2004 Nov; 68(11): 1417-21.
19. uizing EH.Long term results of
reconstruction of the septum in the
acute phase of septal abscess in
children .Rhinology. 1984 Mar; 22
(1): 55-63.
20. Zur Korrektur der sattelnase.
Correction of saddle nose.Laryngol-
Rhinol-Otol-Stuttg. 1985 Feb; 64(2):
81-8.
21. Hellmich-S. Reconstruction of the
destroyed septal infrastructure.
Otolaryngol-Head-Neck-Surg.1989
Feb; 100(2): 92-4.
22. Masing,H.Zur plastische-operativen
Versorgung von Septum hamotomen
and abscessen. HMO, 1965; 13, 235-
240.
23. Hellmich,S. Die vertraglichkeit
konservieter homio-plastischer
knorpelimplantate in dernose.
Zeitschrift fur Laryngologie
Rhinologie and ihre Grenzgebeite,
1974; 49,742-749.
24. Vase,P and Johannessen,I. Homograft
cartilage in the treatment of an
abscess in the nasal septum. Journal
of Laryngology and Otology, 1981;
95, 357-359.
Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes