Nasal septal hematoma drainage

Trauma to the nasal septum may result in the development of a hematoma. The mucoperichondrium provides the vascular supply to the septal cartilage. Bleeding may lift the mucoperichondrium from the cartilage creating a hematoma. Since the hematoma lifts the mucoperichondrium, the cartilage is deprived from blood supply. If left untreated it may result in cartilage necrosis with subsequent nasal dorsum depression (“saddle nose” deformity), or septal perforation.

Treatment of septal hematoma is performed via small incisions through the mucoperichondrium to evacuate the blood. After the drainage the nose is packed or quilting stitches are put in. Silicone stents can also be used to prevent re-accumulation of the hematoma.

The quilting stitch is a running absorbable suture that goes back and forth across the septum to assure that the mucoperichondrium is pressed against the cartilage, thereby preventing re-accumulation of blood.
Nasal packing is optional.

The hematoma may be aspirated in the office using a needle and a syringe. If adequate drainage is accomplished, the nose is packed for a few days and rechecked at the time of package removal.
Note: The hematoma may re-accumulate in which case aspiration drainage can be repeated or a more formal drainage procedure with quilting stitches may be performed.

Keeping the patient’s head in a raised position both preoperatively and postoperatively may significantly improve edema and pain.

To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days following NOE fracture repair.

The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.

• No aspirin for 7 days (nonsteroidal antiinflammatory drugs (NSAIDs) use is controversial)
• Analgesia as necessary
• Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.)
• Nasal decongestant may be helpful for symptomatic improvement in some patients.
• Steroids, in cases of severe orbital trauma, may help with postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
• Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.

Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended to assess complex fracture reductions. In centers where intraoperative imaging is available postoperative imaging can be performed at a delayed time.

For nasal fractures, postoperative CT imaging is usually not necessary except in severely comminuted fractures.

Remove sutures from skin after approximately 5 days if nonresorbable sutures have been used.

Apply ice packs (may be effective in a short term to minimize edema).

Avoid sun exposure and tanning to skin incisions for several months.

Diet depends on the fracture pattern and patients condition but there are usually no limitations.

Clinical follow-up depends on the complexity of the surgery, and the patient’s postoperative course.

In all patients with NOE trauma, all the following should be periodically assessed:

• Globe position
• Double vision
• Other vision problems
• Nasal airway status

Other issues to consider are:

• Facial deformity (incl. asymmetry)
• Sensory nerve compromise
• Problems of scar formation
• Anosmia
• Epiphora and dacryocystitis

Implant removal is rarely required. It is possible that this may be requested by patients if the implant becomes palpable or visible. In some countries it will be more commonly requested. There have been cases where patients have complained of cold sensitivity in areas of plate placement. It is controversial whether this cold sensitivity is a result of the plate, a result of nerve injury from the original trauma, or from nerve injury due to trauma of the surgery. Issues of cold sensitivity generally improve or resolve with time without removal of the hardware.