Hematoma and abscess of the nasal septum: causes, symptoms, diagnosis, treatment

A nasal septum hematoma is a limited accumulation of liquid or clotted blood between the perichondrium (periosteum) and cartilage (bone) or between the perichondrium (periosteum) and mucous membrane due to closed injuries to the nose with a violation of the integrity of its vessels.

An abscess of the nasal septum is a cavity filled with pus and separated from surrounding tissues and organs by a pyogenic membrane, located between the perichondrium (periosteum) and cartilage (bone) or between the perichondrium (periosteum) and the mucous membrane, arising as a result of suppuration of a hematoma of the nasal septum or chondroperichondritis in infectious diseases (erysipelas, nasal furuncle), dental caries, diabetes mellitus, etc.

ICD-10 code

J34.0 Abscess of nasal septum.

Epidemiology of hematoma and abscess of the nasal septum

There is currently no precise data on the prevalence of hematoma and abscess of the nasal septum. This pathology is recorded in 1.1% of patients with various traumatic injuries to the nose and paranasal sinuses. Nasal injuries in the structure of facial skull injuries make up from 8 to 28%, and in the structure of all bone fractures - from 12 to 43%.

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Causes of hematoma and abscess of the nasal septum

The immediate cause of the hematoma is trauma to the nasal septum (in case of bruises, fractures of the external nose, surgical interventions on the nasal septum), leading to damage to the vessels of the perichondrium and hemorrhage. Predisposing factors are disorders of the blood coagulation system, acute infectious diseases of the upper respiratory tract. In these cases, a hematoma of the nasal septum can occur even with minor trauma to the nose.

When a hematoma that is not emptied in time becomes infected, an abscess of the nasal septum is formed. The typical microflora in such cases is staphylococci (Staphylococcus aureus, epidermidis, saprophyticus), as well as beta-hemolytic streptococcus group A.

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Pathogenesis of hematoma and abscess of the nasal septum

The leading pathogenetic mechanism is the rupture of the vessels of the inner layer of the perichondrium with subsequent hemorrhage. A significant role in the occurrence of a hematoma of the nasal septum is also played by diseases accompanied by plethora of the nasal mucosa, impaired blood coagulation processes, increased permeability of the vascular wall (acute and chronic rhinitis; hypertension and symptomatic arterial hypertension; circulatory disorders of various origins with increased arterial pressure in the vessels of the head and neck; coagulopathy, hemorrhagic diathesis, hypo- and avitaminosis, etc.).

A feature of nasal septum hematoma is a rapidly developing inflammatory reaction in response to damage with the formation of biologically active metabolites - the cause of secondary tissue alteration and suppression of the activity of various links of the immune system. Violation of the barrier function of the nasal mucosa contributes to transepithelial migration of bacteria vegetating in the nasal cavity and infection of the extravasate.

Less often, a nasal septum abscess is a consequence of the spread of infection from the site of inflammation in periodontitis, nasal furuncle. Endocrine diseases, primarily diabetes mellitus, have an adverse effect on the incidence, course and prognosis of a nasal septum abscess: hypovitaminosis, poor nutrition, diseases of the digestive system, immunodeficiency states, etc.

Symptoms of hematoma and abscess of the nasal septum

The most common symptom of a nasal septum hematoma is difficulty breathing through the nose, which develops shortly after a nasal injury. The addition of complaints of headache, malaise, and increased body temperature indicate the formation of an abscess.

When analyzing the clinical manifestations of a nasal septum abscess, one should keep in mind the high probability of involvement of the quadrangular cartilage in the process, rapid development of chondroperichondritis with the formation of a perforation of the nasal septum, deformation (depression) of the nasal dorsum. In addition, it is necessary to take into account the risk of developing severe septic complications. To a large extent, it is associated with the peculiarities of the outflow of venous blood from this anatomical zone, which is carried out through the anterior facial and orbital veins into the cavernous sinus. This circumstance creates real prerequisites for the spread of the purulent-inflammatory process not only by contact in the cranial direction to the roof of the nose and the base of the skull, but also the generalization of the infection hematogenously with the formation of septic thrombosis of the cavernous sinus. In this case, an infectious syndrome develops with high temperature, chills, sweating, and in typical cases, circulatory disorders occur - pastosity, swelling of the periorbital region, injection of conjunctival veins, chemosis, exophthalmos, congestive changes in the fundus.

Classification of hematoma and abscess of the nasal septum

There is no clear classification of hematoma (abscess) of the nasal septum. In everyday clinical practice, a distinction is usually made between unilateral or bilateral hematoma. In case of abscess of the nasal septum, attention is paid to the presence of symptoms of purulent-septic complications, deformation of the external nose due to melting of the quadrangular cartilage. The listed features of the pathological process are taken into account when determining the volume and nature of treatment measures and are reflected in the diagnosis.

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Diagnosis of hematoma and abscess of the nasal septum

Recognition of a hematoma and/or abscess of the nasal septum is based on an analysis of the patient's complaints, anamnestic information and examination data of the nasal cavity.

Physical examination

During anterior rhinoscopy, a thickening of the nasal septum on one or both sides of a reddish-bluish color is determined. In these cases, the nasal cavity is poorly or completely inaccessible for examination. In some cases, pillow-like protrusions can be seen already when lifting the tip of the nose. In the case of bilateral localization of the hematoma, the septum acquires an F-shape.

Laboratory research

When examining peripheral blood in patients with nasal septum abscess, neutrophilic leukocytosis and an increase in ESR are detected.

Instrumental research

In some situations, in order to recognize a hematoma (abscess), it is necessary to remove exudate and blood from the nasal cavity using an electric aspirator, resort to palpation of the protrusion with a button probe or cotton wool, in the case of a hematoma of the nasal septum, fluctuation is determined. A reliable sign is the detection of blood during a puncture of the swelling and aspiration of its contents: when the hematoma suppurates, purulent exudate is obtained.

Indications for consultation with other specialists

Complicated course of nasal septum abscess, presence of pathogenetically related diseases in the patient requiring special treatment (for example, diabetes mellitus) are considered indications for consultation of other specialists (neurologist, neurosurgeon, ophthalmologist, dentist, endocrinologist, etc.). If nasal septum hematoma occurs in children, consultation with a hematologist is necessary to exclude blood diseases.

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Treatment of hematoma and abscess of the nasal septum

Treatment goals for nasal septum hematoma and abscess

Regression of local inflammatory changes, normalization of the patient’s general condition, restoration of working capacity.

Drug treatment of hematoma and abscess of the nasal septum

In case of nasal septum abscess, opening and drainage of the purulent cavity is supplemented by systemic antibiotic therapy. The drugs of choice in these cases are cephalexin, oxacillin; alternatives are cefazolin, smoxicillin + clavulinic acid, vincomycin, linezolid.

Surgical treatment of hematoma and abscess of the nasal septum

The nasal septum hematoma is drained under local or general anesthesia by cutting the mucous membrane with a scalpel. After the liquid blood and clots have been evacuated, drainage (a strip of glove rubber) is inserted into the resulting cavity, and tampons are inserted into both halves of the nasal cavity, which are left for 24-48 hours, depending on the specific clinical situation.

Tamponade may not be necessary if the nasal septum can be sutured with a through U-shaped suture after opening the hematoma.

In case of a small unilateral hematoma, a puncture is performed followed by tamponade of the corresponding half of the nose.

When a hematoma (abscess) is combined with post-traumatic deformation of the quadrangular cartilage and (or) bony sections of the nasal septum, opening and drainage of the hematoma (abscess) with simultaneous reconstruction of the nasal septum in the acute period is indicated.

Further management

In case of uncomplicated course of the disease with nasal septum hematoma, the approximate period of incapacity for work is 5-7 days, with an abscess - 7-10. With the development of septic complications, the period of hospitalization can reach 20 days or more.

Recommendations for patients should contain information on the advisability of consulting an otolaryngologist after a nasal injury, and the need to follow doctor's orders when treating a hematoma (abscess) of the nasal septum.

Prevention of hematoma and abscess of the nasal septum

Primary prevention of hematoma (abscess) of the nasal septum consists of preventing injuries (microtraumas) of the nose and the mucous membrane of the nasal septum. Timely treatment of acute infectious diseases of the upper respiratory tract, as well as sanitary and hygienic measures aimed at reducing the concentration of industrial aerosols and dust in the atmosphere of industrial and domestic premises play an important role.

Secondary prevention is a system of measures aimed at preventing hematoma (abscess) of the nasal septum in risk group individuals - patients with congenital and acquired hemorrhagic diseases, diabetes mellitus, immunodeficiency states of various genesis. Of great importance are periodic medical examinations of such patients, their level of awareness of the causes and clinical manifestations of hematoma (abscess) of the nasal septum, possible complications of this disease, timely sanitation of foci of infection (carious teeth, tonsils, paranasal sinuses, etc.), correction of existing systemic disorders.

Prognosis of hematoma and abscess of the nasal septum

The prognosis for timely opening of the nasal septum hematoma and evacuation of the contents is favorable; if a secondary infection occurs and an abscess forms, melting of the quadrangular cartilage is possible, with the formation of a persistent deformation of the external nose (recession of the nasal bridge).

When the purulent-inflammatory process spreads, septic complications occur, and concomitant diseases are present, the prognosis depends on the severity of the condition, the timeliness and adequacy of treatment measures, and the degree of compensation for concomitant pathology.

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