Nasal Septal Hematoma – May 16, 2024

Nasal Septal Hematoma – May 16, 2024

A 30-month-old presents to the emergency department (ED) for evaluation of a nosebleed (epistaxis). Mom reports the child had an injury two nights ago when he jumped off his bed and struck his face on the nightstand. The child was taken to a local ED where he was noted to have a bloody nose and a small laceration to the base of his nose. The laceration was repaired with three sutures and the child was discharged. His mother reports that the child has continued to have bleeding from the right nostril and seems congested. His physical exam is notable for extensive bruising to the tip of the nose and below both eyes. There are two sutures in place to the right lower ala with a small amount of bleeding at the site. His interior nasal exam, utilizing the Wispr digital otoscope for anterior rhinoscopy, is shown.

Which of the following is indicated based on the child’s findings?

  1. Emergency physician consultation with otolaryngology (ENT) for urgent management
  2. Referral to ENT for management in the outpatient setting
  3. Cautery of the lesion with silver nitrate
  4. Oxymetazoline (Afrin) spray and nasal packing in ED, follow-up with the primary physician

Answer: A. Emergency physician consultation with otolaryngology (ENT) for urgent management

The child’s Wispr exam demonstrates a right-sided nasal septal hematoma. The hematoma is seen as a bluish bulge on the upper nasal septum and is contributing to the ongoing epistaxis and “congestion” noted by his mother. Nasal septal hematomas require immediate evacuation to relieve pressure necrosis of the septal cartilage which can result in complications including septal perforation, abscess, or collapse of the nose (“saddle deformity”). Otolaryngology (ENT) was consulted, and a maxillofacial computed tomography (CT) was recommended. The CT demonstrated a non-displaced nasal fracture and confirmed the septal hematoma. The patient was taken to the operating room where the hematoma was drained and splinted. Upon follow-up, he was doing well, and the family expressed gratitude for his expedited care.

Here is the complete video of the nasal exam. Note the usefulness of the Wispr’s video capability in this squirming child.