Post-Traumatic Diseases of the Nasal Septum: Diagnosis and Treatment of Hematomas, Abscesses and Perforations

The nasal septum is a bony cartilaginous plate dividing the nasal cavity into two halves. Its pathologic changes, such as nasal septal hematomas, abscesses, or perforations, are serious complications of trauma or infections. These conditions require timely diagnosis because they can lead to serious consequences, including irreversible nasal deformation.

Classification of conditions of the nasal septum

In otorhinolaryngology, three main groups of post-traumatic septal pathologies are distinguished:

1. Nasal septal hematomas:
   • Unilateral hematoma;
   • Bilateral hematoma.
2. Nasal septal abscess:
   • Unilateral;
   • Bilateral.
3. Nasal septal perforation.

Etiology

In most cases, the common cause of the aforementioned pathologies is mechanical damage, such as household injuries, falls, and traffic accidents.

In rare cases, the cause is surgical interventions in the nasal cavity. These conditions can be caused by chronic slow infections or autoimmune diseases in the nasal cavity, for which patients do not seek help from otorhinolaryngologists for a long time.

Causes of hematomas and abscesses

Nasal septal hematomas can arise from blunt trauma or a viral infection. Signs of it are hyperemia and increased fragility of the vessels of the mucous membrane, which contribute to spontaneous hemorrhages.

Nasal abscesses are most often a consequence of the suppuration of a hematoma. It can also be formed:

• By transferring an infection from the skin (swelling or nasal furuncle);
• When an infection spreads from the oral cavity during caries processes.

Causes of perforation

A nasal septal perforation develops due to:

• Trauma and burns (chemical, thermal);
• Surgical interventions;
• Atrophic processes, autoimmune, and infectious diseases;
• Abscesses of the septum (purulent melting of tissues);
• Prolonged use of intranasal medications or narcotic drugs;
• Chronic traumatization (‘nose-picking’).

Idiopathic perforations, i.e., when the exact cause cannot be established, also occur.

Pathogenesis and anatomical changes

Hematoma

A hematoma is an accumulation of blood between the cartilage and supracartilage. It occurs within the first 24 hours after an injury. In the nasal cavity on the side of the lesion, a fluctuating, tense bulge of the mucous membrane of a cyanotic (bluish gray) color can be identified.

The hematoma may involve the cartilaginous part or extend into the posterior bony part, although this is extremely rare. It’s also common to encounter a bilateral lesion, in which blood accumulates on both sides.

Abscess

A nasal septal abscess is an accumulation of purulent contents under the mucous membrane, more often in the area of the septal cartilage. It occurs as a complication of an undrained nasal hematoma or after trauma and intranasal interventions.

In the absence of treatment, the purulent inflammation spreads deeper. The cartilage, deprived of nutrition and in a purulent environment, quickly degrades via chondrolysis. Complication of the condition includes the development of a nasal septal perforation, deformation of the back of the nose (its depression), and spread of inflammation to the periorbital area and intracerebral structures.

Perforation

When the nasal septum is perforated, the anterior parts in the area of the septal cartilage and Kiesselbach’s plexus are affected. At the site of ulceration of the mucous membrane, a perforation forms in the area of the cartilage, which increases in size over time. Granulations may form along the edges of the perforation.

The appearance of the perforation changes the natural laminar airflow to a turbulent airflow. This leads to the drying of the mucous membrane, the formation of crusts, and impaired ventilation of the nasal cavity and paranasal sinuses.

Perforations are categorized according to their size. The size of the perforation affects treatment tactics and prognosis.

Clinical presentation

Symptoms depend on the type of pathology and the stage of the process.

1. The hematoma is a moderately painful or painless mass. When it is small, nasal breathing remains unchanged, and the condition goes unnoticed. The contents may degrade on their own. However, without proper treatment, the hematoma will often fester and develop a nasal septal abscess in a clear clinical presentation. If bilateral or large hematomas are present, nasal breathing becomes difficult.
2. A nasal septal abscess presents with distinct symptoms:
   • Complaints of marked nasal pain;
   • Difficulty with nasal breathing on the side of the lesion;
   • Chills, weakness, headache, and increased body temperature.
3. A perforation forms via atrophy:
   • Dryness in the nasal cavity with the formation of crusts;
   • Reduced sense of smell;
   • Recurrent nosebleeds;
   • Possible whistling in the nose when breathing (with small defect sizes).

Diagnosis

A thorough history and routine examination via anterior rhinoscopy are sufficient to clarify the diagnosis in this group of diseases.

• If necessary, endoscopy of the nasal cavity is performed.
• To assess the state of bone structures and exclude intracranial complications, a facial CT scan can be performed.
• If both hematomas and abscesses are present, a diagnostic and therapeutic puncture can be performed. Obtaining blood confirms the diagnosis of a nasal septal hematoma, while obtaining pus indicates a nasal septal abscess.

Treatment of nasal septal conditions

Therapeutic tactics are determined by the type of pathological process and are aimed at evacuating the contents, preventing purulent complications, and restoring the integrity of the nasal structures.

Treatment of nasal septal hematomas

The nasal septal hematoma is punctured with a needle to aspirate the contents, then a tight anterior tamponade is performed to fix and graft the mucous membrane to the underlying structures. When indicated, oral antibacterial therapy is prescribed, and antiseptic solutions are applied to the nasal packing to prevent purulent complications.

Treatment of nasal septal abscesses

With nasal septal abscesses, only surgical treatment is used. A wide incision of the mucous membrane is performed where the swelling is largest, and the pathologic contents are removed.

• The resulting cavity is washed with antiseptic solutions, drainage is installed, and then the nasal cavity is packed (tamponized).
• Oral antibacterial therapy is prescribed depending on the patient’s sensitivity. Regular dressings with a change of drainage are performed.
• With bilateral abscesses, the mucous membrane incision should be performed on both sides, but not symmetrically, in order to prevent the formation of a nasal septal perforation.

Treatment of nasal septal perforations

Closing a nasal septal perforation is currently a difficult task for nose surgeons. To achieve the best effect, the first thing that should be done is identifying the cause of the perforation and attempting to eliminate or minimize it.

1. Non-surgical therapy

To reduce clinical manifestations, it’s recommended to regularly moisten the nasal cavity with saline solutions and soften crusts with ointment preparations. This only prevents the perforation from increasing in size. Doing so does not close it. Silicone implants are also placed in the site of perforation. However, they sometimes contribute to an increase in its size.

2. Surgical Therapy

Rhinoplastyof the nasal septal perforation is performed using autochartilage and mucous membrane on a vascular pedicle. The tissues are then fixed with nasal protectants until it heals.

However, even with surgical correction, it is currently rarely possible to completely eliminate the defect. In some cases, surgical interventions can even contribute to the perforation growing larger.