Nasal septal hematoma is a collection of blood between the cartilaginous nasal septum and its overlying mucoperichondrium, typically caused by blunt trauma to the nose with shearing of submucosal vessels. Because septal cartilage is avascular and depends on diffusion through the perichondrium, an intervening hematoma deprives it of nutrients and predisposes to ischemic necrosis within 72 hours. Bilateral hematomas have an even higher risk of cartilage loss because both perichondrial layers are stripped from the cartilage.
Patients usually present with progressive nasal obstruction after facial trauma, accompanied by pain, fullness, and tenderness over the nasal dorsum. Anterior rhinoscopy reveals a unilateral or bilateral bluish-purple, fluctuant, compressible swelling on the septum that fails to decongest with topical vasoconstrictors—an important distinguishing feature from simple mucosal swelling. Pediatric cases are particularly worrisome since cartilage necrosis can disturb facial growth, while delayed diagnosis can progress to septal abscess with fever, severe pain, and intracranial complications such as cavernous sinus thrombosis or meningitis.
Treatment requires prompt incision and drainage under local or general anesthesia, ideally within 24-48 hours. A horizontal mucoperichondrial incision evacuates the hematoma, irrigation with saline removes residual clot, and either through-and-through quilting sutures, septal splints, or anterior nasal packing is placed to reapproximate mucoperichondrial flaps to cartilage and prevent reaccumulation. Empirical antistaphylococcal antibiotics (amoxicillin-clavulanate or cephalosporin) are recommended given the risk of secondary infection. Late presentations with established septal abscess require formal surgical drainage and may need delayed septal reconstruction with cartilage graft to address resulting saddle nose deformity.