Management of Nasal Trauma with Bleeding and Hematoma
Nasal trauma with bleeding, hematoma, and a small cut requires immediate evaluation and treatment to prevent serious complications including septal abscess, cartilage necrosis, and subsequent nasal deformity. 1, 2
Underlying Explanation for Presentation
The presentation of nasal trauma with bleeding, hematoma, and a cut on the nasal ridge is consistent with:
- Direct trauma to the nose causing rupture of blood vessels leading to epistaxis (nosebleed)
- Collection of blood between the cartilage and its overlying perichondrium forming a hematoma
- Laceration of the skin over the nasal ridge
Potential Complications
Immediate Complications:
- Airway obstruction due to bleeding or swelling 3
- Significant blood loss leading to hemodynamic instability in severe cases 4
Delayed Complications:
- Septal or alar hematoma progression to abscess (occurs when bacteria infect the hematoma) 2, 5
- Cartilage necrosis due to separation of cartilage from its blood supply by the hematoma 2, 5
- Nasal deformity including saddle nose deformity or nasal collapse due to destruction of supporting cartilage 2, 6
- Septal perforation following cartilage necrosis 5
- Persistent nasal obstruction due to septal deviation or scarring 6
- Cosmetic deformity requiring subsequent rhinoplasty 6
- Infectious spread to surrounding structures (rare but serious) 5
Management Algorithm
1. Initial Assessment and Bleeding Control
- Apply firm sustained compression to the lower third of the nose for 5-15 minutes 4
- Position patient sitting with head slightly forward to prevent blood aspiration 4
- Remove blood clots and perform anterior rhinoscopy to identify bleeding site 4
2. Epistaxis Management
- For visible bleeding site: Apply chemical cautery (silver nitrate) or electrocautery 4
- For persistent bleeding: Consider topical tranexamic acid (TXA) which controls bleeding within 10 minutes in 71% of patients 4
- If bleeding continues: Consider nasal packing 4
3. Hematoma Evaluation and Management
- Thoroughly examine the nasal septum and alar cartilage for hematoma formation 1, 5
- Surgical evacuation is mandatory for any nasal hematoma to prevent cartilage necrosis 1, 2, 5
- This procedure typically requires general anesthesia, especially in children 5
- After drainage, nasal packing is placed to prevent reaccumulation 5
4. Antibiotic Therapy
- Initiate antibiotics to prevent infection and abscess formation 5
- Target common organisms: Staphylococcus aureus, Streptococcus pneumoniae, and group A beta-hemolytic streptococcus 5
5. Imaging Considerations
- X-ray or CT imaging may be necessary to evaluate for associated nasal fractures 1, 6
- Imaging is not routinely indicated for simple epistaxis management 4
6. Follow-up Care
- Schedule follow-up within 3-5 days to assess healing and check for complications 4
- Monitor for signs of infection or abscess formation (increasing pain, fever, worsening swelling) 2, 5
- Provide patient education on nasal moisturization and when to seek emergency care 4
Critical Pitfalls to Avoid
Failure to recognize and drain a hematoma promptly - This is the most critical pitfall as untreated hematomas can lead to cartilage necrosis within days 2, 5
Inadequate examination - Always perform a complete examination of the entire nasal septum and alar cartilage, as hematomas may not be immediately obvious 1, 5
Delayed treatment - Studies show diagnosis is often delayed 1-14 days (mean 5.9 days) after trauma, increasing complication risk 5
Inadequate follow-up - Complications can develop days after the initial injury 4, 5
Underestimating severity - What appears to be minor nasal trauma can lead to significant complications if hematomas are present 6, 5