What causes a septal hematoma?

Causes of Septal Hematoma

Nasal trauma is the primary cause of septal hematoma, resulting in blood collection between the mucoperichondrium and septal cartilage that can lead to avascular necrosis if not promptly treated. 1

Mechanism of Septal Hematoma Formation

Septal hematomas develop when blood accumulates between the nasal septal cartilage and its overlying mucoperichondrium. This typically occurs through the following mechanisms:

• Direct nasal trauma - Most common cause, especially in children 2, 3
• Nasal fractures - Often associated with septal hematoma formation 3
• Surgical complications - Can occur following nasal or septal procedures
• Atraumatic causes (rare) - Including:
  • Infections spreading from adjacent structures 4
  • Spontaneous bleeding in patients with bleeding disorders
  • Complications of sinusitis

Risk Factors

Several factors increase the risk of developing septal hematoma:

• Pediatric population - Children are particularly vulnerable due to:
  • Higher incidence of nasal trauma from falls and play activities
  • Thinner septal cartilage that's more susceptible to injury 5
• Anticoagulant/antiplatelet medication use - Increases bleeding risk 1
• Intranasal drug use - Can cause direct trauma to septal tissue 1
• Bleeding disorders - May predispose to spontaneous hematoma formation 1

Pathophysiology

The pathophysiological progression of septal hematoma follows a predictable course:

1. Initial injury - Trauma causes separation of mucoperichondrium from cartilage
2. Blood accumulation - Bleeding into the potential space between cartilage and mucoperichondrium
3. Cartilage ischemia - The hematoma separates the cartilage from its blood supply
4. Potential infection - Untreated hematomas frequently become infected, forming abscesses 4, 3
5. Cartilage necrosis - Prolonged ischemia leads to cartilage death and resorption

Important Clinical Considerations

Delayed Presentation

Septal hematomas may not be immediately apparent after trauma. Research has documented cases where hematomas developed 48-72 hours after the initial injury, despite initial negative examinations 6. This highlights the importance of follow-up evaluations after nasal trauma.

Complications

If left untreated, septal hematomas can lead to serious complications:

• Septal abscess formation - Infected hematomas typically contain saprophytic bacteria 3
• Septal perforation - Due to cartilage necrosis
• Saddle nose deformity - Collapse of the nasal dorsum from cartilage destruction 3
• Intracranial infections - In severe cases, infection can spread to the brain 4

Warning Signs

Key clinical indicators of septal hematoma include:

• Nasal obstruction (bilateral)
• Nasal pain and tenderness
• Visible septal swelling on examination
• Difficulty breathing through the nose 4, 5

Prevention and Management

Early recognition and prompt surgical drainage are essential to prevent complications. Complete intranasal examination should be performed in all cases of nasal trauma to detect hematomas before complications develop 2.

Careful evaluation for septal hematoma should be part of the standard assessment for any patient presenting with nasal trauma, with particular vigilance in pediatric cases.