Auris Nasus Larynx 27 (2000) 339 342

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Sequelae after nasal septum injuries in children

lvarez a,b,*, J. Osorio a, J.I. De Diego b, M.P. Prim b, C. De La Torre a,
H. A
J. Gavilan b
b

a
Department of Otorhinolaryngology, Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
Department of Otorhinolaryngology, Hospital Uni6ersitario La Paz, Paseo del la Castellana 261, 28046 Madrid, Spain

Received 24 December 1999; accepted 10 March 2000

Abstract
Objecti6e: To study the results of surgical treatment and sequelae in nasal septum injuries in children. Methods: Between
January 1990 and December 1997, 16 pediatric patients with septal haematoma and/or abscess were treated. Mean age was 5 years
(range: 214 years). Thirteen were male (81.2%), and three were female (18.8%). In nine cases (56.2%) the disease was a
consequence of a minor trauma. Only two children had nasal fracture associated (12.5%). Minimum follow-up after the first visit
was 10 months (mean, 3 years). Results: All cases were surgically treated. Minor sequelae were observed in six cases (37.5%), and
major ones in ten patients (62.5%). In this latter group, multiple reconstructive procedures were needed. Conclusions: It is
necessary to be aware of the possibility of haematoma and abscess of the nasal septum. Major sequelae can be also expected after
cases following minor traumas. 2000 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Haematoma; Abscess; Septum; Complications; Sequelae; Nose; Trauma; Children

1. Introduction
Haematomas and abscesses of the septal cartilage are
not usual [110], a surprising finding when one considers that the nose is the most frequently injured organ of
the body [9]. In most cases haematomas and abscesses
are due to traumatic nasal injury [1 5]. Nasal surgery,
ethmoid or sphenoid sinusitis, dental abscess, nasal
furuncle, and tobacco snuffing [2,6 8] have been described as etiologic factors. Also, more rarely, spontaneous appearance has been observed in the clinical
practice [8].
Although the precise mechanism for haematoma formation is unknown, bleeding under the mucoperichondrium and/or mucoperiostium of the septum following
nasal trauma can explain these clinical situations. These
structures are loosely adhered to the septum in children,
and this facilitates both occurrence and spread of septal
haematoma. In addition to this, the pressure and secondary infection can originate in abscess and/or
isquemia and damage of the cartilage. Even when the
disease remains as a subclinical situation, collection of
* Corresponding author.

blood under the mucoperichondrium or mucoperiostium dissolves the outer layers of the hyaline cartilage of the septum [9].
Haematomas and abscesses of the septum are of
concern not only because of the potential cosmetic
deformity that can occur if they are not properly
treated, but also because of the significant functional
disturbances that can result. Nasal obstruction is the
most frequent symptom following these pathologic conditions [1,4,8,10]. Moreover, brain abscess, subarachnoid empyema, meningitis, cavernous sinus thrombosis,
lateral sinus thrombosis, and naso-oral fistula have
been described after these situations [1,8,1115].
The goal of this work is to study the results, and the
frequency of sequelae after nasal trauma. The modalities of treatment are discussed, and a review of the
current literature concerning these diseases is also
included.

2. Material and methods

Between January 1990 and December 1997, 16 cases
of haematoma and/or abscess of the septum were seen

0385-8146/00/$ - see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved.
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l6arez et al. / Auris Nasus Larynx 27 (2000) 339342

H. A

Table 1
Clinical features in the patients of our series (n= 16)
Haematoma

Enlargement of septum
Hyperemia of nasal mucosa
Nasal obstruction
Rino-septal deformity
Epistaxis
Swelling/echimosis
Nasal pain
Haematoma of the dorsum
Nasal bone fracture
Headache
Fever
Purulent rhinorrhea

Abscess

Total

7
7
4
4
4
3
3
2
1
1
0
0

43.7
43.7
25.0
25.0
25.0
18.0
18.0
12.5
6.2
6.2
0.0
0.0

9
9
7
7
3
4
3
0
1
1
1
1

56.3
56.3
43.7
43.7
18.0
25.0
18.0
0.0
6.2
6.2
6.2
6.2

16
16
11
11
7
7
6
2
2
2
1
1

100.0
100.0
68.7
68.7
43.0
43.0
36.0
12.5
12.5
12.5
6.2
6.2

at the Department of Otorhinolaryngology of the Hospital Infantil de Mexico Federico Gomez. The age
ranged from 2 to 14 years (mean, 5 years). Thirteen
patients were male (81.2%) and three were female
(18.8%).
In all patients the following parameters were registered: etiology (major or minor trauma), symptoms,
signs, associated nasal fracture, time until diagnosis,
previous treatments, treatment needed, surgical findings, sequelae, employment of reconstructive procedures, and time of follow-up. The traumas were defined
according to the next criteria:
Major trauma: patients with immediate fracture,
and/or deviation of nasal bones, cartilaginous and/or
osseous obstructive septal deviation, or soft tissues
laceration.
Minor trauma: cases without nasal fracture, with no
dorsum, tip or piramid deformation, and without
laceration of soft tissues of the nasal piramid.
Likewise, all subjects were classified into three categories with respect to sequelae after the trauma:
1. Without sequelae.
2. Minor sequelae were defined as the following: minor
esthetic deformities, and minimal septal and vault
alterations without airway compromise.
3. Major sequelae comprise cases with the next conditions: dorsum, tip or piramid deformation causing
important esthetic impairment, deviation of the septum with nasal obstruction, swelling of the septal
cartilage, functional vault deformity, and septal
perforation.
All patients were available for follow-up during a
period ranging from 10 months to 7 years (mean, 3
years). Twelve of the 16 children were observed beyond
1 year after the treatment of the disease.

3. Results
Etiology was a minor trauma in nine cases (56.2%)
and major in the remaining seven (43.8%). Clinical
findings are detailed in Table 1. Mean time elapsed
before evaluation for haematoma and abscess following
nasal trauma was 2.2 and 12.5 days, respectively, with
an overall mean of 8 days (range, 6 h28 days). Only in
two patients radiological and clinical evidence of nasal
fracture were found (12.5%).
All children were surgically treated under general
anesthesia. Drainage was performed incising and tunneling the nasal mucosa. Close reduction was employed
in the cases with associated nasal bones fracture. The
diagnosis of haematoma in seven (43.8%) children and
abscess in nine (56.2%), was postoperatively confirmed.
All patients had sequelae. Ten developed minor sequelae (62.5%) and six major ones (37.5%). The relationship between trauma and sequelae is showed in Table 2.
An microorganism of the material obtained was cultured in only two cases (Staph. aureus). All patients had
a nasal packing and PENROSE drains inserted at the
time of the initial surgical procedure. Both were left in
situ for 3 days. According to the trauma, hematomas
and abscesses developed major sequelae in equal percentage (Table 3).
Table 2
Sequelae according to severity of trauma (n = 16)
Trauma

Minor
Major
Total

Minor sequelae

Major sequelae

Total

4
2
6

25.00
12.50
37.50

5
5
10

31.25
31.25
62.50

9
7
16

56.25
43.75
100.00

 l6arez et al. / Auris Nasus Larynx 27 (2000) 339342

H. A
Table 3
Sequelae according to diagnosis (n =16)
Diagnosis

Hematoma
Abscess
Total

Minor sequelae

Major sequelae

lead to a more detailed search for other injuries or

evidences of previous traumas [19].
The concept above exposed calls for a thorough nasal
examination by anterior rhinoscopy in all cases of nasal
trauma. Sequelae were found in all patients in this
study. According to the high incidence of deformities
following these injuries, only radiograph and/or external examination of the nose could lead to disastrous
functional and cosmetic consequences. Barrs et al. [21]
reported that 50 of 100 children evaluated in an emergency room after a nasal trauma had an X-ray of their
nose; however, an intranasal examination was performed in only 20 children. So, although rhinoscopy
performed by an otolaryngologist is the goal, a preliminary exploration of the nasal passages by the casualty
doctor or the general practitioner, by means of an
otoscopy, should be done in all cases. In cases of
confusing findings, the patient will be promptly submitted to a center with an otolayngologist head and
neck surgeon. We think that radiological studies are
also adequate in these situations, despite the low incidence of fracture associated to these processes
[2,8,10,12,13,1619].
Management of these entities is universally accepted
to be the immediate surgical drainage of the collection
with nasal packing and antibiotic cover. Drainage in
children is best accomplished under general anesthesia.
Although routine preoperative needle aspiration has
been suggested [2], we believe that it is neither practical
nor cost-effective to use it. Controversies remain about
the efficacy of postoperative PENROSE [19]. Because
of their rarity, little information is available about the
bacteriology of infected nasal haematomas. S. aureus is
the primary pathogen isolated regardless of the age;
strains of Haemophilus influenzae, Streptococcus pneumoniae and group A b-hemolytic streptococcus have
also been isolated [2,4,11,12,22]. According to this, a
penicillin (i.e. floxacillin) and/or clindamycin are the
agents initially recommended until the results of cultures and susceptibility studies are available.

Total

2
4
6

12.50
25.00
37.50

5
5
10

31.25
31.25
62.50

7
9
16

43.75
56.25
100.00

341

4. Discussion
The incidence of nasal septal haematomas and/or
abscesses complicating septal traumas is not well
known. Only few references to these entities exist in the
current medical literature, and this is especially true in
the pediatric population. It seems that their occurrence
has been variable along the years, and along the world
ranging between 0.8 [8] and 1.6% [2] of the cases of
nasal trauma attended in the emergency room by otolaryngologists (see Table 4) [2,8,10,12,13,16 19]. The
reasons for these facts are not clear. Whether it is due
to racial susceptibility, environmental factors, geographic influences or health conditions of the population in each epoch, should be studied with additional
research.
The literature suggests a strong male predominance
in haematomas and abscesses of the septum [19] with
minor nasal trauma as major causal factor. Nasal
anomalies caused by trauma are frequently seen in
newborn-girls, but at older ages they occur prevailingly
in boys (especially teenagers) due to the aggressiveness
of their activities [10]. However, the incidence is about
equal if we just consider traffic events [20].
Although nasal injury is commonplace in childhood,
septal hematomas and/or abscesses are often neglected
and frequently go undiagnosed until complications ensue [1]. So, these processes may be suspected in any
child who has suffered a nasal trauma. In addition to
this, when a newborn or a toddler presents this disease,
one should consider the possibility of child abuse and
Table 4
Previously reported series of haematoma and abscess of the nasal septum
Authors, year

Time period (years)

Age

Larchenko (1961) [16]

Fearon et al. (1961) [13]
Eavey et al. [12] (1977)
Ambrus et al. (1981) [2]
Blahova [10] (1985)
Close et al. (1985) [3]
Kryger et al. (1987) [17]
Chukuezi (1992) [8]
Jalaludin (1993) [18]
Canty et al. (1996) [19]

6
8
10
10
10
0.3
10
5
10
18

Pediatric
Pediatric
Pediatric
Pediatric
Pediatric
Pediatric
Adult
Adult
Pediatric
Pediatric

and adult

and adult
and adult

and adult

Haematoma/Abscess

Total

11/105
13/43
0/3
0/16
13/12
0/3
27/12
38/8
0/14
8/12

116
56
3
16
25
3
39
46
14
20

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The incidence of sequelae is high and directly related

to the delay in diagnosis and treatment, presence of
septal abscess, cartilage destruction observed at surgery,
and positive bacterial culture [2,8,11,12,22]. So, this
subgroup needs long-term follow-up [19]. Surprinsingly,
negroid nose with an haematoma or abscess is more
likely to be resistant to deformity when compared to a
Caucasian one [8]. Whether it is due to the shape of the
nose, the blood supply or the type of tissue collagenases
has to be established by additional studies.
When fracture is associated with these entities, close
reduction offers satisfactory results [23]. In order to
minimize iatrogenic procedures, surgery is only performed for draining by incision and tunneling below
the septal mucoperichondrium, with immediate septal
correction, at the time of injury [10]. Late correction of
bad nasal passage due to haematoma or abscess is a
delicate problem due to the difficulty of subperichondrical resection in these cases, and the potential damage of
growth centres in the first 10 years of life.

5. Conclusion
It has become necessary to create more clinical
awareness of the condition of haematoma and abscess
of the nasal septum because of the frequent occurrence
of sequelae. Major sequelae can be also expected after
cases following minor traumas.

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