Innovative management of nasal septal hematoma in an infant.

Nasal septal hematoma is a collection of blood between the cartilage or bone and mucoperichondrium or mucoperiosteum of the nose. This condition requires immediate surgical drainage to prevent complications. All patients need nasal packing postoperatively to prevent recurrence. This causes a lot of discomforts due to mouth breathing more in infants who are obligatory nose breathers. They can go for cyanosis in the postoperative period. Here, we discuss the case report of an infant who had tubular nasal pack with endotracheal tube postoperatively to maintain the patency of nose.

Nasal septal hematoma can be unilateral or bilateral and can occur at any age. The commonest etiology includes trauma, bleeding disorder, violent sneezing and drugs like aspirin and warfarin. In children, it can occur even following minor trauma as in our case. Nasal septal hematoma without injury should arise suspicion of child abuse, especially in infants.[1] Patients present with nose block, pain, rhinorrhea[2] hyposmia, fever and other constitutional symptoms. Anterior rhinoscopy shows bluish/reddish fluctuant swelling at the anterior part of the septum, nasal tip tenderness. Surgical drainage is the treatment of choice with nasal packing for 2–3 days to obliterate the potential space. Nasal packing cause great discomfort due to mouth breathing and dryness of mouth. Infants who are obligatory mouth breathers can develop cyanosis due to inadequate mouth breathing, which will be relieved by crying. In our case, we packed the nose with an endotracheal tube as tubular pack on one side to allow nasal breathing and drainage of mucus into nasopharynx.

Case Report

A 9-month-old infant came with a history of repeated attacks of cyanosis, relieved by crying with tenderness at the tip of the nose by mother. Mother also gave a history that the infant was not able to take breast feeds continuously. On further questioning, she gave a history of fall 1-week back with no history of nasal bleed. On examination, child had diffuse swelling on either side of the septum with minimal tenderness. Immediate surgical drainage was planned under general anesthesia. After drainage, we did not want to pack the nose completely as the infant can go for cyanosis. We packed the nose with 4 mm internal diameter endotracheal tube as tubular pack on one side [Figure 1]. Endotracheal tube was cut measuring the size of the floor of the nose extending from the posterior choana to half inch beyond the columella. The potential muco perchondreal space was totally obliterated maintaining the nasal patency [Figure 2]. The child was extubated fully awake. Postoperatively child was able to breathe comfortably with mouth closed. Supplementary oxygen was provided through the tubular nasal pack [Figure 3]. The child was given systemic antibiotics. Child started feeding normally and tubular pack was removed on third postoperative day. Child is on regular follow-up for the past year till this date with no other complaints.

Figure 1

4 mm internal diameter endotracheal tube which was used as tubular pack

Figure 2

The infant with the tubular pack

Figure 3

Supplementary oxygen via the tubular pack

Discussion

The most common cause of septal hematoma is nasal trauma. In a study in Nigeria the majority of the cases (65.6%) were of unknown cause and were, therefore, grouped as spontaneous hematoma whereas 30.4% were due to trauma.[3] Trauma was more common in patients below the age of 15 years while spontaneous hematoma was common in patients above that age. The buckling force pulls the perichondrium from the cartilage tearing the submucosal blood vessels resulting in stagnant blood.[4] If not drained immediately the perichondrium stripped off the cartilage deprives the cartilage of its nutrition leading to necrosis of cartilage.[5] This leads to saddle nose deformity, supra tip collapse and columellar retraction.[6] Delay in diagnosis and treatment can also cause septal abscess and perforation.[7] 3 patients died from a brain abscess as a complication of infected hematoma.[3] Direct spread of infection via emissary vein can cause cavernous sinus thrombosis and a high mortality.[8] Surgical drainage is made by incising over the area of greatest fluctuation without incising the cartilage. After evacuating the blood, a strip of mucoperichondrium is excised to prevent early closure of the incision. Nasal package is kept on both sides tightly to obliterate the potential space and give support to the septal cartilage. The patients are put on systemic anti-biotics and anti-inflammatory drugs. This pack can cause a lot of discomfort postoperatively due to mouth breathing and dryness of mouth. It can be more dangerous in infants and children causing cyanosis and desaturation. The larynx in infants is situated higher up than normal. This enables continuous breathing when the baby is breast feeding. But this also makes infants obligate nasal breathers, and any nasal obstruction can cause serious respiratory obstruction resulting in cyanosis.[9] In our case, the infant was very comfortably breathing through the nose as the tubular pack helped in maintaining the patency of nose whether asleep or awake.

Conclusion

All cases of septal hematoma require urgent incision and drainage to prevent cosmetic deformities and dreadful complications. Postoperative packing should be done, which cause more discomfort to the patients particularly infants who are obligatory nasal breathers. Our idea of using tubular pack in postoperative period is a patient friendly alternate for conservative nasal pack. The child was very comfortable in postoperative period with normal nasal breathing and on follow-up till date with no recurrence.