The Journal of Craniofacial Surgery & Volume 22, Number 6, November 2011 Nasal Septal Hematoma and Abscess in Children I brahim SayN n, MD, Zahide Mine YazN cN , MD, Eyüp Bozkurt, MD, Fatma Tülin Kayhan, MD Objective: The objective of the study was to evaluate the demographic factors, trauma type, treatment, and long-term results in patients with nasal septal hematoma (NSH) and nasal septal abscess (NSA). Methods: Between the years 2006 and 2010, subjects who received a diagnosis of NSA and NSH were included for the study. Demographic data, the surgical findings, and long term follow-up results were recorded. Results: Twenty-nine subjects were identified. Eleven subjects had a diagnosis of NSA, whereas 19 subjects were identified as having NSH. Eighteen subjects (62.1%) were male, whereas the remaining 11 subjects (38.9%) were female. Mean age of the subjects was 7.79 T 3.99 years. The etiologies were fall in 26 subjects (89.6%) and blow in 3 subjects (10.4%). Four subjects were previously examined by a physician. In 9 subjects (31.1%), radiologic and clinical evidence of nasal fracture exists. Eighteen (72%) of 29 subjects experienced sequelae. No significant difference exists for clinical properties, demographic data, etiology, and so on, except mean duration; P 9 0.05. Mean duration was significantly high in the NSA group than in the NSH group (8.40 T 8.46 days vs 3.58 T 3.64 days, P = 0.025). Conclusions: This study demonstrated that both NSH and NSA have similar properties for demographic data, etiology, and sequelae. Key Words: Nasal trauma, septal hematoma, septal abscess, sequelae N asal trauma in childhood is a common entity. However, development of nasal septal hematoma (NSH) and nasal septal abscess (NSA) after a trauma is relatively rare. The incidence of NSH and NSA is reported to be between 0.8% to 1.6% of the nasal trauma cases.1 These are also one of the rare emergency situations in the field of rhinology that needed early intervention and close followup. Although nasal trauma is a common entity, NSH/NSA was seldom reported in the literature especially in pediatric population.2 This study presented and discussed the clinical properties of subjects with NSH and NSA in the light of current literature. MATERIALS AND METHODS Pediatric subjects who had a diagnosis of and were treated for septal hematoma and abscess were enrolled to the study. This study was From the E.N.T Clinic., BakNrköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey. Received May 4, 2011. Accepted for publication July 12, 2011. Address correspondence and reprint requests to Ibrahim SayNn, MD, BakNrköy Dr. Sadi Konuk Education and Research Hospital, ENT Clinic. Tevfik sa?lam Caddesi, No. 11. 34147, BakNrköy, Istanbul, Turkey; E-mail: dribrahimsayin@yahoo.com The authors report no conflicts of interest. Copyright * 2011 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31822ec801 Brief Clinical Studies undertaken between January 2006 and January 2010. Subjects who completed at least 1-year follow-up were included in this study. All children were treated under general anesthesia. A hemitransfixion incision was made, and the hematoma and abscess were drained. Appropriate abscess material was obtained for culture. The septal cavity was irrigated with isotonic saline solution. After drainage, the septum was inspected and palpated with a Cottle elevator to detect the defect areas. If cartilage continuity remained, no additional procedure was done. If cartilage necrosis was present, the necrotic parts were removed, and residual cartilage parts were reimplanted into the nasal septum, and mosaicplasty was done. No fibrin glue was used to stabilize the pieces of the septal cartilage. Then a penrose drain was used in the septal cavity, and mucoperichondiyal layers were approximated to the nasal septum with absorbable suture. A tight nasal packing was also done. During the hospital stay, all cases were treated with systemic antibiotics. (ampicillin-sulbactam for NSH and ceftriaxone for NSA). The nasal packages were removed 2 or 3 days after the surgery. According to drainage findings (hematoma or abscess), subjects were divided into either NSH or NSA group. Patients were revisited, and all subjects were classified according to the degree of sequelae after the NSA or NSH, similar to that of Alvarez et al.1 These classification was as follows:  without sequelae.  minor sequelae: minor esthetic deformities, minimal septal, and vault alterations that did not cause airway compromise.  major sequelae: nasal dorsum, tip, or pyramid deformation resulting to important aesthetic problems, deviation of the septum causing airway compromise, functional vault deformity, and septal perforation. Statistical analyses were performed using the Number Cruncher Statistical System 2007 and Power Analysis and Sample Size 2008 statistical software (NCSS, Kaysville, UT). During the evaluation of the study data, along with the descriptive statistical methods, W2 and Fisher exact tests were used to compare the parameters between the NSH and NSA groups. The confidence interval was 95%, and P G 0.05 was considered to indicate statistical significance. RESULTS Thirty-eight subjects were identified. Nine subjects were excluded because control examinations could not be done. In total, 29 subjects’ results were presented. Nineteen (65.5%) of 29 subjects had a diagnosis of NSH, and the remaining 10 subjects (34.5%) subjects had a diagnosis of NSA. Clinical features are summarized in Table 1. No statistical difference was found between the groups for the mentioned features (P 9 0.05). Eighteen subjects (62.1%) were male, whereas the remaining 11 subjects (38.9%) were female. Mean age of the subjects was 7.79 T 3.99 years. No significant difference exists for sex and age between groups. Mean duration was significantly high in the NSA group than in the NSH group (8.40 T 8.46 days vs 3.58 T 3.64 days, P = 0.025). The etiologies were fall in 26 subjects (89.6%) and blow in 3 subjects (10.4%). Four subjects were previously examined by a physician. In 9 subjects (31.1%), radiologic and clinical evidence of nasal fracture exists. Nasal fracture was seen high in the NSH group, but significant difference was found for etiology, previous nasal examination, and associated nasal fracture between groups (Table 2, P 9 0.05). The results of the cultures were not satisfactory; only 1 culture was positive for Staphylococcus aureus in the NSA group. Mean follow-up period of the subjects was 30.1 months (range, 12Y58 months). Eighteen (72%) of 29 subjects experienced sequelae. * 2011 Mutaz B. Habal, MD Copyright © 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. e17 The Journal of Craniofacial Surgery Brief Clinical Studies TABLE 1. Clinical Features of the Patients According to Groups & Volume 22, Number 6, November 2011 TABLE 3. Sequelae of the Patients According to Groups Total (n = 29) NSH (n = 19) NSA (n = 10) Total (n = 29) Clinical Features NSH (n = 19) NSA (n = 10) n (%) Nasal obstruction* Hyperemia of nasal mucosa* Enlargement of septum* Headache/fascial pain* Swelling/ecchymosis on nasal dorsum* External nasal deformity* Epistaxis† Purulent rhinorrhea† Fever† P 29 (100) 29 (100) 19 (100) 19 (100) 26 (89.7) 14 (48.3) 11 (37.9) 16 (84.2) 10 (10) 10 (52.6) 4 (60) 9 (19) 2 (10) 10 (34.5) 5 (17.2) 4 (13.8) 2 (6.9) 7 (36.8) 5 (26.3) 1 (5.3) 0 (0) Sequelae 10 (100) 10 (100) 3 0 3 2 (30) (0) (30) (20) V V No sequelae Minor sequelae Major sequelae n (%) 7 (28) 12 (48) 6 (24) 6 (37.5) 7 (43.8) 3 (18.8) P 1 (11.1) 5 (55.6) 3 (33.3) 0.355 0.688 0.630 Fisher exact W2 test. 0.184 0.518 0.149 0.713 0.134 0.105 0.111 *W2 Test. †Fisher exact test. There is no statistically significant difference for sequelae between the groups (Table 3, P 9 0.05). After the removal of the package, no secondary collection was observed. No extension of the infection was observed. DISCUSSION Nasal septal hematoma or NSA is defined as collection of blood or pus between septal cartilage and mucoperichondrium or mucoperiosteum. The exact mechanism is not known; however, the bleeding from minor mucoperichondrial blood vessels after a trauma is generally regarded as the inciting event.3 Children are at risk because the mucoperichondrium or mucoperiosteum is loosely adhered to underlying cartilage. This anatomic specialty facilitates the form of hematoma formation.1 Once the hematoma is developed, it serves as an adequate medium for bacteria and progresses to NSA if left untreated.3 Nasal septal hematoma or NSH will develop after several days of trauma. The initial examination always did not rule out the pathology.2 The leading symptom is nasal obstruction, which will be accompanied by less nasal pain and headache.4 An intranasal examination with anterior rhinoscopy is the crucial step for diagnosis. However, Barrs and Kern5 reported that among the children with nasal trauma only 20% of the subjects underwent an intranasal examination. On physical examination, the nasal mucosa is unilateral or bilaterally swollen. The hematoma formation will have a late onset. Four of the cases in this study reported a previous nasal examination. The examinations were not performed in our clinic, so we cannot clearly demonstrate if these are misdiagnoses or they developed at late onset. Once the NSA or NSA is suspected, a needle aspiration will be useful to prove the diagnosis. For NSA, it is hypothesized that needle aspiration before drainage will decrease the pressure and may decrease the spread of infection to the intracranial area.6 Controversy also exists about the use of fine-needle aspiration (FNA). Alvarez et al1 noted that the FNA is not practical, and it is not cost-effective. Despite this report, we also suggest preoperative FNA. Usually, for NSH, no computed tomography (CT) scanning is required. However, in the case of septal abscess, CT scanning will be needed especially in the suspicion of additional complication such as intracranial extension. A previous study suggested the use of CT when there is ‘‘Iextensive facial cellulitis, focal neurologic deficits, altered consciousness, meningism, significant headache, extensive time delay for diagnosis and treatment, and isolation of an unusual microorganism.’’7 We did not routinely perform a CT scanning. In 4 cases in the NSA group and in 1 case in the NSH group, a CT scan is required. TABLE 2. Demographic Parameters of the Patients According to Groups Total (n = 29) Pathology NSH (n = 19) NSA (n = 10) n (%) Mean age,* y Mean duration, days* Female‡ Male Etiology fall§ Etiology blow§ Associated nasal fracture‡ Previous examination§ 7.79 T 3.99 5.24 T 6.08 11 (38.9) 18 (62.1) 26 (89.6) 3 (10.4) 9 (31.1) 4 (13.8) 8.00 T 4.32 3.58 T 3.64 8 (42.1) 11 (57.9) 17 (89.5) 2 (10.5) 8 (42.1) 1 (5.3) P 7.40 T 3.47 8.40 T 8.46 3 (30) 7 (70) 9 (90) 1 (10) 1 (10) 3 (30) 0.746 0.025† 0.694 1.000 1.000 0.076 0.105 *Mann-Whitney U test. †P G 0.05. ‡W2 Test. §Fisher exact test. e18 * 2011 Mutaz B. Habal, MD Copyright © 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery & Volume 22, Number 6, November 2011 The abscess rarely extends beyond the nasal septum, which will result in orbital complications, meningitis, cavernous sinus thrombosis, and severe intracranial abscess.4,7 In our subjects, no additional extension of the infection was observed. Pressure-induced avascular necrosis and liquefaction resulted in the loss of septal cartilage including the growing centers. Besides avascular necrosis, cartilage necrosis is also a result of digestive process. Cathepsin D and leukocytes are responsible for the digestion process. Two growing centers exist, which are the sphenodorsal (shapes the height and length of the nose) and sphenospinal (basalforms the anterior nasal spine and maxilla) zones. The location and extent of the lost parts will alter the development of the nose by affecting these growing centers.8,9 Anterior smaller defects that occurred between these centers will not affect the outgrowth of the nose; however, if these growing centers are both destructed, severe impairment will occur. Three possible ways exist to reconstruct the lost cartilage. The first one is the exchange technique in which the healthy posterior bony or cartilage residues are used to repair the anterior parts. This technique is not suitable for the children because it destroys the posterior parts of the septum and will affect the septal growth. The other one uses the rib or conchal cartilage. This is an invasive procedure, especially in the case of rib cartilage, for children. The latter one is mosaicplasty, which used healthy small pieces of residual septal cartilage to reconstruct the lost septum.10 Although the NSA is more likely to result in sequelae, long-term results did not show any difference for sequelae between the NSA group and the NSH group. This will be due to highly associated nasal fractures in the NSH group. Associated nasal fracture is a sign of more severe trauma, which also increased the long-term sequelae. The nasal fracture is present in 8% to 37.5% of the cases.2Y10 In our series, radiologic or clinically proven fracture was present in 9 cases (31.1%). Nasal fractures were significantly high in the NSH group. Nasal fracture will lead to an early admission and early diagnosis of the disease, preventing the hematoma from late abscess formation. CONCLUSIONS Nasal septal hematomas and NSAs are emergency situations in the field of otolaryngology because of short- and long-term morbidities. If treated effectively, short-term as well as long-term comorbidities will be avoided. The results of this study did not find any difference on clinical properties and sequelae between subjects with NSH and NSA. ACKNOWLEDGMENT The authors thank Emire Bor for performing the statistical analysis of the data. REFERENCES 1. Alvarez H, Osorio J, De Diego JI, et al. Sequelae after nasal septum injuries in children. Auris Nasus Larynx 2000;27:339Y342 2. Dubach P, Aebi C, Caversaccio M. Late-onset posttraumatic septal hematoma and abscess formation in a six-year-old Tamil girlVcase report and literature review. Rhinology 2008;46:342Y344 3. Alexander AA, Shonka DC Jr, Payne SC. Septal hematoma after balloon dilation of the sphenoid. Otolaryngol Head Neck Surg 2009;141:424Y425 4. Huang PH, Chiang YC, Yang TH, et al. Nasal septal abscess. Otolaryngol Head Neck Surg 2006;135:335Y336 5. Barrs DM, Kern EB. Acute nasal trauma: emergency room care of 250 patients. J Fam Pract 1980;10:225Y228 6. Ambrus PS, Eavay RD, Baker AS, et al. Management of nasal septal abscess. Laryngoscope 1981;91:575Y582 Brief Clinical Studies 7. Thomson CJ, Berkowitz RG. Extradural frontal abscess complicating nasal septal abscess in a child. Int J Pediatr Otorhinolaryngol 1998;45:183Y186 8. Menger DJ, Tabink I, Nolst Trenité GJ. Treatment of septal hematomas and abscesses in children. Facial Plast Surg 2007;23:239Y243 9. Canty PA, Berkowitz RG. Hematoma and abscess of the nasal septum in children. Arch Otolaryngol Head Neck Surg 1996;122:1373Y1376 10. Dispenza C, Saraniti C, Dispenza F, et al. Management of nasal septal abscess in childhood: our experience. Int J Pediatr Otorhinolaryngol 2004;68:1417Y1421 Etiology and Patterns of Facial Lacerations and Their Possible Association With Underlying Maxillofacial Fractures Fabio Roccia, MD, Francesca Antonella Bianchi, MD, Emanuele Zavattero, MD, Federico Baietto, MD, Paolo Boffano, MD Background: This study was designed to analyze the etiology and patterns of soft-tissue facial lacerations associated with maxillofacial fractures and to identify associations between facial lacerations and underlying fractures. Methods: Of 1960 patients who had been admitted for maxillofacial fractures between 2001 and 2010, only patients with complete clinical records presenting with facial lacerations were considered for this study. Facial lacerations were classified according to the MCFONTZL system.Results: Of the 1960 patients admitted with maxillofacial fractures, 637 had 836 associated facial lacerations. Motor vehicle accidents and falls were responsible for most injuries to patients with facial lacerations. According to etiology, fractures resulting from work-related accidents more frequently produced associated lacerations. For all causes of injury, more facial lacerations were observed over the ‘‘T’’ area formed by the upper orbit and forehead, nose, upper and lower lips, and chin. Lacerations and maxillofacial fractures were more frequently localized to the middle third of the face, followed by the inferior third. There was a strong association between lacerations and fractures in the chin region, considering both symphyseal and parasymphyseal fractures (direct trauma) and condylar fractures (indirect trauma). Conclusions: An association between facial lacerations and underlying maxillofacial fractures was observed, particularly in the inferior orbital area and over the zygoma, mandible, and chin. From the Division of Maxillofacial Surgery, Head and Neck Department, San Giovanni Battista Hospital, University of Turin, Turin, Italy. Received May 4, 2011. Accepted for publication July 12, 2011. Address correspondence and reprint requests to Fabio Roccia, MD, Corso A. M. Dogliotti 14, 10126 Turin, Italy; E-mail: Fabio.Roccia@poste.it The authors report no conflicts of interest. Copyright * 2011 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31822ec934 * 2011 Mutaz B. Habal, MD Copyright © 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. e19