A young man comes to the ED with severe pain in his nose – specifically the left nostril. He states that he was punched in the face yesterday while “minding his own business.” The initial swelling over his nose has improved, and he states that the initial nose bleed stopped. The pain in his nose was so severe that it awoke him from sleep this AM. On physical exam you see the following.
What is it?
This is a septal hematoma – a collection of blood along the nasal septum that accumulates under the perichondrium. As the blood fills the potential space it elevates the bone, and makes it hurt – bad.
What is the next step?
Call ENT (Otolaryngology) as this needs to be drained emergently lest the patient suffer septal necrosis. The perichondrial flaps must be plicated after the blood is drained. Then, systemic antibiotics should be started pending cultures – covering for Staph spp., Strep spp. and H. flu. Clindamycin would be a good choice. PO would be acceptable if the patient can tolerate it. Close follow-up over the next several months is warranted, as the dreaded saddle nose deformity is one of the potential adverse cosmetic outcomes.