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Nasal fracture, septal haematoma and septal surgery
Nasal fracture is the commonest facial fracture, and closed reduction is done within a few hours before swelling develops or after it settles (about 7 to 10 days); the truly urgent issue is septal haematoma, which is drained at once to prevent cartilage necrosis and a "saddle nose".
Why it matters in the exam
In every nasal injury the septum is examined from inside: a soft, bluish, bilateral swelling indicates septal haematoma — the blood separates the cartilage from its blood supply, and without prompt drainage an abscess, cartilage necrosis and a saddle nose deformity develop. The danger is especially great in children. Nasal X-ray is not needed for a simple fracture — the diagnosis is clinical; CT is needed when another facial fracture is suspected. The commonest complication after repair of a nasal fracture is residual deformity, which sometimes requires later rhinoplasty.
The internal nasal valve is the narrowest part of the nasal airway: it is bounded by the septum, the caudal margin of the upper lateral cartilage, and the head of the inferior turbinate, at an angle of about 10 to 15 degrees. The Cottle test (pulling the cheek sideways) improves breathing when the problem is at the valve. Septoplasty suits persistent nasal obstruction from septal deviation after failed medical treatment; an L-shaped cartilage strut at least about 1 cm wide is kept to prevent collapse. Complications: septal perforation, haematoma, saddle nose and rarely CSF leak.
Septal perforation comes from surgery, cocaine use, GPA, trauma or picking. A cocaine user with destruction of the septum and palate, facial pain and loss of smell — cocaine-induced midline destructive lesion (CIMDL), which can look like GPA and even give a positive ANCA. Rhinophyma is thickening of the nasal skin in rosacea, treated with layered excision or laser. In non-allergic rhinitis that does not respond to conservative treatment, the inferior turbinates can be reduced or the posterior nasal nerve ablated.
Key points
- Nasal fracture — clinical diagnosis.
- Septal haematoma — drain at once.
- Closed reduction within hours or after 7 to 10 days.
- Internal valve: septum, upper lateral cartilage, inferior turbinate.
- Septal perforation: cocaine, GPA, surgery.
Summary table
| Situation | Clue | Treatment |
|---|---|---|
| Nasal fracture | Deformity and pain after a blow | Closed reduction within hours or after 7 to 10 days |
| Septal haematoma | Soft bluish swelling, usually bilateral | Immediate drainage and packing |
| Septal deviation | Persistent obstruction | Septoplasty, keep a 1 cm L-strut |
| Narrow internal valve | Positive Cottle test | Cartilage spreader grafts |
| Septal perforation | Whistling, bleeding, crusting | Look for cocaine or GPA; button or repair |
| Rhinophyma | Thick nasal skin, rosacea | Layered excision or laser |
A free exam question
בעת טיפול בקריסטה המקסילרית בניתוח ספטופלסטי מופיע דימום עורקי משמעותי. איזה מה עורק ים הבאים הכי סביר שנפגע? (the question as examined, in Hebrew)
- א. Facial
- ב. Superior labial
- ג. Posterior superior alveolar
- ד. Greater palatine
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Sources
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Nasal fractures; septoplasty and nasal valve surgery
- Scott-Brown's Otorhinolaryngology Head and Neck Surgery, 8th edition (2018) — Nasal trauma and septal haematoma
- AAO-HNS Clinical Consensus Statement: Septoplasty with or without inferior turbinate reduction, 2015 — Indications and outcomes
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.