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Hematoma of the Nasal Septum Roytesa R. Savage and Christina Valvich Pediatrics in Review 2006;27;478 DOI: 10.1542/pir.

27-12-478

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/27/12/478

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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in brief

pected. In hypospadias, which results from failure of complete fusion of the developing penis, the foreskin covers only the dorsal surface of the penis. This dorsal hood represents failure of the foreskin to fuse and serves as a visual clue for the presence of hypospadias. Strongly diverse opinions abound as to the medical benets and liabilities to the infant and adult male of retaining the foreskin versus losing it through circumcision. Risk of urinary tract infection, penile cancer, cancer of the cervix in a sexual partner, sexually transmitted diseases, and degree of

sexual pleasure are some of the debated issues. Even the most supercial analysis of the literature addressing the benets and risks of circumcision is beyond the scope of this brief treatise. The American Academy of Pediatrics Task Force on Circumcision Policy Statement and the article on costutility of circumcision are good starting points for a review of those data. Comment: As mentioned, paraphimosis is a urologic emergency. Hyaluronidase, injected into the prepuce, has been used as a strategy for relief of

paraphimosis by relieving the edema. Granulated sugar also has been shown to be effective by creating an osmotic gradient that allows uid transfer away from the edematous prepuce. Either of these procedures should be performed by a health-care professional who has experience with such techniques. Circumcision is indicated at a later date to avoid future recurrence.

Janet R. Serwint, MD Consulting Editor, In Brief

In Brief
Hematoma of the Nasal Septum
Roytesa R. Savage, MD Christina Valvich, MD Brody School of Medicine East Carolina University Greenville, NC Minor nasal trauma occurs in children almost daily. A serious but rare complication of nasal or facial trauma is a nasal septal hematoma, which is a collection of blood between the cartilage and the bony nasal septum. The nose has a very rich blood supply from the external and internal carotid arteries. The Kisselbach plexus is the blood supply for the anteroinferior nasal septum, which is the location of most episodes of epistaxis. When the nose is subjected to trauma, the blood vessels may tear, leading to blood collection in the space between the cartilage and the perichondrium. If the blood continues to collect, the cartilage blood supply can be obstructed, causing pressure-induced avascular necrosis of the nasal cartilage. A hematoma of the nasal septum may present immediately or, more commonly, several days after the initial injury. In one study, the time of presentation ranged from 1 to 14 days after the trauma (mean, 5.9 days). Many children or parents recall specic trauma to the nose, such as a ght, a fall, a hit in the face with a ball, or a collision with an object. For young children who have sustained trauma, child abuse also must be considered. The most common presenting symptom is nasal obstruction, but pain, rhinorrhea, and fever also may occur. The presence of fever must increase suspicion of nasal septal abscess. Intranasal examination is imperative. The septum appears boggy (or doughy) and swollen. Pain may be present that is localized to the septum along with tenderness to palpation of the nose tip. The nasal mucosa has blue, purple, or cherrylike swelling over the septum that often obstructs airow. The hematoma may be unilateral or bilateral, with bilateral lesions being more common in the presence of a septal fracture. If an intranasal vasoconstrictor has been given to the patient, the mass remains the same size and is uctuant when probed. Management of a nasal septal hematoma includes consulting an otolar-

Author Disclosure Drs Savage, Valvich, and Serwint did not disclose any nancial relationships relevant to this In Brief.

Septal Hematoma and Abscess After Nasal Trauma. Lopez M, Liu J, Hartley B, Myer C. Clin Pediatr. 2000;39: 609 610 Complications of Nasal and Sinus Infections. Hengerer A, Klotz D. In: Bluestone C, Stool SE, Alper C, et al, eds. Pediatric Otolaryngology. 4th ed. Vol. 2. Philadelphia, Pa: Saunders; 2001:10211022 Nasal Septal Hematoma. Ginsburg C. Pediatr Rev. 1998;19:142143 Hematoma and Abscess of the Nasal Septum in Children. Canty PA, Berkowitz R. Arch Otolaryngol Head Neck Surg. 1996;122:13731376
478 Pediatrics in Review Vol.27 No.12 December 2006

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in brief

yngologist for immediate incision and drainage. If the swelling is not relieved, the cartilage can be destroyed, leading to nasal airway obstruction, septal perforation, and nasal deformities. Such complications are especially relevant in the developing child, who needs the cartilage for support of the nose and facial growth. Collapse of the cartilage can lead to a cosmetic deformity such as a nasal hump or saddle-nose. Because the hematoma supplies a rich medium, the patient is also at risk for infection. Staphylococcus aureus, Streptococcus pneumoniae, group A beta-hemolytic Streptococcus, Haemophilus inuenzae, and anaerobes are potential pathogens. Abscess formation can lead to additional complications, including meningitis, cerebral abscess, subarachnoid empyema, and cavernous sinus thrombosis. Clindamycin is recommended as initial treatment pending culture results.

Nasal packing and coverage with antibiotics is indicated during initial treatment. Nasal packing, typically for 2 to 3 days, helps prevent blood reaccumulation. Patients should be followed closely for reaccumulation of the hematoma or any signs of infection. Reconstruction and repair may begin as early as 6 months after the active disease process has been controlled. Patients should continue to be followed for any signs of cartilage destruction and cosmetic changes for the next 12 to 18 months. When discharging a patient who has suffered any type of nasal trauma or facial injury, parents and patients should be cautioned to watch for signs and symptoms of a nasal hematoma. Comment: Occasionally this diagnosis may elude clinicians because of the overlap of symptoms between hematoma of the nasal septum and the more

common upper respiratory tract infection. In one study, only 50% of patients who sustained a nasal septal hematoma presented with pain. Symptoms of nasal obstruction, rhinorrhea, and fever could be attributed easily to marked nasal congestion from an upper respiratory tract infection. Hence, asking about a history of trauma is imperative. Because some cases may be associated with minor trauma and the time to presentation may range from 1 to 14 days, parents may not recall the injury without prompting. Using a topical anesthetic, administering a decongestant, and probing may aid in making the diagnosis because the nasal swelling from a hematoma is not relieved by decongestants.

Janet R. Serwint, MD Consulting Editor

Pediatrics in Review Vol.27 No.12 December 2006 479

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Hematoma of the Nasal Septum Roytesa R. Savage and Christina Valvich Pediatrics in Review 2006;27;478 DOI: 10.1542/pir.27-12-478

Updated Information & Services References

including high resolution figures, can be found at: http://pedsinreview.aappublications.org/content/27/12/478 This article cites 3 articles, 3 of which you can access for free at: http://pedsinreview.aappublications.org/content/27/12/478#BIB L

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